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fe^j^ansi 


DR,".'-;.i.Ic;Li:i;.:H.a! 


p 


THE    TREATMENT    OF 

DISEASES 


OF  THE 


NERVOUS    SYSTEM 


A  MANUAL  FOR  PRACTITIONERS 


BY 

JOSEPH  COLLINS,   M,D. 

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 


NEW    YOIEK 

WILLIAM   WOOD   AND   COMPANY 
MI>CCCC 


Copt  mo  BT,  l«W, 
Hv  WILLIAM  WOOD  ASD  Cl)«l'ANV 


Htwvomi 


PREFACE. 


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© 


5e3q.?8 


IT  PRBFACB, 

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. 


CONTENTS. 

PART  L 

CHAPTER  r. 

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 

CHAPTER  IL 

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 

PART  II. 

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

Disease,      - 47 

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


fl  CONTENTS. 


CUAPTEB  L 

Drags, 49 

Speclflc  TraatEuent, 60 

The  ftomedlkl  Action  of  Drugs 53 

The  Abuse  ftnd  Ubo  of  Drugs, M 

CHAPTER  n. 

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 

CHAPTER   m. 

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 

CHAPTER  IV. 

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 

CHAPTER  V. 

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 

CHAPTER   VL 
Diet,       . 120 

'  CHAPTER  VIL 

Psychotherapy, 130 

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


OONTKNT9.  ¥U 


PART  IIL 

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

CHAPTER  I. 

'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 

CHAPTER  n. 

,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 

CHAPTER  IIL 

The  Treatment  of  Infantile  Cerebral  Palsies, 180 

Little^  Disease Igt 

Treatment 182 

CHAPTER  IV, 

The  l^vatuient  of  Multiple  Scleroeis, 180 

Etiology 186 

Symptoms,        .         .         ,         .         , 188 

Treatment 180 

CHAPTER  V. 

The  Treatment  of  Tvimoni  of  the  Brain, 100 

Etiologj- lei 

Symptoms,        ...  193 

Trealnieni 105 


fUl  CONTBNTB. 

ExploTftUnr  and  Palliative  Operations, 198 

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

CHAITBH   VL 

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 

CHAPTEB   Vn. 

The  Treatment  of  Aphasia, 214 

Etiology, aie 

Symptoms  oC  AphaaLa, 219 

Treatment 220 

CHAPTEB   VHL 

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 

CHAPTER  JX. 

lie  Treatment  of  the  Hereditary  Atojltui 252 

1.  HeredlUiy  Spinal  Ataxia, 262 

2.  Hereditary  Cerebellar  Ataxia, 254 

3.  HeredLUjyAtAifc  Paraplegia, .  ^55 

CHAPTER  X. 

The  Treatment  of  Syringomyelia, 256 

Rymptoms 257 

Treatment, 258 

CHAPTER   XI. 

The  Treatment  of  Acute  Myelitis, 2tl4> 

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


CONTKKTS.  ix 

Symptoou, ......,,  263 

TtBaunent, 304 

CHAPTER   XII. 

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 

CHAPTER  xnr 

TBo  TreatDxeut  of  ChroQlo  Myelitis 274 

Etiology, 274 

Treatment, 276 

Gubacuto  AtAxic  Paralysis  and  Combined  Scleroala, 273 

CHAPTER  XIV. 

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 

CHAPTER  XV. 

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 

CHAPTER   SVL 

The  Treatment  of  Huacular  DyHtropby,  310 

Treatment  of  the  Dystrophies, 312 


Z  OONTBKTS. 

CHAPTER   XVn. 

PIOK 

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

CHAPTER   XVIIL 

The  Treatment  oi  Tetanua, 317 

Etiology.  .     _ 317 

SymptotUH, 318 

Treatment, 3lft 

CHAPTER    XIX. 

Tlie  Treatment  of  Teiany 322 

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

Treatment  oi  Ihe  Bpaem, 324 

CHAPTER   XX. 

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 


CHAPTER   XKI. 

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

Etiology  of  Facial  Paralyaie, -iSl 

Symptoma, 333 

TreatmenI 3.19 

CHAPTER   XXIL 

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 

CHAPTER   XXni. 

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^ 


CONTKEVTS.  Jl 


CBAFTER   XXIV. 

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 

CHAPTER   XXV, 

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 

CILAPTKR   XX VL 

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 

CHAPTKk   XXVll. 

'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 


Ul  CONTENTS. 

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 

CHAPTER  XXVIIL 

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 

CHAPTER   XXIX, 

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 

CHAPTEK   XXX. 

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

Etiology  of  the  Tic  Neuroais, 4f50 

Treatment  of  theTic  Neurosis.  470 

Summary, 472 

CHAPTEli   XXXI. 

The  Treatment  of  Migraine 473 

Symptoms .         ...         i         •         .         -  473 

Treatment, 475 

Treaiment  of  an  Attack, 470 

CHAPTER  XXXll. 

The  Treatment  of  Chorea, 481 

Treatment *»W 


CONTENTS.  Xm 


CRAFTEB  XXXin. 

TbtTrMtmentOf  FUftlyslsA^Una, 490 

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

Tre»UDent 497 

CHAPTER  XXXIV, 

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

Trewment, 609 

Sur^CAl  Trafttmant  of  Exophthalmic  GoitfQ, 6015 

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

CHAPTBE  XSXV. 

Tie  ItcMmeol  of  MfXCOdemA, 608 

Treitmaat* 500 

CHAFTEB  XXXVI. 

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

CHAFTEB  XXXVU. 

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

Tnatment 515 

luiermiitent  Swelliog  o(  the  En«e, 515 

CHAFTEB  XXXVHL 

TiBTreiimeniof  Acromegalr 616 

Sjrmptooaa,       .        ,        ,        . 510 

Tratment, 617 

CHAPTER   XXXIX. 

TbeTreatmeat  of  Scleroderma, 51V 

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

CHAFTEB   XL. 

Tbf  Treatmeat  of  ProgreaaWe  Facial  Hemiatrophy, 521 

TreatmeDi o2^ 

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

CHAPTER   XLI. 

Tbt  Treatment  of  Erjthromolalgia, 623 

Treiiment 524 

CHAFTEH   XLIL 

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

TreainwDl j2S 


ZIV  CONTBNTB. 


CHAPTER   XLin. 

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

Paralysis), 62 

Treatment, 62 

CHAPTER  XLIV. 

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 

CHAPTER  XLV. 

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 

CHAPTER   XLVl. 

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 

CHAPTER  XLVIL 

The  Treatment  of  ConTulsloos, 67 

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

Lajynglsmus  StridaliU, ^67 

Spasmus  Nutans^     ^        •--...,.        .  ,67 

CHAPTER  XLVni. 

The  Treatment  of  Hemiplegia, 67 

Treatment, 67 

CHAPTER   XLIX. 

The  Treatment  of  Insomnia, 68 

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


THE  TREATMENT 

OF 

DISEASES  OF  THE  NERVOUS  SYSTEM. 


PART  I. 


CHAPTER  L 


THE  CAUSES  AITO  ORIOINATH^N   OF     DISEASE 

SYSTEM. 


OF    THE    NERTOU5 


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 
1 


2  TBEATUENT  OF  DISKABBS  OF  THB  NBBVOUB  SYBTBH* 

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 
parts- 

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 


CACSBfi  OF  DISEASE  OF   THE  NERVOUS  SYSTEM. 


3 


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 


TBBATMENT  OF   DISEaBBB  OF  THB  NERVOUS  BY8TKM. 


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 


CAI 


07  DIBBABB  07  THB  NBRVOUB   SV&TEH, 


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 


TEttATMENT  OF  STSEASES  OF  THH  mGRVOUS  BTSTBIM. 


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 
degenerate. 


CAOSES  OF  DISKASS  OP  TUB  XESTOU8  SYSTKU. 


^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. 


8 


TBKATUBHT  OF  DISEASES  OF  THE  N&BTODfi  &YaiSM> 


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 


CAUa&8  OF  PlSaASa  OF  TUS  NEBVODS  SYQTBU. 


9 


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- 


10 


TRSATUDNT  OF  DI9BAS09  OF  THE  NBRVQUB  SYBT&U, 


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- 


CAV«£S  OF  DISBABB  07  THS  KfiBVOUS  BYflTBH. 


11 


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- 


X9 


TRHATMBNT  OP  DISBASBS  OF  THE  WBBVOlTfl  STSTKM. 


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* 


CACraSS  OF  DISSASR  Oy  THE  ^'£RTOUS  SYSTSJI. 


13 


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- 


14 


TRKATfcnCNT  OF  BrHRASBB  OF  THE  NERVOUS  SrSTKH. 


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 
above. 

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 


GAtFSBS  or  DtSEABB  Or  TBB  !«ERVOUS  STSTSV. 


15 


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»  ooourrence  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- 


IR 


TRBATMBNT  OF  DTBEASES  OF  THB  NBRVOTTB  BYBTEM- 


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- 
tion. 

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 


CArSZS  OF  DI&EABE  OF  THE  NKRVOUa  ST3TEM. 


17 


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 


if 


TTtKATMENT  OF  DISBABKS   OF  THB  IffBRVOCTS  STBTEU. 


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  dUeu.se  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  disea.se  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 


CAUSB3  OP  DISSASB  OP"  THE  NBRV0D5  SVSTEM,  19 

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 


ao 


TTtBATHENT  OF  DI&EASEB  OF  TQB  NERVOtTB  SYSTEM. 


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 


CAUSES  OP  DISBASa  OP  THE  NEBVOCS  eVSTEM, 


21 


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- 


2-^ 


TRffATUENT  OP   DI3EA9Ea  GF  THE]  NfiBYOUa  SYSTEM. 


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 


CAU3ES  OF  t>I9BASE  OF  THE  NKRVOUfl  SYSTKlf. 


23 


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 
jttrtifiw. 

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 


34 


TREATUBNT    OF    DIHEA8ICS    OF    THB    NBKVOUB    BY8TKM. 


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- 


4 


CADSIB  OF  DISRASU  OK  THE  >iERVOUa  SVSTKM, 


25 


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 

pwatfvative  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^^ 


THK  PREVESTIOK   OF  DI3BA8BS  OP  THE  KRBVOrS  STflXtM.      27 

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- 


28 


TREATMENT  OF  DISHASBS  OV  TUB  NERVOUS  BTfiTEM. 


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 


» 


I 


TffE  PBEVSNTION  OF  DISEASES  OF"  T!IB  NBRVOCS  8YBTSM.      90 

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- 
uensary. 

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 


80 


TREATMENT  OP  DISEASES  OP  TBE  ^'ERV0^8  BYSTB3I. 


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 


THE  PREVENTION  OF  DiaEASES  OP"  THK  WBRVOUS  SYSTEM.      ?« 

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 


32 


TREATMENT  OF  DlflSAflSS  OF  THE  NERYOUS  fiYflTEM- 


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 


IHE  rftEVEKTIOW  OF  DISEAdBS  OF  THE  WgRVOUa  SYSTtM.      33 

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 
3 


54 


TREATMENT  OF   DISEASES  Of  THE  NBRVOUfl  STflTBM. 


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 
Utter. 

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 
fwaawjr  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- 
fneatea9«i- 

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, 


36 


7RBATUBNT  OF  DIBEABBB  OP  THD  NERVOUS  SVaTBH. 


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. 


3B 


TRffiATMBNT  OF  1>T3BA3HI9  OF  THB  NBRVODB  BYBTEM. 


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 


'     THB  PEBVBNTIOfJ  OP   Dl8£Ag£a  OF  THE  KfiBVOUB  BYaTEM.      ^^ 

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 


40 


THBiTMENT  oy  I>1SBASEf4  OF  THB  NKKYOUS  SYSTEM, 


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 
moderation. 

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 


TffK 


TTION    OP 


'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 


42 


TREATMENT  OF  DISEASBfl  OF  THE  NBRVOrS  BT«TEM. 


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 


THK  PRfiVKNTluK  UF  DISSASKS  OV  THG  TfKRVOUB  BYBTEU.      43 

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* 


TREATatEfT  OF  DIBEASBS  OF  TBK  yBRVOUS  STflTKM. 

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 


THE  PREVENTION  (/F  t>I5BASE3  OF  THE  NERVoLS  M'fiTEM-      45 

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 
oi^izatioii, 

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. 


PART  IT. 


THE    GK^'ERAL     AFPUCATrON    OF    REMEDIAL    MEAi^L'RES 
Uf   THE   TREATMENT   OF   ^'ERVOl  S    DISEASE. 

IXTRODUCTIOS, 

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 


48  TREATUEKT  OF  DISEASES   OP  THE  NERVOUS  BYSTEH. 

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- 


CHAPTER  L 


DRUGS 


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- 
1 


50 


TRSATMKS'T  OF  DI3KA9R3  OF  THE  N'GRTOUS  SYBTEU. 


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 


DRUGS. 


n 


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- 
fOtucsts. 

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' 
IWKC  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. 


52 


TRKATMK>JT  OF  BISEASKS   OF  T9E  NERVOUS   SYSTRM. 


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- 
soever. 

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 


B3 


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 


TRRATMKKT  OF  DIfiRABRS  OP  THE  NRRVOUB  STaTEl!. 


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 


Dftros. 


55 


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 


W  TREATHSWT  OP  DtSfiABBS   OF  THB  NBRVOUS  SYaTEM- 

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 
adukiniatration. 

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 


53 


TREIjLTMBNT  op*  nSEA^ES  OF*  THE  yERVOUfl  &VSTEU. 


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 


TiBCQS. 


s» 


^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 


60 


TaKATMBST  OF  DISEASES  OF  THB  NKHVOCg  ST9TEU. 


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. 


DRCae, 


m 


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. 


^KiMp: 


1 


62  TRBATUVNT  OF  DTSEA8BS  OF  THE  NERVOUS  STSTBH. 

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

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

^'■"'■'n^:itt^^^?-:;:::;::;:}«'-«-'»- 

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^MinttDreof.gr.  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. 


64 


TREATUEKT  OF  DlBEABES  OF  THE  NERVOUS  BYSTEU. 


StrychnlQC,  gr.  ^-.\ 

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

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

sn. 

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

31*. 

:H.  32,  34,  a5. 

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

13,  a3,  36- 

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

13,23. 

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. 

Koitre). 

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. 

CILVtTER  It 


HTDRUTHERAPY. 


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 


66  TKBATMKNT  OF  KTSBAl^BS  OF  TEiB  NURVOUB  8TBTRV.  ^^H 

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- 
stitatiou* 

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 
meauures. 

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 


HYDROTHERAPY. 


?T 


^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. 


68  TREATMENT    OF    Dl&aABK8    OF   THE    NBRVOUS    SV^TSM. 

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    0  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 


U  Y  D  BOTHKKAP7. 


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 
tiMinieni. 

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- 


70 


TRKATHKNT    OF    DISEASES    OW   THW    NWRVOUB    9TSTEM, 


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 
applications. 

The  hmmogenic  effect  of  oold  applications,  followed  by  prompt  and 


HYDBOTBBRAPTh 


n 


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- 


73  TRBATHBNT  OF  DISEASES  OP  THE  NEBVOC8  BYBTBH. 

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. 


HVUROTRBRAPY.  7S 

&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, 


74 


TBBATHENT  Or  DISEASES  OF  THE  KERTOtTS  STftTKM. 


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 


HTDROTBKRA  PY. 


W 


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 


TREATHBKT  OF  DISEASES  07  THE  IfBRVOUa  fiTaTBU. 

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 


H  YD&OTU  KAAPy , 


rr 


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 


76 


TREATUENT  OF  DIflEASBS  OT  THE   KERVOUS  BTSTElf. 


*«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 
wtGtoh«d. 

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  pa.ck  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 


H  YD  ROTHES  APY . 


7» 


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 


so 


TltBATH£ST  OF  &I9BA3BB  OP  THE   NERVOUS   SYHTGIX. 


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  th.it, 
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 


HTDBOTH  SHAFT. 


81 


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 
6 


THEATMBNT  OW  DT9BASB9  OP  THE  MBRTOUS  SYfiTBH. 


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. 


^V  HVDROTHERAPT.  W 

?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 


TEEATUENT  OP   DrSEABES  OP  THE  NERTOUfl  aYflTKMp 


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 
determined. 

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. 


CHAPTEK  UL 


ELECTROTHERAPY, 

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 


m 


TfiEATMBNT  OF  DISKASKS  OF  THB  NEBVODS  SYSTEM. 


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 


K  LECTROTHKB  APT . 


87 


■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.  «, 


r 


88  TREATMENT  OF  rrSEAflES  07'  TUB  KERVOITS  BTBTSU. 

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 


EL.ECTROTBSBAFT. 


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  sq.cm. 
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 


90 


TREATMENT   OF"  D1B1CASK9   OF*  THH    JTRRVOTTH   8TSTEM. 


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  li.fi  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 


ELECTBOTHEKAP  Y . 


61 


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- 


92 


TKEATMKTn"  OF  DTfiEASES   OF  THE  liERTOUS  SYflTBM- 


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  ha.ve  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 


KLBCTROTH  BKA  P  Y . 


93 


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- 


>K 


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 


84 


TREATMENT  OF  r»ISffiA8BH  OF  THR  yBBVOU8  &Y&TKU. 


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 


Itii 


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- 


ELfiCT  ROTH  ERA  P  Y , 


95 


^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 


96 


TASATMKNT  OF   DISEASES  OF  TBS  >EBVOUa  SYaTBM. 


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 


EIxECTROTH  ERAPT, 


97 


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 


ne.  IX— MUUUUPCIBUH^CT. 


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 
7 


98  TREATMENT  OP  DT9BASBB  OT  TBK  KEBVOTTS  8TSTBM. 

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^ 


BLBCrrROTHEBAPT, 


99 


r~ 


'^. 


^ 


u"  _  .      .  _ 


t3 


H   Fi 


"^ 


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


100 


TREATMENT  OP  nSCAfiBS  OF  THE  KERV0U8  BrSTEM. 


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- 


ELBCTRDTH&OAPT . 


IW 


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 


102 


TEBATMENT  OF  DlSEAaBS  OP  THH  NBBV0U3  BYSTSU, 


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- 


ECjECTROTHER  A  P  T . 


1(@ 


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- 


104 


TRaATUBNT  OF  DIBBA8B6  OF  THB  NBRVOCB  SYSTSH. 


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- 


KLBCTBOTHERAPT . 


lOfi 


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- 


d 


106 


TRBATMSIfT  OF  DISBASBS  OF  TH&  VBRTOUB  8TBTBU. 


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 
work. 

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* 


BLSCTBOTBBBAPY. 


107 


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, 

p«loeiio«phalitia)- 

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. 


CHAPTER  IV. 


MASSAGE, 


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 
mas.sa,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. 


UASSAGE. 


lOft 


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 
pootidiiigp 

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- 


110 


TBEATWRNT  OP"  DISEASKS  OF  THE  NEHVOUB  SYSTEM. 


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 


Ill 


^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 


112 


TKKA'nfE>T  OF  DISEASBB   OF  TEG  NEftVOUS  BT9TBM, 


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- 


U3 


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 


TEEATMENT  OP  DTSBABBS  OV  TUB  NBRVOUS  BT3TBU. 


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- 


HASSAQB. 


115 


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 


116  TBBATUENT  OT  DIBKAflBB  OT  THS  K^RVOUB  STSTBM. 

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. 


CHAPTER  V. 

EXERCISE,   REST,   AND  OCCtTPATION. 

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 


I 


IIB 


TRQATHSNT  OF  DISEASBB  OF  THB  KBHVODS  SYSTBH. 


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 


EXKRCTBK,    REST,    AND  OCCUFATIOM. 


119 


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. 


120 


TBBATUEXr  Off  DIBSASES  OF  TUB  KBRVOUa  BTSTBU. 


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- 
Bpicnoiis. 

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 


fiXEBClSB,  REST,  AND  OCCUPATIOK. 


Ifll 


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- 


122 


TEKATMBNT  OF  1>I3BAHB5  OW  THB   NCEVOU8  8T9TBM. 


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 


KXSRCmK,   RttST,   AJ4D    OOOUPATIOS. 


139 


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 


TRKATMl 

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 


BXERCISK,    RKHT, 


►ATrOW. 


US 


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. 


SCHBDVLS    FOR   FoiX    HbaT    CuftB. 

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. 


3 


12^  TREATMENT    OW    EiIBEASES   OV   THE   NBRVQUS   SYSTEM. 


S01IBI>Vl4B    yOA  pAJlTIAIi   ReBT    TftKATMR^T. 

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 


KXElCCIf^,   EHST,   AKTJ  OCCUPATIOlf, 


isrr 


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 


TRDATUfiNT  OF  DI3EA8SB  OF  THB   KEBVOUS  STBTBM. 

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 
opilepay. 

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. 
tobacco. 


CHAPTER  VI. 


DIET. 

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 


TIIBATMENT  OV  T>I61tASSa  OF  THE  NBRVOITB  8TBTZV. 


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 
uutritioD, 

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 


DtOT. 


131 


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 


132 


TKICIATUHNT  OV  DlSKAfiEa  Or  THK  NKRVOITB  HVSTRV, 


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 


DIKT. 


133 


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- 


134 


TRBATUEINT  OF  DISEASES   (IF  THE  NERVOUS  BYSTKU. 


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. 


DIET. 


135 


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 
kpon- 

>'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. 


^Bflfec 


CHAPTER  VIL 

P8YCH0THERAPT. 

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 


PS  YGH  OTKEB  AP  V . 


m 


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 


138 


TftEATMBKT  OT  DIS«ABEa  OT  THE  NSRVOUS  8YSTBM. 


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 


psychothkbapt. 


139 


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- 


140 


TKKATMttNT  Of  DISBABKS  Of  TH«  yiCRVODS  &V9TKII, 


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 


V  PSTrHOTHERAPY.  141 

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 


142 


TRKATMKKT  OB*  iHSKAflEH  OF  THE   NBRVOL'S  STSTKM. 


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 


PS  rcHOTHHR A  FV . 


wfcieat  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  a.re  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. 


!l 


144 


TBEATUKNT  Or  DIBEASBS  OF  THE  NBBVOTTS  8VSTEH. 


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. 


PART  III. 

DISEASES  OP  THE  MENlNfiKS  AND  THE   BRAIK. 


CHAPTER  L 

THE  TREATMUNT  OF  MENTSGITIS, 

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^ 
«ptm«ly. 

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 
10 


14ft 


TKEATHENT    OF    DISEASES    OF    THE    NK&YOUS    fiYdTEH. 


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 


THE   TBEATMENT    D^    HKN1\01TIS. 


147 


«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 


148 


TREATUEXr  OF"  DISEASES  OP  THE  NEKVOUS  BYSTEU. 


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 


TUB  TREATUE^r  Of  UKMSGITIS. 


1« 


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- 


ISO 


TRBATHRT 


or  DIBBA9Ee«  OP  THK  KBRVOUS  8V9TK1 


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 


THE  TRCATlf£2;T  OP*  UBNINOITlft. 


161 


■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. 


TREATHI 

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 
hydrocephaUis- 

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 


THB  THKATMKKT  OP"  MaNTNGITlS. 


153 


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 


154 


TREATUfiXT  OF   DISEASES  OF  THS  KftRVOUfl  BV8TBU. 


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 


16$ 


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 
brdncephalua. 

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. 


155 


TRKATMCNT  OF  DIBEASBS  OF  THE   KETtVOUS  SV8TBtt. 


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 
posBibilit}', 

When  the  diannosiB  has   been   made,    or  when  the  presence  of   the 


THS  TREATMENT  OW  MBNTNmTTf?. 


157 


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- 


158 


TREATMENT  OF  mSBASES  OF  THE!  TfERVOra  SY3TKM. 


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, 


THK  TRICATUKNT  OF  VENTNOTTIS, 


159 


\^  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 


160 


TREATMENT  OP  DTSBASKfi  OF  THB  NEnVOUfl  SVSTEW. 


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 
eymptomp. 

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- 
ment. 

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. 


THE  TTIEATMBKT  OP  MBSHNGITIS.  161 

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 
U 


im  TEEATMEKT  OF  DISEASES  OT  THE  JCEBVOrS  ST^TKM. 

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  idatkwiahip- 
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 


THR  THEATHEKT  OF  MBVIKOITTS. 


163 


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. 


« 


CHAPTER  II. 

THE  TREATMENT  OP  ENCEPHALITIS- 

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. 

AdlTTE    HkHORRHAOIC!  NoN-PU  KIT  LEST   BNtTEPHALITIS. 

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 


lOG 


TREATMENT   OF  DTBBABBfl  OP  THB  >"BBVOCa  BT3TEU. 


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. 


XtiK  TKKATMENT  ijy  KKCHPHALITIfl. 


167 


ChBONIC   ExcBFUALlTlH. 


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 


168 


TRKATMEirr  OP  1>iaHA9RS  OF  THR  NKHV0C8  BT9TKM- 


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 


lAtUEXT    ilF    B  NrRPHAUTIS. 


IfiS 


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 

njilignuit. 

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- 
tr»nitlooarditiA. 

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 


170 


TRSATM^NT  OP   D18BASES   OF  TUB  ttSRVOrfl   STSTEH. 


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- 


^^^m  THE  TREATUB^CT  Of  G1VCBPHAL]TI9,  171 

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 
finar«. 

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 


m 


TttEATMKNT  OP  DI3BA8SS  OP  THB  tTBBVOrS  gVflTKM. 


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: 


173 


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- 


174  THEATMENT  OF   MSEASEd  OF  THE  NERVOUS  6T9TEU.  ^M 

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 


THK  TREATMENT  OP  KKCKPHALITIS- 


175 


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 


^ 


176 


TREATMENT  OP*  TUSEASES  OF  THE  K&ltVOVS  STSTEM. 


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 


fATMENT  OP 


in 


I 


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 
12 


178 


TRKATMrWT   Off  DISEASES  OF  THB  NKRVOCfl  flTBTBM, 


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- 


THE  THKATlfBNT  OF  KNOBPHALITIS.  179 

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. 


CHAPTER  riL 

THE  TREATMENT  OF  INFANTlLK  CEREBRAL  TAJAtBB. 

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« 


THR    TRKATHKNT    07   IxrANTTLE    CERRBKAL    PALSIES.  181 

»  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 


182 


TBKATMBNT  OF  1>!9EA8S9  Of  THH  KEBVOUS  STaXBM. 


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 


TUB  TRBATMENT  OF   INFANTILE  CBREBRAL  PALSIITS. 


183 


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 


J 


184 


TltEATMEKT   OF  ]>t3fiASRB   OF  THE  NERVOUS  SYBTEM, 


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 


TRK   TKffiATSlKNT    OP    IXFANTILB    CEREBRAL.   PAI^SIES- 


185 


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. 


CHAPTER  IV. 

THE  TREATMENT  OF  MILTIPLE  SCLER0916, 

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 


TBB  TREATMENT  OF  MULTIPLE  SCLEROSIS, 


187 


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 


188 


TREATMBNT  OP  DIBBASIB  OF  TOE  NERVOUS  SY8TEM- 


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 
aaLerodifl, 

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. 


THB  TRBA.TUENT   OP  MULTIPLE  BCLEHOSlS. 


I8d 


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. 


CHAPTER  V. 

THE  TREATMENT  OF  TUMORS  OF  THE  BRiUN. 

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 


THK   TKB4TMENT    OF   TUMOKS    DF    THK   BRAIN, 


191 


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^ 


192 


TRSATUKE4T  OK  TJISBA^KS  OP  TRC  N'ERTOUl^  SYdTEM. 


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 


THE  TRRATMKTfT  OF  TrMOHS   OF  THE  BRAIK. 


198 


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 
13 


TREATMENT  OP  DlflSABC!^  OF  THR   mCRVOtJS  BTSTBl!. 


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- 


^ 


THE  TRBATHENT  Of  TUMORS  OF  THK  BRJlTK.  195 

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' 


196  TKKAnCKST  OP  DtSKASK^  OP  THS  XVKVOrS  STSTKM. 

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 


THE  TUKATMEST  OP  TL'MORS  OF  TilB   BRAIN, 


197 


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 


im 


TR&ATME>JT  OF  DISEASES  Or  THE  HBfiVOija  BYatBM. 


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 


THK  TREATMENT  OF  TITMORS  OF  THK  BRAm, 


199 


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 


900 


TftSATMEST   01 


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 
commeudabla^ 

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- 


THE  TRKATMKNT  OB"  TUMOB9  OF  THE  BRAIN. 


201 


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. 


202 


TREATMENT  OP  1>ISBA3IG6  OF  THIS  NERVOtTfl  SYSTEM. 


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. 


CHAPTER  VL 

THE  TREATMEJTT  OF  CEREBRAL   APOPLEXY.   . 

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 


%4 


TREATMENT   OF   DIBEASHfl   OF  THE  NERVOUS  SYSTBH. 


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 


IHE  TREATMENT  OF  C£RBBRAL  APOPLEXY, 


205 


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- 


206  THEATMEMT  OP  PtSEASES  OP  THE  NRRVOUfl   SYSTEU.         ^1 

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 


THE   TfiHlATMEXT    OF    Cl>:KEmLAL    APOPLEXY, 


207 


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- 


208  TRB\TMRMT  OF  DIBEASBB   OP  THE  SHRVOUB  SYSTHM. 

\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- 


THE  TREATMENT  OF  CERBBRAL  APOPLEXY. 


ao9 


^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 
U 


210 


TREATMENT  OF  D!SB!A3133  O**  THE  THHtVOCS  8T8TBM. 


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 
mstituttid. 

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- 


THB  TBSATUENT  OF  CBSEBIUL  APOFIiEXV. 


2U 


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 


%12 


TKEATMKNT  OF  T>I3RAdsa  OF  TUB  NERVOUfl  fiTSTEK- 


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 


THB  TREATH&NT  OF  CEREBRAL  APOPLSXT.  213 

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. 


CHAPTER  Vll, 


THE  TRK&TUENT  OF  APHASIA.. 


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^ 


THK  TRKATMBNT  Or  APHAfilA 


SIS 


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' 
uu., 
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 


TTlEATVBirr  07  DISEASES  OF  THQ  NEBT0U3  8T9TSM. 


HOTOK 


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 
luotdou. 

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 
eniailmpnt. 

'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 


Auditory, 


r«anf. 


Total 

OH  CariiitiiNi> 
AniAHIA, 


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- 


THE    TREATMENT   OP    APHASIA. 


21T 


^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 

blocd. 

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 
njnjpUmiH, 

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 
known, 

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 


THE  TREATMENT  OF  APHASIA, 


ai» 


■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 

PPtaervod, 

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 


320 


TREATMENT  OF  DIBEAS&Q  OF  THB  KBRVOU8  SYSTEM, 


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 
speech. 

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 
dictation. 

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 


THE  TREATMENT   OF  APHASIA. 


sai 


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 


222 


TRKATa[ENT  OT  DISEASES   OP  THE  NKRVOCS  8T9TKM. 


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 


Tax  TBSATMENT  OF  APHASIA. 


SS3 


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- 


TREATMBNT  OF  DlflSASBS  OP  THK  XHRVOrB  BV&TEV- 

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' 
sphere. 

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 


THE  TBEAXUEXT  OF  A?BAS1A. 


226 


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 
15 


TREAXUEIfT  OT  ]>I8KABE!^  OI>*  TQB  ffEKVOtJS  SYfi7KM. 


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 
type. 

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 
gyrus. 

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. 


CHAPTER  Vm. 


THE  TREATMENT  OF  TABES, 


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 


228 


TREArMKyT  OF  msnAeES  OP  THE  NERVOUS  ST8TEM, 


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 


H  TBB  TREATMENT  OF  TABBti,  399 

^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 


328 


i  ySavOUS  SYSTHM. 


femalos,  '•' 
private  i 

in  the  <  ':■ 

sensory  ii 

sequeiil  \\ 

and  exWs! 

fatigue,  y- 

ing  l\v  *■! 

Bider*'!  ■ 

Dudieni," 

rarely,  il 

French  .- 

impiirtijT. 

tors  in  : ' 

diathesi: , 

Graasci 

of  wid< 

only  ill  ■ 

organs  ' 

apply  ^ 

they  <li' 

preseni 

fouiuhi:- 

in  a  ft" 

pathir  < 

weariir 

ing  ^s\. 

or  perJi 

oftenrr 

them  K 

oc<iii]»:ir 

who  !;:■ 

camp 
erati'  i 

sol*>  v-y 
hausts 
precii>i 
Tl,- 
in  alii.' 
but  H- 
const  It 
aoler<".'' 
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- 


.0-'-*^ 


^.^i*:^**" 


'.howiforuiT  athetoid.  and  tremulous, 


...^^ 


^  ^^  f-^re  motor  acconnianiments 


THB  TREATMENT  OF  TABES. 


SSI 


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\- 
■■■^s'-olo'-ifal^'ondttiiin,-'. 


•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 


234 


TREATMENT   OP  DISEASES  OF  THE  NERVOUS  BYflTEM. 


Bpaken  of  hj  some  writers  of  perm:adiiig  patients  to  onntinue  the  hypo- 
dermatic iiiedicatiun  beciiiae  of  the  paia  which  it*  ia  aa.id  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, 


THK  TREATMinrr  OF  TABBS.  255 

<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 


236 


TRBATMKTJT  OF  DISEASES  OF  THE  WERX"OUa  SYaTEM. 


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- 


i 


THE  TRHATUXNT  OF  TABKB. 


2X7 


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. 
lOgni, 


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 


238 


TRBATKHNT  OF  DTBflABBS  OP  THS 


EVOU«  9TS' 


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 


TUB  TREATUGNT  OF  TABES, 


239 


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.  Ma.uy  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 


240 


TREATMENT    OF    DISEABKS    OIT  THR    NKRVOUS    SYSTEM. 


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- 
16 


242 


TRKATUKNT  OlT  DIftKAflEB  OF  THB  KERVOUB  SY9TB1I, 


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> 


TBBATMBNT  OF  XABBS. 


343 


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, 


244 


TRF-ATilENT  OB*  BISEASE3  OF  THE  KTIRVOUS  8Y3TEM. 


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 


THE  TBKATMBVT  OF  TABK8- 


245 


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 


246 


TREATMENT  OF  D]SKA,eS9  OT  THK  HaeVOTTS  flT8T«3*. 


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 


THE   TRKATMEXT    OF   TABES, 


247 


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 


Pia,SL 


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 


1 


248 


TRBATMENT  Or  DISCASBS  OF  THB  KBftVOUS  STSTR&r. 


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 
aymptoms. 

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 


THE   TRKATME-VT    OF   TABKS, 


249 


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 


860 


TKSATMKNT  OF  DISBABE8  OF  THE   NKTlVora  ST8TKM. 


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. 


CHAPTER  IX. 

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 


THE  TRKATMBNT  OF"  THE  HEHEDITAttY  ATAXIAS, 


S5S 


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- 


254  TRBATMBNT  OF  DlfllASBB  OF  THB  NEEVOD8  ST8TBU. 

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' 


THE   TREATUENT  OF  THE   HERBDITAnY   ATAXIAS, 


255 


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. 


CHAPTER  X. 

THE   TREATMENT  OP   SYRINGOMYELIA. 

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 


THE  TSEATMBNT  OF  SYRINGOUTBLtA. 


257 


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- 
17 


258 


IBSATMENT  OF  DISEASES  OF  THE  NBRVODS  SYSTEM. 


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 


THE  TB&ATH£KT  OF  STRINQOMTELIA. 


269 


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 
eid«aU, 


j"_ 


CHAPTER  XL 

T[fE  TREATMENT   OP   ACUTE  MTKLIT!S. 


Thb 


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 


THB  TRBAIHSNT  07  ACCTS  UTKUTIS. 


aei 


«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 


9ti2 


TRKATBAENT  OF  DISEASES  OF  THE 


ITEU 


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- 


THE  TRZATliEyT  OF   ACUTE  MTEUTIB. 


263 


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- 


264 


TRKATJ1£NT   OF  DlSl£A8ES  OF  THE   NBBVOC&  ftTSTBU. 


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- 
sores- 
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 


THR  TEOATMENT  OP  AOTTTE   UTZLITIS. 


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 


sen 


TBKATMEKT  OF*  DTftBAflEa  OF  THB  NKRVOUe   ST6TXH. 


b 


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 


THH  TRSATUBKT  OP  ACVTE   UV&LIT18. 


267 


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- 


i 


268  TBKATICBNT  OF  D18BASE3  OF  TBB  KRRVOUS  BTBTKH. 

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 
oonfldenoe. 

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. 


CHAPTER  XII. 

THE   TREATMENT    OP   COMPKESSION   MYELITIS. 

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 


^1  TEJLATMKNT  OP  DISKASSS  OF  THE  NEBVOUS  fiTBTEU. 

<[«^^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 


THE  TKKATlflKNT  OF  COHPRBSSIOH  HTBUTia  971 

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 
pain- 

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«- 


TKKATUENT    O^    DiaSASHlB    OF   THf 

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^^ 


THK  TRBATHBNT  OF  COHPB&SSION  UTfiLlTlS.  273 

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, 
18 


CHAPTER  Xm. 

THE  THEATMENT  OF  CHRONIC  MYELITIS. 

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 


TOE  TR&ATMBNT  OF  CHRONir  MTBL1TI£. 


275 


|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. 


iTi  rTSJkTliCXT  C-F  PISE^SES  OF  THB  KEBVOCB  fiTflTEU. 

$^msta:i.tr  ^  %»  ^  ^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  THflATHBNT  OF  CHRONIC  HYSLIT1B.  277 

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 
angpmm  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 
stages- 


CHAPTER  XIV, 

TKE  TREATMENT  OF  INPLAMMATION  OF  THE  CENTRAL  QRAT 
MATTSK  (POLIOMYELITIS  AI*D  POLIOKNCKPHAUTIS  Stl'EKIOR 
AND   INFERIOR) - 


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- 


kLiIOEVCEPIlALlTlS.       279 

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,  Jilimi.st  <'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 


TREATMENT  OP  P0L10MTBLITI9  AND  POLIOa^CEPBALmii.       *i81 


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. 


TREATMENT  OK  DISEASES  OT  TTTE  NKRTOra  SYSTKW. 


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- 


TREATMKXT    OF    POLIOM YKLITIS    AND    POUORN CEPHALITIS.        28^ 


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" 


TBBATMENT  OF  POLIOUVBUTIS  AND  POLIOfiNCBPHALfTlB.       266 

Isolated  by  the  feelings  of  the  patient  and  th«  apparent  efFect  that  it 
produoea. 

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;<> 


TRE\TMBPfT  OP"  POLIOMYBLITIS   AND   FOL-IOENCEPRALITIS.       2b7 


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 


288  TRSATMKNT   OF  1>1SEA9BB  OF  THE  HERVQCS  fiT8TfiU. 

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 
tendon, 

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. 


(2)    BULBAB   PtjLlOKVKLITlll.       AoUTB    BULBAB    HtBLITI^* 


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 


I 


TIOATIIKNT  OF  POLIOKYELITIS  A.!J1>  POUOSMCBPHALlTIS,       2«9 

>;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- 
19, 


290 


TREATMENT   OF  7>I 


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. 


TBMJLTMWrr  OF  POLIOHTEUTIS  AND  POLIORNCBPHA.Lrna.       291 


(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 
polioenoepbalitis. 


CHAPTER  XV, 


IE  TREATMENT  OF  THE   PHOGKKSSIVK   MtlBCrLAR  At^i 
OF  CENTRAL   ORIGIN, 


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 


TRKATHENT   GIT  THB    PROORESSE VK    MUSCL'LAH    ATKOPHtKS.        293 


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, 


394 


TREATMENT  OF   DISEASES   OF  TTIE   NERVOUS   BTfiTEU. 


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 


TB£ATkifiNT  UF  TUB  FSOOBBSdIVB  UVSCULaR  ATAOPHi£d.       395 


^%|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. 


i&il  TREATMENT  OF  DISEASES  OP  THE  NERVOUS  SYSTBH. 

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- 


« 
T^BaTUBNT  of  THB  PROORE8SIVK  MUSCrLAB  ATROPHIES.       297 

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 


I 


998 


TKKATMEXT  UK   DISRA4ES  OP  THE   N'KKVQUB  BVBTEH. 


J 


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 


^iple 


TaEATMBOT  OP  THE  PROCREt*SR''E  MUaCXXAR  ATBOPHIEB. 


I 


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. 


300 


THRATMENT  OW  DE8KASE»  OT  THK   NURVOUS  SYBTKH. 


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 


m      TSEaTMENT  of  the   FBOGRESSIYB  MUBCtLAR  ATROPHIES,       301 

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. 


ASTHBKIO     BuLaAa    FxaALTSlH. 


i 


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 


rBfcATHEST  OF  THE  PROCTRESarVE    MU^CTLAK  ATROFHlK*5-       303 


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 
0  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. 


TREATWEKT  OF  DlfiEASK^  OF"  THE  NHRVOUa   STGTEU- 

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 
period, 

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- 


TKEATHENT  OP  TEIS  PROGRB&SIVB  MUSCULAR  ATRQPaiRS.      305 

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 
amdoned. 

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 

■xclnsion. 

The  rongenital  variety  is  invariably  osaooiated  with  lack  of  develop- 
ment and  funt^tional  incapacity  o£  the  facial  nerve.     This  form  of  the 
20 


300  TREATMENT    OK    I>1T{KA&KS    OV   THR    NRRVOUfi    SYSTKU. 

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- 


TUKNT  OP  THE  PROORESSIVB  MCSCULAE  ATROPHIES.      307 


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 


30S 


TBBA.TUBNT  07  DISKASES  07  THE  VBBTOUB  flTSTEM. 


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. 


TilB   TnEATMB^TT    OB'   NKTKAL    PBOGRBSHIW    MUSCtTLAB   ATKOPHY- 

{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 


TBEATMEST  OF  THE  PKOOKESSIVE  MCSCTUAK  ATBOPHIBa. 


;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  diaes.se,  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. 


CHAPTER  XV J, 

THE  TREATMENT  OP  MUBOVLAR  UYSTROPHY. 

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. 


THE  TREATMENT  OP  MUBCULAR  DYSTHOPHY. 


311 


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- 
sideroaia. 

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 : 


1)12  TSKATUSNT  QY  DI9EASB3   OF  THS  NKfiTUUS  SYSTEM. 


iiTi*n'flP>iJ- 


Parl  n  rat  al^.  Lt^jB  (calve*) 

DJoLributinn   of^  Cslvca,  nttsly  thighn. 


DiBLTltiiilLon 


of 


TJitghn,    ctf^tp  initsclfw 

aiid  nCBpuLiir  iiiiiV' 
cli^,  CalveA  during 
Jater  poriod  ,  \l  th^v 
ilm«  aIbo  niDueritl 
fltrnpUy- 
¥iui&.  loraAmi,  nnd 
liHlirl- 


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. 
Xuim, 


Bboukkr 


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* 


THB  TREATMEITT  O^  KCSCULAR   DYSTHOPRY. 


813 


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 
tTCfitnient. 

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 


^ 


314 


TREATMENT  OF  DISBAaBS  OP  THK  NEBVOCa  6T8TBU. 


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 
Contrftchire. 

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 
ditteaaei 


CHAPTER  XVIL 

THE    TREATMENT    OP  MYOTONIA   CONGENITA    (THOMgEN'6 

DISEASE) - 

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. 


316 


TiCKATHKNT    OV    1)IHEA.HKS    OF    TUK    NiCKVOUa    SYfiTKH. 


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. 


CHAPTER  XVIIL 

THE  TREATMENT  OP  TETAMTJa 

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 
MTcring. 

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- 


31S 


TRKATUENT    OF    BISKAflKS    OK   THB    N^RVOCS    8TSTKH. 


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- 
tioti- 

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 


THE  TBEATMBNT  01^  TBTAJTUS. 


S19 


■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- 


320 


TREATMENT  OF  DISEASES  OF  THE  NERVOUS   SYSTEM. 


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 


THE  TREATMENT  OF   TBTAKVS, 


321 


«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. 

21 


CHAPTER  XIX. 

TriE  T[IEATMENT  OP  TBTAKT. 

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- 
tion. 

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 


THE   TREATUKVT    O*"   TkTAXT 


m 


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. 


J 


324 


TREATMENT   OF   DISBASBS   OP  THE  NKRVOUS  SYSTEM. 


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 
symptoniB. 

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. 


CHAPTER  XX 

THE  TREATMENT  OP  MULTIPLE   NEURITIS. 

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 


32G 


TREATMENT  OF  DISEASES  UF  THE  KKRVOUfl  BY3TEM> 


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 


THE  TREATMENT  OF  MULTIPLE  NEralTIS. 


327 


(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 


I 


338  THKATMENT  OP  maBASKS  OF  THE  NBttVOCS  flYflTEM. 

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 
condition. 

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- 


"M 


THK  TREATMENT  OP  MrLTIPLE  NKURITIB, 


329 


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- 
lioa. 

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- 


830 


TREATMBUT  OF  DTSEASBB  OF  THB  NERVOCS  SYSTEH. 


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 


THE  TREATUEXT  OF  MULTIPLB  »EUJUT15. 


m 


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 


33Q 


THEATMBNT  OF  D13BASEB  OF  THB  NttHVOUS  SYSTSH, 


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, 


THE  TREATUEXT  OP  HULTIPLB  NEntlTIS. 


333 


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^eg,  repeated  three  or  four 

tJBiBB  daj3yi  and  if  no  beneficial  effects  are  manifest  after  a  few  days  its 

ii«  entirely  sto[iT'ed- 

Failure  of  the  inspiratory  power  is  to  be  treated  iu  c^uite  the  Bama 
w«r  aa  vhen  it  arises  from  any  other  condition.  That  is,  a&  endea- 
Tor  flbould  be  mad©  by  flagellating  the  skin  op  by  the  application  of 
aftrong  faradlc  current,  to  incite  the  iuspiratory  centre  iu  the  oblongata 
10  more  powerful  and  reuHwed  effort;  while  some  benef  cial  effects  may 
be  obtained  from  the  inhalation  of  oxygen.  Altlirmgh  physiology  teaches 
that  the  amount  of  oxygeo  breathed  stauds  iu  no  relationship  to  thequau- 
ti^  which  the  blood  will  take  Lip,  nevertheless  the  patient  often  gets 
relief  from  the  use  of  such  inhalations.  The  respiratory  movements  may 
ilsc  be  aided  by  any  of  the  mechanir^al  lueans  which  are  used  for  the  fa* 
cilitatioD  of  a?cpansiou  aud  cuiitraction  of  tlie  che^^t.  iTLJectiinis  of  strych- 
nine ahoold  likewise  be  given  up  to  the  point  of  alight  manife&Utions  of 
its  physioloeical  effect.  It  is  frequently  necessary  when  there  is  paraly- 
(it  of  the  fauces,  aiteh  as  often  attends  diphtheritic  multiple  neuritis, 
that  the  greatest  care  )>e  exerrised  that  particles  of  food  do  not  find  their 
way  into  the  respiratory  passages,  thus  leading  to  a  form  of  pneumonia 
which  is  almost  invariably  fatal.  A  tendency  to  such  oi'ciipreucB  is  her- 
alded by  prolonged,  spasmodic  attacks  of  coughing  which  tbe  patient  has 
after  swallowing  liquid  or  solid  food,  especially  the  former,  Althongh 
itia  aduisab)e  to  d^lay  the  resort  to  the  feeding-tube  aa  long  as  possible,  no 
heiitation  should  be  had  in  u^ing  it  when  the  indications  are  sufficient  to 
demand  it.  It  is  well  to  bear  in  mind  that  its  introduction  under  such 
rircumstATLces  i^  rather  diBerent  from  that  under  nomidt  coudltions. 
Ordinarily  the  glottiavery  promptly  closea  the  entrance  to  the  respiratory 
tract  when  the  guiding  finger  of  tbe  surgeon's  hand  is  passed  into  the 


^ 


334 


TREATMENT  OT  DISEASES  OT  THE  NERVOUS  BTSTEK. 


phnrTngeEnl  region  to  direct  tbe  ontt^ririg  tube,  but  in  diphtheria  tbeae 
parts  are  parBlyzeil  and  llie  tube  may  reaiiilj  filter  tbs  laryni.  Not  that 
the  tube  wtJl  bo  p^aaed  into  the  respiratory  traot.  bub  tbe  elTorte  of  guid- 
ing it  iuto  tbe  gullet  luay  be  provocative  of  eihauating  abt&oks  of  cough- 
ing  whiotk  may  load  to  profouriiJ  and  fatal  ayticope. 

General  Restorative  Treatment— Mter  having  thua  paseed  in  review 
the  Byiiiiil«nmUo  trefttnieut  of  multi|de  neuritis,  the  general  leetorativc 
treatment  remains  to  be  considered.  The  lueaaures  Ch&b  are  uaefui  fci 
this  purpDee  do  not  difi'er  materially  from  those  enumerated  and  dif- 
ciisfied  in  the  chapter  ou  af*ule  poUomydilifl.  The  objecta  are  to  daUf 
and  prevent  trophic  nhanges,  to  facilitate  restitution  of  the  diseased 
uvrveA,  and  to  prevent  deformity.  Ati  important  question  to  decide  in 
every  inatance  is,  When  ahuuld  such  treatmeut  hu  began?  It  is  impos* 
sible  to  answer  tbie  queatiou  in  a  way  that  will  be  applicable  to  eretj 
case.  31  dependa  very  largely  upon  the  nature  and  inlenaityuf  the  in- 
flammatioOr  and  to  &  lesser  eKtent  upon  the  fKLtient^^  ntorale  and  reaiat- 
anoe.  Aa  a  general  mle^  however,  it  may  l>e  sfliri  that  a*  soon  ai  the 
affected  extremity  or  parts  jnay  be  handled  carefully  without  cauaing 
the  patient  oouaiderablo  pain,  tbe  application  of  electricity  should  be 
bi<gun.  Aa  iu  the  flaccid  paralysis  resulting  from  anterior  poliomyc* 
litie,  tbe  galvanic  eurrent,  applied  in  th&  labile  fnahicn,  should  be 
utilized  atlirat;  while  after  the  tnllamniation  has  further  siibaided|  at- 
tempts should  be  maiia  to  get  contniutton  of  tbe  rmacla  directly  or  indi- 
rectly through  the  nerve  ly  means  of  whichever  current,  famdio  or 
galvanic,  to  which  the  parta  aro  most  reaponaive.  The  electrical  treat- 
ment sbould  be  ^iven  iu  abort  a^ajtccsf  twice  a  day  if  possible,  and  kept 
up  for  a  long  time,  or  imtJl  th©  parts  are  ao  restored  to  health  that  the 
patient  v^n  give  them  the  necessaiy  exercise  by  voluntary  mcivemenla. 
The  mistake  ia  frequently  made  of  causing  an  atrophied  muscle  to  eon- 
tract  too  often  by  the  use  of  the  current  to  which  it  is  r#apoTiaive.  Three 
or  four  oontractLonft,  produced  twice  daily,  are  far  more  serviceable  for 
thia  purpose  than  several  times  that  nurnher,  given  with  the  idea  of 
forcing  tbe  recdvery.  Light  friction  to  tlie  skin  and  very  gpntle  mas- 
sage may  he  inatituted  coiucidenl^ly  with  tlie  electrical  treatmeut  for 
Hm  purposes  of  improving  the  circulation  and  the  nutriUou  of  the  para- 
lyzed parts.  As  the  inflammation  in  the  nerves  aubaides,  the  severity  of 
the  niasaage  may  he  lienefioifllly  inereaand.  It  is  a  powerful  ageooy  for 
good  in  the  prevention  of  deforming  eontraccuraa.  It  is  by  no  means 
neccjtaary  to  have  a  prufeaaional  operator  for  its  application,  for  ita  bene- 
ficial efTctts  are  dependent  entirely  upon  simple  rubbing  and  manipula- 
tion, whioh  may  as  well  be  done  by  a  nurae  or  by  one  of  thd  family  who 
gives  the  time  to  it. 

The  most  important  medicine  lo  facilitate  tha  restitution  of  the  pan- 
lyzed  parts  ia  unquestionably  strychnine.      Ita  administration,  preferably 


TUB    TREATURKT    OF   ML'LTIFLK    NRfRtTlS. 


33S 


•obcatAAeously,  should  be  begun  aa  aoon  as  the  aouleueas  of  the  iuflaiu- 

■uoty  process  hxA  aubaid^d,  ainl  k^pt  up  for  several  mijuthe,  with  occa* 

iktial  inLeE-ml^ions,  rluHug  which  time  other  tonic  administi'utioiimay  be 

sabstitated.     It  U  ad^able  to  hegia  with  a  da^e  of  from  one-on^-huu- 

dndih  to  ODP'sixtiethr  and  the  quaubilj  is  gradually  inoreased  uutil  the 

pfttust  b  takmg  from  oae-twelfth  to  one-aixth  of  a  graiu  iu  tn^saty-four 

\onir%.     The  latter  qaa&tity  can  often  tie  given  without  aay  perceptible 

toxic  6fFecU^     The  cauaative  agencies  of  alcoholio  multiple  neuritia  act 

ppTiuciuusl;  upon  the  hluud  and  upon  tha  blot^d-elabotstrng  organs,  and 

il  U  therefore  expedient  to  look  to  the  restoration  of  these  tisEuea.      Pif- 

fe*Dt  cases  caJl  for  different  treatment  iti  thia  tespect,  but  as  a  rule  it 

Biy  be  s^d  that  small  doses  of  iodide  of  fKrtaesiuTn,  the  dilute  niinetal 

acidi  if  th^re  are  no  pointed  eonlraiu dilations  to  their  use,  aiid  some  ab- 

sorbabte  preparation  of  iron,  are  always  in  order      If  refri^ration,  the 

tbeumal^ic  diathesis,  or  auboLutoxication  eeeiu8  to  play  a  part  in  the  eti- 

lAitgjt  the  aalta  of  salicylic  acid,  such  aa  those  of  sodium  and  potasaium, 

Aould  be  administered. 

1q  another  coim&ctioii,  attention  ha^  been  drawn  to  the  fact  that  many 
cwpe  of  multiple  neuritia  terminate  fatally  from  Hu|H-ra(]ded  tubercoloua 
iofrction.  The  infection  of  tuberculosis  is  one  of  the  least  virulent,  and 
labcrcle  bacilli  never  secure  a.  foothold  except  in  Btates  of  profound  de- 
pravity of  QUtrititiu,  either  local  or  general.  If  thcro  wore  no  other  indi- 
cationa  than  this  in  the  treati^ieiit  of  multiple  neui-itia  to  increase  the  pa- 
txot'a  nutritioDf  we  might  still  justi^bly  speak  of  the  necessity  of  moBt 
Fsrefu]  attention  to  tho  patient's  diet  and  his  absorptive  and  eliminative 
jTsbems.  But  considering  ttiat  tlie  degree  and  rapidity  of  his  recovery 
Etand  in  direct  relationship  to  the  nutritional  state  of  tlto  blood,  the  iu- 
didttiona  for  such  treatment  are  still  more  pointed.  Genernl  admonition 
nmcftmiug  diet  is  never  sufficient  in  aay  ease  of  acute  nervous  disease, 
iny  more  than  it  Is  in  typhoid  fever.  The  patient  uiu^t  hiive  ti,  dietary, 
every  detail  of  wbich  haa  been  scrutinized  by  the  physician.  Not  that 
therft  are  particular  articles  of  diet  that  injure,  except  as  they  teplace 
tboae  that  might  be  very  helpful.  Foods  that  have  been  shown  empiri- 
cally to  be  rich  iu  tissue  coostructivea,  such  as  milkj  yolk  of  egg,  cereals, 
fiah,  and  the  ieguminuuB  vegetables,  in  combination  with  easily  digested 
taiSt  should  lie  the  mainstay  of  the  dietary.  As  a  general  rule,  all  alco' 
Wia  drioks,  even  though  when  taken  in  small  quantities  they  facilitate 
tissue  coustTuction,  oro  to  be  avoided.  But  to  this  rule  there  are  many 
flxoeptioDS^  Tor  initance,  in  the  post-infectious  polyncuritideSj  tliere 
ean  be  no  doubt  that  small  quantitli^s  of  Burgundy  or  claret,  sherry  with 
yolk  of  egg}  and  in  some  cases  even  the  malt  liquors,  may  l>e  taken  for  a 
short  time  with  very  beneficial  e^ect. 

After  the  patient  has  made  such  progress  toward  recovery  that  it 
»e«m9  advisable  to  allow  him  to  indulge  in  voluntary  movement,  a  plan  of 


536  TBEATMEKT  OF  I>IREAS^  OF  THB  NBRVOUS  SYBTBU. 

re-etlncaticn  of  Ibe  muacie  sense  ami  of  cn-crdmation  of  ^urpoaefuL  uioi 
ments  ahouM  bo  iuutituted.      No  more  useful  plancau  le  fonuuUteil  U 
the  GiTnpJa  ii^ovementa  deacribefl  in  tLe  chapter  on  locomotor  atu^iji 
lecoiuraanded  by  Fraenkcl.      Orteutii^iea  it  is  Qot  Qeoeasary  to  utilize 
jQore  (ft^m  plicate  J  ones.      If  the  patient  is  a  woman,  thd  exercUi^Ei  fur 
Lands  may  be  Biibatituted  Liy  eudtravora  at  bucIl  hamliwork  aa  kuiuii 
fiewiog,  crocheting,  aiid  the  like,  or  the  practiMug  of  muairftl  cxerci: 
The  relicts  of  an  attack  of  acute   uiultiple  uouritid  are  uftrntiinej^ 
tcemel^  t&rdy  in  their  disappearance,  nnd  much  may  be  done  to  exp«dii« 
their  departure  by  the  eontiniianre  of  tiu.^se  evt^rdseH. 

This  rhapter  would  Iw  im;t>niplHt«  without  reference  to  the  neoessitj 
of  treatment  direttt^d  immediately  to  the  patient's  mental  sphere,  or  wh^l 
may  perhajiB  bo  called  ilm  vtortiln.  Two  factDrs,  poaaibly  mure,  aaaiat  iu 
making  a  profound  imp r-(>B(»ioQ  i]]>on  the  jiatieut^a  t'onscionanew.  Tbt^se 
are,  in  the  first  place,  the  »gcn<?iea  that  are  dire(»Uy  tfgpiinsible  tar  the 
polyneuritia  ac^t  iiijuiiinialy  upon  the  celljj  of  the  brain  corCex>  uid 
eecoudly,  that  the  piult>uged  enffering  which  the  patient  eifjerienccs 
leaves  memorie^s  of  pain  aud  impotence  that  are  dilticult  toer&dic&tc.  Ir 
JLdditiou,  the  pfttient  has  become  act'UHtomed  to  certain  phyaical  short- 
comings  and  enforced  conditions,  und  no  voluntary  ofFort  is  inude  to  over- 
come  them.  The  wise  and  ex|>eripikc«d  phys^irian  will  take  all  tliese 
into  con  a  i  deration,  giving  them  greater  or  JeaHcr  pioaiinetice  aci'ording 
to  the  psychical  disposition  of  tbe  patient,  and  be  guided  accordmi^ly^ 
lu  many  instiinces  no  other  therapy  is  reftnired  to  overfrimo  such  ttam- 
fcetations  cf  the  induence  of  mind  qvpf  matter  than  tbe  assurance  of 
the  physieian,  coupled  with  inaistcnco  or  command.  On  lh«  othor  hand, 
the  eutira  paraphernalia  uf  mental  therapeutics  must  he  lirouj^ht  to  bcAr 
upon  the  patient,  m  order  to  restore  a  pru|ier  equilibrium  of  the  quaJilini 
of  conaoiouaneaa*  In  brief,  it  may  be  asid  that  the  keynote  of  the  physi- 
cian's relationship  to  his  patient  should  be  loth  iiiBpiring  aud  inspiriting. 

Despite  tbe  greatest  ears  in  ket^piug  the  patient^a  iiuiba  in  the  proper 
position  during  the  inflammatory  part  of  the  disease,  and  tbe  utiliaation 
of  measures  to  preveut  contractures  and  fixatioua  of  the  jointa  during 
the  later  stages,  botli  by  uiasaage  aud  orthopo^dio  appliances,  deformity 
neverthelesa  eometimas  renults.  To  overcomo  these  deformitiea,  the  aid 
Af  the  aitrgeon  should  be  obtained.  The  patient  should  be  fvjJly  amvstb*' 
tized,  and  the  enntraoturcfi  broken  itji,  tbu  aiikylosea  liberat^d^  and  the 
defoi-mitiea  overcome.  Multiple  tenotomies  may  be  necessary  in  order  to 
accomplish  thia  end-  The  after-treatiuent,  after  the  case  has  ceased  ti- 
be  a  surgical  one,  ronflists  of  the  instnihition  cf  that  plan  of  tieatmeot^ 
already  detailed  to  prevent  the  occurrenoe  of  defotmitiea. 


CHAPTER  XXL 


tTHE  TREATME:(T  of  paralysis  op  the  facial  NBRVE-BELL-a 

PAI-SY- 

Pajultsih  of  tlie  fft*^ial  nerve  is  cue  of  thft  commoneflt  forma  of  in- 
diTidual  noTTis  palsj-  Its  c&uaatious  axe  m&Difold.  The  lesioa  upon 
vLkh  paralysis  of  the  muscles  supplied  by  the  ^erenth  nerve  ia  depend- 
ttt  tDAj  ba  in  the  nuoleuB  of  the  seventh  nerve,  in  its  intraoianial  coarse, 
tt  the  iatepiial  auditory  meatus,  in  the  Fallopiau  canal,  or  of  il3  trunk 
nd  bt^nches  after  the  e^it  of  the  nerve  frum  the  Btylo-mastoid  foi'amen. 
LatioQ  cf  the  facial  nprve  nucleiis  ici  tUe  puiis  raiines  jmralysih  known  as 
tuclear  facial  palsjt  while  if  the  leaioit  ia  central  to  the  nucleus  the 
jtralyats  is  called  supramiolear.  When  the  lesion  is  peripheral  to  the 
pCQB  it  ia  knouTTY  as  utfranuclear  paralysis  ar  BeJl'a  palsy.  There  is  a 
BDUgenitalnuelear  de^neration of  the  facial  and  ot^ulcttnoUir  nerved  which 
ouisea  paralyma  in  the  muscle  supply  of  these  two  nervee  which  will  Dot 
b  nxsidereil^ 

Uolo^  of  Facial  Faralysia. — Paralysis  of  the  facial  nerve  dependent 
vpoa  disease  cf  the  nucleus  is  extremely  rare  eompared  with  iiifraunolear 
fValysifi-  It  is  caused  by  inflammatory  and  degenerative  proceEses 
■riihin  the  pons,  and  especially  those  which  are  in  relationship  to  dU- 
and  blood -Tfosels.  Facial  paralysis  due  to  injury  of  the  iuCrxeruiial 
put  of  the  nerve  trunk  is  commonly  dependent  upon  hasilar  mBcingitis, 
ramora  in  the  posterior  fossa,  aneurism  of  the  liasilar  arteries,  tiauuLa 
irtu«h  injiirefl  the  base  of  thft  shull,  and  diseases  of  the  l>ones  over  aud 
dinagh  which  the  nerve  passes.  Facial  palsy  caused  by  injury  of  the 
urveatthe  internal  audilDry  meatus  and  in  the  Fallopian  c^nal  is  usually 
A^eikdeat  upon  disease  of  the  internal  aud  middle  ear,  disease  of  the 
prtnma  portion  of  the  temporal  bone,  or  fracture  of  the  middle  fossa  of 
the  akull.  The  commonest  caoses  of  facial  paralysis,  dependent  opon 
infiaianution  or  perineural  exudation  of  the  facial  nerve  after  its  exit 
tram  the  atylQ-mastoid^foramfti^  are  local  refrigeration,  eiEjiOhure  to  4:okl 
diaughU  which  impinge  upon  the  trunk  of  the  nerve  at  ita  exit  from  the 
skull,  and  exposiiro  to  general  coM^  Cold  alone  is  sufficient  to  produce 
mflunmaUoD  in  the  nerve,  but  usually  there  are  some  predispoeiug  factora. 
These  may  be  arimmarized  under  the  caption  of  depreciaiors  of  vitality. 
Thus  it  occurs  in  those  whtj  have  rerifntly  gone  through  some  infectious 
diKase,  in  Lhoae  who  are  liable  to  outbreaks  of  rheurnatio  manifestation  a, 
ia  tboBB  who  h.^vQ  conatitational  diseas&s,  euch  as  diabetea,  leukitmia, 
22 


3S8 


TKKATtfKNT    OF    DISEASES    OF    THBl    NERVOUa    BTSTEM- 


aiid  uucmiiiT  Euid  in  tboae  whofle  eysUms  have  beec  intoideated  by  alcohol] 
lead,  and  arBem<'.     Its  ootiurrence  with  inuuipa  iu  cliildreD  h&A  often  beea 
DotfHi,     Peripheral  fadjil  pamlj'^ia  is  occasionally  the  reault  of  traunm. 
Thia  trauma,  ins. J  be  from  tlie  furcapH  dviriiig  duUvery^  or  later  in  life  it  ml/ 
Iti  froinabiow,  a  fall,  or  compre^GioQ,    Facial  paralysis  occurs  from  iiijaTj 
to  tlie  trunk  of  tho  nerve  wLioh  caasM  a  atsverance  of  its  continuity  acci- 
dentally or  doTLug  an  operctton.     Occasiooally  it  has  been  observed  after 
e^Ltraji-tiua  of  a  tootb.     InsucliiLstancefl  it  is  not  unJilcely  th^it  a  pnruleDt 
procesj^  is  at  Ibe  Ixitbom  of  it.      Tbe  diaeaseooiLiiiraofteDer  in  lat«  cbildhood 
aud  early  maturity  tlmn  at  uny  oiber  tJiue  of  lift,  aud  in  mtn  oftener  th&a 
irt  wouien,     Tbo  latter  xa  to  be  explained  by  th«  fact  tbat  lorn  Are  more 
liable  to  exposure  and  to  the  fac^tors  that  bring  about  rheumatic  condi- 
tions, and  also  to  tli«  deleterious  inHuenct-s  of  alcohol  and  tbe  met^lic 
I«iBOEis  with  which  they  may  ccme  in  rontaot  in  their  oeoupationa.      The 
relationship  at  syphilis  to  facial  paralysis  is  occasionally  very  striking. 
Usually  facial  paralysis  of  syphilitic  cauAatJou  is  dependent  upon  iorolve- 
mentof  tho  intracranial  portion  of  the  nerve  by  syphilitic  lesion  of  th9 
meningea,  or  ayphilitie  diaeafle  of  the  blood-vessels.     Oooajsiunally  niicl«ft&* 
Carnal  palsy  occurs  with  m^nifestatioDa  of  cer^bro' spinal  syphilis.     Per 
ipberal  faoial   palsy  may  occur  during  the  Qorid  stage  of  syphili.s  ap 
from  any  evidences  of  focal  syphiUtic  iuH^mmatton.     I  bare  soeu  tw 
caaes  of  this  kind  vithin  a  year.     There  eikn  be  uu  question  that  fac 
paralysis  i&  more  common  in  those  who  are  of  nenrutio  inbentago 
tendency  than  those  who  are  iLOt.     In  fifty  conBeciitive  oaaes  of  facL^d 
paraTysis,  an  inherited  or  a(?qulred  nearotia  predisposition  was  noted         j 
upward  of  fifty  per  cent.  ] 

Bymptoma. — The  symptoms  of  facial  paralysis,  especially  tho  iufrairzj 
clear  variety,  are  quite  unmistakable  when  well  developed.     Thej  t — 
in  dislribitlion  and  in  intensity  with  tbe  part  of  the  nerve  implicated 
the  degree  of  the  inflammatory  process.      When  the  paralysis  is  comp 
the  forehead  of  the  affected  side  is  smooth  and  devoid  of  inoveiiifiut  e 
on  the  gi^atest  eHoit.     The  palijebtal  fissure  is  wide,  and  the  eye  cai^^  a^ 
he  closed  either  alone  or  in  coiijunelion  with  the  otlier  eye,      Lagoplit^^ji/ 
mu9  :e  almost  invariutily  present  if  the  t^mpo to -facial  branch  is  the  ^tat 
of  inflammation.     On  aecoiint  of  iimbility  to  close  the  eye,  the  conjxxi^c- 
tiva  is  exj>osed  to  many  un^cnstomed  irritEUitSr   and  lacrymution   or,^ 
occasionally  profound  iuflaiumalion  of  the  conjuuotiva  and  cornea  reeiilt^^ 
The  naso'labial  furrow  on  the  affected  eide  is  obliterated,  the  cheek  seezca  i 
fiat,  the  nasal  aperture  is  somewhat  enlarged,  and  the  mouth  is  dnw-g^ 
toward  the  unparalyzed  side.      When  the  patient  attempts  to  whisU«  (^am 
to  blow  the  angle  of  tbe  mouth  on  the  affected  aide  remains  depr^ssec::^ 
and  unnlnaed.      When  tbe  cheeks  are  pulTed  oul,  iha  one  of  the  aJTi"ciJ^{tal 
aide  is  lax  and  unresistant.      Food  gets  bet^veeu  the  teeth  and  buccal  nui'''J 
cous  membrane,  and  most  be  dislod^d  with  the  tiugern     If  the  paralybi 


7RKATMBNT  OF  PASALTaiS  OF  THE  FACIAL  NERVE, 


339 


* 


of  the  eervioO" facial  ia  profound  saliva  often  dribbJaa  ftom  the  affected 
comer  of  the  mouth.  The  patient  poinplaina  of  a  feeling  of  stiffness  or 
distenlioD,  espenally  around  ttie  (carotid  iBgioii,  aftd  of^f^asiociHlly  of  pain 
UL  the  region  of  the  upper  hraDches  of  the  cerrical  plexus  aud  tho  tri' 
facial  nerre.  If  the  legion  ia  of  any  parb  of  the  tniok  up  to  the  Jevel  at 
whicii  tha  chorda  tympani  nerve  la  given  off,  which  ia  well  within  tha 
mAitoid  foramen,  there  is  no  distiirhanr^e  of  taste  or  hearing  oi  dlflicalty 
in  elevating  the  palate.  If  the  seat  of  the  legion  id  hejnnd  thia  pointy 
that  19,  iuiplicatiiig  tliat  part  of  thd  tniuk  froju  which  tlie  chorda  tjmpaui 
»  given  offf  there  will  he  diaturbancc  of  the  seuse  of  taate,  eapecially  In 
the  anterior  Wo -thirds  of  the  tongtie  on  the  aide  oorresponding  to  the 
lesion,  and  with  thifl  the  psHent  usually  coitiplaiijs  of  dryness  of  the 
mouth.  If  there  ia  paralysis  of  the  palate,  it  is  legitimate  to  iufer  that 
the  lesion  is  peripherally  to  the  point  at  whirh  the  laigo  supetficial  ^le- 
trosal  nerve  is  given  off.  The  nioet  important  feature  of  nuclear  fecial 
paralysis  ia  the  fact  that  the  muaclea  of  the  nppt?r  face,  that  ia,  the  orhio- 
iilarifi  palpebtamm,  frontalis,  and  the  currugator  supercilii,  escape. 
Moreover,  whereas  in  infranucTear  facial  palsy  the  occarrenoe  of  the  re- 
action of  degeneration  in  the  nerve  and  in  the  muscles  ia  prompt  and 
typicaJ,  in  nuclear  palsy  this  pbenomeuoa  is  delayed  and  atypical.  At 
the  end  of  the  iirat  week  in  peripheral  facial  palsy  there  ia  geuerally  par^ 
tial  or  complete  reaction  of  degcuf? ration  in  the  nerre  and  niusclean  Au 
extremely  important  distinguishing  feature  of  nuclear  facial  palsy  is  ita 
aSBociation  with  ether  symptoms  pointiug  to  disease  of  the  poos.  Bilat- 
eral facial  paraljais  is  rare^  hut  it  may  occur  from  the  causations  men- 
tioned ahovej  iu  asi^rciatiun  with  multiple  neuritis,  aud  as  a  part  of  a 
general  extensive  dystrophy. 

Treatment- — The  tendency  of  peripheral  facial  paralyeia  is  toward 
tpontaneoua  recovery,  hut  many  cases  in  wliich  the  lesion  is  profound  and 
in  which  there  are  conntitntional  conditions  not  easily  overcome  the  result  is 
not  so  gratifying.  In  every  ca.*!©  recovery  may  lie  facilitated  and  enhanced 
by  carefid,  persistent  treatment.  The  first  duly  of  the  physician  is  to 
search  for  the  cause  of  the  palsy  and  to  counteract  its  activity  &nd  exist- 
ence BO  far  ad  possible.  In  the  majority  of  oases  the  immediate  eauae, 
snch  as  cold,  trauma,  and  local  inflammatiou,  has  ceased  to  be  operative, 
but  there  ia  often  eome  underlying  cfmstitutional  condition  which  will 
need  to  be  attended  to,  The  exiatence  of  ajphilis  should  be  closely 
looked  for,  and  if  there  are  any  indications  of  its  presence  active  anti- 
ayphilttic  medication,  particularly  the  use  of  inunctions,  should  bo  begun 
fl.t  once.  Cases  associated  with  refrigeration  aud  with  rheuniatio  condi' 
tiotis  are  suitably  treated  by  local  hot  applications,  such  as  hot-water  bags 
or  fomentatiimitT  particularly  if  the  patient  ia  seen  early.  If  there  is 
some  pail),  and  considerable  tenderness  ov«r  the  course  of  the  iierre,  local 
blood' letting,  by  means  of  either  leeches  or  cups,  is  decidedly  beneGcial- 


:^^  TIIKATVKVT  OF  M5RASK9  OF  THX  NKRTOtlS  glbTMM, 

\i  \>.^  ^v.t^w  -f  ibot  fmi  onul  some  timo  after  the  occnricnce  of  the 
y^rA^^>"CN  ih^  Ai^yl^^'-tHvci  -.^t  A  blister  just  behind  th«  osx  Mid  orer  the 
xvxvii  s't >sv-«pp.'f  th^fftoiAln^rrefrom  the  stjlomaatoid  fotftmcn  is  often- 

•^H-.^4*^-^^.VAt>k   t^^.yCiJLV.V  i:i  thd  CaACS  aSftOOlAted  With  rheiUIiatic  KUli' 

u«tA!x  v:t  VA  *';>.v^r  ^^ns  yi  i^t  body.  Inlemally,  the  patient  ahoold  be 
jCiWH  «':o\  tAtv  v'^^v,^;;r,\  in  from  fifteen-  to  tweoty-ifnuzi  doaes,  ornJxy- 
\4io  *-i  l^'-^*v%  ,ir.^  v\  f^v:'.  thre*-  to  five-gtain  doaes,  either  Alone  or  com- 
;■■.,'^^^  \»i''  *'.'**'i  i''<»  *v„\ph*.>retio».  Such  modication  will  natuU j  cuue 
l*,^>^>  V'^  .v^i; -..^tT-v  >'  s-f  rht"  i^in  and  seoution  of  ■ti&wa  in  thend^of 
tTi^^i'vc-  ^'^^^  ^  H  47-.'^  <^f  the  cotijunctiTft  should  be  kept,  uidthopa- 
t'vii^  .4.U:*«\i  ?v  ■  »-  4"  i^^'^Ashof  A  saturated  solatioa  of  boiic  add  in 
**vw  >^  *tvi  (> .  .  ,-  ^>v  1 -^^o<  r,a;ly.  Ou  the  slightest  iudicstioas  of  ksia- 
(it^i  L>x  »lolo»  .1  .^'v^-*  '**'*■■*  **>^  ^T^  should  be  treated  antiseptinUj, 
tuU  ^vititiu  !-.-  ■  .-r^^v>  '(i-tA'.iHi  with  a  patch  which  may  or  may  not 

\ii^'i  ^iv  l^*■^>^■*  '■<*  T^wlusl  its  completion^  electrica!  tteataMDt 
>k',  M  N*  I.  ^^  i:v-s-  S':-^i  wr^:^r*  profess  to  believe  that  electrieitj 
1^  ,-i  u,-  tv<.i'»  ^u  ^•u^  n-*vi;t"fv;  i^f  facial  paralysis,  but  my  own  ex- 
j*sni.*iuo  ^»  ■■  ius*4*;s\\'-i"'^>  s^Vr'^ '^****  t^^  **^**^  a  Tiow.  It  ia  beneficial,  not 
»MiS  i\\  ^^.*  i>'.  .'■■-*  o*>A  I'  ■!  "^  '^e  tMst>  of  long  standing.  It  should  be 
^Vl'i*'^*  *^-i*x-i.iUuni*,^i,  A\  tl.^t  r*vry  day  snd  then  eveiy  second  day, 
loi  Uvm  u----i  t**vi<St  >*vvV*  wv.>,v.!  interruption,  unless  manifestatious 
xM  ilii^  *tv.K'M«^  Ui^*v>vsi*  Nf,Mv  th'.jt  time.  The  galvanio  current  ia  of 
^itMiev  vi-nvinliuv^s,  *.\***viV.o  ''*  •-''*  Ivjriuning,  than  the  faradic,  largely 
Kv.mio  A  ^Iv^i^v  ot  xuiijV;:  (>  iv*  ih*>  fi^rmer  is  usually  preserved  long 
rthi'v  t.ii,^iUo  inii.il'iUu  tx  v\*i.v-.^*iiM.  Tbo  }x»sitive  pole,  connected  with 
A  Lnj;o  vUvtusU',  ?»lu'ivM  Iv  i"'Axv4  I'u  s^o  T*ht\<t  or  other  indifFerent  area, 
tahiio  thi*  iir*;,ii i\ i\  ivuuivivd  ^iiih  A  ^wMiW  fii^cirode,  should  be  placed 
o>*'r  tlio  \wvM^  U\Ai\.  t\\u\  a  ounvut  of  fiom  tu'o  to  three  milliamperea 
is  hUox^M  111  iKtM,  v.\\\\t\  1^0  sMtluvUl  Y^Ao  is  ^liiW  in  labile  fashicm 
**vi^r  Uw  Uuuk  of  tho  Ui*i\i*  and  iis  l>v^ui;lu*s  for  fr\«u  two  to  five  minutes. 
'\'\i^  limiiitittiou  \*  to  iL^i  ti  >^^\m^^-v  onnout  thau  this  aud  to  prolong  the 
i^vin.-i-^  \".\i  tliiit  dlumld  bo  t\'^i!iio«1.  No  K>no(it  vhatever  is  to  be  ejt- 
piMPili  nor  i.H  the  rujndity  of  r^ivm  in  tlio  uorvo  enhanced  from  the  use 
of  a  oiirront  auHu'iont  to  I'austi  ctiuCr;u4ioii  i>f  ihe  muscles  supplied  by  the 
Atn'inith  uovvo  during  the  first  avih'Ks  of  a  ^^'ripheral  facial  paralysis. 
Neither  shouUl  the  physician  l)e  m  a  hurry  t^j  begin  tho  use  of  the  fa- 
raiHo  rurn-nt.  In  the  first  place,  it  is  not  w>  ngreeahle  to  the  patient  nor 
so  woll  tiitevftt^,  especially  l>y  children,  and  in  the  seoond  place,  experi- 
ence huA  shown  that,  during  the  earlier  part  uf  the  disease,  it  is  by  no 
]nean<»  so  adTantsgecua  as  the  galvanic  curreut.  When  the  mnscles  sup- 
plied by  the  seventh  nerve  begin  to  recover  their  irritability  to  the  gal- 
vanio current,  this  form  of  electricity  may  be  used  every  day  to  throw 
them  into  contractions.     An  important  point  to  remember  in  the  electri- 


T&EATMKST  OF  PARALYSIS  OF  TH£  PACIAL.  NRBTHL  34l 

oU  tifiUmttit  of  tacial  par&jjsia  is  that  no  bene^t  ti«ed  be  oxpectcd  CroEa 
a  mftef  mAoifeat&tions  oE  contf&ctafe  occur  in  the  parsJyxed  sido,  and  thftt 
it  a  idld  to  expeot  suij  reautu  from  the  appticatioDs  of  ele>^tricay  to  th» 
iBpBknljEsd  £ide,  looking  toward  a  counteraction  of  the  coDtracturft.  I 
hare  never  aeeii  .suffit^icuit  benefit  follnw  the  appUration  of  the  ccnlinuoua 
ittUle  galrimic  <iurreiit  wiih  the  auode  over  the  auriculo-mdAtotd  titm  of 
Ibe  affected  side  and  the  cathode  in  the  correapouding  position  on  the 
•KUki  side,  Biich  as  ia  reoommended  by  some  electrotherapeuUstSr  to  var- 
nut  iU  recocamendation, 

Mas9»ge  is  an  intportant  adjnvant  to  eiectricity  in  the  treatment  of 
final  paralysis,  aod  with  the  massage  it  Is  sometimes  adrisabte  lo  eiuploj 
laat  Aunple  orthopedic  apparatus  to  overcome  the  deformity  in  the  angle 
of  the  mouth  on  the  paralyzed  eide.  This  can  eaailj  be  di>ne  b;  having 
ttopstietit  ««ar  a  piece  o£  beat  celluloid  or  hard  rubber  in  the  shape  of 
t  hook,  vhi(*h  Blips  just,  inside  the  angle  of  the  mouth  and  is  attached 
iroond  the  ear  of  tlio  same  side  bj  means  of  a  rubber  baud,  fi>r  a  few 
Horseach  day  or,  better  still,  during  the  uight.  The  angle  of  tlteiuouth 
i»  often  the  only  part  of  the  face  which  patients  with  facial  paralysis  do 
not  recover  complete  contrtil  of,  and  the  use  of  some  siioh  apparatus  has 
seeiuet]  to  me  of  real  servi(;e  in  preventing  this  slight  deforming  relic  of 
the  disease.  There  is  no  particular  method  of  giving  uassage  in  facial 
lanlymthat  isoffiignnl  adyantage.  Light  rubbing  orer  the  course  of 
tba  nerve,  piochiug  and  squeezing  of  the  muscles,  especially  of  the  fore- 
bud  around  the  eye  and  the  naeo-Labial  fold^  are  of  service,  both  in  in- 
ttnaiog  the  biood  supply  of  these  parte  and  in  indirectly  exercising  the 
mnelaa.  When  voluntary  power  begins  to  rehirn  to  the  imis^iles  of  the 
aiFected  side  the  patieut  should  be  urged  to  practiae  moving  the  affected 
fide  while  watching  the  results  in  a  mirroi. 

The  conatitutiouaL  treatment  of  facial  paralysis  ia  sometimea  of  very 

gK^t  importance.     Coae^  that  show  no  teudoLoy  toward  recovery  after 

Ivo  or  three  weeks,  es]te<^ially  under  such  IcHrii!  treiLtEnent  aa  lias  already 

bwD  detailed,  shoulil  again  be  carefully  investigated,  in  oider  to  discover 

if  there  id  any  coasUtutional   dependency  of  the  paralysis.     Many  pa- 

timts  who  develop  paralyeia  of  the  seventh  nerve  are  anaemic,  underfed> 

over-worked  individuals,  whose  recovery  is  very  much  more  enlianced  by 

tlie  administration  of  luedtc-iiial  and  dietary  restoratives,  such  as  iron,  ar- 

MQio,  quinine,  and  an  abundance  of  easily  digested  food,  than  by  lcM!al 

trtabment.     On  the  other  hLind,  overfeeding,  deEcieut  exercise,  and  the 

aceomnlation  within  the  system  of  products  which  are  the  result  of  in- 

Dcnicplete  dig^tive  and  metabolic  changes  may  e^^ercise  such  a  pernic^ious 

soQ^tiea  upon  the  peripheral  nerves  that  the  one  which  has  been  singled 

m  for  disease  cannot  recover  its  natural  coDditinu  until  these  (causes  are 

o^enxime  or  eradicated.      In  such  t^aea  eliminativa  treatment,  not  recon- 

stractive,  is  required.     A  similar  statement  holds  true  for  the  treatment 


M± 


TVCATSKST  OF  DUSA^RS  or  YfiK  ?nCRVOUd  fiY8TSIC. 


«rf  fvnl  pftr^yitt  vhi^  oomn  ftfter  t&e  iaiectiou  dvuu^  exoept  Ih; 
m  UcM  fcnoBctniirtiTe  th^Apy  flhoold  aJwBys  foUow  th«  ulniaistratiot] 
of  gthnfaafliTM,  For  mstanr^  if  the  fickl  pualyns  dtnjopa  in  the  wakf 
ctf  aoj  of  Ifae  iixfecttoufl  diswra^  miall  tlcHei  of  calomel,  foUoired  by 
Mliiiea,  TOtiU  be  edited  fori  ^^  thea  tbe  jatiait  abonJd  be  put  upon  a 
tonic  taedicinal  and  dietetic  pUa  of  tnatmcDt.  Wltoi  th%  diaea&e  occurs 
vith  vQch  coustitutioDAl  conditioas  oa  diabetes  and  rh«um;iti£iUf  the 
trcotmifdt  required,  m  addition  to  th^  local  tr^aUceut  «Jreadir  described, 
li  that  directed  immediately  against  the  existened  of  these  diatheses. 

If  the  palsy  ia  due  LO  trauma,  no  oLher  treatment  save  the  local, 
clectriea],  and  tnechanLcaJ  treatmetiL  already-  detailed  ia  called  for.  ext^ept 
in  those  inabonces  in  vliich  there  is  some  surgical  ixtDditjoLi,  aui:h  aa  troii- 
tuflioD  cr  laceratioD  of  the  soft  parts  which  are  amenable  to  mechanica] 
repair,  or  ia  which  a  scEir  or  splinter  of  bone  and  other  like  eoadidotis 
are  caosing  pressure  tip<iii  the  ner^'e.  Wbeu  facial  paralysis  accompanies 
fracture  of  the  hiins  of  the  skull — aud  it  \a  a  coiumoiL  afCoinpaiiimeDt  of 
such  injury'^ao  aurgical  treaLmect  has  any  iuduciice  upon  tbe  degeuera- 
tioD  of  the  seventh  nerve.  Disease  of  the  middle  and  istemal  ear  should 
receive  most  aeaiduoaa  treatmeutt  not  alone  to  assist  in  the  cure  of  the 
facial  paralysis,  but  to  overcome  tbe  constant  soiiroe  of  danger  of  the 
development  of  intpacraxiifll  absrpss  which  surh  psitients  are  liable  to. 

The  prophyldctiu  treatment  of  facial  paralysis  conaists  really  iti  an 
endeavor  to  prevent  recurrence.  Prophylaxis  of  a  £rrit  attack  is  quite 
ifflpcseibleT  infianuclear  facial  paralyaia  being  prai:tically  aii  accidental 
wmdition-  Recurring  f^kcial  pEUa>%  a  not  uncommon  condition,  is  usually 
the  result  of  an  accident  or  constitntlonal  condition  similar  to  that  which 
pracaded  the  first  attack.  The  efforts  should  therefore  be  to  avoid  these. 
the  incumbency  of  the  Grst  resting  largely  with  the  patien^  that  of  the 
second  with  the  physician. 


CHAPTER  XXlt 

THE  TREATMENT  OF  JiEfKALOU. 

Thb  tfirm  neuralgia  is  uaed  to  iudicai«  the  prominent  fij'niptom,  p&iu, 
lUeudiuga  uomber  of  different  conditious-  lu  other  won1».  tlitf  uaiut^ 
ttiriM  with  it  00  particular  rtfoitnc©  to  the  nature  of  Uil-  ijjat*ase,  be  it 
faacuonal  or  organic,  which  causes  it  Much  objootiou  lias  bocu  bToiigUt 
IffTTfard  against  the  tetio,  as  it  signifies  literally  pain  iu  the  iierva,  and 
u  pain  can  occnr  in  no  other  way,  it  is  flt  once  seen  that  the  word  algia 
u  unfile  to  cover  the  conditiuDs  now  indicated  by  neuralgia.  The  use  of 
'Ju  word  algia  in  connection  with  the  name  of  the  part  that  ia  the  eeat  of 
tLe  pain,  such  as  cephalalgia,  brachialgio^  rarclialgia*  etc.,  is  becoming 
Mon  common  and  should  be  encouraged.  The  term  neuralgia  has,  how 
«ttr,  tieoome  ao  tixcd  in  onlinary  and  scientiCic  nomenclature,  and  it  has 
cme  to  have  such  a  dB6nite  applicjition  that  no  attempt  iiUonld  be  made 
tofiubfititute  the  more  legitimate  word  for  it* 

Topo^aphioal  DiviBion  of  Neuralgia, —Neuralgia  is  a  eymptomatio 

jaia  dependent  upon  functional  or  organic  disease  of  the  sejiaory  ueu- 

na$,  particularly  of  the  peripheral  sensory  neurons.      It  is  chnTScteriKed 

fry  its  occurrence  in  paroxysms,  its  Im^alizatjun  to  a  single  nerve — some 

one  or  all  of  its  bniuches — and  by  a  tendency  to  lecurreuce.      It  iB  claaai- 

fied  topographically,    according  to   the   nerve   involved,   into  trigeminal 

ueuralgLa-,    aeurilgia  of  the  cervical   plexvis,   induding   oceipital^    bra- 

cbiil  neuralgia;   intercostal  neui-algia;  neuialgia  of  the  lumbar  plexuGp 

subdivideJ  into  ai^dominal  neuralgia,  testicular  neuralgia,  crural  neural* 

giB.  &Qd   femoral  neuralgia;    neuicilgia  of  the  sciatic  plexus,  sciatica; 

Dcualgia  of  the   uri^enital  orgaus;  coccygeal  neuralgia;    podalgia  and 

voetatataaJgia.      Other   subdiTisions  may  be  made  if  aeceBOBry,  but  thcso 

'wiU  be  found  to  include  most  of  the  neuralgic  conditioua.      NeuralgJo 

paina  occur  with   certain  well'detined  diseases,  such  as  lueomotor  ataxia, 

bu'  niLturally  such  algia£  are  not  considered  here. 

Qcneral  Etiological  Factors.— Before  taking  up  each  of  these  coodi- 
"tiwis  separately  and  enumerating  tlie  diBerent  modes  of  treatment  to 
•hich  they  are  amenH^ble,  it  is  necesBary  to  say  a  few  words  about  the 
general  orcorrenee,  symptomatology,  and  therHpy  of  neuralgia.  The  fart 
thai  «e  are  aa  yet  ignorant  of  the  oatnre  cf  pain — that  is,  whether  it 
lA  in  itself  an  individual  condition  the  tKcnrrence  of  which  is  eutrtftrrved 
by  ipeeial  nerves  and  pathways  conducting  to  the  central  perceptive 
Tn«cbanism,  the  sensorinini   or  whether  it  is  a  quality  of  other  seosa* 


344 


TfiEATMKNT   OF   DI3BA3KB   OF   THE  NBRTOUB  STSTSU. 


tioDfl — prevents  ua  from  speaking  at  any  length  of  iu  p&thogeneais. 
FroTn  ol^aervatiOD  of  cufna  and  study  of  atatiBtioB  bearing  on  the  occur* 
rencQ  of  tliin  aymptom,  we  learii  that  the  pririt^ipal  fiiCtorB  in  iLs  etiotogj 
aro  bereditj,  tx^ie,  oext  exposure,  cxcoaaes*  aud  factors  that  lower  vitality 
and  depreciate  tbo  nutritional  power  of  the  hlood.  Direct  hcredil; 
occurs  in  about  twenty-^ve  per  ceut  of  all  cases  of  neuralgia,  it  toftttan 
not  what  its  topical  distributiLon  may  be.  A  t^orreHponding  jieTi^eDtage. 
or  perhaps  even  greater,  shews  indirect  heredity;  that  is,  aome  branch 
of  the  immediate  faojily  mauifesta  one  or  mora  of  the  degenerative  or 
acquired  neuroson,  Neuralgia  is  most  rife  during  the  years  of  grdateat 
physical  and  mental  activity ;  the  period  of  fullest  maturity,  from  twenty 
to  forty.  It  is  rare  in  chiJdhood,  aiid  soarcely  ever  occurs  after  the  end 
of  tlie  sixth  decade.  It  has  a  special  tendency  U)  appear  at  one  of  tb^ 
phyKiulogicaL  epocha,  the  establishment  of  the  ae.\u&l  functions,  denoting' 
the  onset  of  maturation ;  or  the  decay  of  these  functions,  pointing  to  the 
pasBiog  of  it.  It  is  iuu<*h  more  GommuiL  in  males  than  in  females^  a  fact 
that  is  explained  largely  by  the  greater  physical  and  mental  eEigenciea 
vith  whiab  the  Ufe  of  the  former  is  lulled.  Thia  does  not  entirely  ex- 
plain the  occurrence^  howi.'ver.  form  latter  years  when  tbe  weaker  eex  has 
so  oonapicviously  usurped  utjuiy  occupations  for  which  meu  were  aapposcd 
to  he  exclusively  Httetl,  the  pro]>ortio]i  of  patients  who  sutTer  from  neu- 
ralgia has  uot  been  materially  changed,  Jn  women  tlie  oiH'urrene^  of 
neuralgia  has  rdationship  frequently  not  only  to  the  menstrual  functions, 
but  tcj  the  entailments  of  maternity,  includiug  lat^taUou, 

It  is  unnecessary  to  enumerate  the  factors  that  may  help  to  depreciate 
vitality  and  nutrition-  They  might  all  be  legitimately  aptiken  of  ae  indi- 
rectly provocative  of  neuralgia.  Directly,  however,  they  cauae  anit^mia, 
dyscrasia,  or  cachexia,  n]Mn  which  tha  neuralgia  is  immediately  depeud- 
ent.  In  this  way  the  infections  diaensea  may  prm^ede  an  attack  of  neu- 
ralgia and  justly  be  considered  thecausQof  tlic  latter.  It  ia  probable  that 
the  iafectioua  diseases  may  euuso  neuralgia  by  tlielr  mfoctions  ot  intoxi- 
ufltious  acting  directly  upon  the  sensory  nerve,  and  not  indirectly  through 
the  bViod,  The  far>t  that  neuralgia  ocrnra  with  influeD/a  and  iti;itMna 
is  pEirtioularly  suggestive  uf  thin  view.  It  juay  be  that  the  iutoxicatioua 
and  infections  of  the  acute  diseases  acting  on  the  aeusorj  nerves  arc  mani- 
fest ayraptomatieally  accordiug  to  the  intensity  with  whioh  the  actvo  is 
involved.  In  other  words,  a  mild  degree  of  jioat'infectifius  activitjr  on 
tbe  centra]  nerves  may  result  in  neuralgia,  whereas  a  severer  degree  may 
cause  the  phennmena  uf  seusory  neuritis,  lu  t^he  same  way  it  ib  possible 
to  explain  tlie  iuHueuce  of  ^uch  iutoxic^aUous  as  alcohol,  tobacco,  lead^ 
mercury,  and  arsenic.  These  substauceA  are  all  capable  of  causing  neu- 
ralgia, and  freqiieutly  they  play  a  much  more  important  part  than  ia  gen- 
erally believed.  Their  power  to  cause  neuritis  is  pointed  cut  in  another 
chapter.      Autointoxication  in  the  causation  of  neuralgia  is  likewise  a 


fci 


im  TmXATXKKT  OF  yECRALGlA. 


8tf 


•&bi«et  thiLt  might  be  discuued  at  som«  Uagth;  but  we  do  not  posoasa 

Buny  ftj^toal  data,  aside  from  Ihose  basnl  on  clinical   observation,  irhicli 

na  be  oaed  bo  support  positive  assertious  as  to  tixe  fr^ueacy  oE  autoin- 

tMicatioQ  m  cauaiog  neuralgia,  or  tho  mode  of  its  action.      Clinical  oa^ 

p«rtea^,  however,  is  uoequivwaJ  on  this  point,  and  espMialiy  that  part 

<if  It  irhichU  the  result  of  therapeutic  testa.      In  many  ca^esof  neuralgia, 

Mpeetally  thoae  fonns  cot  dependent  apoa  organic  disease  of  the  sensory 

nmtaif  the  moat  gratifying  r^^sults  follow  the   adininistTation  <if  sub- 

fltoocn  which  act  solely  upon  the  eliminative  aveuues.     In  such  ca^es  it 

11  «fe  to  infer  that  pain  baa  been  the  result  of  something  in  the  system 

v)ath  tbe  elitoiuotive  has  removed. 

The  rdle  played  by  eoM  and  dampness  in  causing  neuralgia  ia  ft  lead- 
Dg  Mi»,  It  is  abundantly  proven  by  statistics  that  this  symptom  is  more 
UlD  trice  a^  frequent  in  vinber  and  in  spring  than  during  the  other  twi^ 
UMiaj  Moreorer.  in  lULtuy  cases  of  neuralgia,  particularly  facial  and 
((frical  neuralgia,  the  effect  of  cold  in  precipitating  an  attack  is  very 
obnous.  In  the  same  way  it  can  be  shown  that  neuralgias  are  very  eom- 
QuQ  in  tbose  whose  occupation  or  duty  necessitates  exposure  to  changes 
of  olimate  and  iuclemenciiifS  oF  weather. 

Neuralgia  may  be  the  direct  expression  of  injurioas  encroachment 
npM  some  part  of  the  peripheral  aensoty  neuron,  either  from  intianuna- 
tioaof  the  nerve  and  ita  immediatf^  enviionmentr  or  from  pressure,  sweh 
IS  may  result  from  the  ooutraction  of  a  cicatrix;  or  the  development 
of  a  new  growth  in  the  hard  or  soft  parts;  or  from  external  presaLire. 
SjpkliB  is  often  responsible  for  neuralgia*  which  occurs  ijumediately  in 
tUawaj.  There  may  be  no  syphilitio  or  parosyphilttic  implication  of 
t&s  B«ntory  nerves  themselrea^  but  ByphiJitio  disease  of  a  caual  through 
whioh  sensory  nerves  pass,  or  of  hanl  aud  soft  parts  travt^raed  by  those 
QPTTes^  may  produce  nt-uralgia  by  eacTuaehmeDt  upon  the  nerve.  If  the 
Encroachment  is  great  euough,  it  may  cause  different  degrees  of  destruc^ 
DOQ  in  the  nerve.  A  \erj  stmilar  explanation  holds  good  fifr  the  neuralgia 
tli*toocar3  secondary  to  Irauiaa.  Thetraumai  may  be  of  suliieieut  severity 
to  produce  change  in  the  nerve  itself,  or  change  in  the  euviroament  of 
its  carve,  eilber  of  whii^h  h  mmi^^'St  hy  pain.  On  the  other  hand,  a 
tniuua  may  cause  ueuralgia  without  appa^rent  lesiun  of  the  nerve  or  at 
the  eaviionment  of  the  nerve,  and  this  forui  of  nenialgia  ia  nob  taaj  to 
uiterpret-  It  seems  to  be  a  fact  that  the  immediate  anteoedeut  of  neu- 
ntgta  caused  by  traumjiT  which  is  not  severe  enough  to  produce  detnoa- 
amble  lesion,  depends  upon  changes  of  nutrition  in  the  peripheral  sensory 
ntniTOU.  These  are  analogous  to  the  alterations  of  nutrition  which  trauma 
pmducea  in  the  motor  nerves  when  it  causes  the  tiausicnt  motor  palsy 
Vaona  as  night  palsy  and  the  lighter  degrees  of  pressure  palsy.  The 
Inmaientness  of  these  palsies  shows  that  there  are  no  orgiinio  alteratioue 
i!Lili«  nerve.     Alterations  of  the  nutrition  in  sensor}'  neurons  may  like- 


346 


TREATMENT  OF  TIBEASEa  OF  THE  NERVOUS  STSTBU. 


Wise  be  coQiiider^d  as  the  bAsis  cf  tboee  neuralgias  which  oc<:ur  in  organi 
or  ciafiues  that  hive  been  put  to  exceasi^^e  iiae.  It.  u  w«]I  known  that  m- 
dulganca  in  Jiexual  exi^eases  ix  often  followed  bj  spermatic  or  lesticiLlar 
neuralgia,  and  on  the  other  hand  ptolou^ed  and  fatiguing  use  of  the  ea- 
tremitiea  is  IJkevrise  followed  by  pain,  even  though  no  organic  chajige  be 
present  to  account  for  the  neuralgia-  It  may  be  contended  that  in  such 
neuralgias  aa  tarsalgia  there  is  a  tensioti  put  upon  the  ligsinenta  and  the 
Btipportive  stnictiire  nf  ibe  iv^i  that  dii^ctly  caurteji  the  pain,  and  thia 
may  Vre  a  fact.  It  uevertheUBB  ramitLua  that  audi  condiliona  cannot  be 
demonstrated,  and  we  are  forced  to  aoi'cpt  the  theory  thut  exhausting  in- 
fiuonoea  :uay  cause  tropbio  changes  in  the  seuaory  nerve,  which  are  mani- 
f^t  by  pain.  Some  siieb  explanation  as  this  must  be  given  of  the  neu- 
ralgias ooourring  wiLh  the  fmkctit^i^al  diseases  of  the  nervous  syFiteui,  whii;h 
axe  by  uo  uiezius  itncojumuji. 

General  Symptomatology. — The  symptomatology  of  a  symptom  aeema 
Tatber  absurd,  but  tho  variations  in  the  aymptom  itself  and  its  aecompani- 
meutfl  as&  so  great  thnt  they  require  particular  deacriptiou.  The  ebarac- 
ter  of  the  pa.in  da^ieuda  upon  the  cause,  nature,  seat,  and  intensity  of  the 
neuralgia,  while  the  ccimplaint  of  the  patient  varies  with  his  jxtwer  to 
portray  by  word  or  action  the  degree  and  iiitenaity  of  bis  suffering.  The 
pain,  almost  invariably  paroxysnaal  ia  its  ocourc-enoej  ia  deaoribed  aa  lauci- 
Dating,  boring,  gnawiug,  tearing,  or  lightniug-lilfe,  as  the  imapnation  or 
experience  of  tbe  individual  may  furnish  a  eimile.  The  exak^erbatioQ 
nay  bo  for  only  a  second  or  it  may  last  for  several  minutes,  a  degree  of 
pain  being  felt  during  the  intervale  thot  is  comparative  comfort  con- 
trastad  with  that  at  the  height  of  the  paroxysm.  It  is  manifest  in  a  sin- 
gle nerA'e  or  in  one  of  its  branches,  and  radiatea  as  a  rule  from  tho  root 
toward  the  periphery-  Generally  it  is  indicated  by  the  patient  to  be  in 
the  superfimal  structureH^  but  in  many  cases,  such  as  trigemina]  neural* 
gia,  it  ia  described  as  being  very  deep  seated-  As  a  rule,  the  pain  is  in* 
creased  by  movement,  by  e^po^ure  to  transient  and  varying  degrees  of 
cold,  by  all  kinds  of  mental  irritation,  and  by  anything  that  lovpcra  re* 
sistance,  For  tnstauee,  sleeplessness  ia  a  very  potent  cause  to  inereaae 
the  intensity  and  the  frequency  nf  the  pain.  On  the  other  hand,  it  is 
soothed  and  made  more  tolerable  by  the  opposite  of  these  facian^  and 
occ^isionally  by  tbe  continued  ajiplicatiou  of  [l  uniform  degree  of  cold. 
The  ooi'urreuoe  of  ueumlgio  paroxysms  is  uften  pieccdod  by  local  and 
premonitory  phenomena  and  by  ancillary  symptoms.  I'aiienta  who  are 
accustomed  to  attacka  of  neuralgia  are  usually  able  to  tell  hy  dcfinile  feel- 
ings of  iudispoaition  uianifeat  in  different  ways,  that  they  are  in  for  a 
siege;  while  during  an  attack  there  are  often  vssoinotor,  aecretory,  uid 
trophic  disturbances,  depending  upon  the  part  in  which  the  neuralgia  is 
manifest,  and  upon  the  implication  of  sympatbetio  nerves  directly  or  re- 
flejtly.      These  vasomotor  symptoms  may   consist    in    blaticbiug   of   the 


THE  TRE-\TMBST  OF  XKrSALClA. 


3fir 


l^im,   of  an   angioparetic  coDdidon   areompuiied  b^  diciLaifibed  or  id- 

cnuvd  secretion  o£  cataueous  ajul  uiucoua- membrane  glands,  aciL  by 
dungea  m  the  general  euculatioD,  mo^it  strikingly  atipurent  iu  tlie  ex- 
trtuutica.  Ocoasioaally  Euch  Bjuiptoma  as  nauseAf  vomiting,  expuleion 
of  Uie  coDteiits  of  tbe  boveta  and  bladder,  vertigo,  apet^ks  before  tlie  ej«B, 
Und  tven  some  oliscuratioD  of  the  mental  faculties,  may  occur.  Tbese  nre 
tcnditiODed  directly  b;  tho  orerwhelming  effoct  of  the  paia  upon  the 
ijmpathetic  oerroua  ayatem  and  are  in  reality  nothing  leas  than  manifea- 
atictiB  of  abock, 

Tiia  objective  aouompau intents  of  n^Liralgia  are  toudtant  and  of  luuoli 
dilgaostic  sigrtticsDee,  The  mo.st  impcrtantof  these  are  painful  points 
m  Uus  course  of  the  nerve  mauifesting  tlie  paiiij  whii?h  ai^  usually  de" 
Kribod  as  Valleix'a  poiata,  aft*r  the  phyakiau  who  called  atteution  to 
tk«m  m  such  a  way  that  they  became  more  universally  recopniaed  than 
60DI  Uw  deBcriptions  of  preceding  writers.  If  a  nerve  which  is  the 
mi  of  neuralgia  is  subjected  to  pressure  at  different  poiuia  along  Jls 
courae,  the  patient  will  t^ompluiu  that  it  is  KeuslLiver  and  v/hea  presa- 
ur«  ifl  mado  $.t  certain  points  he  will  cry  out  with  piiiii.  These  painful 
puiotB  are  principally  at  a  aituatioEi  where  tho  uerve  emerges  from  a  bouy 
anal  or  wht^re  it  passes  through  a  fot^sa,  or  at  aoioe  otlier  puint  at  wlueh 
the  pressure  of  tbu  finger  Is  opposed  by  a  jirm  reaistiug  surfaee,  suuh  aa 
bODfi-  These  painful  poiots  will  he  t'oasiderwl  in  detail  under  the  indi- 
ridual  forma  of  neural  gia>  Here  it  need  onlj  be  aaidthat  it  la  yet  dehat'- 
aUe  vhether  tlie  pain  thus  produced  is  caused  through  the  nervo  itadf  or 
Ibe  nervi  nervorum.  Other  objective  aeoompauimentQ  are  byverA'Stbeaia 
of  the  akin  and  mucoug  meuibrane  supplied  by  the  atfecled  nerve, 
utmtbesia,  nanally  never  complete  and  more  evident  on  tactile  Htimnla- 
lioa  than  on  thermal  and  electrical  tj^timulation.  Ofteii  tlie  neuralgia  in 
wcompanied  by  tonic  muscular  contractions,  more  rarely  by  clouie  pbt- 
wna&aa  that  are  uaually  thcughb  to  point  to  on  Lrradiatiou  of  the  paio< 
hil  Btimuli  from  the  peripheral  aenaory  neuron  to  the  peripheral  motor 
ncufon. 

Patients  who  suffer  many  attarkij  of  neuralgia  are  likely  to  become 
eLuged  it]  disposition,  in  rcaiatancd  to  all  forma  of  painful  atimulif  and, 
iL  short*  in  increased  susceptibility  to  all  forma  of  physical  and  pajchical 
dcfiands.  Some  of  these  are  to  bs  interpreted  as  the  direct  results  of  the 
djurdered  general  nutrition  which  suffering  iaducesj  but  a  part  of  it,  on 
^  other  hand,  is  the  immediate  effect  of  the  suffering  u|>on  the  general 
morale  of  tlje  patieut.  This  diaorganiziation  of  the  patieut'a  morale,  or 
cwrage^  or  mental  resistance,  or  call  it  what  one  will,  must  bo  taken  very 
Mrioualy  into  account  in  the  treatment  of  every  case  of  Tocurrent  andpei- 
mteut  neuralgia. 

Tr«atmcnt- — The  tTcatment  of  neuralgia  resolves  itself  into  two  neces- 
^tles:  First,  and  by  all  means  the  moatp  lujportant  to  the  paileut,  at  least 


948 


TREATMnNT  OP  tUBEASKS  OV  THE  NKBVOD9  fiTSTEU. 


for  the  time,  ia  the  relief  of  the  p&inj  &nd  seooad,  the  overcouiing  o£  the 
oonditione  on  which  it  is  dependent,  therefore  the  prevention  of  its  recui- 

Mere  dnumeTatioa  of  th«  medicines  which  have  b«en  suggested  fof 
the  relief  and  cure  of  neuralgia  would  lill  a  number  of  pages,  I  shall 
therefore  be  obliged  to  limit  Ju^self  to  &  brief  consideration  of  thoae 
that  are  kuown  to  bo  o£  real  value.  Natiu'Edly,  the  most  powerful  aub- 
stance  in  the  relief  of  neuralgio  poicia  is  opium.  It  requifee  littto  argu- 
ment, howei'er,  to  convince  even  the  most  venturesome  that  it  is  the 
last  dnig  that  should  be  resorted  to.  Neuralgia  is  peculiarly  a  condition 
tliflt  favors  tlio  ruady  acquisition  of  the  morphine  habit^  from  tlie  fact  thai 
it  is  oiiroiijo  and  ten  da  to  recur.  The  adminbtratiou  of  opium  merely 
temporiz£i3,  and  the  Eame  conditions  that  call  bo  loudly  for  it  wiU  recur 
and  with  greater  force  later  on.  The  patient  bimneli  will  bo  less  able  to 
lesist  cTarooTing  for  it,  and  the  physician  will  find  tho  apparent  indica- 
tinits  foi'  its  uae  mora  insistent  than  they  were  at  first.  The  first  step, 
therefore,  is  the  fatal  oue,  and  it  should  be  delayed  so  long  as  tL«re  is  a 
leg  to  stand  upoa.  In  the  chapter  on  headache,  many  of  the  drugs  that 
may  advantageouBly  be  used  instead  of  opium  hove  been  enumarated,  and 
the  combinations  ivhich  are  thtre  given  are  often  as  suocesaful  in  relieving 
neuralgia  as  they  are  Id  c&using  the  diflappearance  of  headache.  The 
more  imiiortaiit  of  thoflo  ilrngs,  it  is  well  known,  are  aatipyrin.  pliBnacctio, 
e;ialgin,  antifebrin,  lactophenin,  and  tho  sal  icy  lato  group.  It  needs  only 
to  be  iMirne  in  mLud  that  all  of  these suhdtanoes  are  depreasanta  asweU  oa 
annlgesicB,  and  th;^t  they  nmst  be  given  f^auiiously,  often  in  conDeetion 
■with  ihffitmblestltnulancs,  such  oa caffeine,  ammonia,  ether,  and  camphor 
When  they  hiive  lieen  found  to  be  ust^lesst  one  should  resort  to  the  less 
harmful  alkaloids  of  opium  before  £nal?y  determining  to  give  morphine- 
Tbeae  arc  codeine,  narceine,  and  thebaine,  and  drugs  that  are  known  to 
have  the  8pei:ial  prO|»erty  cf  benunjjiing  sensory  nerves,  such  as  aconitinoT 
gelsemlurn,  Crotou  chloral,  butyl  chloral,  atropine,  and  cocaine^  These 
medi'^amentf  have  eiirut^  u  rt'putatiLiu  for  thu  relief  of  certain  kiodft  of 
nii^uralgio  pain,  tuch  &s  trifacial  neuralgia  and  cervico-occipital  neuralgia, 
aud  they  may  wt-U  be  couaiderad  under  thoae  headings.  When  theeo 
drugs  fail  to  give  relief,  it  is  cowardly  not  to  cut  short  the  patient's  euf- 
ering  by  the  administration  of  morphine.  If  the  n^f^essitiea  of  the  case 
do  nut  esll  for  immediate  r^llf'f,  it  Is  advij^able  to  do  this  in  aome  other 
way  than  Lypodermatioally.  A dntini stored  iuthe  latter  fashion  it  makes 
a  certain  mental  impreaaiou  that  it  ia  best  to  avoid.  \^en  atropine  ia  com- 
bined with  morphine,  it  net  only  has  a  better  effect  in  reliovmg  pain,  but 
it  prevents  the  disagreeable  after-effects  which  follow  tbe  administration 
of  morphine.  It  should  always  be  kept  in  mind  in  prescribing  morphine 
for  the  relief  of  severe  neuralgia  that  the  dose  must  be  |irO|HDrtioDate  to 
the  seventy  of  thti  auSering.     It  is  far  better  to  give  one  large  do6e, 


THE  TREATMENT  OP  NBTTRALOIA. 


which  will  qoelt  the  pain  for  a  niimher  of  hiurSj  duping  which  time  ar^es- 
•dry  medication  and  application  may  be  indulged,  than  to  give  a  Tkumtter 
tl  smftU  doses.  Moreover,  the  admiiiiBbr&tioii  cl  auiticient  narcotic  in  one 
4Me  bo  relieve  the  patient  for  a  considerable  length  of  time  may  be  grati' 
fjitigly  sofjplemented  bj  some  simple  Bleep  producer,  buch  aa  euJfonal 
or  trional,  that  will  carry  the  patient  through  au  entire  daj  cr  two  until 
tbe  force  of  the  neuralgia  ha»  tiX|>euded  itself. 

Much  has  been  wiitteii  by  enthusiasts  about  tlie  efEi^acy  of  psyoho- 
iLetapj  in  neuralgia.      It  is  difficult  to  make  a  just  estimate  of  Jta  worth, 
btfoauaei  as  I  have  already  saidt  the  pajchical  element  enters   iuto  the 
EtoMtioQ  and  maaifeatations  of  ueuralgia  to  a  degree  varying  with  each 
ffidindual,  and  because,  moreover,  psychotherapy  19  such  a  flexible  em- 
tndimeat.      It  may  mean  inertity  the  inspiring  presence  of  th«  oue  whom 
Lhc  patient  has  been  accustomed  to  use  aa  a  shield  from  pain,  or  it  m>iy 
aieau  an  impressioa  upon  the  Bupralimiual  coneoiousnefis  that  oames  it 
jubr  a  Etate  of  compltrta  iuaetivity-     lu  arty  case,  the  b^neht  whiuh  may 
}jirf«ib]y  be  expected  from  it  abould  he  welcome.      It  ia  more  efficacious 
viUi  patients  who  have  siifTered  for  a  long  time  and  who  ooatract  a  paiD 
h&bitor  who  become  hyeterical  Irom  long  fiuffeiing,  thau  with  any  others. 
The  physician  £iida  a  large  £eld  for  iLsefuines^  when   face  to  face 
v;th  tieuialgiOf  ia  the  treatment  of  the  underlying  causea  of  whi(?h  it  IS 
a  aymptomr  for  when  they  are  succesafnlly  combated  the  symptom  ceases- 
In  fulfilment  of  this  misflion,  he  not  oaly  direoia  his  endeavors  toward 
iffuoviug  tho  apparent  causation^  whether  it  be  an  LutoiLcatiou,  iufectiun, 
djacrasia,  or  cachexia  or  a  lesion  accessible  to  surgical  inlcTfercuce,  but 
ta  the  fortilicatioa  of  the  general  vitality,  by  the  uaa  of  all  those  meaQurea 
kaowD  to  increase  nutrition  and  make  it  more  stable,  while  at  the  same 
dme  he  employe  physical  measureSi  such  as  filectrinity^  niaasnge,  external 
applications,  such  as  compression,  heat  and  cold,  hatha,  sidmtitaneous  iii- 
JACtiana,   aa  carbolic  acid,   ether,  and  strychnineH      The  indications   for 
Special  medication  directed  toward  the  rehef  of  the   individiud  causes 
moat  be  determined  for  each  case.     In  one  it  may  be  the  administration 
Gf  quinine  to  counteract  malaria,  in   another  mercurials  and  iodide  of 
polaasiuiii  tjo  battle  with  syphilis,  hi  another  colchicum  for  its  seleolivs 
aotioQ  in  gout,  and  m  another  the  BdmlniatratLOU  of  iron  andarecoii- 
Btnctive  dietary  to  overcome  aujEmia.      None  of  these  is  sufficient  by  it- 
Mif  to  overcome  the  neuralgia.     Ita  action  must  be  aided  by  a  building- 
up  plan  of  treatment. 

The  TTm  of  Electrioity  jo  the  Treatment  of  Kenralgia. — One  of  the 
iDOii  im[>ortiant  measures  iu  the  treatuieut  of  ^leuTatgin  is  electricity. 
Ip  the  chapter  on  electricity,  it  ia  said  that  this  agency  is  of  incom- 
parably greater  value  aa  a  diagnostio  than  as  a  therapeutic  agency, 
hut  here  it  needs  be  aaid  that  it  is  m  neuralgia  that  it  &nda  one  of  its 
most  important  and  efAeacioua  usages.     It  is  applied  iu  the  shape  of 


b 


860  TREATMENT  OP  UISHASEa  OF  THH  NERVOUS  STSTHM. 

galvamsm,  faratJiam,  or  alatin  electricily.  Tbe  galvanic  ciirr^Dt  ^nd  the 
rapidlj  intftrrupted  faradits  current  obUined  fmrn  a  lung  ixjil  of  eitremdj 
Eiue  wire  are  moat  eMc&cious.  The  mode  of  application  of  the  galvaoLc 
(jurrent  is  the  kbile  metbi^d,  the  irntating-  pale  (that  is,  the  negative 
polo)  boiii|f  always  placed  over  Bome  indifferent  part  of  the  body^  while 
the  anode  (the  positive  pole)  is  a[ip1ied  nibbed  up  otid  down  over  tb« 
ruLirsfl  of  tlie  !ifrve  niniiifeHtlng  tlie  pain,  and  finally,  the  a^anrr  termi' 
uated  by  the  application  of  this  poltr  dlL~ectly  over  the  motit  painful  point 
of  the  nerve  for  froro  one  to  two  minutea.  What  has  already  been  said 
donc^erniii^  the  in?c?(?aBity  of  having  a  rheostat  and  gaWonoineteT  for  the 
Tcg^ation  and  nieasnrin^  of  tho  current  should  be  bome  in  mind  in  thiB 
connection.  Without  these  appEianees  the  galvanio  crurrent  should  never 
be  used  aa  a  therapeutic  agent,  especially  in  neuralgia.  The  intensity  of 
the  current  will  depend  somewhat  upon  the  part  of  the  body  to  which  it 
is  applied.  When  the  neuralgiin  is  of  the  cephalic  e&tremityf  a  ourrent  of 
two  111  ill  i amperes  is  all  that  will  1>e  tolerated,  while  for  sciatica,  for  m- 
fitanee,  a  (Current  of  frnm  six  to  ten  tDilHamperea  may  be  advantageously 
adminiBtcred.  As  a  general  rule,  however,  more  bFuefit  is  to  lie  obtained 
from  the  prolonged  application  of  a  vreak  current  (two  to  four  mi]]ieuEi].ierefl 
for  from  one-half  Ut  tvro  hours  daily)  than  from  a  strong  current  for  a 
short  time.  ^H 

The  faradic  current  obtainefl  from  a  long,  closely  wound  coil,  some^^ 
times  gives  most  Btriking  relief  in  neuralgia,  especially  in  neuralgia 
associated  with  dyscrasia.  Usually,  its  {application  through  the  ordinary 
electrodes  ia  more  aatififactory  than  through  the  brush  electrodes  which 
oftentimes  cause  irritation  and  acoeasion  of  the  pain.  In  eome  cades  it 
may  be  advantageous  to  allow  the  current  to  pass  through  the  bodj*  of  the 
physici;m  £.nd  therefore  a[iplied  immediately  by  the  operator's  hand- 
TTudoubtedly  the  element  of  anggefllion  here  is  very  potent*  Static  elec- 
tricity, if  given  with  suflicienl  iiitensity  and  duration,  is  also  frequently 
of  great  acrviue  in  the  treatment  of  neuralgias,  i^atticulurly  those  that  are 
deep-seated,  sueh  aa  neuralgia  of  the  lumbar  and  sacral  nerres.  The 
mode  of  application  is  either  by  large  sparks  directly  to  the  part  in  which 
the  paiu  occurs  or  hy  means  of  the  roller  electrode. 

The  utility  of  maasagc,  and  it  is  oftentimes  great,  in  the  treatment  of 
the  various  forms  of  neuralgia  will  he  considered  under  the  iadividnal 
headings.  Here  a  word  must  be  said  concerning  the  adviaabihty  of 
adopting  surgical  measures  in  rebellious  cases.  These  consiats  of  neive 
stretdhing,  the  bloodless  form  or  by  operation,  neurotomy,  neurectomy^ 
and  the  reAe<:tifjn  of  the  seiusory  ganglia,  nueh  as  the  GaBsetian  gacigliafor 
uncompromising  trifacial  neuralgia.  All  these  measuiea  have  had  their 
eulogists,  and  at  different  timee  waves  of  enthusiasm  concerning  their 
efficacy  have  swept  over  the  medical  pTofesaiiin.  Unfortunately,  the 
casual  observer  bas  seen  only  the  crests  of  the  waves,  unmindfid  of  the 


TBK  TREATUKyr  OF  Xfir&XLGLL, 


tiwflu  betwoeo  kfaera.    The  troagb  eiisteii,  uitl  ofteotimea  Laa  br«u  b 

man  ooospicaioua  ittAu  Uie  nTCo.    Ko  obj«clioD  cui  be  offet^d  to  th«  tral 

of  aerre  stretdimg  whea  ik\s  cftu  be  dooe  vitbout  openiUcm,  ii*>t  i£  thtro 

uj  oDiuid^ Able  dui^r  aixcudin^  tli«  opemcioQ  bj  expowog  the  D«rve  miU 

Etrftohiiig  it.     It  moBt,   howOTer,  DOt  b^  forgoCMa  that  rweciion  cf  a 

iirrve>  pArticutulj  of  such  uerves  as  the  tngeminus,  may  be  f^«l]oT«i]  bj 

Tcfj  lenoQfl  paral;ftic  and  trcpbk  pheaotnma  which  must  b«  tftkau  int» 

fi]ll<«t  conaid«T&tioii  vhen  tbe  taaCtcr  is  being  laid  befora  th«  patient 

I'lirlheT  detaiJg  of  these  procedures,  as  veil  aa  of  suboutaneouB  injeotioaSr 

titemaJ  applications,  baths,  etc.,  viU  b«  found  under  the  special  lubdi- 

TirioDS  of  this  subject. 

3onie  aeuralgias  are  rebellious  to  all  forma  of  medicinal  and  mechan- 
if&I  trcatmeDt,  and  the  aid  of  the  surgeon  must  be  sought.  The  iudica- 
ticaa  for  operation  will  be  considered  under  the  individual  betdin^. 
Ciupiult  has  recently  recorded  an  example  of  the  great  beuetit  that  may 
Utend  surgical  interference.  The  patient  had  auffered  for  foui'  jeAr» 
ffiihu  unbearable  imuralgia  of  tlie  right  anu^  which  bad  reAiflted  ever}' 
fomd  treatment,  including  repeated  secttOQ  of  the  ulnar  nerve.  TLe 
toot  of  the  eighth  oerrical  nerve  waa  cut  intradurolly.  Two  acd  Ei  half 
j?tn  liter,  when  the  case  was  reported,  there  had  been  no  reourrenee  of 
iii«  pain.  There  were  no  permanent  sensory  distUTbaucea,  but  there  wab 
fuiue  fttropbj  of  the  hypotheuar  dQirieuce- 


t 


Thb  fifth  nervd  or  some  of  its  braDcbeB  is  ofteu  the  seat  of  Deui 
SqcIi  neuT&lgia  may  be  Bjmptoioatic  of  a  number  of  condltiofia^  pri! 
piiUy  thoan  that  cBuee  liji^iiiol^'sia  aud  tlioae  that  inttirfere  with  hji^niogeap^ 
sis,  CT  it  may  be  itidicfttive  of  orgauio  cbftngo  in  the  nerve  itself,  Jt 
hoa  not  always  boon  recognized  Umt  trifacial  neuralgia  may  be  of  u 
many  forma,  both  ia  its  clinical  course  aikI  in  ita  termiDfltioti,  a.3  tbere  ate 
catisea  (if  tlie  nauditioiu  Even  to-day  the  therapy  of  the  affeotion  doefl 
not  talcB  the  tnith  of  this  into  fiuffideiiti-ODaiderdtiou.  The  term  tngem- 
jnal  jieuNilgia  h  used  ajnoujiiioualy  with  tic  douloureiis,  i)roBopal(jia, 
aiid  Fothergiira  painful  atI*H?Liori  of  the  face.  It  would,  however,  be 
wise  to  restnct  the  use  ot  the  dQeignatioD  tic  douloureux  to  indicate  on 
affection  of  the  fifth  nerve  occurring  in  middle  or  advanced  life,  esi>ecially 
in  thoHe  who  have  inherited  or  arquired  n  tendency  to  neurotic  luaui' 
feKtiLtionf  which  haa  rather  a  (uinstaiit  clinical  course  tind  terniination.  It 
is  one  of  the  tno»li  yminful  conditions  that  afflict  mankind,  and  happily 
]t  is  comparatively  a  rare  disease.  I  say  dieeaao  advisedly,  for  unlike  tho 
ordinary  iieuTalgiue  of  the  trigeminal  nerve  it  ia  not  a  aymptom  bat  a 
pathological  and  (^linical  entity. 

Trifacial  neutnlgia  has  occupied  D  eoUApieuona  place  in  the  annals  of 
mcdicice  for  mauy  hundred  years,  and  loniea  upon  tomes  have  been  vriit- 
teii  iLhout  it.  The  early  Latin  ^'ntors  called  it  tortiira  oris  Some 
idea  of  the  widely  (diverging  eoneeptiona  that  different  writers  have  bad 
of  this  condition  may  be  infern.'d  from  tbo  published  rejiorts  of  th* 
efUcacy  of  certain  plans  of  tre;itri:ent  and  of  certain  dnrgs.  Contrast 
these  with  the  status  of  the  therapeutics  of  tliia  affectjon  lo-day  and  the 
result  ia  extremely  paradoxical.  In  tjie  same  way  the  diametri^ially  op- 
posed Iea<^h]ng9  concerning  tlie  vaiue  of  el*H?tvieity  lu  the  tiealment  of 
tluB  condition  may  be  explained.  There  can  be  no  doubt  whateoeTcr  that 
eleetrtcity  is  of  considerable  value  in  overcoming  certain  format  of  tri- 
faLual  nenralgin  —  the  symptomatic  varieties*^ but  in  tine  tiL^  douluiireux, 
on  the  other  hand,  it  is  quite  useless. 

The  morbid  changes  in  the  primary  eenaory  neuron,  be  it  of  thft 
penphery  or  of  its  arborisations  rn  the  Gasserian  ganglion,  upon  which 
the  neuralgia  is  dependent  hava  not  yet  b«en  satiBfactonly  determinnl. 
Undoubtedly  in  many  inatanceB  tbe  nerve  la  organically  diseased,  even  in 


THE  TREATMEXT  OF  TBIPACIAL  NBCRALOIA. 


•dS^ 


:fc«  BTmptooutdc  form,  and  this  state  nisty  have  been  brought  about  ty 

mjtjrious  agCDcies  acting  directly  ufioD  the  nerves  <^i   iuditeotl}'  through 

ti»  b]oo*i-Tes5cl3.     Trifacial  neuralgia  may  be  merely  an   indici^tion  of 

toiiilered  function  of  the  nerre,  which  in  turn  may  he  tlepeudeLt   uimri 

D^  tai^tors^      PinilJy,  it  may  te  a  mauiFeatatioo  of  a  degenerative  ncii- 

::   siA.te  somevvhn^  akin  to    epilepsy  and   migrate.      IjOug-fTuntinued 

••raion  of  function  may  lead  tci  organic  clianga  b  tha  nerve  and  gau- 

rhfacia)  neuralgia  i&  a  eymptom  of  functional  or  otgautc  affeotion  of 

piotfi  part  of  the  fifth  cranial  nerve  or  the  Gaaserian  gaagtion^  character- 

md  by  pain  in  one  or  all  of  its  branches.      Tn  the  Byia[itoiDatic  form  the 

pain  IS  mure  or  less  trontinuoiia,  but  in  the  degenerative  furiu  it  UBually 

tDanif«ts  itself  in  paroatjama  varying  in  intensity  from  a  slight  twinge 

ttp  to  the  most  agouizing  tcrtare,     Tfue  tic  douloureux  is  almost  iuvaria- 

bij  of  the  second  and  third  branches,  the  first  branch  being  spared.     In 

fTnptomatlc  irigeininal  neuralgia  the  ophthalmic  branch,  and  partioularly 

iatanainal  filament,  the  mipniorbJIal,  in  aJTH^ted  in  l^he  i^iajority  of  iu- 

lauMeot  oanstitabtDg  aboLit  seventy  per  cent  of  all  caaea  of  f^*-M  paiu>     Oc- 

cui')DaI]y  a  local  cauaation  may  he  found  to  account  for  it,  such  as  inHam- 

aatton  of  the  frontal  sinuses,  latent  olitiSf  or  inflammation  of  the  inastoid 

pincees,  but  generally  it  is  the  eirpieesioM  of  some  conatitutional  condition 

or  ovural  exhaustion.     It  baa  a  Etrikliig  l^udent-y  to  recur,  aud  this,  in  ad- 

itjon  to  the  fact  that  it  oft*n  occurs  with  malarial  aBection,  has  g^^'^n 

it  the  name  brow  ague.     Pain  in  other  branches  of  the  ophthalmic  nerve 

is  rare.     The  eyeball  may  be  the  seat  of  pain»  but  when  it  ia  confined 

to  this  organ  there  i3  usually  some  loc^al  condition  to  account  for  it,  such 

udsfeeCive  refractive  media,  muscular  iasuffioiencieSr  iotlammatary  con- 

Utioif  orglaaeoma.     The  second  branch  nr  su  pram  axillary  i^  alfectttd  iiioio 

Eteqonitly  than  the  third,  or  tiitraot axillary^     The  yarn  may  ho  uiauifest 

a  the  eotiie  diatribntion  of  any  one  of  these  brandies,  or  it  may  be  con- 

fiakl  to  one  of  their  eubdivisions,  aneh  aa  the  supraorbital  branch  of  the 

oplithalinicT  thfl  supdrior  alveolar,  or  infraorbital  of  the  second  trunk,  or 

i^  ^ijental  branrb  of  the  Uiin!  divi^iou  pf  the  trifacial^     tTsually,  the 

EUualgia  does  not  involve  more  than  one  of  the  divisions  of  the  trifacial 

aem^     Occasionally  the  Brst  and  second  divisions  are  simultaneotLsly 

lffMtt«d,  and  very  rarely  are  all  the  branches,  including  the  motor  {caua- 

ioj  masticatory  paralysis),  implicated.     Sometimes  tfae  neuralgia  shows 

itnlf  Eirst  on  one  side  of  the  face,  and,  after  avariable  time,  on  theother, 

ctllier  before  or  after  the  pain  has  ceased  ou  the  aide  first  alTected. 

fitiology.— Aside  from  the  general  etiological  factora  which  have  been 
ttuaetated  as  caosattve  of  nenralgia,  trifacial  neuralgia  seema  to  have  a 
;i[W  relation  ship  to  a  few  individual  conditions.  These  are:  <I)  Diaeaae 
or  disorder  of  some  of  the  organs  and  cavities  to  which  this  nerve  ia  dis- 
Inhited,  aneh  as  the  nasal  and  orbital  cavities,  the  alveclar  processes 
23 


354 


TREATMENT  OP   Dlt^EASES   OF  THE  NERVOUa  BYSTBU. 


ftnd  their  coiuinuiiicatiQiiA,  aiid  the  argOEiA  of  specifd  sense-      Two  casee  of 
inreterato  pain  in  the  faoe  ocRurmg  iu  men  fifty  Euid  thirtj-eiglit  ye&n 
respectiTolj,  cured  by  r^moT^I  oi  Qxteusively  diHoascd  middle  turbinated 
bone,  haTfl  reeently  tieeu  reported  by  Mayo  Collier     (2)    Condition! 
which  operate  directly  on  the  nerve  itaelf,  parciculatly  refrigeration   by 
eipuflure  to  diauglita  or  inLeusa  cold;    blu^a  or  other  forma  of  trauma, 
and  ditect  encrwichment  upon  the  nerve,  particularly  at  a  foramen  of  catit 
or  in  a  bony  canal  throngh  ^hich  it  passes  i  by  inflammatory  or  esudatire 
conJitloiiT  the  mo9t  ciommon  f>xeitaiit  of  which  ia  ByphilisT  Trhich  oausda  aik 
iiidamina.tury i«QctioD  in  the  earlystoges  aud  n  degenejration  in  the  lattitf, 
(>1)  Arterio(!apillary  fibroHia,  ami  (4)  the  iuheritance  or  ac'xuisitton  of  a 
tendency  to  neurotic  degeneracy.     These  are  the  principal  ones.      What 
hsia  been  said  concerning  the  inilueDCC  o£  heredity,  instability  of  nutritinD 
and  depressionj    physical  and  mental  strain  and  overactivity,   and   the 
harmful  effects  which  infections  and  intoxications  hare  upon  periphery 
fien»ory  nerves,  in  the  previous  remarks  on  the  geueral  etiology'  of  neLirsl' 
gia,  appi;  to  trifacial  neuralgia.     A  word  in  addition  is  neceesaij  to  call 
attention  to  thf>  relationahip  exiatinff  between  chronic  constipation  and  the 
occurrence  of  trifaoial  neuralgia.      Ihat  there  is  such  a  causal  relation- 
ship BtatiGtifis  abundautly  prove,  but  it  is  not  aatisf acton ty  interpreted. 
KoBt  writers  attribute  the  c^usaticu  of  trifacial  neuralgia  accompanying 
a:id  apparently  depeodent  upon    roiistipation  to  autointoiication.      But 
this  does  not  entirely  explain  it,  for  none  of  t]je  seneory  nerrea  of  the 
body  aeema  to  be  auaaeptibie  to  such  an  intoxication.     The  four  importajit 
factors  are :  those  above  mentioned,  via. ;    (IJ   Diaense  or  disorder  of  the 
cavities  and  parts  to  which  the  trigeminal   prooeedsi    (2)   traiims,  and 
encroacbment  upon  the  uerve;    (3)   degeufitative  disease  of   the   blood- 
resaelBi  and  (4)  interabitial  and  parenoh^matoiLS  change  in  the  Gaaseriaii 
ganKlion.     The  clinical  Tatietica  of  trifacial  neuralgia,  including  the  in- 
tensity of  the  aymptoms,  the  duraliou   of  the  paroxyama  of  pain,  and 
the  amenability  of  the  r-otidition  to  tceatniont,  stand  in  very  close  rala* 
tionship  to  the  one  of  these  four  conditions  with  which  it  develoiutf  and 
it  can  be  readily  seen  that  the  form  of  treatment  which  might  be  success- 
ful in  one  vnhety  would  have  no  beitelieial  influence  whatever  on  any  of 
the  others - 

Symptoms. — The  essential  symptom  is  pain — thepaie  of  genuina  tic 
doutoureiix.  Iu  symptomatic  trifacial  neuralgia  the  paJu  often  begins  as 
&  mild  headaohc,  limited  to  the  distribution  of  the  supraorbital  nerre. 
This  headache  gradually  increases  until  it  ia  of  [dmost  intolerable  seTcr- 
ity-  It  occurs  in  paroxysms,  and  it  ia  of  very  variable  intensity.  Some- 
times it  is  preceded  by  premonitory  phenomena  such  aa  intolerable  itobing 
in  the  domain  of  the  nerve  wbicih  later  maiiife^ta  the  (>ai]i,  punpsthoaia,^ 
formit'ation,  and  more  rarely  by  a  sense  of  unwieldinesa  or  ]]K;ition  of  one 
Bide  of  the  facCn     On  the  other  hand,  patients  often  arc  awakened  during 


THK   TBEArUKST    OF    TRIFACIAL   NKtIKAl-OtA. 


3a5 


th«  Dtght  With  &  painful  Bensation  as  if  a  hmiidred  lieated  ooodli^a  were 
trag  ilfirea  with  superhuman  force  tUfough  the  side  of  the  faoe  into  the 
imtts  of  the  upper  jaw.     This  agonizing  p&in  Insti;  trvta  a  at^i^ond  to  a 
aiaucA,  and  is  then  fD]]owe<l  by  au  interval  of  cDuip&r&tire  le&t,  during 
vLch  the  patient  is  m  mortal  iextvv  of  Pk  revisitatioii.      Some  fiuffeicrs 
ipBcnbe  the  poin  bj  cumpariug  it  to  that  wUich  might  ho  produced  by 
boring  into  the  eye  with  a  large  auger,  or  of  drilling  into  the  nerve  of 
a  inflamed  tooth,  but  the  majority  flnd  thems^lvt^n  too  poor  m  Ian- 
goffi   to    express    even    a    muiety   of    Uieir    Buffering.     Ita    ictenHity 
oMj  be  gathered  by  wituesaing  their  agony  during  the  paroxysms  ftnd 
Ite  eridencos  of  fear  and  tetrot  daring  the  inter  vallum.     Ofbcutltnea 
Ai  pain  ia  fio  severe  that  the  patient  becomes  delirious  and  mania- 
ol  tf  the  height  of  the  paroxysm^  esjieoially  if  the  paroxysms  are  of 
fnqnesit  oorrarreDCe.     Under  auch  circnni stances  th^y  may  oomniit  deeda 
dl  fiolence   against   themselves   or   others,    for    which   Qtej  are  by   no 
aicaas  responsible.     On  the  other   hand^  oocaaioually  suffering  so  de- 
nunJitea  the  patient  that  he  eatinot  keep  up  the  courage  to  £uco  the 
li^iihtiea  of  leonrring  paroiyams,  and  deliberately  8ui!^iili?fl.      The  dan- 
ger of  this  should  not  be  forgotleu  by  hiin  who  eiiaayfl  to  treat  a  oitse. 
Tba  paroxysms    aro  often    aaaooiated  with   muscular   twitcibiugfi.     The 
satife  bead   may  be  agitated  by  tk  number  of  clonio  vibrationSf  or  llie 
t¥itching  may  be  confined   to  the    muscles    supplied   by  the    motor 
bcuuh  of  the  fifth  nerve,  oocasionally  to  those  inDervated  by  the  eev- 
eath  nerve.     MovemeDts  of  all  kinda,  active  or  passive^  increase  the 
|BiiL,  and  the  patient  learns  early  to  avoid  any  miiiumlar  SftioOf  sui'h  as 
u  (DTelred  in  speaking,  laughing,  coughing,  e^tiug^  sneezing,  turuiog  the 
ImA,  and  walking.     He  stands  in  mortal  fear  of  draughts  and  exposure, 
iaAM  eSort  of  any  kind  which  he  has  learned  to  know  are  sufficient  to 
pee^tati  su  attaobu 

VHonotor  disturbances  rarely   precede,   but  often   aocompaoy  the 

peoijsma    of   the  paiu^   and  often  coutLune  in   the  intervals   between 

iU  paroijsm3'      These  may  conaiat  of  blanching  of  the  &kin  in  a  nar- 

rovlr  cen&oed  area  of  the  faee,  ear^  head,  nech,  and  of  the  antithesis 

of  xhJM    condition,  ru,^  a  suffusion^   with    apparent    distention   of    the 

Uood'vesaels  associatt^  with  subjeotire  sennations  of  tension  and  heaX- 

WiHi  thia  condition  there  may  be,   and  often  is,  some  disturbaoca  of 

MsbkjU  in  the  glands  of  the  skin  and  crbit,  and  of  the  nasal  mucous 

Mlbnao  and  salivary  glanda.     There  ia  no  regularity  in  the  appaaraooc 

«f  these  manifestations,  however,  nor  do  they  form  an  integral  part  of 

eW  fyiDpCom  romplex.     Trophic  diaturbancea,  such  aa  loas  of  color  of 

IIm  hur  and  bearfi,  neurotit?  infiammatioa  of  the  akin,  in  the  shape  of 

bopes  BOflter,  an  anakipiufl  eonditioD  of  the  conjunctiTa,  knova  »■  opfa- 

ftalBttia  neorotica  vldcfa  oecaaionally  leads  to  very  profotuid  deettuttioo 

[«f  the  ttifnea,  may  all  oecor.     More  profound  troi-hifl  rninifratattfW, 


J 


35fi 


TESATMK^T  OP  UrSEASKS  OF  THE  NERVOUS  8Y9TKU. 


suiih  &a  ukbicktiuii  and  Hloughing  of  Ihe  soft  parts,  alv^eolar  CDDtractloii 
and  atrophji  wilh  ooDaequeob  loss  of  the  teeth,  and  facial  hemiatropliyi 
]iQp|>iIy  oijcur  reiy  raiely,  and  their  ooduirence  indicates  almost  invariably 
serious  disease  oE  the  G^LBBorian  ganglia.  During  and  immediatelj  fol- 
lowing the  attnck  there  la  usually  conaider'ahle  hyperjtstbesiEi  in  the 
L'cwrae  of  the  inrve  whidi  is  niaiiifesting  the  jiaiu,  and  tlie  nerve  is  seusi- 
tire  when  firmly  preaaed  at  aonie  puint  at  which  it  approachefl  the  surface 
or  at  which  it  escapes  fmm  a  canal  or  a  formnen.  The  si^nidcance  of  such 
teader  or  painful  poiuts  in  tieurjilgia  haa  already  heen  considered.  On 
the  other  haiid^  generalized  pressuie  Gver  a  considerahle  svirfaue,  such  03 
by  the  palm  of  the  handj  ia  often  grateful.  Usnally,  there  is  no  disso- 
CLation  of  aeufiation  and  very  rarely  aua^atheaia.  The  presence  of  the 
latter  should  prompt  one  to  search  immediately  for  orgauio  diaeaec  of  the 
pone  aud  oblongata, 

The  dviration  of  an  &ttac<k  is  very  variable.  In  the  beginning  it 
rarely  lasts  for  more  than  a  few  hours,  but  the  paroyyaras  may  reeur 
every  few  minittea  during  tliid  time.  Ou  the  other  hand,  when  tlie 
disease  is  clironio  and  of  what  may  be  called  a.  degenerative  type,  the 
attack  may  laat  for  weeks,  the  parosyama  occurring  once  or  less  often 
in  the  tweuly-four  hours.  They  are  very  liithle  to  occur  between  mid- 
night and  Buurise,  thus  adding  to  the  misery  of  the  patient  by  preveTiting 
sleep.  Occa.^iotjiilly  individuals  will  have  attacks  only  during  certain 
seasoua,  such  as  tho  springy  and  after  a  few  weeks,  duriug  which  time 
the  paroxysms  may  be  of  daily  or  bi-weekly  occurrence,  they  cease  and 
do  oct  recur  imtil  the  same  timo  the  following  ysEir,  There  wonld  seem, 
however,  to  he  no  rule  for  the  frequency  or  tijiie  of  their  occurrence, 
except  ill  sa  far  aa  they  have  relationship  to  the  etiological  factors  that 
have  b»en  mentioned. 

Bcforo  taking  leave  of  the  symptom  complex  of  trifacial  neuralgia,  a 
word  must  le  said  anent  the  state  of  physical  and  mental  depravity  into 
which  aofferers  with  trifacial  neuralgia  <|aickly  fall.  Although  they 
may  he  stroug  in  mind  and  body,  brave  ard  valorous  in  their  resistance 
to  paiii  and  RufferingT  a  few  attacks  often  suffico  tc  shatter  their  mor- 
aJe  and  courage  so  that  thty  becou^e  depressed,  uncoulldeut,  lacking  in 
hcpCf  and  in  a  general  way  quite  incompetent  to  decide  what  is  or  is  not 
to  their  advaittage.  This  mental  state  must  be  continually  taken  into 
account  in  treating  the  patient.  Naturally,  there  are  very  many  cases  of 
trifacial  neuralgia,  happily  so,  in  which  the  pain  is  so  moderate  that  the 
^>atieut  can  ket^p  t^r  his  work.  In  instances  of  thia  sort  the  patient's 
general  neurtJ  and  mental  tune  may  nut  be  diseemihly  loweied- 

Treatment. — The  first  indication  in  the  treatment  cf  trifacial  aevral- 
gia  is  to  discover  its  cause,  and  the  second  indication  is  to  remove  it, 
overcome  it,  or  Tender  it  non-operative»  all  of  which  may  be  sumumriaed 
under  the  derfignation  of  causal  treaiment.     In  the  mean  time,  it  may 


THB  TREATMErrP  OF  TRIFACIAL  KECRALOIA. 


367 


be  rccessaiy  to  relieve  tlie  putient's  fivjffering;  in  factj  it  is  oftentimes 
incnmb^Dt  Dei  the  physician  to  do  this  before  any  consideraticn  ie  given 
to  the  cause  of  the  pa.iQ  ur  its  removal.  Bearing  this  !□  luind^  I  s\is\\ 
ipQak  £rijb  o£  the  causal  treatment.  lb  is  not  aulficitiitt  to  a^y  that  the 
state  of  tha  buccal  cavity,  the  naaopbaryux,  the  eyea^  eare,  and  accea- 
Bory  eavitiea  be  investigated,  and  any  abnormal itiea  vbioh  they  prc^aeat 
be  corrected.  Although  this  ia  entirely  true^  some  physicians  seem  to 
pror;a*jfl  on  the  ii]ea  that  the  pain  must  hava  its  origin  in  one  cf  these, 
aud  forbhwitli  proceed  to  treat  it.  It  in  thougbt  necea^ary  to  emphaaizQ 
thia,  because  my  expfirieuce  haa  beea  that  many  patkiita  comiug  imdet 
treatmeot  for  trifacial  neuralgia-  have  had  Borne  or  all  of  the  teeth  qk- 
traoied  from  that  aide  of  the  superior  maxillary  in  -which  the  pain  ia 
situated,  on  the  supposition  naturally  that  the  pain  whir'h  ia  referred  to 
the  teeth  waa  due  to  decay  of  theae  organs.  Although  tic  dotiloureui 
may  aometiiuea  he  caaaed  by  a  chronic  alveodental  arthritis  and  defectire 
development  of  the  wisdom  toeth  which  leavea  the  gums  eipoaed,  these 
are  so  rui'e  that  they  need  not  ba  considc^red.  Moreover,  it  is  cot  un- 
commou  to  find  thttt  often  the  nasopharynx  and  eves  havi^  been  under 
prolonged  trealment  when  the  pain  is  referred  diret^tly  to  these  parta, 
even  though  there  ate  no  evidences  of  local  disease  which  deujand  suck 
treatment. 

The  general  oondition  of  the  patient'a  health  having  been  investi' 
gat^d,  the  indications  for  giving  antirheumatic,  antiayphilitie,  anti- 
malarial m^dieation  must  be  considered.  If  (be  attacks  of  pain  oceiir 
periodically,  and  jiarticularly  if  tlie  neuralgia  U  of  the  first  hranch  of  the 
trigeminal,  careful  investigation  of  the  blood  should  be  made  for  the 
malarial  plasmodinm-  If  plasmodia  are  found,  quinine  should  be  given 
in  quantities  suflioient  to  rendi^r  the  parasite  quiescent,  and  then  tha 
general  nutritional  tone  so  restored  by  means  of  the  adnkiniBtration 
of  arsenic,  in.in,  and  the  application  of  aoine  form  of  physical  therapy, 
that  the  plasmodia  will  be  removed  from  the  aybtem.  The  most  aat- 
iafaotory  way  of  administering  qninine  will  vary  with  the  intensity  of 
the  infection  and  with  the  constitution  cf  the  patient.  It  ia  weU 
known  that  in  malarious  localities  and  ecuntries  the  same  person  will 
tolerate  ineompatably  larger  qnaniities  of  quinina  than  when  in  a  lo- 
cality free  from  malarial  iDfeetioa.  Happily,  quinine  has  tha  capacity 
to  bliint  the  coiiLluctivity  of  the  sensory  uervea^  and  therefore  acts  as 
a  pain  reliever,  ao  in  malarial  neuralgia  it  fulfils  a  double  indication. 
This  latter  quality  may  account  for  the  fact  that  in  some  cases  of  tri- 
facial neuralgia,  even  in  which  there  is  no  malariril  infection,  the  ad- 
ministration nf  quinine  ia  often  of  benefit-  The  Bame  may  lie  sriid  of 
arsenic,  whir;h  ii  leally  a  potent  measure  in  the  cure  of  many  neuralgic 
affeotiona.  It  shouUl  be  givi?n  either  in  the  ahapo  of  Fcrwler's  solution 
■nJ  combineci  with  one  of  the  simple  bitters,  such  as  cinchona,  and  tha 


358 


TBEATMBNT  OP"  D19KASE8  VT  THE  NEKVOUB   SYSTEM. 


doaa  increased  from  three  or  four  drops  three  tinjes  a  (lay  up  to  MUtea 
or  twenty  dropSj  aud  perhaps  even  liiglur,  or  araeuiate  of  eoda.  That 
is^  it  should  ho  hicreAsed  until  its  phyHiologii^al  actiou  is  wpII  nanifest- 
If  there  asema  to  lie  a  rlieuiuatitj  elenient  in  tlie  attack  tbe  lattei-  prap&ra' 
tion  Diay  be  given  io  coDnection  with  alkaliea. 

Without  a  history  of  eyphilia  or  aome  iiidicatioDs  of  ayphilia  that  &raj 
disoemibJe  to  tha  eye,  it  ia  diMi^^uit  to  foiK^Iude  thiit  a  trifaoiiU  netiralj^A- 
calla  fur  anlisyphilitio  medicatioo,  even  tliougli  soma  of  tbe  accessory 
occurrenf^ea  of  the  fiymptom  suggest  the  eyphilitic  origin  of  the  Deuralgia. 
WLeu,  hovever,  tlio  pit^vicuH  iufectiou  by  s^philia  ia  uuc^uuationable^ 
and  especially  when  there  are  any  dcjaotistrabla  eonditioi^a  pointiog  to 
syphilia,  there  ia  urgent  jieceBaity  for  iuaugurating  troatmeot  by  mercury 
and  the  iodides,  proviijing,  of  course,  the  neuralgia  is  not  a  paraayphilitic 
expreesion.  UsLiallyf  Gjpbilis  causes  trifacial  neuralgia  by  producing  a 
perioatitia  of  oue  of  the  cauala  or  foramina  through  which  the  uervo  or 
flome  of  ita  branches  poas,  Thia,  at  Icattt,  id  true  of  the  Deuralgiaa  oc- 
curring in  tbe  early  career  of  the  affection.  Tbofio  that  acooinpany  late 
inanifestationa  of  sypMlis  are  d^ie  primarily  to  degeuei-ation  which  it 
causes  in  the  Iilocd-veaeela  from  wliich  the  disordered  nerve  receives  ita 
nutrition.  Suoh  cases  may  demand  marc^urial  treatmeiiti  but  tbey  re- 
quire the  administration  of  Iodide  of  putaaaiuni  or  of  aodiuin,  aud  the 
vascular  dilators  more  urgently  than  they  do  the  former,  Jtowcrer, 
every  case  of  syphihtic  endarteritis,  it  luattera  not  how  far  removed  it  is 
temporarily  from  the  initial  infeetiou,  calls  for  uiercu rial  medication.  Iii 
two  caspHof  trifacial  neuralgia  ofcurring  in  syphiliti^s,  1  have  aeen  benefit 
result  very  quickly  when  tbe  inunctioua  of  merfiury  were  applied  to  the 
side  of  the  nei:k  aud  face  and  behind  the  ear.  It  may  be  that  the  rub- 
bing and  massage  had  some  iuHueuce  in  accelerating  the  response  of  the 
pain  to  this  treatment. 

Trifacial  neuralgias  which  occur  in  the  wake  of  the  infectiouB  dia- 
eaaea,  such  as  influenza,  pnenmoiiia,  and  typhoid  fever,  aa  well  as  those 
occurring  after  refrigeration  and  with  the  vasculai-  and  articular  phenoin- 
eua  of  rheuniatism,  are  vary  often  iiuiokly  ameliorated  by  the  adminia- 
tration  of  the  ccmmoa  analgesics  :uid  antirheumatioa :  phenacetin,  antl- 
pyrin,  antifebriu,  ealipyrinj  and  the  salts  of  aalicylic  acid.  The  dose  of 
each  one  of  thssB  substances  must  lie  determined  fur  tbe  individual  case, 
but  it  needs  to  be  euiphaaLzed  that  larger  doses  of  almost  any  one  cpf  these 
substances  can  be  given  in  neuralgia  aud  with  better  results  than  in  any 
other  condition.  Their  admiui  strati  on  should  be  aasooiated  with  eiimiQa" 
tive  treatmeot,  more  particularly  by  tha  giving  of  subatances  that  stimu- 
late the  activity  of  the  kidneys,  the  bowels,  aud  the  skin.  If  there  is 
phrenic  constipation,  it  should  be  vigorously  combated,  for  a  well-estab- 
liahed  relationship  evists  between  this  condition  and  the  occurrence  of 
trifacial  neuralgia.     Wiatever  means  may  lie  laken  to  overcoino  it,  it  is 


THE  TREATMENT  OP  TRIFAaAL  NElTRALaiA. 

we]\  td  b«Ar  iu  mind  tbat  some  iiitestiikal  anUseptia  can  be  Adir^anta- 
geoiisly  gi^Btk  at  the  same  time,  such  aa,  for  isstancB^  tbe  following 
fonuLiU: 

^  Ext-  casi'ara  sa^adn,  -.,,.-.  S  ■>. 
E^L  tiuuiA  vuniicie,                   ,         -         .  ,     fjT.  1}. 

Eit_  alwB.                ,  K'-  iij' 

Ichihjol. gtt.  xvi.-  im. 

M.   ft.  caps.  Ifo.  xiL     One  CApAula  (o  be  taken  three  tjm«aadni  kfler  me&ls. 

Vety  Batdstactorjr  roaulta  in  OTeroomiDg  chranio  constipation  hy  tlie 
use  o£  water  have  been  gained  by  Guaaeabftuer,  who  dirocts  tlxat  it  bo 
utiJiaed  in  the  following  way :  Tho  patient  reeaives  a  cold-water  clyalet, 
adminUtered  in  tbe  ordinary  way,  with  a  syringe,  every  day.  In  severe 
cases  the  iiijet^tton  is  intruliiceil  by  latiana  of  a  recUd  tiibu.  tn  addition 
to  tbia,  tho  abdoinen  is  ntbb«d  fur  af veral  minutes  uni'e  a  day  with  cold 
water,  and  for  the  remainder  of  the  time  the  abdomen  ia  covered  with  a 
Prieaanitz  compreaa  or  Neptune  weirdie-  Cold  water  may  olao  be  applied 
over  the  entire  bodyfi'oiti  the  palm  of  an  attendant's  hand.  These  regn- 
lations  are  kept  up  until  the  howeEs  berome  regular  in  action  and  copious 
in  the  amount  of  their  discharge.  If  this  reuult  cannot  be  obtained  from 
the  meaaarea  mentioned  and  from  a,  regulation  of  the  diet,  it  is  tecoiU' 
mended  that  the  patients  go  upun  a  full  milk  diet*  Following  this  plan, 
the  author's  results  have  been  very  gratifying.  Meaaarea  looking 
toward  the  impi-oveiuent  of  the  ]:iatient*s  general  nutrition,  whether  they 
consist  of  administration  of  Iron,  t-od-liver  oil,  etc.,  the  applieation  of  hy- 
driatir^  in  the  way  already  deseriljed  as  of  bpuelit  in  neurasthenia,  in- 
ducing the  saO'erer  to  makea  change  of  ulimatdandof  surroundings,  must 
be  adapted  to  eaclx  case,  A3  a  general  mk,  jiatieula  with  any  form  of 
neuralgia  are  better  when  they  live  in  a  moderately  warm,  dry  climate. 
This  allowa  them  to  be  out  of  doors  most  of  the  time.  Even  a  temporary 
sojourn  in  such  a  place  is  followpcl  hy  an  improvement  of  the  general  nu- 
trition and  by  amelioration  and  [Kjasibly  disappeai'auf  e  of  the  neuralgia. 

Under  causal  treatment  there  reniaits  to  bo  consi^lered  the  treatment 
of  trigeminal  neuralgia  occurring  with  arteriooapitlary  fibruAia,  Tbi^ 
form  of  vascular  degeneration  is  probably  responsible  for  more  cases  of 
trigeminal  neuralgia  oeeurHng  in  the  lalter  third  of  life  than  all  tlie  other 
enumerated  etiological  conditions  coinbLned.  The  clinical  form  of  tic 
douloureux  that  accompanies  such  conditions  is  somewhat  different  from 
that  asaociabed  with  refrigeration,  trauma)  inboKLcations,  and  after  infec- 
tions. Jt  may  not  be  of  such  unbearable  sereril^,  but  tbe  paroxysms  are 
more  likely  to  be  of  frequent  ooourrenee.  They  la^t  longer,  stuI  they  are 
Tery  raiiclj  leas  amenable  to  treatment,  Th<*»e  attributes  may  not  be 
dependent  entirely  upon  the  arteriocapillary  fibrosiitj  they  may  be  cansed 
10  part  by  the  coincident  disparagement  of  nutrition.  From  a  therapea" 
tic  fltandi>oint  thia  group  of  cases  haa  formed  the  moat  unsatisfacCory  of 


360 


TREATMENT   tyfr   DISEASES   OF  THE  NEftVOUS  flYfiTKM. 


all  tli^ao  cases.  It  has  usvLtJly  heGa  recommeniieii  that  the  meaaures 
known  to  ha,ve  u  bE^netiuial  inlJuen^.'^  ud  arterial  ilegenBratLon,  such  aa 
potuBsluiu  iudidi.-  ur  sodiutLi  iodide,  l>e  given  in  coLinection  witph  nitroglj- 
cerin  and  nitrite  of  BoiLa,  and  with  smaJl  daada  of  digitalis.  In  trntb, 
this  treatment  liaa  not  been  attended  with  vcty  i^rilliant  Ttaulla.  Re- 
cently Dr,  C-  L.  Diina,  utilizing  the  euggeetioii  of  I?r.  G.  R.  Elliott^ 
hELS  iiaeil  lafge  doses  of  stryeltnina  hypodetmntieally,  either  iiLlo  tlio 
tissues  wliidi  are  the  seat  of  the  pain  or  into  other  parts  of  lliti  biidy, 
nud  at  the  same  time  putting  tl^e  patinit  thixingh  a  rest  cnre  with 
lill  thnt  it  inipHos  concerning  re^Ldatiou  of  diet  and  reinforcement  of 
nutntion  by  the  ^dniinistratioii  of  food,  iron,  and  arsenic.  The  iodind 
salts,  and  nitroglycerin  if  specially  indicateilj  sliould  also  he  adminis- 
teretl.  The  beginning  dose  of  nitnite  of  strychnine  i a  from  one-fortieth 
tn  one-siitieth  of  a  grain.  This  ia  increaat'd  daily,  so  that  at  the  end 
of  a  week  tho  patient  is  taking  from  one-eiehth  to  one-fonith  of  a 
grain  uz  each  injection.  Tbe  vahie  of  tbis  mode  of  treatment  ia  ideally 
great.  I  ha.vQ  bad  a  Lunab^r  of  cusea  yie]d  to  it  when  all  othtr  inediciaal 
treatment  had  frilled.  The  cases  for  its  application  must  be  seleeted, 
however^  and  the  difieipliiie  of  the  re^t  axira  muHt  hu  o;Lrried  out  io  si] 
its  details.  At  the  present  time,  it  seeiuB  to  the  writer  advisable  to  rec- 
ommead  that  tho  iDJc<^liouQ  of  atrychaine  be  given  (combined  with  mor- 
phine, the  Jatter  in  doaoa  ouo-half  of  the  amount  of  strychnine.  The 
treatment  must  be  kept  ap  fi<om  six  to  twelve  weeks.  In  tho  ciajority 
of  cases  it  is  by  no  ire^tTis  necessary  to  keep  the  patieDt  in  bed  the 
entire  time.  Indeed^  in  souie  cases  it  may  not  be  advisable  to  keep  the 
patient  in  bed  continuously  for  any  of  the  time.  It  may  only  be  neces- 
sary for  him  to  lie  dovTi  for  an  hour  before  and  an  hour  between  meahf 
while  if  the  parosysma  of  paiu  ai-e  not  frequent  and  eevore,  the  remain- 
ing houi-3  of  the  day  are  spent  in  the  open  air. 

The  local  treatment  of  trifacial  neuralgia  is  by  no  means  so  importinfe 
as  the  symptomatic  and  the  constitutioual  treatment*  The  moat  important 
local  measure  is  electricity,  ll^nfortunately,  enthnsLaalic,  intemperate 
eleetrotherapeaticB  has'O  come  near  to  bringing  this  agency  in  the  treat- 
ment of  the  tio  douloureux  into  disrepute  by  advancing  claims  for  its 
clBcienpy  which  conld  not  be  substantiated  by  the  average  prBctitioner 
who  understood  its  nse.  It  is  an  agency  of  comparatively  small  value 
in  tbe  treatment  of  trifacial  neuralgia,  yet  the  hene^t  that  is  some- 
times  derived  from  its  use  is  suthciently  great  to  warrant  giving  it  a 
4*enapicuoua  place,  particularly  when  we  recall  that  no  one  di'ug  or 
physieal  agent  is  pre-eminently  useful  in  this  condition.  Any  form  of 
electricity  may  he  UBed^  but  it  la  generally  agreed  ujhiu  by  neurolngisis 
that  the  galvanic  current  \^  more  [serviceable  \}v.uj  the  faradlc,  whilt' static 
electricity  is  of  no  other  service  aave  in  assisting  to  increase  the  patientS 
general  nutrition  and  resistance.     The  mode  of  application  of  the  gal- 


THE  TREATSiKNT  OF  TRIFACIAL  NEUBjLLGIAh 


361 


vanic  current  is  nub  all  imyoitaQt.  Aa  a  rule,  the  positive  pole  should  be 
placed  over  the  p^iinful  area  and  the  negative  pole  on  some  indifferent 
p]a<:e,  auch  as  the  back  or  the  sternum.  The  fa.cial  eleetrode  may  be  o. 
small  ontif  or  it  may  be  lavge  enough  to  cov&r  the  entire  sida  of  the  face. 
In  the  tirflt  caae,  a  cuiTeiit  of  from  two  to  four  milUampeTes  ia  allowed 
to  flow  fur  from  five  U)  ten  iDitiulr^s,  the  application  lieing  a,t  flrat  at&- 
1>i[d  and  afterwaid  labile.  In  the  latter  caae  a  omrent  of  from  one  to 
t^^O  milliamperea  should  be  allowed  to  pusa  for  from  one  to  eeversd 
house  a  day^  (.^fteiitimea  the  pain  la  greatly  i-elJeved  by  this  plan  of 
long -continued  application  of  tlio  eiiTTeuL  Galvanism  seems  to  be  of 
greater  servioe  in  tha  very  aoute  teases  which  develop  after  refrigeration 
and  the  iutoiicatlons  and  infections  tbau  in  the  subacute  and  chronic 
fonna.  I  have  ticver  seen  much  benefit  from  the  use  of  the  faradic  brush 
OOT  from  the  appheaticn  of  the  lapidlj  vibrating  induced  current.  On 
tiie  other  hand,  the  administration  of  cocaine  and  aconitine  by  means  of 
oataphoresis  (aee  page  10."')  has  pi-oven  very  b^ueficial  in  some  instances. 

The  next  most  important  louil  application  i»  heat-  Thta  ia  best 
applied  by  means  of  a  closely  matted  coil  of  Bmall  rubber  tubing,  tvliich, 
laid  on  the  aide  of  the  htad  and  face,  doeeiy  adaptij  itself  to  it,  A 
Btceam  of  water  of  a  temperature  of  from  98''^  to  105"  is  allowed  to  flow 
tbrougJi  the  tubing  rery  slowly  but  constantly.  One  of  the  moat  obsti- 
nate cased  tliat  I  have  ever  had  under  treatment  was  relieveil  by  the  ulili- 
zatioa  of  thta  measure  kept  np  for  a  number  of  -weeks-  The  patient 
meanwhile  was  put  through  a  rest  cure  and  given  small  doses  of  iodide 
of  potasflium  and  tonics.  The  patient  was  a  woman  eixty-one  years  old 
in  whom  the  sjTuptonis  were  associated  with  marked  trophvo  distTirbances 
of  the  skin,  half,  and  soft  tissues,  She  refused  to  receive  injpctions  of 
atrychuine  and  morphine  which  wan  propotied^  and  this  plan  was  tried  as 
a  substitute,  fortunately  with  good  results.  Moist  heat  may  also  be  uaed, 
but  the  dif)icuUy  uttending  its  oonstant  applicaLiou  niilitatca  against  it 

It  is  difficult  to  estlujate  the  worth  of  eounternrritatiou  in  trifacial 
nfiuralgia.  Almost  every  substanca  that  will  irritate  or  inflame  the  skin, 
varying  from  the  rtppli^-ation  of  tincture  of  indine  up  to  the  actvial  rau- 
tery,  bnj^  been  recommended  and  tried.  At  the  present  day  they  do  not 
have  a  rery  conspicuous  position  in  the  therapy  of  this  condition,  Rtim- 
nlatiiig  iinimonls  and  oiutmouts  are  occasionally  of  soiuo  sorvico  in  re- 
lieving the  pain-  The  action  depends  in  the  case  of  the  liniment  u]>ou 
the  cooling  of  thd  skin,  which  is  brought  about  liy  evaporation  and  by 
maaaage  of  the  parts  lo  whioli  it  h  applied.  The  eMcaciotisuess  of 
the  oiutments,  unless  some  active  pain  reliever,  such  as  opium,  bdla- 
doQ&at  or  cocaine,  is  a  constituent  of  them,  la  dependent  entirely  upon 
the  ntaasage.  Not  that  I  mean  to  eay  that  madsage  itself  is  of  great 
value  ni  the  rehef  or  cure  of  trifacial  neuralgia.  It  d'^es,  howevpr,  ^^^ 
very  eJiiciBntly  in  some  instances,  and  especially  in  those  caaas  in  whiclj 


8G2 


TBKATMBNT  OF  DISEASES   OF  TRK  NERVOUS  BYSTSM. 


the  trifa<*ial  neurnlgm  ia  dtvelopetl  u^ioii  a  diathetic  condition,  such  as 
rh^^umatiaui,  gout,  and  sfow  degeueration  of  the  blood-Yeaselif.  The 
moda  (?f  its  application  ib  by  no  nieaiia  sd  iropurtant  as  ths  Sn^iUsh 
school  of  ntasseura  would  have  ug  beHeve,  The  foUuwiiig  forntula  pro- 
Tides  a  ImiujtDt  whic:'h  can  often  be  used  advantageously  in  acute  tii- 
facl&l  neuralgia: 


4  Campbone, 

Cblomt., .IJI3L 

&i|t  Hub  on  A  fow  drops  ata  lioiB. 


J 


y&noiiii  forme  of  meohanicol  devicea  have  heen  reoonnnended  m 
tho  troatinent  of  trifacial  nouralgia-  Boudet  has  devised  a  mMhud  by 
which  the  vibrattcnia  of  a  tuning-foik,  maintaineil  by  an  electrical  cm- 
nut,  are  applied  directly  to  the  nervd  or  its  braoehee,  A  piece  oj 
wood  about  one  ceatimetTC  in  diameter  attached  to  n  tuning-fork  in 
couuectiuii  with  the  electriciil  current,  ia  placMl  over  the  |i&iuful  point. 
The  incesaantaud  rapid  alight  Uowa  on  thia  pi&cd  oC  wood  inducea,  he 
aontends,  a  loi^al  aniuBthesia  and  is  attocded  with  marked  soporific  ef- 
fect, Granville  baa  likewise roustruolfld  a  percuaHor  whieii  acts  in  a  vetj 
similar  wny,  and,  according  to  ths  author  and  some  other  writers,  with 
beaeliciHl  elTcct. 

The  Surgical  Treatment  of  Tic  doLiloareua. — Despite  the  great  number 
of  drugs  that  are  rooommendediiBBOrviceabJe  iulho  treatniontof  thiacondi- 
tion,  and  notwiih standing  the  macy  phyaical  agenoiea  that  are  employed  for 
its  relief^  a  oocaideTable  percentage  of  all  the  caaes  of  severe  trifact^  neu' 
rnlgia  do  not  yield,  at  lea^t  with  any  degree  of  permanency,  to  any  or  all 
of  theac  meaauren.  Tliis  condition  of  afl'aira  has  created  a  demand  for  aur 
gical  interference.  The  adTiaability  of  performing  any  operatioo  upon  the 
trifacial  ner^'e  ot  the  GafiBeriaii  ganglion  has  not  yet  been  satibfactorilj 
aettled,  notwithatandrng  the  great  number  uf  oi)eralions  that  have  been 
done  and  the  strikingly  beuefieijU  results  that  have  been  reported  to  follow 
such  ojieratioua.  Miuiy  neurologiHta  ot  large  experinnne  contend  that  the 
results  of  o^TfrationT  be  it  neurotomy,  neurectomy,  iieureiaresiB,  or  partial 
or  complete  cxCdrpation  of  tho  <.iassertati  ganglicn,  do  not  justify  surgical 
interference  save  in  exceptional  inEitancea.  Surgeons,  on  the  other  hand, 
iKLaintain  Lbat  their  fitatistica  sie  aiich  as  to  w.irrant  them  in  undertaking 
any  of  theae  sntgical  procedures  that  may  seem  to  be  indicated  in  a  given 
case.  It  should  nut  be  forgotten  in  eatimating  the  factors  for  and  against 
o^^eration  that  trigeminal  neuralgia  is  in  the  majority  of  coacs  a  aelf-lim- 
iting  diseaae,  and  if  its  intensity  can  be  so  modilied  by  drug  and  mcchani- 
oal  therapy  that  the  patient  can  withstand  it,  the  disease  wt31  get  better 
of  itself.  On  the  other  hand,  the  sufferer's  courage  ia  often  so  weskened 
that  he  warmly  af'cepta  any  procedure  which  gives  him  promise  of  relief, 


THE  TREATMENT  OF  TftlFACI^L  KRCRALOIA, 


363 


«T«n  though  it  be  &  dangenma  one,  t3  eztirpfttioo  of  the  Gaascnac  gui- 

Tbe  tirat  opeT&tion  that  was  fluggeeted  foi  the  relief  of  ttifacikl  iieii- 
r&lgift  was  section  of  the  temporal  mod  occipital  TCins.  Trousseau  ra* 
portwi  Borae  casea  that  had  bf»en  eiibjected  to  this  treatment  with  appar 
catit  bcueficial  resulta,  but  his  &QCGea5  aeems  to  hikre  templed  uo  imitators, 
preuion  of  the  c&iocids  and  orea  li^ttire  of  them^  vas  abo  applied 
in  I  Qiuaber  of  cases  and  apparently  ^th  similar  good  refiulte ;  but  this 
iko  quickly  fell  into  disrepute.  Simple  sectton  of  the  painful  brauoh  of 
tht  trigemiDal  nen  a  was  the  next  surgical  procedure.  This  always  sne' 
tt^rd  in  relieving  the  pain  temporarily,  but  it  invanably  recurred,  &o 
IhAC  at  the  present  time  the  operation  of  neurotomy  is  rat^ly  uudettak<-n, 
Neurectomy  of  the  painful  branch  ia  the  jirocednre  that  is  unqueetiooablj' 
Jwked  upoa  with  most  favor.  Exposure  of  the  paJoful  nerve  by  opera* 
to  Bnd  patling  it  out  from  its  euiroundings  ho  a^  to  thoroughly  streh:h 
lb«ifi1iree  liare  likewise  fallen  Eome^vbat  into  di;^ repute;  although  JLiclglng 
from  the  atatiatira  this  is  the  moat  useful  aTailable  surgical  procednrenot 
lUdided  with  considerable  danger.  It  should  always  be  tried  before  rec- 
<icjinending  the  ps.tient  to  submit  to  extensive  extra-  or  intracrnuial  rea^e- 
tion  or  extirpation  of  the  ganglinn.  There  can  be  no  qiieRtion  that:  these 
Bflvent  operations  should  be  undertaken  in  cases  that  are  totally  imamen- 
Ableto  &11  other  forms  of  therapy. 

The  ntortality  attendini;  complete  eatirpatitjn  of  the  Gasserian  gan^ 
glino  IS  Uss  than  twenty  per  cent,  and  although  its  removal  is  attended  by 
^Miy  diaagreeable  shortcomings  the  relief  from  agony  more  than  counter- 
^BHuices  them.  One  nr  all  *•(  the  peripheral  operatioiis  sliould  alnitya 
U  doae  before  the  more  radical  one  is  thought  of,  even  thougli  the  pain  be 
ol  til  the  branctiea  of  the  trigeminal  aen'e.  But  Eione  of  them  should 
be  advised  until  the  possiljility  of  cure  by  medication  has  been  ex- 
iaost^d-  If  division  of  the  peripheral  nerves  and  thorough  stretehing 
bil  to  afford  relief,  nothing  short  of  the  radical  prucedure,  uaitkoly,  ei- 
«noa  of  tbe  ganglion,  should  be  cousidered.  Operationa  for  removing 
CKtracraELiEd.  sogmenta  of  the  Mth  neive,  such  as  Meckel's  ganglion,  and 
ligAtion  of  the  carotid,  are  to  be  rejeeted- 

There  are  many  methods  of  performing  the  intracranial  operation. 

Tbfi  technique  varies  with  the  operator.      The  one  most  favored  at  prea- 

Cut  is  the  Hartley 'Kiause  method.     A  horseshoe  ^shaped  l^ap  is  made,  the 

bue  of  the  flap  being  the  zygoma.    An  osteoplastic  flap  is  cut  by  chisels, 

tLhe  Oigli  saw,  or  the  surgical  engine,  and  the  buse  of  the  Hap  is  hrokrn 

by  prying  the  bona  outward.     Tbe  dura  ia  separated  from  the  middle 

fcBHL.     The  thirfl  division  of  the  nerve  is  found  at  the  foramen  ovale  and 

tiie  second  dtvisLon  at  the  forameri  rotunduin.      Each  nerve  Ja  cut  through 

above  ltd  foramen.     The  nerves  are  followed  up  to  tbe  giuiglion,  and  the 

latter  being  then  exposed  is  grasped  with  forceps  and  twisted  out,  and 


364 


TEEATMEKT  OP  DISEASES  OP  TEE  yERVOUS  SYSTEM. 


during  the  twisting  Lke  aeusory  ruot  will  uauaUj  Le  brought  out.  The 
pressing  danger  ia  heroorrliage  fi'om  tlie  middle  meningeal  artery  or  from 
the  Tfins  ou  the  floor  of  the  akiiil.  The  oparation  is  ao  hckzardous  that 
it  should  be  undertliken  only  by  most  skilled  and  expert  en  [?ed  surgeons. 
The  eiiTire  gariglioii  shanld  ht*  rpmoved.  Immediately  after  nperatioQ 
tfaelidflof  thd  COT  responding  side  should  be  stitched  together^  an  opening 
beini^  left  at  each  cfiuthua  for  draioaage.  At  the  end  of  about  s.  week  the 
etitchea  are  removed  and  the  eje  is  cohered  with  a  Buller'a  shield. 

Treatment  of  the  Attaok.— The  piLiiL  of  trifacial  neuralgia  ia  of  auoh 
oharacter  and  intensity  that  it  deioande  immediate  relief  in  very  many 
castiS,  ^"^  ^be  only  suLstiUK'O  that  can  be  relied  upun  tv  do  tbis  ia 
morphine.  As  in  all  other  eoitditiona  having  a  tendency  to  recur  and 
to  bo  chronic  in  their  courae,  the  adminifitratiou  of  niorphiuc  should  be 
avoided  if  posaible^  or  at  least  delayed  until  other  aubfltaneefl  potentially 
leaa  injurious  h^ve  been  ti'ied-  This  statement  should  not  be  consttued  to 
mean,  however,  that  the  injection  of  morphine  is  not  often  immediately 
called  for.  Tn  tho  bugianing,  efi[iecially  rjf  acute  cases,  .one  or  two  injw!- 
tiuna  of  morphine  ijhouM  be  given  and  followed  by  the  administration 
of  ant  in  ou  rallies  that  operate  more  alo^ly  but  with  leaa  certainty,  such 
OB  aconitine,  gelaemium,  butyl  chloral,  and  the  analgesics  of  synthetic 
constitution.  An<mitine,  given  in  gr.  jj^^  doses^  in  the  beginning  every 
four  himrs,  is  freqneotly  a  ]»otent  meiisure  in  relieving  the  pain,  pro- 
viding it  be  carried  bo  tho  point  of  fall  physiological  action.  Tt  ifi  B 
powerfiii  poison  and  its  effect  should  1«  watched  very  closely.  If  the 
neuralgic  pain  continuea  after  tha  aconitine  showe  its  effecta  by  Gauging 
benumbing  of  the  JipSf  tongue,  and  extremities,  very  little  benefit  is  to 
bo  eipeeted  frcim  its  continued  use.  Fhiid  eiiraet  of  gelsemium  semper- 
virena,  given  In  five-drop  doses  every  three  hours  and  tnerensed  until 
ita  full  physiological  action  is  obtained,  is  likewise  of  service  in  some 
cases.  But  if  benefit  doea  not  seem  to  follow  itd  adminibtration  after 
Bueh  poisonous  elfect  as  alight  temporary  motor  paralysis  occurs,  its  use 
should  be  abandoned.  Aconite  and  geUemium  may  be  gi?en  together  as 
in  the  following  mixture  t 

^  Tinat»  aconUI 5ea> 

Tiui^t,  ^lamujl ^  [v. 

Sig.  Tan  drops  fiveiy  hftlf-hooT  t1  II  tingllT^s  it  felt  In  U10  Sngen. 


The  hydrate  of  oroton  chloral,  called  butyl  chloral,  ia  a  drug 
that  has  been  considerably  reeommended,  given  in  doses  of  from  two 
to  three  grains,  combined  with  glycerin  and  with  water.  Its  effects 
ate, by  no  means  constant,  and  it  is  quite  iniposaibJe  to  say  whether 
or  not  it  will  ha  serviceable  in  any  given  case  until  trial  cf  it  has  l>een 
made.  It  baa  the  advantage  of  promoting  sleep  while  relieving  pain - 
The  same  results  are  to  be  obtained  from  giving  brom  Id  ia,  which  is  a 


THE  TREATMENT  OP  TRIFACIAL  XECRALGIA. 


365 


mlxtuie  of  cMoral  lijilrate^  bromide  of  potasBLuui,  extract  of  caiinabis  in* 
dica,  and  byoscyanma^  But  aa  each  toaapuonful  coDtains  fifteen  graiiia 
of  ohioral,  it  can  readily  be  seen  tliat  this  mixture  should  not  be  kept  up 
foe  any  conaiderable  JeEgth  of  time. 

The  local  injections  that  are  most  s«TTiceab[e  io  relicTiiig  pain  are  a 
one -per- cent  solution  of  osniic  anid,  eitbet  in  water  or  gijctrin;  a  two- 
percent  solution  of  carbolic  acid^  in  from  one-  to  ten-drop  doses;  and 
&  one-  to  tive-per-cecit  solution  of  methylene  blue  in  frora  three-  to  five- 
drop  doses.  Although  osniic  acid  ie  a  powerful  esoharoti^i  and  even  in 
thla  weaJc  solution  ni^y  cauae  tissue  uE-erusis,  it  is  ne^^ertbeleia  a  Euh- 
HtiUice  whose  aLlmiuistration  has  been  attended  with  such,  excellent  rs- 
Hutts  that  its  uaa  ia  rticommeuded.  The  techfLique  of  tKis  method  i&  &a 
follows^  The  nerve,  havijig  been  exposed  at  the  spot  indicated  by  as 
small  an  incision  Ets  possible,  rarely  moro  than  balf  an  inch  in  lengtl^  ia 
hooked  up  so  as  to  fijt  it.  The  freshly -prepared  solution  of  osmic  acid  is 
then  injpoted  with  an  ordinary  hypodermic  needle^  properly  ateriliied, 
directly  into  the  substiincfl  of  the  nerve.  The  total  amount  injected 
should  bo  from  £re  to  ten  minima.  Bennett,  of  London,  in  whose  hands 
thia  methcKl  of  treatment  haa  been  very  suocosafu],  recommenia  that  this 
amount  should  be  iotrcduoed  in  t^o  or  three  separate  injectioias  in  order 
that  the  whole  nerve  may  be  as  Luuuh  na  possible  soaked  in  the  solution. 
Dutiug  the  injecticns  a  pledget  uf  sterili^.ed  gauze  should  bu  LeM  firmly 
around  the  needle  at  the  orifice  of  the  wound  iu  order  to  prevent  the 
escape  of  the  fluid  externally.  Thg  effect  of  the  solution  upon  the  soft 
tissues  is  s^n  immedifLte  blackening.  The  wound  unites  by  primary 
union. 

All  in  all,  the  treatment  of  tic  doubureux  is  a  problem  that  should 
bo  approached  with  great  deteruiination,  Ixjth  on  the  part  of  the  physieiau 
and  on  the  part  of  the  [latieut.  The  latter  should  try  to  eliminate  im- 
patience and  despair,  while  the  furmor  should  denide  definitely  upon  a 
plan  of  treatment  and  carry  it  resolutely  through  to  conipletionj  whether 
it  be  to  ignominouH  failure  or  to  partial  or  complete  suecess.  He  should 
studiouT^ly  avoid  therapeuT.ic  vadllatioii,  giving  one  drug  or  mode  of 
treatment  tti-day,  mid  changirig  to  another  to'morrow  because  tlie  first 
haa  not  been  of  signal  service.  The  physicau  should  always  keep  before 
the  patient  the  fact  that  the  disease  is  in  reality  a  self-limiting  one  in  the 
majorl^  of  instances  and  that  time  may  be  oonEidently  counted  upon  to 
briog  with  it  relief.  Tu  the  uisiin  time,  his  life  should  be  so  arranged 
that  injurious  inHuencei^  wtneh  precipitate  an  attaclc  of  neuralgia  or  keep 
it  U[)  after  it  has  oct^nrced  will  nut  be  operalivt;  while  the  general  health 
end  nutrition  are  maintained  at  the  Lighedt  posaiUd  level. 


CHAPTER  XXIV. 

THE  TREATMENT  OP  NEtHtALGLA  OF  THE  CERVICAL  PLEXUS. 

The  two  varieties  of  neuralgia  m  tlie  domain  of  the  cerwioal  pl^itLg 
Lliat  rrquire  individual  ^ment]4)a  are  uccipltal  neuralgia  aiid  cervico'br^- 
diifd  neuralgia.  Occipital  iieuralgiar  or  neuralgia  of  tha  occipitalis  majoi 
aod  minor  and  tlia  great  auricular  nerves,  ia  the  moat  common  fonn  of 
iiiiuralgia  in  tho  cephalic  extremity.  It  is  sontetimca  but  not  always  aa- 
sodated  with  pain  in  the  distribution  of  the  euperlicial  cervical,  and  the 
flupraolavinular  nerves.  In  my  experience  it  is  one  and  one-half  timea  li 
frequent  aa  trifacial  n^uialgia.  The  moat  common  location  of  the  pain 
ia  In  the  diattibution  of  tlje  great  occipital  nerve.  The  pain  of  occipitaJ 
neuralgia  may  be  continuous,  but  it  ia  liable  to  p^roKysmal  outburate^ 
It  ia  lisaoeiated  with  more  or  less  eensitiveneaa  of  thoskin  over  the  af- 
fected area,  and  occasionally  with  local  and  rejected  vasomotor  disturb- 
anu^B.  It  may  radiate  into  the  buck  or  neck,  and  oocaaionallj  it  invadu 
one  or  mote  of  the  braui'lies  of  thetri^iuinal  nerve.  The  comniob  causea 
uf  occipital  neuralgia  are  e:ipoanie  to  cold  and  wet;  direct  trauma;  local 
dmease,  such  as  of  the  cervical  vertobnc,  the  cervical  inlands,  and  very 
rarely  of  the  cervical  blood-Teasels ^  cervical  pachymeningitis;  aod  con- 
Atttutional  shortcomings,  such  as  anemia,  intnitication,  prist- in fectioiu 
states  of  the  blood,  and  exhaustion,  factors  that  are  no  iMinimon  in  all 
forma  of  ucviralgia. 

Treatment  of  Occipital  Nenrat^a.— Before  attempting  to  treat  occipi- 
tal neutalfjia  it  is  importiiut  to  diatin^iish  it  from  the  varieties  of  cephal- 
algia that  are  considt^red  in  the  chupteroo  headat^he.  The  most  important 
faetora  in  niakiug  tliis  differeatiation  are,  the  causes  of  the  neuralgia  and 
tender  points  in  the  distribution  of  the  afTccted  nerre.  These  tender 
points  arc  of  variable  lotatirjn,  depending  upou  the  branches  of  the  cervi- 
cal plexus  tliat  are  the  scat  of  pain.  When  tbe  large  oceipiUd  nerve  ii 
involved  there  is  ulmost  invariably  a  point  tender  to  presf^tirep  midway  of 
a  line  counectiag  the  inastoid  process  with  the  fir*it  cervical  veriebra. 
Usually  tliero  h  a  second  tender  point  between  the  anterior  border  of  the 
trapcMUS  and  the  posterior  buder  of  tbe  stern ociei do- mastoid  muscle  at 
the  level  oE  the  aeccnd  cervical  vertebra.  In  every  cose  of  oecipital  neu- 
ralgia diiigeiit  search  should  be  made  for  orgajiic  dieeaae  of  the  vertebrae, 
their  BOTimnment  and  enclosure.  Such  search  will  occasionally  he  ra- 
warded  by  the  discovery  of  a  IwginniTig  tuberculous  osteitis  amenable  to 
proper  orthopedic  treatment.     On  the  other  hand,  it  may  be  the  means  of 


TREATHEST  OF  NECBALOIA  OF  THK  CKBVICAL  PLHXl'S. 


s«r 


ixraditiou  aoch  as  Gnlu^ttd  gkn^  vhich  act  injurioualy  by 

mere  preseQce>  and  whicli  can  be  letnovfHl.     Th«  pain  of  QCi^ipit«l 

il^^  ia  rar^3y  ao  intense  that  such  examinAticm  ia  not  fcflfiible  before 

■Df  treatment  whatsoever  is  begun.     If  it  is,  the  ex«.iiiiiistion  ahoiLLd  be 

Oida unmediat^ly  after  pain-sublalog  m^d)c]n««  have  l^^n  given. 

Cutm  ot  occipital  ikeuralgia  that  are  the  result  of  «!Lp<jsure  to  colli  and 
vtf^  the  rheumatic  diathe^isj  anitmia,  and  hafmctoxic  couditionA^  are  heut- 
G»d  bj  tlio  application  of  dty  heat  and  by  tlio  iotornal  aJiainiotTatiou  of 
ib«silicjlat«s,  antipyna,  pheLalgiQ,  and  pheuacetiu  on  the  one  haad,  aad 
ntfh  blood  reatopatdves  as  iron  and  quiniueou  the  other.  Ck-oasioiially  this 
Like  other  forma  of  neuralgia,  ia  of  goutj  origin^  in  wlih^h  case  aoiiki3  pre|iH- 
mOod  of  colchicum,  aad  Epsom  salts,  should  be  administered.  After  the 
icute  paia  h^  been  subdued,  mild  counter -irritation  from  appiit^atiou  of 
noilard,  small  cfuitharidal  bliatera,  or  even  Che  actual  cautery,  is  of 
tttgifiateat  aervLce,  Galvanic  electricity  can  hs  used  with  a  coosldorable 
degree  of  asaurauce  in  oociintaL  neuralgia  of  almost  any  caasation.  Aa 
ID  ^  other  ueuralgic  eouditiona  the  anode  ahoiild  be  platted  over  the 
tender  poiitta  aad  glided  ever  the  uonrse  of  the  nerve  and  ila  branc^hea. 
Tilde  the  cathode  eonoeeted  with  a  largo  epoage  js  pliwed  on  soi»e  itidif- 
'«nat  point.  Care  should  be  taken  not  to  eu^ploy  a  current  that  vill  pro- 
'lii(«  vertigo.  A  enrrent  of  two  or  three  nii]liam|H>res  for  three  minutea  onee 
n  twire  a  day  h  flfteu  followeii  by  tbe  inoat  gratifying  results.  Oci-ipiUil 
ifijalgia  which  proves  intractaUe  and  does  Dot  yield  to  causal,  to  paiik- 
nbluing,  and  to  constitutional  treatiueot  should  be  referred  to  tho  Bur- 
/--u,  -with  a  request  that  the  offending  nerve  bo  laid  bare  in  order  that 

IIP  cause  of  the  neuralgia  con  be  determined.  If  the  results  of  sueh  ex- 
piontioa  be  ni^gative,  the  nerve  should  be  resected,  and  if  these  heraia 
nctsures  failt  the  operation  recently  pei formed  Liy  {^'hipault  mid  DemoLilin 
of  iatradural  rejection  of  the  posterior  roots  should  b«  dune  aa  a  last 
tmri.  This  variety  oiTora  a  wide  field  for  the  uae  of  the  meaauroa  that 
^Tebeen  detailed  under  the  caption  of  ths  general  treatment  of  neuralgia. 
Treatment  of  Cervico»brachial  Neuralgia, — Netitalgie  affectiona  t»f  the 
Afiu,  aside  fiom  tho^e  resulting  firom  accidental  or  purposeful  injury,  fluch 
*S  that  inflicted  by  the  surgeon,  are  uncomiuon,  compared  with  like  ooudi- 
^Mtas  in  the  lower  exttemity.  The  ulaar  nerve,  which  gives  cutane^ua 
Supply  to  tbe  lower  part  of  tlie  forearm  and  to  the  iiiuer  part  of  the  band 
^^ti  ita  palmar  and  dorsal  aspects,  seems  to  be  more  liable  to  neuralgic  paSua 
^fcaa  the  median.  Thaloeation  of  the  ulnar  nerve  attheelbawiaauch  that 
^he  nerve  is  easily  injured  by  direct  trauma  or  indirectly,  as  in  fracture 

t*^i  the  oleeranoQ  process.      Moreover,  the  ulnar  nerve  ia  eometiniea  the 
%4at  of  neuralgic  pain  in  looomotor  ataxia.     Occasionally  siukilar  pain  in 
Wii  left  upper  eitfemily  is  associated  with  disease  of  the  heart.      Neu- 
Tfclgic  pain  associated  with  paresthesia  in  the  distribution  of  the  ulnar 
EerreisnotannncommoDOOCurrencoin  gouty  subjects.    The  radial  branch 


3C8  TREATMRNT  OF  DISEASES  OF   THE  KKKVOUS  STSTKM. 

of  the  iDuaculo-epiral  i3  often  tlic  aeat  of  pain  in  brachial  neur&Igia.  The 
character  of  the  paiu  and  its  localization  niil  dBpend  upon  the  eausatton 
of  the  D^uialgia  and  the  n^rvea  involved.  The  nnmber  aixd  looAtion  of 
painful  poiiils  will  vary  also  in  the  same  way^ 

III  ditiCUHsing  the  treatiueiit  of  brachial  ueuralgia,  the  cnlj  special 
etiological  factor  ihat  requires  co us i deration  apart  from  thofie  lueutiooed 
under  the  geuercd  cauaaticu  of  neuralgia  la  that  of  occupation,  <>ciipa' 
tioQS  and  piofesfiionfl  requiring  exhausting  -a&e  of  tlie  uiusf^Ies  of  the  dif^ 
ferent  segments  of  the  upper  extremity  aometimea  cause  neuralgia  witli- 
ciit  other  aneillaiy  phenomena.  It  is  often  very  important  to  rfrognize 
that  tliH  sui%-essful  treatment  of  cervico-bracliial  neuralgia  in  siLch  an 
individual  depnuda  almost  wholly  upon  hia  gmng  up  for  a  time  such  labor 
or  profcflEioual  work.  Asido  from  these  conditions  neuralgia  in  the  do- 
main of  the  hra.chial  plexuu  is  aa^ocjated  with  constitutional  conditionsi 
with  direct  and  Lndireci  injiii-y,  such  as  implication  of  the  nerve  in  eallua 
formation  after  fractuie,  with  disease  of  the  Bpiiial  column  aitd  its  con- 
tents, 8ucb.  as  pachyiueningitis  and  syphilitic  difieafie  of  the  spinal  roots, 
and  with  conditiona  that  cause  encroaclimcnt  upon  the  nerves  in  the 
axillary  and  supraclavicular  spacCBt  euch  asnew  groirtha  and  aneurisms. 

When  any  of  the  causes  of  brachial  neuralgia  are  amenable  to  surgioa] 
or  orthopndic  treatment,  hucJi  treatment  should  he  instituted.  Such  sur- 
gical menHLirea  as  nerve  strBtcbiug  aiid  nerve  rBft(*cth:g  should  uot  be 
thought  of  until  causal  and  restorative  therapy  have  failed  to  give  relief. 
In  obetinate  and  resistant  caaea  the  operation  of  reflection  luay  be  neces- 
Bary,  The  removal  of  a  eegmont  of  a  pure  sensory  nerve,  eucb  aa  the 
radial,  ia  not  a  very  serious  aCair,  and  as  it  is  likely  to  give  relief  from 
suffering  for  at  least  a  long  time,  the  procedure  is  wholly  JTistifiable  tvhen 
medicinal  meaRures  f;iil.  Constitutional  abuormaliLies  should  be  counter- 
acted by  giving  irou^  arsenic,  strycbnine,  and  quinine,  and  by  the  use  of 
phyaical  meaaures  that  cau  be  relied  uikju  to  improve  nutritiou,  Elcctricitj'j 
particidflrly  the  gdvaniu  current,  applied  in  the  name  way  as  in  other  neu- 
ralgias, is  often  a  useful  agency  for  tlie  temporaiy  and  pernLaaent  relief 
of  pain.  The  faradic  brush  is  likewise  of  service  in  many  rases.  The 
pain  cau  usuiklly  be  relieved,  for  the  tinie  at  least,  by  the  application 
of  rubefaoienta  and  vesicants,  suih  aa  chloroform  liaimept,  n^ustard, 
pieces  of  fiaunel  wrongout  of  hot  water  and  sprinkled  lightly  with  turpen- 
tine OP  Cayenne  pepper,  oantharidee,  and  the  actual  cautery.  "NVheu  the 
paiu  IE  not  very  severe,  Btiruulating  linimenta  are  sometimes  all  that  is 
required.     Such  combinationa  as  the  following  will  be  found  serviceable: 

Q  Spiritnn  chlorafonai, ,         ■         .         .         ■         ,         .         -    j  ij< 

Meudin] 5vl< 

A]i?DhoJiB,  ...,,.....    3  11], 

M.     S.  For  cnornai  iiae.     To  be  apptled  with  &  bruab  bad  covered  wilJi 
flavnel.  in  onlir  lu  prevent  too  rapid  evaporaiion. 


TKBATMEST  OF  KBURALGIA  OF  THE  CERVICAL  PLEXUS.      369 


GdinCoL,  .         .         .         .         . 

M.     S,  Apply  locnlljr  u  oFleii  aaiBquired. 


&&  SOS. 

-      ;  I. 

Cover  the  ptrta  with  coilcc. 


Complete  leet  to  the  part  belpa  verj  materially  to  relieve  the  p&in,  and 
its  good  effects  cau  ho  enhaiKied,  especially  at  aight,  by  the  appboatiou  i>f 
warmth  or  a  prolonged  warm  bath.  The  castamary  acalgefiica  and  oeua- 
siooaliy  morphine  iiiur^t  l>e  used  at  some  time  iu  the  treatment  of  nearly 
every  case  at  any  confiiderable  eeverity. 


I 


Neuralgic  affection  of  the  intercoBial  nerrea,  particularly  of  the  ante- 
rioi-  brauches  of  the  sixths  seventh,  eighth,  and  nintli,  is  of  tompara- 
tivelj  frequenb  occurreiLcen  The  causes  cf  intercostal  aeuralgi^  are  the 
cuatomary  prGdisposing  states  in  the  blood,  nutrition  e^d  vLtaliby,  «uch 
oa  actinia,  hysteria,  iniectious  diseases,  partioalaily  syphiliB  and  ma- 
laria, and  cachectic  conditionH.  The  oonimon  exciting  causes  are  ex- 
posure to  cold,  trauma,  intlainmaticn  of  adjacent  stnictures,  pressure 
of  any  kind,  such  as  from  diaea^a  of  the  coverixiga  of  Uie  spinal  iM>rd, 
the  spinal  column  itself,  aneurisms  or  new  growths,  and  reflex  or  radiat- 
ing factors.  For  inBtaDc^e^  intercostal  neuralgia  is  sometimes  associated 
with  disease  of  the  pelvic  organs,  and  no  direct  coune<!tion  can  be  ea- 
tablishecL  On  the  other  hand,  intei-coHtal  neuralgia  may  be  an  ae- 
compauinient  of  eervio- brachial  neuralgia.  The  irtercostal  nerves  are 
fiurrauDded  at  their  origin  bj  large  venous  pleiuses,  and  are  tlms  lialjle 
to  manifest  the  sinister  effects  of  sluggishneaa  in  renoua  circulation. 
Neuralgia  of  this  causation  is  more  liable  to  occur  on  the  loft  side,  as 
there  is  here  greater  obatacle  to  the  emptying  of  these  vesaela.  The 
pain  of  intercostal  neuralgia  is  more  or  less  continuous,  but  liable  to  por- 
oxyamal  exacerbations.  It  ia  often  in  more  than  one  intenrostal  apace, 
but  rarely  bilateral.  Like  all  ikeutalgio  pains,  it  is  increasi^d  by  jarring 
and  forcible  movements,  and  its  presence  is  accompanied  by  easily  de- 
tocted  tender  points.  These  points  are  at  the  exit  of  the  mtercostal  nerve 
from  the  intervertebral  space,  a  point  midday  ia  its  course  at  i«hich 
tbe  nerve  becomes  Huperfidal}  and  at  the  terminbtion  of  the  nerve, 
usually  at  abotrt  the  junction  of  the  costal  cartilage  with  tbe  rlh.  The 
neuralgic  pain  may  be  preceded  or  accompanied  by  an  eruption  of  herpes, 
whose  diatributiou  accurately  maps  the  course  of  the  nerve.  Intercostal 
neinUalgia  accompanied  with  herpes  is  usually  an  extramely  painful 
variety,  and  accompanied  with  marked  hypersatheaia  all  over  the  course 
at  the  nerve.  Tbe  duration  of  an  attack  ts  from  two  to  fotir  weeks,  and 
even  longer.  The  physician  should  not  promise  complete  relief  in  leas 
time  than  this,  for  although  occasionally  well-directed  therapy  may  cause 
24 


370 


TBEATMEHT  OF  DiaflASE^  OF  THE  KEBVOU6   SYSTEM. 


It  to  disappear  in  &  Sew  dayn,  usuallj^  ttte  associatecl  conditioDs  are  not  so 
readily  overcome. 

Tre&tmect  of  Iiiteic06tal  Heur^la.  —  One  of  tlie  most  imporUat 
factors  iQ  the  treatment  of  iuteruoats.1  neuralgia  is  rest  in  bed.  it  ia  not 
the  rest  alone,  but  the  tmUorm  wa^mtli  which  contributes  to  the  com- 
fort of  the  jjatieDt.  If  the  attack  is  not  accompanied  bj  herpes,  the 
applicatjou  of  dertvativea,  such  as  muatard^  a  number  of  small  blia- 
ters.  or  local  hot  packs,  to  which  email  quantities  of  tutpentiue  may  be 
added,  or  freezing  the  nerve  by  the  application  of  a  chloride  of  methyl 
spray,  may  be  done.  The  chloride  of  methyl  may  be  applied  by  aat- 
urating  a  long  Btrip  of  cottoD,  which  is  thea  placed  o^rer  the  distribu- 
tion of  the  nerve  until  tbe  skin  is,  slightly  frozen.  This  oftentimes 
girea  very  prompt  relief.  Another  measuie  that  I  have  often  u»ed 
with  conaidorable  satisfaction,  cYen  in  diapenaary  practice^  ie  that  of  hot 
doachefl  to  the  Bpiue,  foUot^ed  by  the  application  of  dry  beat  over  ike 
courae  of  the  nerre.  No  other  apparatus  is  needed  Bare  a  pitcher  and  a 
tub.  The  water  is  paured  from  a  height,  and  the  banefieml  effects  dd' 
peud  both  upon  the  tempeiature  and  the  foi-ce.  In  the  aaina  way  pa- 
tients are  often  made  comfortable  by  the  full  warm  bath,  given  for  a  pro- 
longed time  and  just  before  retiring.  If  the  patient  will  not  consent  to 
remain  quiet  or  in  bed  for  a  few  days,  it  ia  advisable  to  eti^ap  the  stde 
lirmly  by  means  of  adhesive  plaster  in  a  way  very  similar  to  that  em- 
ployed iu  fracture  of  one  of  tUe  lower  I'ibs.  This  will  give  a  conaiderahle 
dflgree  of  local  rest,  particularly  if  the  adhesive  bandages  be  applied  6rm- 
ly.  In  addition  to  the  rest,  it  aids  in  maintaining  warmth,  and  if  mbe- 
faoients,  such  as  capsicum,  or  a  sedative  like  belliidonnar  be  incorporated 
in  the  plaster^  this  treatment  combined  with  internal  causal  treatment 
may  be  all  that  ia  rerjuired. 

Galvanic  electricity  can  always  be  relied  upon  to  ameliorate  the 
pain.  It  should  bo  applied  with  the  positive  pole  directly  ovei  the 
nerve,  the  anode  on  some  indiJiBrent  part  of  the  body,  for  from  five 
to  ten  minutes  each  day,  and  twit^e  a  day  if  possible.  A  ouTient  of 
from  two  to  four  milliamperefl  is  better  than  a  stronger  ourrent.  I 
have  not  had  any  considerable  experience  with  faradic  electricity  in  the 
trealmeut  of  tntercoatal  nenralgia,  but  the  majority  of  writern  recom- 
mend the  faradic  brush  if  for  any  reason  the  galvanic  ourrent  cannot 
be  employed.  Statio  electricity  applied  by  means  of  the  roller  electrode 
directly  to  the  nerve  can  be  used  advantageously  for  temporary  reliaf  of 
the  paiOr  Massage  is  another  physical  measure  that  is  often  of  much  ser- 
vice. The  necessity  of  determining  and  treating  tlie  cause  of  intercostal 
neuralgia  ia  as  in.cambent  here  as  in  other  varieties  of  neuralgic  pain. 
When  refrigeration  or  the  rheumatic  diathesis  has  an  obvious  ooonoction 
with  the  neuralgia,  the  salicylates  will  ho  found  to  act  almost  like  % 
specific.     On  the  other  hand^  if  the  pain  occurs  with  sclerosed  blood-vea- 


TREATAfKNT  OF  NEURALGIA  OP  THE  CERVICAL  PLEXUS,      371 

sets,  in  syphilitic  individaals,  or  in  the  Bscile,  the  admin  is  tration  of  iodide 
of  potaasiura  will  be  gratifying.  Ftirlin^r  enumeration  of  causal  tlierapy 
would  be  suptu'fluoua.  The  Utiueaait^  for  DverG(»[uing  uoudtitutioadl  Bhort-* 
coiamgB  13  very  evident  iu  viovr  of  the  fftct  that  intetooatikl  neuralgia  is 
patticulEirly  liable  to  occur  in  Ihoaa  who  suffer  from  oiganie  diseoBe  of 
aoiae  of  the  internal  organs. 

Racbialgia. 

Pain  in  the  back  may  h^  an  expresaiou  of  iitterctjatal  neuralgia  and 
of  lumbo-ibdominal  neuralgia,  and  aa  auuh  it  has  already  received  aome 
consideration.  It  may  litewiae  be  Bti  ticcompaniment  of  a  rheumatic 
ooodilioD  in  the  muscles  kao^m  as  myalgia.  Aa  a  rule,  the  majority 
of  uaaea  called  lumbago  by  the  patient  are  to  be  interpreted  aa  va- 
rieties of  myalgia.  Spinal  irritation,  or  that  neiiraaCheuic  aymptum 
complex  lo  whir^h  thia  name  was  formerly  given^  ia  also  attended  with 
rachialgia  and  aensitiveneaa  to  pressure*  Bat  the  term  ^a<^hialgia  is 
here  used  to  iadieata  a  neuralgic  pain  in  the  posterior  spinal  roots  not 
^sociited  with  any  o£  these  f^ouditioDS'  It  la  to  be  looked  upon  as  a 
form  of  articular  neuralgia,  analogous  to  that  whioh  ia  oKcasioaally  met 
ia  the  articulaticufl  of  other  parts  of  tho  budy.  Oocaaioaaily  a  severe 
foria  of  lumbago  occurs  with  aprain  of  the  aacro- vertebral  articuIatioD. 
It  ifl  ohaiacteri;:ed  by  severe  pain  whioh  is  increased  by  the  slightest 
movement.  Absolute  lest  ia  the  most  important  factor  in  its  treatiuent. 
Th»  diagnosis  of  ra<?hialgia  ia  to  be  made  only  by  a  process  of  excluaiou, 
and  the  indicatioaa  for  its  treatmect  aro  purely  a^mptomatto,  it  being  uu- 
deratood  that  the  general  causal  therapy  of  neuralgia  la  ful5lled-  Care' 
ful  iuventigatiou  of  racliialgia  will  result  almost  invariably  in  showing 
that  tha  pain  is  dependent  upon  some  of  the  eonditioas  named  above,  and 
then  the  therapy  will  resolve  itself  into  fighting  these  ootiditiona.  Tho 
measui-ea  that  are  to  be  taken  for  the  relief  of  apinal  irritation,  myalgia, 
dono-Iumbar  neuralgia,  and  symptomatic  pain  uf  diaeaso  in  the  spinal 
column,  are  considered  eUewhere  and  therefore  will  not  be  referred  to 
further  in  this  connection. 


MaMHAKT   Kb[[RALOIA   (MAfiTOIlWtA), 

Mammary  neuralgia  occurs  pTedominantly  in  femalea,  although  males 
are  sometimes  aSecCed.  I  have  seen  two  casea  in  the  latter  sex.  In  one 
of  these  it  was  undoubtedly  the  result  of  the  pendulonsuess  of  enrirmously 
hypertrophicd  mammary  glands  which  hung  down  over  the  upper  part  of 
the  abdomen.  The  aeoond  patient  suffered  from  chronic  parenchymatous 
DephritisH  Mammary  neuralgia  ia  immediately  dependent  upon  a  perver- 
sion of  function  in  the  descondiiig  branches  of  the  Bupraclavii-ular  nerve, 
bvit  espei^ialt^  of  the  peotoral  cutaneoLia  nerves  coming  from  the  second^ 


372  TRKATMBNT  OP  DISEASES  OF  THB  NBRVOC8  87STEIU. 

Uiird,  fourth,  aail  fifth  dorsal  nerves.  The  direct  causes  cannot  &lv&yB 
be  elicited,  but;  iu  mAny  cases  the  relationship  of  la^tHtiun,  pregnancy, 
disease  of  the  uterus,  fiexual  excitement,  and  trauma,  such  as  rrom  a  blow 
or  a  ladlj  iitting  corset,  can  he  luade  out.  It  is  ofteu  seen  in  anfcutio, 
hysterical  ^omeiii  and  particularly  those  who  have  aeen  members  of  theii 
family  or  fTiends  afflicted  with  intiainmatory  or  malignant  disease  of  the 
breast.  The  psychieal  element  in  mastodynia  playa  a  more  coTLsptcuDUS 
r<^]fc  than  in  any  otlier  form  of  neuralgia.  Oce;*aionally  it  occurs  with 
tho  growth  oi  small  fibromata  or  neuromata  in  the  breast. 

Treatment — The  first  thing  to  do  in  the  treatment  is  to  remoTe  the 
cauao  aud  give  complete  support  to  the  brcaatc  If  the  latter  is  physiolog- 
icallyoT  pathologically  enlarged  and  penduloua,  strapping  or  elinging  it  la 
often  eutflcient  to  relieve  the  piiio,  particularly  if  some  soothing  applioa- 
tion,  such  as  a  liniment;  containing  belladonna,  be  applied  at  the  same 
time*  If  it  occuxa  during  lactation  and  is  ncrb  susceptible  to  such  tsimple 
mcasurea  for  relief^  it  may  be  advisable  to  give  medicinea  that  are  known 
to  have  a  tendency  to  cheek  the  seeretion  of  milk,  and  to  apply  an  oint- 
ment containing  atropine.  After  what  has  been  said  as  to  the  conatitn- 
tionnl  ronditions  with  which  it  is  often  aaaociated,  no  apepific  directions 
are  called  for  bo  fihow  the  advisability  of  treating  the  aiiHrmic,  hysterical 
states  of  many  of  these  caeca.  The  following  ferruginous  tonic  is  oftea*- 
times  very  beneficial  aa  a  constitutional  meaaure : 

^  QuJnlii.  autpbRtIa, 

Ferri  pyropho§ph-,  ,         ,         ,  ,         .    1§  3  i. 

Acid,  pbospb.  dil.,         .......  ^{. 

Ac|t]»,     ...._.._..  SltJ. 

M,    S.  TtiOBpiioDFal  thrw  timeB  a  day. 

Electricity  and  masflagc  may  be  used  with  promise  of  service  in  almost 
every  case  in  which  there  are  no  evidences  of  organic  disease,  particular- 
ly in  those  occurring  apart  from  the  puerperium.  Verj  rarely  is  it  neces- 
sary to  give  tho  fiualgeBJes,  except  in  caees  which  are  dependent  upon 
exposure  to  cold  and  those  occurring  with  rheumatism.  Instances  have 
been  recorded  in  which  the  pain  was  so  severe  that  amputation  of  the 
breast  was  necessary*  Unfortunately,  the  heroic  measures  instituted  for 
the  relief  of  the  neuralgia  failed  to  give  the  desired  effect,  as  in  thes* 
cafles  it  is  the  general  ncurDtic  etate,  which  is  being  expressed  as  a  mas- 
todynia. 


I 

4 


CHAPTER  XXV- 

THE  TREATMENT  OP  >'EURALQ1A  OP  THE  LUMBAIC  PLEXUS. 

The  broaches  of  the  lumbAr  plexua  of  uerraa  are  not  the  seat  of  true 
neuralgia  ao  frequentlj  aa  those  of  the  eacral  aad  coccygeaL      It  ia  rarelj^| 
if  ever,  the  cause  of  ia.ohiaiIgia,  or  pa^in  iii  the  k.taclL,  for  as  has  previously^ 
been  showit,  when  this  complaint  is  not  depeodeat  upon  miiBCular  weak- 
neaSj  it  ia  almost  invariably  an  ^xpresBioii  of  neuralgia  in  tha  domain  of 
the  lower  doraal  or  intercostal  nerves. 

Neutalgia  in  the  domain  of  the  lumbar  plexua  may  be  cooTeuicntJy 
considered  und^r  the  five  foUowiag  oaptioDs:  1.  Lumbo -abdominal  aeu- 
ralgla,  to  include  painful  condition  iu  the  distribution  of  the  uppe^^ 
brani^hea  of  the  lumbar  ple:cus,  that  is^  the  ilio- hypogastric  and  the  ilio^J 
inguinal  nerves.  ".  Testdcular  neuralgia^  or  irritable  teytii^k,  wliii^h  \x 
oflentimea  a  manifestation  of  Lhe  paiik  iu  the  genito-cTurd  uerve,  but 
which  is  nevertheless  quite  as  often  on  affair  of  the  sympathetic  system 
of  nerves,  and  espeeialty  those  branches  having  their  distribution  in  the 
apermatio  plexus.  3.  FemortU  or  crural  nouralgia,  aa  uncommon  variety, 
attended  by  pain  in  the  domain  of  the  middle  and  internal  cutaneous 
brancbe^  of  the  anterior  *Tural  nerve.  4.  Nemalgia  of  the  ejcternal  cu- 
tftneoua  nerve,  a  condition  that  has  been  given  individuFtl  recognition  and 
description  only  during  the  last  few  years,     And  5.  Obturator  neuralgia. 

Although  brief  individual  mention  will  lie  made  of  eiwh  rariety,  it 
will  readily  be  understood  that  the  causative  faetnrs  and  the  leaiiing  indi- 
cations for  treatment  in  one  variety  are  much  the  same  aa  in  the  other^^| 

Lnmho-Abdominal  Neutalgift.^The  paincf  Uimbo-alidominalneur^ilgia 
is  confined  to  the  cutaneous  diatnbution  of  thone  nerves  which  embrace 
the  lower  part  of  the  lumbar  region,  a  part  of  tha  hips,  and  over  the  iQ^| 
ptinal  regioiL     The  common  attributive  causes   are  exposure   to  eold,^^ 
rheumatism,  straio,  and  dirtf^t  injury.      Like  ell  neuralgian,  it  is  of  more 
frequent  uocurrauce  iu  those  whose  eonatituLiou  is  depraved  from  exeesaO^H 
or  diseases.      Occasionally  it  ia  a  eymptom  of  disease  in  or  around  thi^ 
spinal  column.     The  pain  of  lumbo-ahdoraioal  neuralgia  is  of  variable  lo- 
cation^  depending  upon  the  branch  of  tha  itio'hypogaatrio  or  the  ilio-iagtii-^B 
nal  nsrve  that  ia  affecterl.      Usually  it  is  of  a  dull  eharacter,  more  or  lea*^ 
condnuoua  but  liable  to  paroxysmal  exacerbation,  eituated  in  the  loin  and 
radintiLg  toward  the  iliac  crest,  the  groin,  and  the  lower  part  fkf  the  ab^| 
domen*      It  may  occur  Bimultaneoualy  with  pain  ;a  the  genito-crural  nerve™ 
and  then  he  accompanied  by  symptoms  whicli  are  considered  diagnoatic 
of  this  form  of  neuralgia,     The  nerve  br^ch  that  ia  the  eeat  of  pais 


S74 


TREATMENT  OF  DIBKASEa  OP  THE  NKBVOUa  BTSTHH. 


seiiaitive  to  deep-seated  preaanre,  eapetially  at  tie  pouit  at  which  it  ap- 
pToaclieB  the  aurface.  Oacas  ion  ally,  it  is  assoi^iated  with  DovrEilgtc  pain 
mauifesC  Uirough  the  lower  intercostal  nerve  sjid  sometimes  also  m  the 
lower  branchea  of  the  himbar  plesns- 

Testiculai  Keiirftlgi^  —  Geuuine  neuralgia  of  tbetfisticlcH  niaj  be  mani- 
fest in  nerve  Rbiea  oiigmatin^  from  the  lumbar  piesus,  from  the  aacr&l 
plexus,  or  from  the  epeimatio  plexus  of  the  ajmpathetia.  Except  in  minor 
de^ret's  it  ia  a  comparatively  lare  ailment.  In  addition  to  the  etiological 
factors  tliat  havG  been  et^umerated  a^  causative  cf  lumbo-abdotuinal  Deu- 
ralgia,  sesaal  exreases  and  variooeelo  are  the  attributed  catjses-  Some 
wrileis  fieem  to  tbink  that  prcloQged  contijieuce  is  a  predisposing  cause^  but 
this  caunct  be  subatan tinted.  Initable  teatick,  which  ia  a  variety  of  bea- 
tioular  neuralgia,  is  of  somewhat  common  oecurreace  in  young  men  of  neu- 
TOtio  disposition,  Ooeasionany  it  is  aa  entailment  of  seaility.  Although 
it  ia  met  apart  from  the  neuroses,  auoh  as  neurasthenia  and  hysteria,  the 
determinLug  factors  in  such  c&sea  am  it^^ually  ap]rareJit,  arid  are^  exposure 
to  cold,  and  trauma.  The  pain  iaalmoat  iu  variably  imilat&ral,  and  is  of  a 
peculiar  dragging,  sickening  character,  lessened  bj  supporting  the  scrotal 
contents  and  by  keeping  them  in  a  poaitiou  of  oociplete  reat.  It  ia  ei- 
acerbated  by  pressure  and  hy  movement,  flucb  as  coughing,  anee7ing, 
^taii(H[ig,  ai^d  walking.  Oftt^utimes  the  paiu  is  so  severe  that  it  causes 
nausea,  great  proetration,  and  firm  retraction  cf  the  testicle.  If  it  La  of 
long  duration,  it  is  veiy  apt  to  produce  a  state  of  mental  depression  and 
of  physical  listleasncfls,  which  reijuire  to  be  combated  in  the  Buccessful 
treatment  of  this  condition.  Its  oconrrenpe  demands  a  close  iuvestigati&u 
of  the  scrotal  conteuts^  of  the  condition  of  the  genera!  health,  and  of  the 
atate  of  the  apiual  coliunn  aud  the  spinal  cord.  Very  rarely  it  occura  a& 
an  early  symptom  of  tubes  dorsalis. 

The  mc>st  important  elemert  in  the  treatmentf  by  all  means,  is  the 
causal  treatment*  If  the  cause  be  discovered  and  removed,  and  if  oon- 
stiliUtional  conditions  predisposing  toward  neuralgia  be  overcome,  usuallv 
all  that  IS  necessary  in  to  support  the  testicle  by  means  of  a  auapensory. 
Thia  variety  of  lumbar  neui-algla  teiiiiires  the  adoption  of  measures  for 
prompt  relief  of  the  pain  more  insistently  than  does  any  other.  The 
same  danger  exists  in  tl:o  use  cf  morphine,  particularly  its  hypodermatic 
use,  as  in  other  forms  of  intractable  or  recurring  pain.  Despite  this,  it 
is  siuiietimes  incumlkent  upon  the  physician  to  use  it.  If  the  pain  is  of 
oaly  moderate  intenatty,  efforts  may  be  made  to  overcome  it  by  means  of 
dry  hea^  by  applying  an  ointment  that  simultaneously  reddens  th?  akin 
and  blunts  the  conductivity  of  the  sensory  nerves,  such  as  one  containing 
cantharides  and  belladonna.  Dry  heat  ia  aoother  measure  that  may 
be  used  with  satisfactchry  reaults.  The  galvanic  current,  occasionally 
serviceable  in  relieving  bimbo-abdoininal  ceuralgfa,  is  not  to  be  applied 
in  neuralgia  of  the  testicle.     Very  nirely  is  the  pain  of  such  aeverity  and 


TRIBATMENT  OF  TTEtTRALGIA  OP  THE  LUMBAB   PLBXrS.       375 


intrax^tability  that  Gaetration  is  demauded.  Atthougti  the  piitieut  aiaj 
iittprpoee  no  objections  to  such  apparently  heroic  treatment,  the  pby^ician 
shoiijd  not  forget  that  in  m&nj  utBtaoceB  in  whit^li  thJH  operation  has  htn^u 
doiie  for  tbe  relief  of  Deuialgia  tbe  pain  h^a  coiitiuued  ut  recurred  after 
the  testicle  was  removed-  Cuatratiou  abculd  always  be  delayed  as  long 
Ofl  possible,  and  such  operatians  as  ligation  of  the  spermatdo  veins^  if 
there  be  any  evidences  of  varicocele,  done  firat.  The  tcnatitutional  treat- 
tnent,  surh  as  regulaiion  of  tb»  bowelsit  the  adoption  of  meB^nrea  that  io- 
creaae  pbyaical  streu^th,  auub  as  hydTothcrupy^  massage,  and  gymnaalics, 
and  the  admin iatration  of  such  restoratives  as  iron,  arsenic,  quinine,  are 
of  greater  importance  than  any  other  treatment  save  that  which  looks  to 
overoomlng  the  pain. 

Heralgla  Parseithetioa— Nenralgla  iij  the  fliatrihution  of  the  eiternal 
cutaneous  nerve  of  the  thigh  woidd  aeem  to  lie  a  commoner  affection  than 
baa  hitherto  been  supposed^  It  issometimescalled  meralgia  paraesthetica, 
a  name  given  to  it  by  Both  cf  Moscow,  who  was  one  o£  tbe  first  to  call  at- 
tention to  this  condition  aa  ai3  individual  occurrence^  As  the  name  im- 
plies, the  symptomfl  of  the  al^ectioa  embrace  paresthesia^  usually  of  a 
SLunewhat  indefinite  character,  aa  well  as  paiHr  in  the  territorial  distribn- 
tiou  of  this  nerve.  A  noteworLliy  feature  of  this  form  of  neuralgia  is  that 
it  disappears  when  the  patient  is  reclining  or  sitting,  and  that  it  returns 
when  he  puts  the  eatremity  to  any  eonaideralle  u&e  in  standing  and  walk* 
ing-  The  pain  is  located  m  the  outer  and  posterior  surface  of  the  thigh, 
reaching  frouL  the  crest  of  the  ilium  tothebneej  but  often  only  a  small  por- 
tion of  this  surface  id  ioiplieated-  Tbe  most  common  painful  press iLre-poi[kt 
is  over  tho  trunk  of  the  nerve,  just  below  the  anterior  spine  of  the  ilium, 
where  it  divides  into  an  anterior  and  a  posterior  branch.  The  attributed 
caiieea  of  meralgia  paresthetica  are  direot  mjury,  which  may  antedate  the 
ocGurrence  of  the  pain  for  Bome  time;  fatigue  of  the  lower  extremitieH, 
induced  particularly  by  prolonged  standing  and  walking;  presaure^  sui^h 
as  from  abdominal  b^iids,  tight  trousers,  and  stocking  suspender!);  e\- 
posore  to  oold  and  wet  -,  and  the  other  common  causes  of  nenralgia,  such 
as  the  into?(ioatione  and  infections,  ^'^^y  rarely  have  enlarged  inguinal 
glands  and  dilated  veins  of  the  lower  extremiti^  been  looked  u|»on  as 
causes-  In  Gerniacy  it  seems  to  have  a  special  inclination  to  affliut 
physicians,  judging  from  the  reports  of  tJiose  who  have  described  their 
iikdividnal  sufferiuga.  Apparently  it  is  not  a  Jiiit^ult  form  of  r^euralgia  to 
overcome^  The  treatment  which  has  been  found  very  satisfactory  cou- 
aists,  after  removal  of  the  cause,  of  the  use  of  warm  full  baths  and  of  ap- 
plication of  di7  or  moist  heat  to  the  attected  part ;  of  massage,  whtch  may 
be  used  in  connection  with  soothing  ointments,  such  as  one  containing 
belladonna;  the  nae  of  galvanic  alectricJly,  tbe  positive  pole  over  the  seat 
of  the  pain,  or  of  the  faradic  bruah;  of  prolonged  rest  when  this  ispoaai- 
ble,  and  of  the  administration  of  tissue  reeonfitmctiveB. 


S76  TRKATMENT   OF    mSKASES    tlF    THE   fJEKVQUS   SY3TKM. 

Femoral  and  Obturator  Ncuialgia.  — The  remaining  two  Tirietiea  of 
lumbar  tteuralgic^  that  ts,  neuralgia  in  the  domain  of  the  femoral  and  cb- 
turatcr  nerves,  are  relatively  of  rare  occurreiK^e,  In  femoral  neuralgia  the 
pain  occiiffl  in  the  area  of  diatri button  of  the  middle  and  ifitemal  catnneouH 
nerve,  extending  to  the  ekiu  upon  the  fure  part  and  inner  side  cf  the 
thigh.  Very  rarely  ia  tho  cutaneous  nerve  which  is  distributed  to  the 
inner  side  of  the  legs  nnd  foot  the  seat  of  pain.  The  oauaes  of  neuralgia 
in  thia  nerve  are  the  same  as  the  caueea  of  aoiatica,  or  of  neuralgia  in  any 
other  branch  of  this  pleius.  Obturator  neitralgia  la  stil]  more  uncommon. 
It  IB  doubtful  that  it  occvirs  with  any  other  coudiLion  save  that  of  obtu- 
rator heruia^  Pain  in  this  nerve  ia  probably  in  reality  through  the  plaJius 
which  ia  formed  by  aenaory  branches,  Theaeanaatomoae  with  the  internal 
cutaneovia  branch  of  the  auterior  omral  norve  and  a  branch  of  the  internal 
Bapheaous,  Casea  have  been  described  in  whieh  the  neuralgia  was  attrib- 
uted to  comprasHioTj  of  the  nerve  within  tho  pelvis  by  pelvic  eiudatea  and 
during  chtLdbirtph,  but  it  is  somewhat  doubtful  whetber  those  renditions 
were  more  than  indirectly  reaponsible  for  the  occurrence  of  the  neuralgia- 
lioth  femoral  and  obturator  neural^a  require  the  same  careful  Boaich  for 
thejr  cause  that  sciatica  doCB,  and  after  ita  removal  prftcticdlljr  the  same 
treatment  aa  that  outlined  for  sciatica. 

Lbo  Fais3  with  Vakicosk  Vbtnh, 

Pain  in  the  legs  reaorubliiig  eciotion  or  orural  aeuralgia  is  aome- 
times  associated  with  superficial  or  deep  varicose  veins.  Although  jiam 
of  this  origin  has  usually  sotus  featurea  aufficiantly  distinct  to  indicate 
itH  proper  interpretation,  it  ia  often  confounded  witli  sciatica  because 
the  oommoneet  locations  of  the  pain  ai^e  in  the  calf  of  the  leg  and  the 
ball  of  the  foot.  In  the  latter  location  the  difitribtition  of  the  pain  may 
be  quite  EUialogous  to  that  of  sciatica.  The  i^nmediate  cause  of  this  form 
of  pain  is,  aa  hns  been  said,  stmetoral  disease  in  the  walls  of  the  veins. 
The  remote  cauaes  are  included  in  the  etiology  of  varicose  veins.  The 
pain  which  accompanies  this  voudition  is  uauatl;  difFuaCt  the  patient 
rarely  localizing  it  to  the  distribution  of  ooe  nerve.  It  is  worse  toward 
eveaingp  and  is  exacerbated  by  any  condition  that  interferes  with  the  re- 
tuTii  of  circulation-  On  the  other  hand  it  is  lessened  by  rest,  by  raising 
the  feet,  and  by  gentle  massage,  the  rubbing  being  directed  toward  the 
bwly,  thus  facilitating  the  blood  retiTni  in  tlie  veins.  The  treiaiment  of 
this  condition  is  palliative  or  radical,  directed  toward  the  diseased  blood- 
vessels; in  other  words,  the  treatment  is  that  for  varicoae  reins,  Thia 
may  be  so  simple  us  taking  appropriate  active  and  passive  exercisei  the 
wearing  of  an  elastic  support  to  the  cutaneous  veins,  or  multiple  ligation. 
It  should  not  be  forgotten  that  conatitutional  states  mtist  l>e  reckoned  with 
in  order  to  bring  about  complete  oure  of  the  di-lated  veins- 


CHAPTER  XXVI. 


THE  TREATMENT  OP  flClATICA- 


SctATiCA  ia  the  Dame  given  to  pain  ia  the  diatribution  of  tEe 
aciatio  nerve.  Like  all  nerve  pains,  it  may  be  depeudent  upon  a  number 
of  different  eondiCiona.  The  fact  that  these  t^onditioaa  are  not  earefally 
diCferen tinted  iiocauiitB  in  a  uie&sure  for  the  very  unsatisfactory  star.ua  of 
tlie  treatment  of  sciatica.  In  the  chapter  on  trifzM^ial  neuralgia  1  h&ve 
drawn  attention  to  tLo  fact  that  a  number  of  different  jiffactiona  of  the 
nerve,  either  functional  or  organic,  have  beeu  iticluded  by  writers  under. 
the  head  of  tic  douJonreux,  and  atao  that  it  was  not  uutil  these  conditionB 
were  diffeientiatad  f.liat  BatiBfactory  results  attended  the^r  treatment,  A 
similar  statement  holds  good  fur  at;iatica.  In  brief,  then,  the  teroj  sci- 
atica ahouJd  not  bo  used  in  any  other  aease  than  to  eignify  pain  in  the 
Bciatic  nerre  and  ita  territorial  distribution.  The  systematic  wiitar, 
however^  finis  it  ditli<.'u1t  to  maintain  this  posUion,  largely  because  the 
term  has  been  used  ollecdvely  to  include  all  the  fuDOtioaal  and  organic 
diseases  of  the  aciatio  nerve.  I  shall  endeavor  to  difTerentiatti  the  pain- 
ful affe^^biouH  of  the  sciatic  nerve,  at  leiist  in  so  far  an  the  therapeutic 
indications  ai^  conacmed.  It  is^  nu fortunately,  abnoot  impossible  todia- 
crimiuato  between  sciatica  due  to  a  mild  degree  of  inflammation  in  the 
perineural  atructurea  and  in  the  nerve  itaelf^  and  sciatica  which  is  the 
result  of  dynamic  or  functional  disorder  of  the  narve.  Natimdly,  when 
iLflammation  or  degeneration  of  the  nerve  is  accompanied  by  such  condi- 
tions aa  marked  tonderness  on  deep-seated  pressure  over  the  nerve  trunk, 
atiophy  of  individual  mu&ctea  or  groups  of  musclea  supplied  by  thenerve, 
pronoitnced  sensory  dieturbance^i  changes  in  the  electrical  reaotiona  of 
the  neuromusf^ular  apparatna,  and  perversions  of  the  tendon  jerks,  one 
can  say  quite  positively  that  the  nerve  is  organii;ally  diseased.  But  ic 
many  caaes  the  luflaiitinatiou  or  degeneration  is  so  slight  aiLd  the  process 
of  repair  do  active  that  tht:so  phenomena  are  not  preaeut  and  elicitable. 
Moreover,  the  factors  that  are  operative  to  produce  inflammation  or  de- 
generation  of  the  nerve  are  the  aauia  as  those  that  cause  funetioual  dis- 
order of  the  nerve  accompanied  by  pain.  Tills  adds  greatly  to  the 
difHculty  of  aaying  where  functional  disorder  of  the  seiatio  nerve  ends 
and  where  oryauic  affection  (jo^'ins.  Despite  this  difficult",  however,  the 
successful  therapeutist  is  ho  whose  clinical  insight  and  CKpenditure  of 
time  and  oare  tead  him  succeasfuLly  to  approximate  this  differentiation, 
and  who  ia  guided  in  hia  selection  of  remedial  agencies  by  the  informa- 


978 


TRKAT«ENT  or  DISICASES  OF  THK  tfRKVOUfi  SYSTKM. 


tion  thus  obtaiaed.  It  ia  of  comparatively  Lttle  eert-k«  to  enumerate  tho 
different  &rMg&  o?  applications  and  applianoea  that  t&ve  be«n  uaed  suc- 
oesBfullj  in  the  treatment  cf  aoiatkca;  indeed  ja^ny  doubt  that  it  U  of 
any  Hervke  at  aO.  That  which  ia  oi  signal  benefit  in  one  siFflctLou  char- 
acterized by  pain  In  the  dcunEtia  of  the  ficiatic  uerve  is  useless  aod  laaj  be 
injuriouQ  in  another^  bo  that  nothing  ia  contributed  to  the  therapy  of  this 
condition  by  citing  oue  case  or  even  a  number  of  cases  that  bava  yielded 
to  thd  fLdministrfltion  of  nitroglycerin  oi  to  the  application  of  the  actual 
cautery  to  the  ear.  The  inRunihent^y  is  to  apei^ify  the  form  or  varie^  of 
disease  upon  which  the  sciatica  that  has  yielded  to  such  therapy  la  de- 
pendent. 

Etiology  of  Sciatic  Pain.— Painful  alfection  of  the  aoiatio  nerve  oc- 
curs much  more  frequently  in  wen  than  in  won^en,  and  the  relativity 
ia  subject  to  great  variations  depending  upon  climatic  conditions,  occn- 
.patioD,  tuodo  of  life,  and  liability  to  injury,  Accsordiug  to  Uie  statLBtios 
of  seme  writers  the  proportion  is  aa  pjreat  as  live  to  one,  whilo  accord- 
ing to  others  men  are  affected  only  one  and  one-half  tinaes  as  fre- 
quently as  women.  My  own  Btatistios  show  that  sixty-five  par  cent 
of  the  caBe?4  are  of  the  i[ia1e  sex.  It  will  at  imce  be  ae^m  that  this  pre- 
dilei^tion  of  sciatic  pnin  for  males  is  in  conformity  with  that  of  neu- 
ralgic affections  in  ^neial  which  are  more  oommOD  in  xaalea,  Sd- 
fiticft  IB  more  apt  to  occur  in  nien  whose  occupation  predispofiea  to 
injury,  to  overexertion,  and  to  exposure.  The  sciatic  nerve  seema  to 
be  more  or  less  immune  to  most  injurious  conditions  until  the  age  of 
puberty.  Front  that  time  until  tlie  thirtieth  year  it  is  rarely  affected  in 
such  &  way  as  to  cause  pain.  From  thirty  to  sixty,  and  parlicuUtly 
from  forty  to  fifly,  It  is  eflpecially  liable  to  be  difleased  functionally  or 
organitally,  to  a  degree  that  causes  pain.  More  casra  of  sciatica  of  all 
kinds  are  seen  during  the  winter  and  spring  than  during  the  other  sea- 
wni.H,  imrtioularly  if  the  weather  lie  inclement  and  severe,  OcciUJationa 
that  neceasitate  expcsure  tc  wet  and  cold,  particularly  aft«r  physical 
efTort,  and  thoae  that  call  for  prolonged  uae  of  the  legs  without  sufHcient 
reat^  are  very  potent  factors  in  cauBing  sciatica. 

The  purely  neuralgic  forma  of  sciatica  ore  oftentimes  in  close  and 
discernible  relationship  to  such  diatbeses  na  rheumatism,  gnut^  auto- 
iutoxi nation,  and  the  fibroid  diathesis  i  also  to  conditicna  that  are  at- 
tended by  dissociation  and  disorganization  of  the  components  of  Uie 
blood,  Buoh  as  the  various  forms  of  aawmia  and  the  coaditiODS  upon 
which  they  are  dependent,  whelhei-  they  be  those  which  prevent  the 
formation  of  the  constituente  of  the  blood  or  tltose  which  facilitate 
and  cause  their  destruction.  Sciatica  of  this  form  occurs  with  preg- 
Qaucy  and  lactation,  diabetes,  and  varioLis  forms  of  poisoning  ia  whick 
the  t4>xio  coeihcient  is  not  intense  enough  to  cause  di&orgauizatiou  in. 
the  nerve  itself.     It  should  not,  however,  be  Eorgotten  that  often  theaa 


TBK  TREArMENT  OF  flCIATTCA. 


379 


aaine  factcie  are  Bafficiently  inteoee  to  cauBe  true  diseAse  of  the  nerve, 
which  is  attendRd  by  seiatic  pains;  for  instance,  alcohol  ism ;  infections 
diseases,  such  as  ^rippv^  pueumODiA,  l^phuid  fever,  malaria,  and  septic 
iuf«ction^  poiaouiiig  hj  l^ad,  ^semc,  &ud  tobaccc,  maj  caoae  sciaticft 
which  is  not  dependent  upon  organic  affection  of  the  perineuriiun  of 
the  nerve  or  of  the  nerve  itself^  But  if  they  act  with  auHicient  intens- 
ity ftnd  duration  they  may  cause  such  nffaetion.  Of  the  trnuioBtic  con- 
ditions that  caiiHe  apiatica,  the  most  important  are  expoaure  to  cold,  either 
directly,  as  by  a  driiught  on  the  naked  hipa  while  sitting  in  a  closet,  or 
indirectly,  through  the  clothing. 

The  oext  most  common  form  of  trauma  is  from  direct  blows  or  falls 
on  the  buttocks  and  back  of  the  thigh,  which  may  or  may  not  be  at- 
tended with  surgical  coudttiona,  such  as  fracture  of  the  thigh  or  pelvic 
bone.  A  very  much  rarer  variety  of  trainna  is  from  pimctured  wounds. 
Many  intrapelric  conditions  give  rise  to  sciatica'  These  may  be  so 
simple  and  amenable  to  treatment  aa  impaction  of  feeccs,  ehronio  con- 
stipation,  displacement  of  Lho  uterus,  or  a  variety  of  aimpJe  iDttapel- 
vic  inflammation,  or  they  may  be  »o  severe  as  malignant  disease  aris- 
ing from  the  pelvis  or  its  viscera.  Fain  in  the  domain  of  both  sciatic 
nerves  may  be  caused  by  inturapiual  growth,  ptessing  upon  tho  roots 
oF  the  spinal  nerves  and  cauda  equina  from  which  the  sacral  plexns 
takes  its  origin.  The  most  common  variety  of  aucli  intraepiuBl  ueoTilasm 
ia  unquestionably  gumma.  iTinnlly^  the  sciatic  plexus  and  its  continua- 
tion, the  great  sciatic  nerve,  may  be  themselves  the  seat  of  new  gTOVtha, 
which  causa  scint.ica^  Hyatencal  sciatica  is  an  untximmou  affection,  in 
this  country  at  Itiaat,  but  th«  rt^port  of  carefully  studied  cas^a,  prin- 
oipally  From  France,  which  hare  yielded  to  suggestion  shc'ws  that  its 
occurrence  is  a  reality. 

Symptoms.— The  symptoms  of  sciatica  are  by  no  means  constant.  As 
will  be  readily  inferred  after  the  remarks  anent  its  causation,  the  cliuical 
picture  is  subject  to  profound  degrees  of  shading  and  coloration,  varying 
with  tlie  cause,  the  individual  atYectcdf  and  the  pathological  dependency 
of  the  pain.  The  distinctive  feature  is  pain  iu  the  course  of  the  sciatic 
nerve  or  some  segment  of  it.  In  one  case  the  pain  will  be  conlined  to 
the  hip,  in  another  to  the  calf,  and  in  a  tbird  to  the  ball  of  the  foot. 
Usually,  however,  before  the  termination  of  the  sciatica,  the  patient  will 
experience  patn  thniughout  the  entiie  nerve.  The  pain  is  sometimes 
preceded  ^d  more  often  accompaniod  by  more  or  less  parsDstbesia,  itch- 
ing, crawling  sensation,  tingling,  or  a  feeling  of  mimbnesB.  The  pain  is 
of  vamble  severity  nnd  its  character  may  be  boring,  burning,  lancinating, 
or  a  dull,  heai.'y,  nauseating  ache.  It  is  almost  aluaya  worse  at  night, 
and  especially  during  the  hours  when  tbe  geiieL'al  vital  teaistanoe  aeems 
to  be  lowered — between  midnight  and  early  morning,  The  pain  is  in- 
creased  by  movement  of  the  extremity,  by  attempts  to  stand  and  walk, 


TREATMENT  OF  DISEASES  OF  THK  NERVOUS  SYSTBU. 

and  by  anything  that  tenda  to  incraafla  venous  iiresaur©  and  at  tlie  a&me 
titUG  jar  tlitf  body,  3uoh  aa  coughing,  euee^ing,  aud  atraiuing  at  stool.  It 
not  iQfL-e<)ijent]y  radiates  iuto  otber  tiervca,  bciog  thus  occompaiiied  l^ 
pain  in  the  domain  of  the  Jumbo-Bacml  nervea,  aad  occ^asionally  in  n^rr^t 
of  other  parts  of  tha  b<>ily.  Thete  fliu  f  ^w  constitutioTial  Eymptoma  uide 
frum  thoHH  roiLditiuiied  by  the  disease  of  whit^b  thu  sciatic;!  la  a  coiii^lica- 
tioiif  imleas  the  sciatica  ia  dejiendeDt  upon  oeuiitiK.  These  aymptoniai 
however,  ixiaj  be  very  i^romitient,  and  their  interpretation  is  of  the  ^reat- 
eBt  service  iu  onontuiK  oiie  as  to  the  proper  treatmoat- 

On  examination  the  sciatic  nerve  will  almost  in^'arlably  b^  found  B^nai' 
tire  to  deep-seated  prei^Btire,  nnd  efipecially  where  it  can  be  pressed  jigainat 
a  bony  surface  or  where  it  becouitfs  auperlicial.  The  fuur  poinU  at  which 
proaauie  usually  causes  pain  are  at  its  exit  from  the  a^cro-aciaUc  uorch  be- 
tween the  trochnnter  and  the  tuberosity  of  theischium;  at  the  inferior  bor- 
der of  the  ^Uiteua  muacle;  in  tlia  n^iddle  of  tbi^  thigh,  juat  above  a  point 
At  frhicb  the  nei've  usually  divides;  and  finally^  in  the  middle  nf  thecalf- 
Occasionally,  tlih  entire  postt^rinr  surfihoe  of  the  thij^h  and  \e^  is  »eiiai< 
tivo  to  any  conaiderablf]  preaaura  and  manipalation.  If  the  [^aiu  is  due 
to  neuritis,  perineuritis^  or  to  adhesions  L»f  tho  ncrro  sheatha  paia  on 
pressure  will  he  very  great.  The  patient  usually  keeps  the  alTected 
lower  extremity  in  a  moderate  state  of  flexion  at  all  the  large  joints.  If 
the  kuee  be  held  exte^dt^d  ami  the  hiwer  eslremity  forcibly  flexeil  on  the 
pelvis,  be  will  complain  of  an  inteuse  liuraiiig,  shooting  pain  along  the 
entire  course  of  the  nerve-  When  the  patient  stands  or  walka  the  aemi- 
flexed  condition  of  tlie  lower  extremity  gives  bim  a  somewhat  character- 
istic attitude  and  gait,  which  togetlier  with  the  compensatory  cutvaiupe 
of  tha  spinal  column  that  results  if  the  sciatica  bo  of  long  duration  has 
been  much  studied  and  described.  Sciatic  fiiudioais  is  purely  a  static 
alTair  and  its  extent  and  intensity  depend  upon  the  degree  and  duration 
of  the  seiatioa^  AVhon  the  aoiatica  is  dependent  upon  organic  lesion  of 
the  nerve,  whioh  is  the  result  of  injury  or  pressuro  from  without,  or  from 
interHtitial  ohauges.  the  acnompanying  Bymptoma  ivill  depend  upon  the 
degreo  aud  iutenaity  of  the  destruction  of  nerve  tissue.  Tbeie  will  be 
variable  degri^ea  of  muscular  atrophy,  changes  in  electrical  excitability, 
alteration  of  the  tendon  jerks,  sou soiy  disturbance!),  cramp  in  the  diua- 
cles  supplied  by  the  diseoaed  nerveSf  contractures,  and  other  iii&nifesta' 
tionii  of  neuritis. 

Tha  duration  of  an  attack  of  eciatica  is  very  variable.  It  stamlsmore 
cluaely  in  relation  to  the  cause  of  the  attack  than  to  anything  else.  An 
acute  attack  of  sciatica  dependent  upon  refrigeration,  or  a  manifestation 
of  the  rheumatio  diatliesiB,  n^ay  last  only  a  few  weebs.  On  the  other 
haitil,  miother  attack  which  apparently  has  the  same  causation  may  \zbx 
several  munlhsT  during  which  time  there  may  be  more  or  lesa  iromplete 
lemiasLon  in  the  severity  of  the  bymptoms.     The  duration  of  the  attack 


THE  TREATMENT  OF  BC1ATICA. 


depeuda  verj  largely  alao  upon  the  trejitment  adopted.  If  tha  altempb  is 
made  to  treOit  the  patient  while  lie  continuea  at  hia  work  or  while  he  is 
allowed  to  go  afjout  as  uau&l,  it  ia  safe  to  prophesy  that  weeks  and 
iQOntha  will  elapEe  befoi-e  he  ia  thoroughly  nd  of  pain.  When  the  con- 
diiiDB  ia  entirely  cured,  however,  the  tfiadenoy  to  relapse  is  not  so  great 
as  19  ordtuanly  siJppoBed, 

Treatment — Before  treatment  ia  begun  it  ia  absolutely  iiecessary  to 
decide  whether  the  sciitica  is  idiopathic  or  whether  it  is  socondai?  to 
some  other  disease.  It  ia  alao  very  desiritbJe  to  estimate  aa  elosoly  as 
poaaible  the  pathological  diagnosis,  Sufiicient  has  already  been  said  eon- 
EBTning  the  necessity  of  iDdividualiatir',  treatment  when  confronted  with  a 
patient  suffering  with  Bciatica.  It  muat  be  impre^^scd  upon  the  reader 
that  fli-iatica  ia  one  of  tho  conditions  in  the  treatment  of  which  be  cannot 
be  guided  esoluaively  either  by  precedent  or  by  expericDce,  Irijeetiona 
of  carbolic  acid  or  osmie  acid  may  be  just  the  treatment  required  for  one 
case,  whilo  in  the  ne^t  case  their  uad  w^auld  mean  great  injury  to  the  pa- 
tient. Tho  physician  wbo  treats  sciatica  iu  a  routine  way  a*5Wir(Hng  to 
a  p^an  that  he  has  found  auc<;eaafiil  in  soma  cases  or  according  to  iufitruc- 
tioDfl  whieh  he  has  got  from  a  text-book,  is  foreordained  to  a  larger  par- 
centage  of  failure  than  he  wbo  makes  the  most  aeari^hlng  iuvestigation  to 
find  the  eaiise  of  the  sciatica  and  the  eotiditlou  of  which  it  ia  an  csiprea- 
siou,  although  he  follows  a  mere  or-  leas  indexible  plan  of  treatment. 

Treatment  of  Becent  CaseH.— The  general  plan  which  ahuuM  Ije  adopted 
in  the  treat;aent  o£  recent  and  acute  cases  of  sciatica  may  be  said  to  be 
about  as  follows:  The  first  and  moat  insistent  necessity  ia  that  the  pa- 
tient eh^ll  go  to  bed  and  Btay  there  until  the  acute  pain  has  E^ubsided, 
Absolnte  rest  ia  by  all  means  the  most  important  element  in  the  treat- 
ment of  acute  ftciatica,  and  the  phyaiciau  who  compromises  wil.h  the 
patient  on  this  point  ia  the  oue  most  likely  to  fail  in  effecting  a  rapid  and 
cciuplcto  lecoverj^  It  is  rot  suihcient  that  tho  patient  icmaia  witliin 
doora  and  be  allowed  to  get  about  the  house  or  lie  on  a  loun^je,  and  to  go 
to  the  closet  in  response  to  the  calls  of  nature.  Eest  should  be  absolute 
and  in  bed.  Moreover^  tbsoanUnual  app1t(^tiou  of  either  henL  or  cold, 
which  is  nearly  aa  impurtaut  aa  rest,  can  bti  ejected  in  no  other  way 
than  by  keeping  the  patient  iu  bed.  Attention  to  tho  details  of  mattreaa 
and  coveriDga  will  bo  leworded  by  a  gratifying  det^ree  of  comfort  to  the 
patients  They  should  be  of  such  a  nature  that  no  irregular  pressure  will 
be  made  upon  the  posterior  surface  of  the  lower  extremity,  and  th^t  the 
bodily  teat  be  prevented  fruui  dia^ijiating.  The  patient  soon  learns  that 
the  pain  is  less  intense  when  the  knee  ia  partially  ttexed,  and  thia  positiOD 
flhoold  be  maintained  by  pillowa  or  bj  aaitd-hoga  if  it  bo  decided  to  uae  dry 
heat  inatead  of  cold  as  a  eedativo  and  autiphlogiatio  ageacy.  A  most  im- 
portant decision  which  tho  physician  has  to  make  is  whether  to  use  heat 
or  oold.      The  advocates  of  tlie  first  are  quite  aa  confidBnt  of  its  auperior 


382  TREATMENT  OP  DTfiEASKS  OF  TOK  NERVOUa   BTSTXlL 

offlcary  as  are  tboae  of  the  second.     As  a  mat^t  of  fact  the  determiniiig 

fa[^turd  fihoLiUI  be  the  idiosyDCrasiea  of  the  patient  and  the  dependenoy  of 
iht  pain.  All  aiiQumic,  ruii-dowu,  irritablu,  ut^rvaus  nom&ii,  wbu  dreAda 
the  very  thought  oE  cold,  will  bo  very  likely  to  look  forward  to  an  appli- 
cation of  dry  htMLt  with  more  pl^iaaure  and  ountidoncd  tlicui  ahe  will  to 
ice-bags  or  cold,  v/et  appZicatioiis^  Nevertheless,  if  the  aacUlaiy  ph«< 
i:oiDeii&  fiiid  Qndin^a  set-m  to  indicate  thfit  the  sciatica  ia  an  eipreBsion  of 
an  iuflaiimiatory  stute  in  the  nerve  itaelf  or  in  it9  (uveTiugs,  the  feelinga 
of  the  patient  should  not  he  allowed  to  stand  in  the  way  of  the  applica- 
tioa  of  oold,  either  in  the  shape  of  chloride  of  methyl  spray  or  ice-bags 
from  the  exit  cf  the  soiatio  nerve  to  Ita  plantai*  distribution.  There 
seems  to  l>e  a  very  nearly  nnanimouH  belief  on  the  psit  of  those  who  hare 
Lad  esperience  that  this  measure  far  outranks  any  other  in  ameliorating 
the  pain-  The  ice  must  be  applied  continuously  for  several  days,  even 
wesks^  ftnd  it  should  be  discarded  only  when  cessation  of  the  pain  shows 
tliat  the  inaammatory  condition  has  nearly  if  not  quite  sulaided.  When 
the  pain  is  limiled  to  one  section  of  the  ertremity,  such  aa  the  gluteal 
region  or  the  thigli,  it  is  of  i^iurae  not  [Le<^essary  to  apply  cold  to  the  eo- 
tire  extremity.  On  the  other  hand,  if  it  is  found  that  the  application  of 
cold  n^ay  be  necessary  fur  a  uousLderablo  timet  it  can  be  appliod  by  a 
simple  apparatus  conBtructed  from  rubber  tubing,  through  which  a  atroam 
of  tee  water  ia  allowed  to  Gow  alowty. 

The  plan  proposed  by  I>r,  Weir  Mitehell,  of  Philadelphia,  of 
bandaging  the  eKtremity  with  a  thiu  all  flannel  bandage  reachiug  from 
the  foot  to  the  groin,  may  be  used  jn  connection  with  the  applicatiou 
of  contbuouB  cold.  The  bandage  by  oausiug  gentle,  iirni,  erenly  dis- 
tributed pressure  It^Hsens  the  amount  of  blood  circulating  in  the  1^, 
and  aets  na  an  important  act^aaury  to  the  anttphlogistie  pain-b^nurnt^ 
ing  qiiallUes  of  the  ooiititiuous  cold.  Cases  in  wliieli  tliere  are  no  evi- 
dences timt  the  ficlatioa  h  dependent  upon  iuilauimation  of  the  nerve 
or  its  sheath,  and  ia  which  there  are  no  g^voaJal  itidicationa  which 
call  for  the  use  of  oold,  are  best  treated  by  the  application  of  d^ 
heat.  This  may  be  applied  by  the  hot  fomentation  compress  or  by 
hot-water  bottles;  but  one  of  the  niost  eatisfactory  methods  ia  by  the 
uae  of  sand  euoased  in  long  flannel  b^s-  After  being  heated  In  an  orea 
they  retain  their  heat  for  eevcral  hours.  The  leg  is  baudaged  in  fiannel, 
as  described  above,  autroiULded  with  layers  of  cotton  or  wool,  so  as  to 
prevent  the  sand-bags  from  pressing  directly  upon  it;  then  the  aand- 
bagH,  which  have  b«en  previously  heated^  are  put  along  each  aide  of  the 
extremity  wliich  they  maintain  in  whatever  position  Is  found  moat  com- 
fortable for  the  p;htient.  I  have  used  this  measure  as  an  adjunct  in  the 
treatment  of  sciatica  for  mauy  years  ^ith  gratifying  socoeas.  It  is  par- 
tionlarly  useful  in  sciatica  caused  by  refngerjition  and  acoompanying  tha 
rheumatic  diatheaia  and  impoveriahment  of  the  bleed.     The  hot  fomi 


THK  TREATMENT   OF    SCIATICA, 

tatioo  oompreaa  is  a  most  servioe&ble  agent  in  tho  treatment  of  aoute 

scubea.     It  oftea  gives  Gpeedy  and  gratifjiog  rt^Ii^f.     Much  depends 

vpoD  iU  careCul  aDd  proper  tLpplicatiotj.     Pteoea  of  wooLea  Maaket  or 

fl^ael,  two  feet  fiijuure,  are   soaked  with   hot  wal«r   and   th^n   pa^sad 

iLnAigi  a  clothea  wringer  when  they  are  ready  for  appUfiatioii.     Tlie  jjart 

t&vliich  tlicf  JLTQ  applied  must  be  tljoroughtjr  corered  with  some  oily  aub- 

Moee  to  praretit  formation  of  blieters-     The  alotha  are  removed  e^ery 

twooty  miQutes,     Their  application  aoon  causes  perspiratit^Uf  which  may 

btvibaiLoed  by  wrapping  the  pati+'nt  ia  blankets.     They  should  be  kept 

u^k  for  about  two  honrH  and   re[>eatt^d  twice  in  the  tweutyfoitr  hours, 

After  each  application  the  patient  ahoiild  be  washed  off  with  water  of 

'y  Y.  and  a  moderate  degree  of  dry  heat  applied  to  the  leg> 

Id  iaa[iy  caaes  of  acute  sciatica  it  is  unueeesaary  to  employ  either  beat 
Of  cM  in  the  vay  deecribed  above  or  In  any  other  way^  All  that  is 
napmary  after  putting  the  jjattent  to  bed  may  be  counter-irritation  by 
Eoeuia  of  the  actual  c^titery  applied  over  the  coitrse  of  the  oerve  by  in- 
iLU1aD«oas  tctuches  from  its  exit  to  the  lowest  level  at  whii;h  paia  is  pres- 
^ui,  Tliis  is  followed  by  appropriate  dreaaLsgr  baada^^tig,  and  immobi- 
LiuOoa  of  the  eTti-amity,  or  by  the  use  of  large  tntistard  and  flajaeed 
poalciMS  U[itil  the  skin  h  thoroughly  eountei^iiritated.  Thene,  with  the 
ip(^pfiate  iiitemal  treatiaent,  will  be  found  eiHcacious  iu  many  caaea  of 
aodente  severity.  Natur^ly  it  ii  understood  that  they  may  be  repeated 
if  Deoeeaaiy.  Occasionally,  the  application  of  di-j  cups  over  the  coiu'se 
rft]i«aeiatie  nerve^  particularly  at  the  sciatic  notoh,  and  over  the  seat  of 
HiMiPWt  pniii,  is  followed  by  relief.  If  the  patient  is  a  man  of  plethoric 
dilpawtioTit  the  extraction  of  blood  by  leeches  or  by  wet  cui>s  is  eitremely 
ttlutuyi  not  alone  in  relieving  the  pain  at  the  time,  bub  in  influencing 
IV  permanent  disappearance. 

Id  addition  to  th^se  measures  careful  attention  shoald  be  giveu  to  thd 

pacieDt*a  diet  and  to  the  slate  of  the  alimentary  canal     The  effects  of  a 

pviupt  and  vigoTona  oathartio,  and  the  adnption  of  a  light  and  easily 

di|e»ted  diet^  principally  oE  milk,  not  a  low  diet  necesaarily,  are  often  very 

liabiag.     The  necesaity  of  overcoming  conatipation,  eapecially  in  women 

aai  la  men  of  fledentary  habits,  is  very  great.     Many  a  patient  has  reeov- 

end  after  prolonged  medication  when  placed  upon  a  eourse  of  Carlsbad 

alts.     It  ia  unnecessary  to  add  that  Btiniolaitta  are  to  be  avoi<led.     Before 

atilinng  anj  of  these  meaaurea,  however,  it  is  necessary  to  relieve  pain, 

ut  in  the  beginning,  if  the  pit  In  is  of  such  severity  that  it  prevents  the  pa- 

tiut  from  obtaining  a  re^^uieito  amount  of  sb-ep  and  exhausts  his  nervoas 

*B^r^,  a  full  dcse  of  morphine  should  be  given,  both  for  its  moral  and 

i'^  physical  effects.     After  that  reliance  can  safely  be  placed  upon  the 

leas  injurious   patii  relievers,  auisb  as  antipyriu,  phenaeetin,  and  the  flali- 

fyUtes.     In  ca^^a  which  have  apparently  Wen  caused  by  refrigeration 

Aad  in  those  occurring  with  manifestation  a  of  the  rheumatio  state,  the 


TREATMENT  OP  DiaRASBS  OF  THE  SEttVOTS  HTSTBlf- 

salts  of  s&licylic  aciil,  parlicularlj  thosd  of  aodiimi  and  potaAsium,  tth 
ba  giTCD  ill  fuU  doses.  Eapcciully  should  &  ifirge  dose  bo  given  at 
time,  and  if  tKcre  be  espeisial  indication,  it  may  be  given  eimultaueo 
with  one  c>f  the  ii^ilder  hy[motios.  Hvery  caaa  iti  which  there  is  a  bis 
of  g<»ul:  or  denioDBirable  eYiden<;e  of  ita  viiatencc  c^IIh  for  the  determi 
usa  of  colcbicum,  and  sLriut  abtuutioQ  to  Uie  diet.  Tha  use  of  aconi 
and  of  gelaemiLun  to  benumb  soiutic  patna  is  according  to  many  a  question" 
aUe  procedure.  They  have  been  highly  recommcaded  by  aonie  writets, 
but  they  have  lost  caste,  particularly  Buice  the  iutroduction  of  the  laodeni 
aualgesica. 

The  tudicationa  for  causal  therapy  should  be  vigoi'ously  Houglit  iu  th« 
receut  as  well  as  iu  the  aitcient  case  of  Bciatiaa.  If  it  can  be  shown  that 
aity  of  thd  couditiODs  which  hava  previously  beou  meutioucd  as  c^usatire 
of  scmtioa  nro  oporativt^,  sucb  as  ayphiUtJ,  malaria,  poioouiu^  from  l€ad 
or  arsenie,  diabetet;^  autoi r t to xi cation,  or  impai^Liou  of  f^^ces,  specific 
medicatioD  should  be  dtreobtid  to'waid  fighting  it  as  soon  as  the  geueral 
dicaticna  for  treatutent  above  mentioned  have  bcea  fulfilled. 

The  caitsal  treatment  should  be  supplemented  by  earnest  admiuia- 
tration  of  di«teti<;  and  medieinal  recouHtruetiyes-  It  seems  unnecefiBUy 
to  enumerate  theae  in  detail  here,  as  they  have  already  been  often  o<in' 
ftidered.  Furthermore^  thow  medicipea  which  act  a*«  rwonstructivea  in 
one  individual  have  ro  such  effect  In  another.  Tbe  alert  practitioner 
will  not  need  explicit  diiectioua  when  to  give  iron,  arsenic,  cod-Uver  oil, 
and  phOHph(>rus,  no  more  will  he  Tieglect  to  give  one  or  all  cf  them  if 
direct  indiratieiis  for  their  use  exi^t.  Although  sciatica  often  occurs  in 
apparently  healthy  persons,  that  is,  in  tliose  who  {]c  nut  stand  in  need  of 
reconr^tructive  treatment,  the  sufFeritig  aud  sleepleflsnesa  usually  eiitml 
perversion  of  the  general  mitrttioii.  This  in  turn  tends  to  prolong  the 
duration  of  the  sciatica  unless  it  ia  combated.  Sleepleastiesa  iteelf  ofben^ 
limes  requires  the  adoption  of  measures  directed  immediately  against  it, 
I'siially  the  pain  relievers  are  Hunieient  to  overcome  it,  bit  when  th^ 
fail,  no  hesitation  should  be  had  in  giviiig  such  hypnotics  as  trional,  sul- 
fenal,  and  paraldehyde,  providing  tlierc  be  no  direct  contraindi cations  to 
their  use.  It  ia  usually  not  nc^cassary  to  continue  giving  them  km 
should  any  ous  of  them  be  repeated  more  than  a  few  tim«B, 


M 


TiuiATiiKnr  OK   SuBAt'iiTrc  ANfj  Ohrosic?  SciATrflA, 


■  The  mode  of  treatment  and  the  above  enumerated  meaaurea  suffice 

I  the  majorily  of  sufferers  with  acute  sciatica,  whether  the  seiatica  be  de* 

I  pendant  upon  true  neuralgia  or  elight  perineuritis.      This  being  true,  it  ia 

I  astonishing  that  so  many  cases  of  this  arfectiun  go  on  Ui  a  chronic  atata- 

I  That  they  do  is  beyond  question,  and  it  is  due  mainly  to  haphazard  treat- 

I  ment  and  to  compromising  with  the  patient  regarding  the  plan  of  ti 


THE  TREATMEHT  OP   SCIATICA. 


385 


Soma  cases,  hcwever,   are  Bub&cut«  or  cbronio  in  their  clinic&t 

VKiifeatalJi^us,  cveci  £roiu  the  beginning.     ScLatica  manifosting  itself  ia 

ft  mbftOtitd  or  cht-oiiio  fashion  Tequires  some^vhat  difTeTont  treiiUiieiit  from 

Iba  ftcutti  rftiietj.     Although  the  methods  of  tteatment  of  both  forma  have 

BQoh  in  cominoti,  it  is  iii  the  latter  especial/  that  counterlrritfttlou,  elec- 

thdtj,  massage,  gyTunasties,  h>drotherapj',  bslueothtrapy,  nerve  aUetcL- 

DfE,  ftcupunctuie,   ausp&iiaioa,   etc,  in  short*   wh&t  may  1>q  termed  the 

|ih^ad  treatment,  &re  of  the  groateat  service.      £&Gh  oue  of  these  meBS- 

%ia  has  its  adv^^cates  now,  as  it  has  h[ui  lu  the  pii3t.     The  impju-tial 

H«det  tVLigbt  infer  fi-om  peiueal  of  the  lavish  eulogiurna  of  thesd  advo- 

gM  anent  the  service^ibLlity  of  their  ^it^t  remedy  that  &11  othfra  were 

onftweaarj  save  th&  one  under  con  side  ration.     For  inatauce*  one  phyai- 

ciuttporta  an  enormous  percentage  of  curca  from  the  use  of  dectricityi 

pQlhof  had  had  equally  good  resn^t^  frou;  acupuncturef  while  a  third, 

tteb«hi«otheFapUtT  contends  that  chrouiG  sciatica  yields  more  imdfotmly 

tfiibe  procedures  ap^ilied  at  the  particular  thermal  spring  at  vhich  he  is 

roulsut  than  aintoat  any  other  eymplom  or  diaease  which  ha  encounters. 

Tq*  truth  of  the  matter  U  that  chronic  sciatica  will  yield  to  aliii4>st  any 

pki  of  treatment  that  liad  for  its  purpose  the  improv^ement  of  tht)  local 

tjiC  ^E^t^l  nutrition,  if  it  19  eombiaed  with  csuaal  treatment,  regulation 

of  ihe  bowelsr  and  the  general  dietetic  auJ  diaciplinary  entailments  of  a 

viU'fonnulated  plan  of  treatmenL 

The  Traatment  of  Chrooio  Sciatica. — Ono  of  th«  moab  iiuportant 
tUnfS  h>  deterraino  early  in  the  treatment  of  chronio  sciatica  iB  vbebher 
«T  aot  the  patient  should  have  rest.  As  a  general  rule,  if  there  are  no 
indications  of  organic  involvement  of  the  nerve,  acd.vily  is  mueh  more 
MHcaable  than  rest.  The  movements  that  maj  be  advised  are  active 
ud  lasaiTCT  the  Latter  being  by  Far  the  more  important  They  may 
be  utilized  in  the  shape  of  mnaaage  and  resiatanoe  exercbes.  Maasage 
W  Ue  virtue  of  improving  both  the  local  and  the  general  nutrition. 
A^linl  directly  to  the  parts  that  are  the  seat  of  pain,  it  canses  a  deier* 
miutiun  of  blood  thereto  and  promotes  active  metjitaorphosis,  which  Is 
tB  important  factor  in  aasistiog  the  nerve  to  regain  its  normal  condition. 
IhHx  lamo  way  it  tends  to  prevent  inactivity  atrophy  or  to  overcomd  it 
•i  it  already  exiEt£.  It  is  very  necessary  Co  tell  the  patient  that  massage 
omt  he  done  thoroughly  and  kept  up  for  a  considerable  time  before 
flial  efTeets  will  be  seen.  Moreover,  it  ahuuld  rot  be  relied  ujion  as 
■Die  therapeutic  agency.  The  maimer  of  its  administration  is  not  so 
fepOrtant  as  many  eKponeuts  of  the  ai't  would  have  aa  believe.  The 
pttieat,  lying  on  the  belly,  should  have  the  entire  extremity  from  the 
tolttlotbe  ilium  gently  rubbed  and  kneaded,  beginning  from  above  and 
fodnfilly  working  <lowuward  to  the  ball  of  the  fiiot.  If  the  nerve  or  ila 
Buin  iiranehes  are  particularly  sensitive  to  pressure,  the  Jtias^age  should 
tt£rst  be  very  gentJe  and  not  of  prolonged  application,  tiever  for  more 
25 


38*5 


TREATUEITT  07  DISEAGBS   OF  THE  KETITOUS  STeTEU. 


than  from  ten  to  fifteen  minutes;  for  often  the  patients,  esEieciaHy  men, 
IjecojiiG  irritable,  sletjilesa,  atui  filled  nith  unreal^  if  the  alleioiit  is 
made  ta  force  it.  At  each  fiucceeding  a^aooQ  it  should  be  applied  more 
vigoroualj,  so  that  eventually  Hit  ftiotiou,  stroking,  and  presiiuie  oper- 
ate directly  upon  the  nen^e  trunk  attd  its  branches.  At  the  encl  at  each 
appLi(!ation  the  patient  may  profitably  he  put  through  &  series  of  teelflt- 
ance  niovemerilfl  which  bring  into  activity  not  only  the  muscles  supplied  by 
the  sciatic  nerve,  hub  their  phyaiuloj^iual  antagoui^ts.  If  it  ia  foimd  that 
these  mi^venienta  tiavo  a  tendency  to  increase  the  pain,  they  should  Ue 
dis^jeut^cd  with,  whilo  an  effort  is  made  to  obtain  similar  reeulta  by  hfiv- 
ing  iha  patient  walk,  inland  on  the  toes,  bend  over  and  touch  the  floor 
without  Geiing  the  knees,  etc.  If  there  be  deformity  of  the  trunk  as 
the  result  of  prolonged  iJiciipaclty  of  the  affected  extreniitiea,  suitable 
cali^theuicH  to  overcome  this  fihould  be  instituted  in  coujuiictiou  with 
masaage  and  resistance  e:(crcL3ea. 

Electricity  in  the  Treatment  of  Chronic  Sciatica. — Electricity  may  be 
used  simultaneously  with  massage  to  advantage.  By  far  the  moat  impor- 
tant form  of  electricity  is  galvacism.  Like  all  other  therapeutic  a^uciea, 
it  must  beusedmethcKiically  aiid  persistently-  Disappoiutmeut  will  follow 
almost  invariably  if  the  atteui  pt  be  made  totiae  it  othei-wiae.  Tho  patient 
ehould  be  treated  lying  down,  a  lurge  sponge  electrode  cotuiectcd  with  the 
negative  pole  applied  over  the  email  of  th^  back  at  the  aacro-Uiao  junction^ 
The  positive  electrode,  one-third  or  one-fourth  tlie  size  of  the  negative,  is 
piflcpd  immediately  below  it  and  a  current  of  frcim  tliree  to  five  milliam- 
pt^rea  allowed  to  flow.  The  uegative  electrode  is  kept  iii  this  aituabioii  for 
abutit  a  minute,  and  then  glided  to  the  cutaueoua  area  just  bolow  it.  In  thia 
way  the  entire  distnbution  of  the  nerve  ia  gone  over,  the  sdance  lai^ting  from 
ten  to  twenty  minutes.  Aa  the  polt>3  are  more  widely  separated,  the  current 
can  advantageously  be  increased  up  toBix  or  even  eight  niillinnipetee.  At 
llie  end  of  tlie  s^nce,  if  the  patient  complains  particularly  of  the  jiainful 
pointa  iu  the  distribution  of  the  nci-ve,  beneiit  often  follows  causing  a 
current  of  about  ten  milliamperea  to  pass  through  the  nerve  over  thcae 
pointa  for  a  few  Becouda,  the  negative  pole  being  all  the  time  on  some 
indifferent  part  of  the  body.  At  the  eod  of  each  applicatiou  the  patieut 
should  be  advised  to  rest  for  from  f  fteen  iidnutea  to  an  hour.  Then  he 
may  be  allowed  to  go  about  hia  dutiea  or  pleaaures,  providing  the  pain  is 
uob  exacerbated  by  so  doing.  I>ifFt.^rcnt  therapeutists  gi^e  different  in- 
structmns  eonceming  the  mode  of  applying  the  galvanie  current,  and  un- 
doubtedly one  plan  is  about  aa  aerriceuble  as  another.  I  hnve  found  thia 
plan  useful  in  both  private  and  dispensary  practice,  and  as  it  has  the 
advantage  of  being  tilmple  artd  eaay  to  use,  recourse  Is  not  often  had  to 
any  other.  Naturally,  in  individual  caaea  it  may  be  modified  aomewhat. 
For  lustFuice,  if  there  is  considerable  inactivity  atrophy  or  aluggiahneaa 
of  the  muaeleg  physiologically  antagonistic  to  those  impaired  by  the  sci- 


THE  TREATMENT  OF  SCIATICA. 


887 


atica,  these  muscles  may  be  atiniulat^  to  contraction  by  t]ie  nee  of  ik^ 
inlermptPil  galvanic  oiirreoc.  The  two  thiugs  to  be  remembered  are  that 
the  inteTrupted  galvanic  should  not  be  applied  to  the  nerve  Itself,  and 
secoud,  wh«u  appH«d  to  produce  mu&t'ular  couLraution,  the  danger  is  of 
Dverdoiixg  the  matter.  Each  muscle  or  group  o£  muaclea  should  not  be 
m&de  to  coatr^t^b  moro  than  a  few  tlmta;  otherwise  the  applicatiou  will 
be  followed  by  painful  reactions. 

The  uexl  most  important  method  of  ufllog  electricity  is  by  means  of 
the  rapidly  vibrating  indulged  ourrent  which  has  been  rondnoted  through 
a  long*  fi^s  coil  o£  closely  wound  wire.  The  battery  used  for  this  pur- 
pose is  described  on  page  101.  This  variety  of  induced  electricity  is  of 
special  aervice  in  cas«s  of  suUact^te  and  chronic  sciatica  in  which  the  pain 
is  out  of  proportion  to  the  attributed  causation  of  tlie  disease  and  the 
fuwiisting  phenomena.  The  application  ^honld  be  made  tviee  or  three 
limes  doily  immediately  over  the  nerve,  each  stance  lasting  about  ten 
miuutca. 

Static  electricity  has  received  very  high  praise  from  certain  quactors 
for  the  relief  of  sciatica.  Some  time  ago  ten  consecutive  oasea  of  Bciatica 
coming  to  my  clinic  for  treatment  in  tlie  mibacuteand  chronic  stages  were 
subjected  to  this  form  of  electricity.  The  mode  of  application  waA  that 
usually  recommeoded,  viz.,  the  application  o£  a  spark  from  four  to  siji 
inchea  loug  <iirectly  into  the  trunk  of  the  nerve  from  the  point  of  ita 
escape  to  its  terminal  distributions^  each  apphcation  lastiiig  from  three 
to  six  minutes.  The  results  of  the  trial  were  siicb  as  to  enhance  the  be^ 
lief  previously  held  that  static  elKrtricity  was  the  form  least  deserving  of 
confidence  in  the  treatment  of  sciatica.  Despite  this,  however,  static 
electricity  ia  an  agency  of  considerable  service  in  the  treatment  of  in- 
veterate cases  associated  with  a  great  deal  of  muscular  stiffness  and  un- 
wieldinessof  the  extremity.  It  is  an  im portant  agency  to  cause  muscular 
contraction  and  consequent  tissue  metamorphosis.  Aside  from  this  the 
moral  elTects  r>£  its  use  and  its  power  to  produce  temjKirary  alleviatiou 
of  pain  justify  its  application,  but  it  is  senseless  Ut  rely  upoa  it  exclu- 
sively ad  a  therapeutic  agency. 

Hydriatto  Frecedore  in  the  Treatment  of  Subacute  and  Chronic 
SoUtlcft,— Kvery  phyniJ'i.T.n  should  understand  the  proper  use  of  water  iu 
the  treatment  of  aiicimit  sriutir^.  There  are  few  agencieo  that  aro  more 
useful  in  this  affectiou  if  properly  and  vigorously  applied,  I  have 
already  epokeu  of  tho  Lydriatio  procedure  that  la  Bcrviceable^  in  oasea  of 
acute  sciatica.  The  most  impertatit  mode  of  applying  water  in  obetinate 
sciatica  is  by  means  of  the  Scutch  douche.  It  will  depend  largely 
upon  tha  putieut*9  capacity  to  react  what  temperatures  and  under  what 
pressure  the  streania  be  made  to  impinge  upon  the  affected  estreiiiity-  If 
tbe  patient  is  ameniio,  aen^^itive  to  changes  in  temi^erature,  and  of  ^loor 
Tcactive  capacity,  it  may  be  necessary  to  prepare  tbe  outaneoue  system 


388       TBKATMBarr  op  DissASEa  or  thb  nsbyous  btbteh. 

bj  giving  cold  ablutioQfl  (water  from  65°  to  60°  F.)  fot  a  few  aeconda, 
followed  by  brisk  friction  all  over  the  bodj  to  cause  prompt  reaction,  for 
a  few  days  prerionB  to  the  application  of  the  douche.  After  the  patieat 
has  been  thus  prepared,  the  douche  may  be  applied  in  the  beginning  with 
water  of  from  110^  toGO^  F.  and  from  twenty  to  tweuty-five  pounds  pressure 
for  £rom  thirty  to  fifty  seconds.  After  a  few  applications  the  temperature 
of  the  hot  water  may  be  increased  to  12^^  F,,  but  it  is  rarely  advisable  to 
decrease  the  temperature  of  the  cold  jet  much  below  C0°  F.  At  the  end  of 
the  stance  the  patient  should  be  given  a  fan  douche  of  from  65°  to  55°  F. 
over  the  entire  body  for  about  five  secooda.  Thia  is  followed  by  an  in- 
tense cutaneous  hyperemia,  a  condition  that  ia  very  deairable,  especially 
of  the  affected  part.  After  this,  the  patient  may  be  given  gentle  massage 
for  about  twenty  minutes,  and  then  allowed  to  dress  aad  go  out-  I  have 
found  this  plan  of  giving  light  mass^e  of  especial  benefit  in  women  who 
suffer  from  sciatica.  Hen,  aa  a  rule,  do  not  tolerate  general  massage 
very  well,  and  aa  a  substitute  for  it  iu  these  cases,  a  ram  bath  of  from 
60°  to  50°  F.  for  two  or  three  seconds  is  given  in  order  to  facilitate  and 
intensify  reaction.  The  patient  is  then  dried  quickly,  and  if  the  weather 
is  not  inclement  nor  the  temperature  very  low,  the  patient  is  advised  to 
go  into  the  air  and  walk  briskly  in  order  to  maintain  the  reaction.  Such 
procedures  as  these  can  be  had  only  at  hydriatio  institutes  and  hospitab 
provided  with  hydriatic  appliances,  but  the  time  is  at  hand  when  such 
facilities  must  be  provided  in  all  large  cities  and  in  institutions  for  the 
treatmeutof  the  sick.  If  it  is  impracticable  to  use  the  8cotch  douche, 
some  beneficial  general  tonic  effects  may  be  obtained  from  the  use  of  cold 
ablutions,  which  are  often  so  serviceable  in  the  treatment  of  neurasthenio 
conditions,  and  from  the  use  of  the  half-bath  from  75'  to  SO''  F,  for  from 
two  to  five  minutes,  given  just  before  retiring. 

Certain  thermal  springs  and  watering-places  in  this  country  aod 
abroad  are  more  or  less  justly  famous  for  their  efficacy  in  the  cure  of  all 
neuralgic  conditions,  sciatica  among  the  rest.  It  should  not  bo  forgot- 
ten that  the  beneficial  effects  of  a  sojourn  at  one  of  these  places  is  not 
more  dependent  upon  the  water  aud  the  mode  of  applying  it  than  upon 
the  change  of  environment,  diet,  discipline,  and  other  factors  that  stimu- 
late tissue  metamorphosis  and  improve  the  general  bodily  health  and 
'neuromuscular  tone.  The  truth  of  this  is  indicated  particularly  by  the 
fact  that  sciatica  dependent  upon  or  associated  with  diathetic  states,  and 
sciatica  th^  sequela  of  intoxications  and  infectioos,  are  more  frequently 
and  uniformly  improved  or  cured  than  other  varieties.  The  springs  in 
thia  country  that  have  a  reputation  for  the  cure  of  sciatica  are  particularly 
the  Hot  Springs  of  Virginia,  Richfield  Springs  of  New  York,  the  Hot 
Springs  of  Arkansas,  Mount  Clemmons  of  Michigan,  and  Poland  Springs 
of  Maine.  The  latter  two  owe  their  efficaciousness  in  the  relief  of  sciatica 
to  the  ancillary  factors  hinted  at  above.     The  technique  of  giving  the 


THE   TREATMENT    OF    SCIATICA- 


389 


baths  and  water  at  each  of  tlicae  springs  varies  witli  tbe  phyaiciaos  who 
are  in  charge.  It  is  geaeratty  combined  with  some  such  hydriatic  pro- 
cedure ^s  those  already  detailed, 

AcnpQQctnre.—Avu puncture  in  the  treatment  of  sciatica  is  a  therapeu- 
tic measure  that  has  lieeii  donated  t^j  ua  by  tliB  Chinese.  They  have  fionj 
time  immemorial  ihractiaed  it  by  thruatiug  fine  needles  of  gold  or  silver 
deeply  into  the  tissues  which  are  the  seat  of  pain,  not  necessarily  iuto 
the  nerve  itself.  It  isappoaeclure  with  which  I  have  had  no  conEiderahle 
personal  experienee,  hut  as  it  has  teoeiiily  been  highly  praised  by  se^'CTsl 
English  phyai<:iaiL5,  it  seeniii  advisable  to  deauribe  it  aiid  give  an  ^' 
timation  of  its  worth,  niado  by  one  of  its  latest  advocati^a.  Gibson.  It 
is  done  in  tbe  following  way  :  A  single  spear-pointed  needle,  two  and 
one-h^f  inchea  lung,  is  plunged  direetly  into  the  trunk  of  tho  nerve, 
particularly  that  part  in  which  there  is  pa.iit  on  pressure-  The  nerve 
should  lie  piei'Ped  ai)out  five  tiuita  befoi-e  the  needle  is  completely  with- 
drawn. There  is  no  ditBciilty  in  recognizing  when  the  nerve  is  pierueJ, 
as  it  La  always  signalled  )iy  sharp  pain  shooting  down  the  leg.  The  needle 
should  not  be  left  in  for  any  length  of  time,  because  if  it  is  severe  pain 
will  follow  itii  withdrawal.  A  uuniberof  needles  may  beaded  aimultane- 
oualy,  but  this  is  not  of  any  particular  advantage  sava  aa  a  time-  and 
pain-spariijg  expedient.  The  external  popliteal  atid  musoulo -cutaneous 
nerve  may  be  pierced  if  they  are  the  seat  of  pointjf  that  are  painful  vn 
preafiiira.  The  prL>caduie  is  thouglit  to  operate  beneticially  by  counter- 
acting  and  overcoming  iudammation  of  the  ncr^e  sheath  and  tnteretitial 
neuritia  when  the  latter  exists^  If  the  nerve  is  pi^r^-ed  in  a  number  of 
places  over  the  inilaTued  nras,  iri  which  there  is  coTjgesi.ion  of  vessels,  and 
consequently  exudation  of  senun  with  round  cell  infiltration,  the  punc- 
tuics  are  supposed  to  give  an  outlet  ttr  at  least  some  of  the  exudation.  In 
addition  it  servea  to  bring  back  the  toue  of  dilated  biood-veaacia  and  to 
restore  the  perivascular  Jyinph  circulation  which  in  turn  aida  the  restora- 
tion of  nutrition  in  the  nerve. 

The  Uie  of  Caunter-irrltanta, — The  lutwis  of  ap|>ly  iiig  cntuiter-irritatitni 
to  tbe  sciatic  nerve  aie  numerous.  That  snch  procedure  often  facilitates 
the  cure  of  aciatii'Q  has  beeu  attesbed  by  almost  every  writer  from  the 
time  of  Gontugno(whogave  the  first  detailed  description  of  5o:atioa)  to  the 
present  day.  Before  speaking  of  the  methods  of  employing  counter' Irrita- 
tiiiUj  remarks  muat  he  made  very  similar  to  those  regarding  the  factors  that 
determine  the  election  of  any  procedure  io  the  trtratment  of  sciatica.  That 
ie>  counter- irritation  {^annot  be  relied  upon  to  tieneSt  nniformly,  unless  the 
eases  in  which  it  is  applied  aro  carefully  aeltoted  and  the  procedure  is  uaed 
diacriminately.  It  ia  particularly  cases  of  sciatica  foHowini^or  associated 
with  perineuritis  and  intecatitialnearitia  that  are  improved  by  connter-irrU 
tatioQ.  Sciatica  dependent  upon  diatheses  and  depraved  states  of  nutrition 
should  not  be  treated  by  this  measure,  unless  there  are  some  special  reasons 


TREATMENT  OF  DJGEABE3   OF  TBS  NRRVOUS  STflTEU. 

for  ita  use.  The  rauat  expedient  way  of  Bjijilyiiig  counter- irnbttioii  is  by 
means  of  the  actual  cautery.  The  course  of  the  nerve  baring  beeu  c&re- 
fuUj  mapped  out  by  mcana  of  mnnipuJatioa,  its  location  is  indicated  by 
th«  tn^rk  of  a  eoft  lead  pencil.  Tbe  cautery  brought  to  a.  white  heat  is 
then  applied  with  the  ^eateat  posuible  rapidity,  either  with  short,  abrupt 
touches  or  by  means  of  jdight  linear  rontai^t  over  tbe  entire  [^ou^9e  of  the 
nerve,  except  at  Bucli  parta  as  are  uoi  covered  by  couaiderable  subcutane- 
ous tbsue.  The  entire  procedure  should  not  consuaie  more  than  a  few 
eeconda.  It  13  not  &o  painful  as  is  ordinarily  supposed,  and  if  the  bums 
fire  properly  dreesed,  the  after-pain  is  in<^on9eqL.ientia],  It  is  a  remark- 
able fact,  and  one  that  brooks  no  denial,  that  when  the  actual  cautery  ia 
applied  to  the  sKin  over  tbe  nerve  of  the  uuaffKcted  op^KBite  extremity, 
tbe  beneBciai  effects  are  quite  as  evident  aa  when  it  is  applied  to  tbe 
painful  extrt'mity.  Tbia  can  probably  be  explaiueid  aloug  tho  aaiDO  linca 
OS  can  the  fact  that  when  oue  extremity  is  immeraed  in  cold  water  the 
surface  temperature  of  the  opposite  estremity  dropa  from  one  or  two  de- 
grees, a  phenomeiion  dependent  upon  change  in  the  vascular  content  of 
that  extremity.  In  other  words,  tlie  beneticial  effect  of  cauterization  la 
brought  about  through  the  syinpathelic  nervous  ajstem.  The  afferent 
impulao  is  conducted  to  the  spinal  cord  and  rejected  through  the  sympa- 
thetic: ganglia  which  prebide  over  the  vascular  iiiuervatiou  of  tbe  extrem- 
ity. The  effect  of  a  peripheral  mulal€ral  etinmlua  ia  manifest  in  both 
eitremilies  l»ecause  tbe  sympathetic  ganglia  to  which  the  impulse  ia  re- 
flected are  functionally  of  bilateral  display.  A  similar  eipUuiation  might 
be  given  for  tho  beneficial  effecta  of  cauterisation  of  other  parts  of  the 
body,  Duch  as  tho  ear,  in  the  treatment  of  aciatica.  One  may  justly  oon- 
teud  perhaps  that  cauterization  of  the  ear,  which  at  one  time  waa  very 
much  lauded  in  the  treatment  of  seJatica,  acted  because  of  the  psj'chical 
effei'ta  wbiph  it  produced ;  Imt  even  then  the  relief  of  the  sciatic  pain  must 
have  been  brought  about  through  the  sympflthetio  uervoas  ayatem  which 
gorema  the  nutrition  of  the  nerve  through  the  nervi  nervorum  aud  the 
vaao  vaaorum. 

Similar  effects  to  those  oljtaiited  by  rjauteri^^ation  may  be  obtained  by 
means  of  bliaterSf  produced  by  cantl>aridp»,  mustard,  or  other  vesioanta 
applied  over  the  tierve.  Indeed,  it  is  oftentimes  better  to  apply  b-  r^um- 
ber  cf  smalt  bliatet  planters  one  iuch  aquare  and  one  inch  apart  over  tbe 
course  of  tho  nerve.  1'he  advantage  of  applying  multiple  blisters  is  that 
they  uaually  necessitate  the  patient  keeping  quiet  for  a  short  time,  and 
tbe  compulsory  rest  itself  is  beneliciaL  After  the  bliaters  have  formed, 
they  should  lie  evacuated,  then  treatf'd  in  the  tiame  way  as  a  burn.  Mua- 
tatd  should  never  be  UMid  to  cause  complete  btiater  formation,  because  the 
results  of  the  application  cannot  be  estimated  as  accurately  as  can  other 
vesicants.  Xeverthelesaf  a  largo  muatwd  poultice  or  plaster  that  envelops 
the  entire  posterior  eurfaco  of  the  lower  extremity  from  the  iaohiatic 


THE  TREATMENT  OF  SCIATICA, 


391 


Dotch  down  to  the  lower  third  of  the  leg,  and  kept  on  until  it  causes  deep 
reddening  of  the  Burfn-e^  but  removed  jitst  abort  of  blister  fornialiDn,  niaj 
ofteji  be  uaed  yery  ad^antageoualy.  In  tlie  eaine  way,  eciue  iiaaea  of  mild 
but  obatinate  eciatic  pains  are  bene^ted  by  the  application  of  a  coatinff 
of  cantharidal  ooUodium  which  need  not  keep  the  patient  from  Ma  oc- 
Capation.  Counter-irritation  is  a  proeedure  that  can  be  easily  ovetUoue 
in  the  treatmenb  of  sciatioa.  There  ia  B<.-arne1y  any  juati£catton  for 
repeated  viae  of  it  providing  two  or  three  trials  are  not  folloneU  by  con- 
siaerable  improvement. 

Narre  Stretchinf  and  Compiefialan. — PreBsure  and  stretching  of  the 
tciatic  nei've  are  recommended  Ly  many  writers  in  the  treatment  of  the 
inveterate  aciatii^a.  Recently,  Negro,  an  Italian  physic'ian,  han  adopted 
a  plan  which,  ronsiata  of  m;iking  a  severe  mei^haiiical  pressure  in  the 
treatment  of  aciatica,  especially  in  obstinate  foruis  wliich  are  depetidenL 
upon  a  Iqvt  grade  of  perineui-itia,  fie  has  constructed  an  apparatus  by 
meana  of  wh»]h  the  pressure  can  be  applied  by  the  turning  of  a  acrew 
directly  to  the  trunk  of  the  nerva  at  any  given  point  over  which  it  is  faat- 
ened.  The  bloi^k  or  pad  that  makes  the  pressure  is  faafpenedto  a  sliding 
borizoutal  bar  so  that  whf  u  the  appuratua  is  ^trapfied  to  the  leg  the  pres- 
sure pad  can  be  glidf^d  up  and  dowu  foraconaiderable  distance  and  preasuro 
made  to  any  area  that  maybe  eelectodp  The  patient  liea  on  the  belly  wit3i 
the  legs  extended.  The  nerve  is  found  at  its  exit  from  the  sciatic  notch 
and  the  ajjparatuii  applied  ao  that  the  pressure  pad  rvhall  come  donu  over 
tbe  nerve  as  nearly  as  iK>B3ib]e  at  this  (loint.  The  preaaure  pad  is  then 
acrened  down  until  the  patient  yella,  and  this  (compression  is  kept  up  for 
from  fifteen  to  thirty  seconds.  It  is  then  loosened  aomcw]iat>  hut  not 
completely,  and  ahd  along  the  hOTtzootal  bar  forward  and  back  over  the 
nerve,  thus  massaging;  it  for  three  or  foitr  uiiTiutes^  The  preesure  pad 
may  be  applied  over  other  points  and  especifilly  where  thfie  is  tenderneu 
on  deep-aeatcd  pressure.  Usually  the  application  is  repeated  after  an 
interval  of  a1)0Lit  a  half  an  hour,  aud  it  ia  recommended  that  it  should 
be  praQtiaed  abuut  aix  times  every  day  and  kept  up  until  recovery  eitsties. 
The  writ&r  make:^  extraoi^dlnai-y  claims  for  the  eflieaciousneas  of  thia 
procedure  in  the  treatment  of  rebellfoufl  sctatica.  Any  one  who  may  be 
tempted  to  try  it  will  tind  an  i]  lustration  of  the  apparatus  used  by  Arullani, 
a  follower  of  Negro,  in  the  Ne^tfohtfUcfir^s  Centra  iblnf/f  1807,  p,  o84,  but 
before  electing  to  use  it,  it  may  be  well  to  try  simple  stretching  of  the 
nerve. 

The  Surgical  Treatment  of  Sciattea.^Ner^e'HCretehijig  for  the  relief 
of  sciatii'a  i^  rather  an  ancient  ailair.  At  the  preseLt  time  the  bloodless 
method  alone  has  any  claims  for  recognition.  A  i]uarter  of  a  century 
and  more  ago  it  became  quite  common  for  the  surgeon  to  expose  the 
aoiatic  nerve  of  patients  who  were  athieted  with  sciatica  uhtoh  would  not 
yield  tc  les^  heroic  treatment  to  draw  ii  up  with  a  biunt  hook,  and  give 


TRKATMEWT  Or  DTSKASEB  OF  THB  ITERTOUfl  6YSTKH. 


it  all  hbe  tension  which  he  tUougbt  would  be  fpwd  for  it.  Others  aatU- 
fied  their  desire  to  inflict  injuiy  upoa  the  neiT©  by  *queeaing  it  between 
the  fingers  or  crushing  with  by  a  pair  of  forceps,  but  some  went  so  far  as 
to  Braver  ita  cantiEiijity  eotirely.  Theae  barbarities  are  mentioned  here 
merely  to  ahovr  tlie  advance  in  oar  art.  They  are  raiely  lueLtioaed  to- 
day, e^ccept  with  bated  breath>  Slight  stretching  of  the  sciatio  netTo, 
ench  aa  maybe  obtained  by  forcibly  flexing  the  affected  tbigh  on  the 
abdomea  while  the  knee  and  pelvis  are  kept  firmly  extended,  ia  aometimes 
benpficial  in  cases  of  estremely  obstinate  and  iTi  term  it  tent  sciatica  that 
occur  without  apparent  cause.  This  is  the  same  procedure  that  is  ooea- 
eionally  of  use  U)  relieve  leg  pains  of  locomotor  ataxia.  Beneficial  alight 
stretohiog  of  the  nervo  may  b9  caaaod  by  firm  digital  manipvilatiou  of  tJie 
nerve  by  the  physician.  Tlie  patient  lies  on  th©  healthy  side,  while  the 
affected  extremity  is  held  in  a  semi-extended  position  by  an  attendant. 
The  physician  endeavors  to  grasp  tlio  ncrvo  after  its  exit  from  tlie  gciatic 
notch  at  the  lower  bonier  of  the  gluteus  muscle  and  presses  it  forcibly 
backward  towavd  the  posterior  and  intCTnal  border  of  the  thigh.  It  is 
probable  that  in  cases  of  sciatica  dependent  upou  a  low  grade  of  [>ei-ineuntis 
and  inteffllitial  neuritis,  snob  luaoipulation,  pressure^  and  massage  may 
be  foUriwed  by  cimsiderable  benefit  due  to  breaking  up  inflammatory 
adhesLous  and  liberating  the  nerve  trunk  from  an  adherent  f^heath  and 
by  stimulating  the  blood  supply  of  the  part. 

In  these  days  of  ascptio  surgery  there  is  absolutely  no  danger  in  cat- 
ting down  upoQ  the  sciotie  iierve  for  diagnostic  and  therapeutic  aid- 
There  can  be  no  donbt  Ihiit  in  many  iTistances  adhesion  of  the  sheath  of 
the  nerve  and  iollamniatory  exudate  cause  a  violent  form  of  sciatica  and 
intense  diaorganiiation  in  the  nerve  which  medicinal  ircatuieiit  is  power- 
less to  combat.  The  pressure  of  the  exudate  serves  to  prevent  repara- 
tive  circulation  and  the  dragging  and  pressure  of  the  adhesions  keep  up 
the  persistent  and  demoralizing  pain.  Providing  the  pathological  diag' 
Bosia  ia  fairly  established  there  can  b«  no  objection  to  such  procedure. 
As  a  pi-eliminary  measure  one  may  attempt  to  withdraw  the  exudate 
from  the  sheath  oF  the  nerve  by  means  of  a  hollow  needle.  But  lay- 
ing bare  the  nerve  ia  such  a  simple  matter  and  bo  much  benefit  may 
come  from  it  that  it  is  urged  in  every  case  of  inveterate  sciatica  in  which 
one  IS  i^ascnably  sure  tbAt  the  condition  is  dependent  iipt^m  perineuritis, 
thickening  of  tlie  sheath,  uTid  adhesions  to  Runounding  tis^jue.  After  the 
nerve  ia  exposed  further  surgical  procedure  will  be  determined  by  the  eon- 
ditiona  foundn 

The  Medicinal  Treatment. ^The  medicinal  treatment  of  chronic  sciatica 
may  be  disposed  of  rather  briefly.  There  are  few  drugs  that  have  not 
beeu  reooDimended.  It  is  unnecessary  to  lepeat  here  what  has  been  said 
concerning  the  necessity  of  searching  for  the  cause  of  the  sciatica,  and 
the  adoption  of  causal  treatment     This  necessiQr  ia  as  great  in  anbaoule 


THE  TREATMENT  OF  SCIATICA. 


39a 


and  chronic  sciatica  fts  it  is  in  the  acute  vu'ety.  I^'eitfaer  ahall  1  again 
revert  to  the  use  of  pain  reliefers,  except  to  say  that  if  the  various  phys- 
ical iLicasiii'es  which  have  be^rtj  apckeci  of  in  some  deLail  are  pi-operly  used 
there  will  not  be  a  very  frequent  or  iusjstaut  demand  for  employing  n&r- 
ootLcs  oi  analgcaica.  The incdiciaea  thatact  inau  unknown  way  and  that 
are  given  em]>incally  ars  turptntiuc,  lodida  of  potaaaiunii  and  arsenic. 
By  far  the  commonest  prescription  given  to  ])aticuts  with  long-standiag 
sciatica  ux  my  irlinic  is  an  emulsion  ctf  turpentluej  each  teaapoouful  of 
which  represents  five  drops  of  tlie  oil,  whiL'h  is  to  be  taken  in  the  Legin- 
niDg  three  times  a  day.  AFlcr  the  patient  haa  becomo  accustomed  to  it 
and  shows  no  symptoms  of  irritation  of  the  urinary  appatatua,  tlie  do^^  ia 
moreaaed  to  two  or  three  times  this  quantity.  Turpentine  may  ba  given 
in  dejciblo  capaules,  m  from  gtt.  v,  to  kv.  doses,  but  it  ia  more  apt  W  dis- 
order the  sUimach  than  when  administered  in  emulsion.  Iodide  of  potas- 
sium 13  a  valuable  uiedicament  in  tho  treatment  of  all  fonua  of  ohronio 
neuralgia,  wLetlier  they  are  dependent  upon  diacernible  scJerotic  changes 
in  the  blood-i'eaaela  or  not.  The  dose  depends  entirely  upon  the  individual, 
and  the  well-known  rules  for  the  administration  of  tho  duig  in  atkahne 
waters  or  in  milk  should  i«  adberud  to,  VVhr»n  there  are  evidences  of 
arterial  suleiosis,  it  should  be  given  simull^aueously  with  nitroglycerin  or  ni- 
trite of  sodium,  and  if  the  sclerotic  changesare  manifest  in  the  large  blood- 
vessels, with  very  small  dosea  of  digitalis.  The  rf  pate  which  araenii-,  iron, 
and  other  aiterativca  have  gamed  in  the  treatment  of  sciatica  is  dcfkcudeut 
entirely  upon  their  capacity  to  alter  and  benefit  nutrition.  That  this  should 
be  the  principal  ohject  in  the  treatment  of  obstinate  sciatira  of  any  origin 
need  not  again  be  emphasized,  noi-  is  it  necessary  to  etmmeratt^  Uie  means 
that  may  be  employed  in  reaching  the  dcBircd  goal.  Even  in  cases  of 
sciatica  dependent  upon  conditions  that  cannot  betemediad,  suohaa  malig- 
nant growths  wluuh  exercise  pressure  upon  the  nerves,  the  nutrition  of  the 
patient  must  be  persistently  fortified,  in  order  that  the  suffering  may  be 
better  tolerated  and  that  snhstani;eB  used  for  its  relief  may  bavo  Rome- 
thing  to  act  upon. 

It  has  been  deemed  madviaahle  to  enumerate  the  various  therapjeutio 
resources  that  may  be  employed  to  combat  smaticas  dependent  upon  dif- 
ferent causes,  largely  in  the  belief  that  it  is  uncomplimentary  to  one^S 
intelligence  to  say  that  quiniEie  and  arsenic  should  lie  n^ed  with  all  jios- 
sible  uxpHdition  in  a  patient  wbo  has  sciatica  and  whose  blood  contdiua 
dome  variety  of  malai'inl  parasite,  or  (hat  a  patient  who  has  evidences  of 
early  or  late  syphdis  should  be  given  autisyphilitic  treatment  in  the  most 
approved  fashion.  There  are  certain  things  in  therapeutics  that  go  with' 
out  saying,  and  such  ns  th«Ke  are  of  rhem^ 

Neuralgia  in  the  doiiiam  of  the  sciatic  [>li-xos,  aside  from  that  already 
eonaidered,  Dccura  under  one  of  three  forms;  posterior  femoral  neuralgia, 
tliat  is,  neuralgia  of  the  small  sciatic  ncrvet  which  is  distnhutcd  to  the 


394 


TREATHENT  OF  DISEASES   OF  THE  NERVOrS  SYSTEM, 


lower  jiiirt  of  the  buttocks,  the  |xiBterioT  part  of  lh&  thigb»  and  the  upper 
part  of  tbe  leg,  neuralgia  of  thopudic  nerre,  one  of  the  t«iiuiQal  braticbea 
of  the  sciatic  plexus;  and  cui^jgodynia,  neuralgia  of  theccccygeal  nerve, 
or,  bettoi'  eaid,  pain  in  tbo  HLm  of  nerve  branohee  which  the  cxxicj^eaL 
netve  uniting  with  the  fifth  sacral  forms,  and  kno^n  aa  the  cix-cygeal 
plexus^  Neuralgia  In  the  domain  oE  the  small  Gfriatic  nervs  is  usuatly 
looked  upon  sb  a  part  of  ordinary  sciatica,  iedIws  tbe  pain  is  principally 
in  the  distrihution  of  the  inferior  pudendal  netve  which  is  distiihuted  to 
tt«  perineum.  ItB  oaueation  and  treatment  are  not  diSercnt  from  tlxat  of 
Eciatica. 

Trb  Treatmext  up  Podaloia. 

Pain  ill  the  feet  is  a  complaint  for  which  the  neurologist  is  frequently 
consulted,  and  as  all  forms  of  podalgia  ^c  extremely  amer^able  to  proper 
treatment;*  ^^  behooves  tbe  physician  to  h^re  clearly  in  miud  the  vatietiea 
of  pain  to  which  the  feet  are  subject,  as  well  aa  the  conditions  with  which 
they  occur.  In  my  experience  by  far  the  most  eummou  variety  of  podal- 
gia  is  tliat  which  is  an  expression  of  some  degree  of  ilat-foot,  varying 
from  weakneaa  of  t]ie  art'h  to  complete  j'es  pUnuB,  The  nifxt  variety  in 
point  of  frequency  is  plantar  nounUgia  nut  aaaociatcd  with  weakness  of 
the  arch,  occurring  in  patients  who  hare  syphilisT  gout,  tabea,  or  atherom- 
atous blofjd-TesseU,  and  in  those  whose  occupation  neceasitatea  long, 
slow  walking,  audi  as  polii^emen.  This  form  of  neuralgia  does  not  seem 
to  occur  in  clerks,  mechaoica,  mill  hands,  and  waiters,  whose  duties 
compel  bliem  to  remain  on  their  feet  more  or  less  stationary  for  several 
hours  every  day>  It  is  in  this  latter  claas  that  podalg'ia  of  Hat-fixtt  is  eo 
common.  The  noKt  commonest  variety  of  pudalgia  is  pain  in  the  heel,  of 
which  two  varieties  are  generally  described;  aohiUioflynia,  usually  de- 
pendent upon  the  prp>?ence  of  a  bursa  in  the  anterior  pari  of  the  tendo 
Achillis^  and  tArsaigia,  which  is  frequently  associated. with  the  piesencs 
of  a  sulcalcanean  bnrsan  Pain  in  the  heel  may  occur  apart  from  either  of 
these  two  conditions,  and  bo  the  expression  of  some  lutoxicalion,  trauma, 
infection,  or  constitutional  state,  flUf?h  aa  rheumaiifim  or  aruenim.  The 
least  common  form  of  podalgia  is  a  peculiar  coudition  first  described  by 
Weir  Mitchell,  now  known  as  Mortoii'a  neuralgia,  after  T,  G.  Morton  of 
Philadelphia^  who  brought  it  before  the  profession  m  a  very  suocinot 
manner  a  few  years  after  reference  had  been  made  to  it  by  Mitchell. 

Morton' s  neuralgia,  or  metatarealgia,  is  a  neuralgia  situated  in  the  an- 
terior part  of  tlie  footj  ehieiJy  of  the  fourth  me tatarso- phalangeal  articula- 
tion, aiid  oftenrimea  involving  the  third  as  well.  It  occurs  occasionally 
in  rheumatic  and  gouty  individuals,  especially  in  those  whose  occii|iation 
requireu  lun^  standing  and  walking-  It  is  essentially  a  pressure  neural- 
gia,  and  tight  boots,  with  tjariow  soles,  are  undoubtedly  the  most  im- 
portant fEictors  in  bringing  it  about,  especially  iu  peieons  of  lowered 


THE    TRKATMaST    OF    SCIATICA. 


355 


vitality.  It  may  follow  a  blow  or  a  sbra^in,  such  as  tbat  caused  bj  pro- 
louged  bicjoliflg  with  ill'titticg  boots,  or  in  ruuniug  a.  lathe  ot  machine. 
Heredity  has  been  thought  to  pJay  a  part  in  its  occurrence,  but  I  am 
Bure  tbat  those  instances  in  which  metatu'salgia  has  occurred  in  mors 
than  «ne  member  of  the  saine  Ca.iiiily  a.ra  to  ba  regardejl  as  acciieolal. 
The  essential  feature  iu  the  luat^banisiu  o£  metiatai&algia  it^  a  colljipse  of 
the  aoterior  arch  which  cau&ea  a  broadening  of  the  foot  and  compreaaioa 
of  tho  digital  ucrvea.  The  pain  of  metataraalgia  ia  liable  to  occur  first 
during  certain  acta  which  cause  te)n[>orarj  bToadening  of  the  foot,  suah 
as  dancitigf  walking  tiptoe,  pedalling  a  biryele,  and  nmnitig  a  machine. 
It  [&  ui^ually  (if  HD  intense  an^l  pan>xyBujal  natLire  ntn\  of  finch  sereriTy 
that  it  crjpidea  the  paUeut  and  uiake^  walking  iiuposstlile-  Tt  li  relieved 
by  Sexion  of  the  toest  by  teat,  and  by  grasping  the  iaatop  tirmly  with  the 
hand.  Two  patients  who  have  recently  been  under  ohaervation  ha.d  ob- 
tained relief  by  tying  a  silk  handkerchi^^f  firmly  about  the  fore  part  of 
the  instep,  and  wearing  it  inside  the  boot-  In  the  majority  of  the  cases 
a  apot  intensely  aeusttive  when  pinched  or  pressed  i?i  found  ou  tlin  dorsal 
aud  plantar  3urf&cea  of  the  third  and  fourtli  metatarsal  bones,  Sometimea 
there  ia  a  corn  beneaththe  head  of  the  thiid  vt  fourth  metatarsal  bone. 
The  foot  ill  Botna  cases  presents  a  peculiar  twist  directed  inward  jiist  in 
front  of  the  metacarpal  articuletjon,  accompanied  by  bulging  behind  the 
ball  of  the  great  toe. 

Treatment  of  Metataraalgia. — Thetreatment  of  metatarsalgiacj^iiBiBts 
in  OTercoiniog  the  cauaal  conditiona,  using  meaaiirea  to  relieve  pain  and  re- 
lax the  painful  apaamodic  conditioua  and  proper  sboaing  of  the  patient. 
If  all  these  be  of  no  avail  e^ccision  of  the  head  of  the  metatarsal  bone, 
where  the  pain  nnginates,  should  he  performed.  This  operaiion  should 
be  pracbifled  in  all  cases  in  which  the  piiiu  cannot  be  relieved  by  the  aim- 
pie  and  palliative  meaaures,  especially  if  the  condition  baa  guue  ou  to  the 
terminal  stage.  It  haa  prcviouHly  been  stated  that  pain  ia  often  relieved 
by  pressure,  and  it  is  therefore  unnec^easaty  to  dwell  upon  the  utiU/atioa 
of  Chis,  combined  with  rest  and  the  iinmereion  of  the  f^et  in  hot  water, 
and  of  massiigfl  ragnlaHy  and  methoilically  ajiplied  whilw  efforts  are  being 
made  to  overcouie  Uio  presaure  ou  the  digital  uervtra  by  aiipportmg  the 
arch  with  properly  conatructed  ahoes*  It  is  now  generally  agreed  that 
the  boot  should  be  constructed  on  what  is  known  as  a  Spanlah  last ;  a 
straight  inside,  high  instep,  and  an  imusually  long  and  high  heeL  The 
lioot  hariitg  a  broad  projecting  hcTe  should  fit  cloaely  over  the  instep  and 
be  of  sulticient  breadth  to  give  abundant  room  for  the  heads  of  the  nieta- 
t&raal  bones,  which  spread  out  when  the  weight  of  the  body  is  thrown 
Upon  this  part  of  the  foot.  The  patient  may  wear  a  rubber  bandage  or  a 
leather  circlet  around  the  baaes  of  the  iiietataraal  bones,  so  as  to  separate 
the  heads  as  much  aa  possible.  In  the  first  stage  the  paiu  may  be  ao 
severe  as  to  retjuire  the  use  of  auodynes,  and  when  it  does  no  heaitatlon 


396 


TREATMENT   OP  DISEASES  OP  TCK  NERVOCfl  SrSTfiU, 


should  he  had  in  employing  them.  TTeu^^  complete  rest  and  hot  appli> 
cations  am  sufEicient  to  relieve  tlif^  yaiu. 

Treatment  of  the  Podalgia  due  to  FUt  Feetn — The  fcot  pains  of  pea 
pluius  tkre  of  quite  a  diSereDb  chiiracter  from  those  of  metatara^gia. 
This  variety  of  podalgia  is  in  reality  a  combination,  of  parafithesia, 
the  form  known  as  kaumu^atliesia  or  barning  aensationa,  and  dull, 
achiug  paiu  which  estenila  up  the  legtf  to  the  thigh»,  associated  with  a 
seiisatioij  of  weight  and  unwieldluesa  of  the  luwer  extremities.  Ono 
of  the  moat  diatiuctive  features  of  thia  affection  is  the  patieot'd  man- 
ner of  walking-  He  toea  out,  takoa  very  short  etepe,  while  the  weight  of 
tbo  body^  instead  uf  coming  lu  a  wave-like  direction  from  the  heeJ  to  the 
ball  of  the  foot,  is  thrown  dirtictly  upon  the  middle  of  the  foot.  Exami- 
nation  of  the  paittut  in  the  standing  posture,  or  better  still  a  plaster  oast 
of  the  foot,  will  show  the  degree  of  breakdown  io  the  plantar  arcL  The 
treatment  of  podalgia  cf  Hat-fout  should  be  carried  out  witb  great 
thorough ne&3,  not  alone  iia  order  to  get  relief  from  ths  piin  for  the  timo 
being,  but  to  overcome  a  most  unsightly  deformity.  Neil  in  importance 
to  getting  the  patieut  properly  shod  in  the  adoptioTi  of  exermes  tLat  will 
streu^then  the  muscular  and  ligamentous  supports  of  the  airch.  The  pa^ 
tieut  should  be  inatnicted  to  perform  methodically  the  following  exercise; 
Steadying  or  supporting  himself  by  placing  the  hand  on  some  tirm  object, 
euch  as  a  table  or  a  bedpost,  he  should  raise  biinseli  on  the  tiptoes, 
theu  abduct  the  heels  as  far  as  possible,  tbeo  bring  them  back  to  a 
parallel  and  fiually  bring  them  to  the  floor.  This  should  be  done  in  onei 
t^'o,  three  time,  Tlie  eiertiae  should  not  be  takeu  at  one  time  longer 
than  to  cause  aliglit  fatigue,  but  ib  should  bo  repeat<^d  at  least  three  times 
a  day.  The  patiout  should  also  alternate  it  with  forcible  inrersion  of  the 
feet,  standing  upou  the  outer  border  of  the  foot,  therefore  putting  tension 
upon  the  eicterafll  luteral  ligament,  nnd  reniouing  it  from  the  ealcaneo- 
ecsphoid.  Those  who  are  obliged  la  stand  ]>ehiud  the  counter  for  several 
houis  without  Testing  will  fiad  that  they  get  cuusiderahle  relief  by  stand' 
ing  m  this  way  and  occasionally  on  tiptoe.  Shoes  for  flat-footed  pardons 
should  be  coQstruoted  on  the  WaukeuphEt^t  last.  A  perfectly  straight 
itiBide,  with  the  arch  well  supported,  and  if  the  foot  be  merely  weak, 
witli  thifl  part  of  the  ahoe  veil  buUt  up.  Tha  muer  edge  of  the  sole  and 
the  lieel  should  be  raised  one  lift  of  sole  leather.  If  this  doe»  not  Huf- 
fice,  the  metallic  supports  derised  by  Whitman  and  made  by  E-  Bend^ei, 
of  2U4  ICast  Fifty-Seoood  Street,  New  York  City,  should  be  used,  Ky 
experience  has  b^en  that  these  Eupporta  are  by  all  means  more  satisfac- 
tory than  any  of  the  great  variety  that  have  been  tried-  Surgical  meSB- 
urea  undertaken  for  the  reconstmctiou  of  the  (»mpletely  sunken  arch 
hare  uot  be^u  attended  by  such  results  that  they  justify  extended  coo* 
61  deration. 

The  treatment  of  other  varictiea  of  podalgia  calls  for  no  other  com- 


THX  TREATMENT  OF  SCIATICA. 


3»r 


Taeat  n^^  the  statement  that  causal  therapy  usually  suiEce^-  Plwitaf; 
WOnJgia  vieM*  more  readily  to  oaosal  ihertpy  than  almost  any  Other 
migtj  of  neuralgia,  wlieu  combined  wiUi  such  g^ii^ral  restorative  mcaa- 
aatbe  applicatioa  of  water,  maaaag^,  and  electrioi^. 


PUDCXDAL    XKCKALflU. 

5eiin1git  of  the  perineum  and  uf  tha  eiternal  orgnns  of  geoeratiou 

mually  conditiuued  hy  functional  disorder  of  the  teriniDal  branch  of 

liesaiTal  plexus,  kuown  ad  the  pudic  tierve.     TLia  aerve  Bends  bianthes 

» ihe  ptrineal  spaL^e,  to  the  extemaJ  sphincter  muocie,  to  the  iutegumeut 

of  the  scrotum,  to  the  exterual  labium  pudeadi  in  the  female,  aad  to  the 

pmls  and  clitoris.      Pudendal  neurulgia  is  occ&aiLmally  observed  iu  young 

aisruats  aaJ  in  others  who  give  themselves  to  sexual  excesses.     Liko 

tmtabis  testicles,  it  is  very  apt  to  occur  in  those  who  are  unstable  ia 

B^:al  development  and  who  manifest  indioatioue  of  neurasthenia  ajid 

by&wria.     Karety  it  occurs  as  cue  of  the  mauifestationa  ^of  tabes.      In 

vvata  it  is  sometimes  an  aecompanlDQeut  of  asthenic  conditions  of  the 

|«lvia  organs  and  other  states  of  depraved  nntritiou.     Ot^ca^ionally,  iieii- 

nlgio  pain  is  oontiued  strictly  to  au  iudividuat  branch  of  the  pudic 

urves,  auoh  as  the  dorsal  nerre  of  thd  penis,  and  under  such  circum- 

BtUKts  the  puiii  may  be  a^sociat^d  with  symptoms  of  paiuful  sexual  ox- 

eiiatian.     In  other  iuatauces,  it  occurs  iu  connection  with  phenomena  of 

(iritable  bladder,  prostatic  ueL]r:dgia,  and  ov&rian  neuralgia,  hut  in  these 

cues  th«re  is  nsually  to  be  found  some  individual  or  Ioc^lI  condition 

vhich  aocoucits  for  the  pain  and  its  distribution, 

Tkd  treatnt^tt  of  pudendal  neutcJgia  is  in  nowise  different  from  the 

ttntment  of  similar  pain  in  the  domain  of  the  geuito-crural  nerve.     The 

fBoera]  condition  of  the  patient  demands  cnrefnl  consideration,  and  local 

Abaorm&liLies^  such  as  narruw  or  adherent  prepuce,  urethral  atricLure,  dia- 

**ae  or  displacement  of  the  uterus,  dilatation  of  the  rectum,  enlargement  of 

^  (irostatQ  aad  the  like,  arc  to  bo  combated.     Treatment  directed  iinme- 

^Hteiy  towiird  the  hysterical  or  neurasthenic  individual  will  generiUly  be 

^i^arded  by  amelioration  of  the  local  symptom  of  pain.     Oftentimes, 

'^^•ed,  it  ia  of  the  greati^st  importance  that  the  phyaioian  atndioiisly 

'^^lects  every  Form  of  local  treatment  in  order  that   the  patient's  attcn- 

i^zr^a  ruay  not  be  concentrated  upou  parts  that  are  already  occupying  him 

^^^ossingly.     On  the  other  Land,  if  the  patient  be  neither  neurasthenia 

^^3F  hypochondriacal,  local  measures,  including  heat  and  cold,  electricity 

^^%id  maasage,  are  as  benelicial  as  in  other  neuralgic  condltiona,  and  lh«y 

**»aj  advantageously  l)e  employtnl.     Cases  in  which  a  hysterical  element 

^-^  predcHntnant  may  oftentimes  be  brought  to  a  speedy  restoration  by  the 

^f  phcfttion  of  the  acUial  cautery  or  bLiaters,  if  the  pain  be  in  parts  that 

"^vill  tolerate  such  measurea- 


I 


396 


TREATUKl 


CoQCTQODVJfrAt 


Coccygodynia,  or  paiiifuJ  affectiou  of  the  cocoya,  ia  relatively  a  very 
rafe  coLdition^  although  one  luight  weU  be  Jed  tc  au]>po9a  otherwise  from 
a.  perusal  of  tLe  writings  of  some  gynaKsologista  who  have  ia  latter  yeara 
hail  muuh  to  say  com-ermng  the  effiLinRy  of  removal  of  the  coccyx  for  th« 
amelioration  of  thia  condition.  There  can  be  do  doubt  that  coccygQdyiii& 
ia  of  real  occurrence,  both  in  men  and  in  Tomen.  The  latter  are  adticted 
oftener  becauae  the  coccyx  of  woman  is  aubject  to  expericnceB  in  child- 
birth  which,  the  coccyx  of  man  is  spared.  Tho  cause  ot  thi3  coioplaint  is 
usually  some  form  of  trauma^  such  as  blows  and  falls^  bicycle  and  horse- 
back ndirLg>  and  exposure  ^  disease  of  the  boiiea  constituting  the  (coccyx, 
and  cei-tam  occiipatious  which  call  for  prolouged  U5e  of  the  feet,  auch  as 
in  machine  operators.  Quite  aa  important  aa  the  exciting  cauaea  are  the 
prediepoaing  oauses,  which  can  be  summarized  under  the  heading  hysteria 
and  neurasthenia.  Coccygodyiiia  leads  to  hysterical  aiid  neurasthenie 
conditiona,  especially  if  it  ia  of  long  duration,  aiid,  ou  the  other  hand, 
these  conditicj^iB  aeem  to  be  favorable  to  ita  developmeuL  The  cases  that 
hare  come  under  personal  obj^erTation,  aside  from  those  that  have  resulted 
from  direct  trauma,  have  bean  in  nervous,  irritable,  depressed  women  who 
complain  of  various  forms  of  headadie,  pain  in  the  back,  great  muscular 
weakuess,  which  was  so  great  in  two  instances  that  it  caused  the  patient 
to  I'einain  in  bed  all  the  titue,  and,  iu  brief,  the  complex  of  symptoms  for- 
merly described  under  the  caption  apinal  irritation.  In  this  class  of  pa- 
tients the  affection  ia  apt  to  bs  very  intractable, 

When  the  coccygeal  neuralgia  is  evidently  dependent  upon  partial  or 
complete  luxation  of  the  co<?cyx,  or  fracture  or  disease  of  these  bones,  the 
treatment  ia  largaly  aurgical.  The  coccyx  performs  no  physiological 
fnm'tiou  in  the  human  species,  aud  there  is  very  little  danger  connected 
with  its  extirpation.  The  objection  to  its  removal  in  hysterical  women 
and  m  neurotic  people  generally  is  that  the  trauma  thus  instituted  is 
Tery  liable  to  be  followed  by  greater  pain  than  was  praseut  before  the 
operati<)Ti.  All  rudiciLl  suigii^  measures  iu  the  treatment  of  neuralgia 
should  be  left  to  the  last,  and  this  holds  good  for  the  surgical  treatment  of 
coccygodynia.  When  there  are  nu  obvious  surgical  indications  to  be  ful- 
filled, thetrentmeut  should  Le  directed  to  overcoming  the  neurasthenic 
state.  It  ia  well  known  that  prolonged  j'est,  tnaasage,  the  application 
of  galvanic  electricity,  tonic  hydrotherapy,  and  general  recoustructive 
treatment,  combined  later  with  indulgence  in  intelligent  (^xercise,  are 
usually  BufGcient  to  cope  with  this  disorder.  The  pain  of  coccygodynia 
ia  usually  worse  during  defecatiou,  especially  on  straining.  Laxatives  by 
overcoming  this  contribute  somewhat  to  the  comfort  of  the  patient.  In 
men,  the  state  of  the  geoito-urinary  organs  should  be  investigated. 


CHAPTER  XXVIL 

TlIE  TREATMENT  OF  NEURASTHENIA. 

NRUTtASTnESU,  or  nervous  exhaustiDn,  is  the  name  given^lo  a  com- 
plex of  &f  mptoiua  cuListi Luted  priiicipiilly  hj  liead  jiaiufi  aud  pard^tlie^i;!, 
insomnia,  a  peculi^  mental  stale  luade  up  of  depreafiion,  fear,  amiet^y, 
anticipation,  and  distruati  oyastbenia,  ractiialgia,  &itd  pariEstbcfliai  ai:d 
disordered  digeatton  and  vasorDOtorcIiaturbonceG,  depepdentupoadisutdtir 
o£  the  nervous  orgauizatioa  without  rec:oguizat>ie  change.  In  brief,  neu- 
rasthenia, ia  a  nauroaia  without  organic  basia.  Many  theories  have  been 
propouude^l  to  explain  the  ottcurreui't:  of  Uih  phmomeua  uf  tlie  iliaeasef 
but  none  of  them  ia  entirelj  satisfactory.  The  most  ujiLTersally  accepted 
one  aeema  to  he  that  the  manifeaLntiona  of  nenraatheoia  are  eipreaaiona 
of  persistent  enfeeblement  of  neural  energy.  Thia  enfeeblement  is  di?- 
penJeut  upon  nutritional  eh^nge  in  the  entire  nenruu,  or  in  that  part  of 
it  whose  function  la  to  convert  the  forcea  of  teconHtructioQ  into  neurJ. 
energy  and  store  it  up.  Thait  an  individual  part  of  the  neuron  ia  thus 
concerned  liaa  cot  yet  been  satiafactorily  proven,  although  it  aeeuishighiy 
probable.  To  diacuss  thia  theory  satisfactorily,  it  would  be  neoeasary  to 
eonaider  the  origin  o(  nerve  force.  Such  discussion  would  Dccessitate  a 
recital  of  ^pecuEatioua  and  facta  that  ia  beyond  my  present  purpoac, 

Btiology. — -A  satisfactory  knowledge  cf  the  causation  of  nBuraathenia 
can  be  obtained  from  careful  study  of  the  cases  of  this  disease  that  comtj 
under  observation,  1  hare  therefore  taken  threa  hundred  and  thirty- 
Ihi-ee  EuccflSBive  cases  froni  private  and  diapenaary  practice,  and  eub- 
jerled  them  to  careful  study,  with  the  view  of  determining  the  pradispos- 
ing  and  exciting  causes  of  neurasthenia, 

Sej^:  Males,  IS,"*  f.jS  par  cent);  married,  9(1  {'2^  per  iient)  ;  flintflef 
87  (-0  per  cent)-  Femaieo,  1^0  [i3  per  ceut)^  loarried,  102  (31  per 
oent)^  single,  4S  (14  per  oent). 

A^ti:  Oldest,  67;  youngest,  6;  average,  33.3;  most  frequent  decade, 
thufd. 

Frequency  according  to  decades:  10-21)  years,  Ct.G  per  cent;  20-ZlO 
jears,  39. i)  per  cent;  30-40  jeara,  27  percent;  40-50  years,  16.2  per 
Oenti  5i)-00  yearsT  S.4  per  centj  60-70  years,  2.1  per  cent- 

Oacupathn:  Houaewivea,  94  (28  per  cent)j  tailors  and  olothl&g 
tfpwatora,  37  (II  per  oent);  clerks,  26  (8  per  cent);  indoor  occupation, 
264  (79  per  cent). 

^almtality:   United  Stales,  145  (43.fi  per  cent);    Buasta,  69  (20.7 


400  TREATMENT  OF  DISEASES  OF  THE  NERVOUS  STBTBlf, 

per  cent);  Germany,  34  (10^2  per  cent)j  Ireland,  34  (10.2  per  cent); 
Austria,  15  (4.5  per  cent);  England,  8  (2.4  per  cent];  France,  2  (0,6 
per  cent] ;  variable,  25  per  cent. 

Attributed  causes :  Overwork,  27;  masturbation,  2C;  worry,  18; 
fright,  10;  childbirth,  12;  sorrow,  11;  tranmati^m,  8;  previous  diBeaae, 
7;  idcobot,  4.     No  cause  attributed  in  210  caaes- 

An  examination  of  these  statistics  shows  that  the  disease  is  more  fre- 
quent in  men  than  in  women,  although  the  preponderance  of  males  is  not 
so  great  as  that  given  by  almost  every  other  writer.  It  occurs  more  fre- 
quently in  the  married  than  in  the  single,  married  women  being  consider- 
ably in  excess  of  married  men-  This  may  be  taken  to  mean  that  the 
entailments  of  marriage — anxiety  concerning  the  material  welfare  of  mate 
and  offspring,  incompatibility  of  partners,  dread  and.  depression  attend- 
ing sickness  and  death,  the  aasumption  of  marital  and  maternal  obliga* 
tions,  etc.— are  contributory  to  the  occurrence  of  this  neurosis. 

Consideration  of  the  ages  of  the  patients  shows  that  infancy  and 
senility  are  practically  exempt.  The  youngest  patient  was  six  years  old ; 
the  oldest,  sixty-seven.  The  average  age  was  33-3.  The  most  note- 
worthy feature  is  the  occurrence  of  the  disease  during  the  years  of  fullest 
maturity,  from  twenty  to  forty.  The  epochal  periods  of  puberty  and  the 
menopause  do  not  seem  to  be  particularly  associated,  and  this  is  espe- 
cially true  of  the  former,  with  the  occurrence  of  neurasthenia.  The  statis- 
tical information  on  this  pointy  goes  to  strengthen  the  belief  that  I  liave 
had  for  some  time.  Although  puberty  is  a  period  in  which  the  individ- 
ual experiences  new  and  unintelligible  emotions  and  sensations,  one  in 
which  he  has  to  resist  seductive  temptationsand.to  assume  responsibilities 
which  he  is  often  ill-fitted  by  heritage  to  bear,  these  do  not  usually  reveal 
their  perniciousness  in  the  production  of  neurasthenia  until  some  years 
later.  Then  a  comparatively  trivial  occurrence  such  as  what  should  be 
an  inconsequential  injury,  some  acute  disease  or  slight  overwork  is  the 
immediate  forerunner  of  the  symptom  complex  of  the  disease,  and  is  held 
responsible. 

That  the  occurrence  of  neurasthenia  has  a  very  important  relationship 
to  occupation  is  shown  by  the  fact  that  about-eighty  per  cent  of  the  cases 
were  in  persons  who  worked  indoors.  This  is  a  remarkable  circumstance 
considering  the  fact  that  the  material  of  the  clinic,  to  which  the  ma- 
jority of  these  patients  eame,  is  not  predominantly  made  up  of  those  who 
work  indoors. 

Nearly  one-half  of  all  the  patients  gave  their  nationality  as  American. 
This  number,  of  course,  includes  many  who  shoold  be  classified  as  Ger- 
man-, Irish-,  and  Russian-American.  The  frequency  with  which  the  dis- 
ease occurs  in  Jews  is  attested  by  the  fact  that,  although  the  clientele  is 
not  conspicuously  foreign,  more  than  twenty  per  cent  of  the  entire  num- 
ber of  cases  occurred  in  Bussiaa,  Polish^  and  Austrian  Jews.     Indeed, 


THE  TREATMENT  OF  NfilTRASTBEmA. 


«1 


t 


t 


highly  probable  that  upward  of  forty  per  cent  of  the  entire  number 
was  of  tht^  race.  The  iiroporiiarts  of  Germ^nH  anU  Irish  in  about  equal. 
The  Latin  lacea  are  not  well  represt^Dted,  but  this  la  due  to  the  fact  ibai 
we  see  very  few  of  these  people  in  the  clinio.  It  is  uniYeraally  coooeded 
that  neuraatheaia  is  patticiilarly  common  in  these  races. 

Heredity  would  seem  to  p[ay  an  important  r6Ie  in  the  occurrence  of 
nenrastbenia^  for  upward  of  fifty  per  cent  of  Che  cases  gave  a  history 
of  the  o<MJurrence  of  nervoiiB  djaeaae  or  diathesis  in  the  i  in  mediate  an- 
cestral or  collateral  family.  In  about  ten  per  cent  of  caaea  there  ia  a 
history  of  n&uraathenia  in  one  of  the  parents-  Ko  distinct  frequent  re- 
lationship between  the  occurrence  of  nauraBtbcuja  and  what  ib  known 
as  the  arthritic  or  rheumatic  diathesis  could  be  made  out.  Special  refer- 
ence is  made  to  this  point,  because  the  modern  French  wrttera  lay  great 
stress  upon  the  r5le  played  by  the  uenro-arthritie  diathesis  tn  the  cau^a- 
tioo  of  nenraethcnia. 

Although  the  patients  were  all  questioned  on  to  the  attributed  or  at- 
titing  causea  of  their  Bymptoms,  Bpecificatton  of  such  causes  could  be  got 
only  in  one  bundred  and  tventy-three  cases.  The  remainder  averred 
that  thej  were  quite  iguorant  oF  l;he  factory  that  could  be  held  responsi- 
ble for  their  sickness.  Of  theao  one  hundred  and  tvventy-three  v:asesj 
orenrcrk  and  masturbation  are  apparently  losponsible  for  the  same  Dnm- 

'i  while  mer^tal  faotorSf  particularly  emotional^  suah  as  ^vorry,  fright, 

in,  and  sorrow,  were  given  iks  the  cause  in  about  one-lbird  of  all  the 
cases;  physical  injury  and  acute  disease  were  believed  to  be  the  exciting 
af^euctea  in  a  uuiuler  of  cases. 

It  is  not  overwork  alone  that  is  sd  pernicious^  but  the  worry  and  anx- 
luty  that  are  entailed  by  the  assumption  of  grave  responsibilities  and  obli- 
gations without  adequate  preparation  and  suffieient  support.  The  emo- 
tional element  in  such  casea  is  a  very  important  one.  The  infectious 
diaeaaca,  by  depreciating  vitality  and  by  throwing  into  the  economy  an 
amount  of  toitio  material  which  it  must  battle  with  for  a  longer  or  shorter 
time,  are  responsible  for  a  aoosiderable  amount  of  neurasthenia.  They 
are  operative  to  this  end  particularly  in  thoae  who  inherit  the  neuro- 
pathic diathesis- 

Perhap[4  the  most  remarkable  feature  of  the  statistics  bearing  on  the 
matter  uf  the  exciting  causes  of  neurasthenia  is  that  alcohol  and  tobacco 
were  not  admitted  or  noted  to  be  causative  of  the  disease  except  in  very 
few  instances-  This  is  in  fullest  accord  with  previous  personal  export- 
^nce  and  belief  based  theron,  Some  writers  have  cluimed  that  excessive 
indulgence  in  alcohol,  T-obacco,  tea,  offee^  narcotics,  an  I  other  intoxicntita 
plays  a  leading  rule  in  the  causation  of  neurasthenia.  With  full  apprecia- 
tion uf  the  pemiciousness  of  these  substances  upon  the  nervous  orgauiza^ 
tjon,  and  roco^ition  of  their  great  potentiality  for  mischief  to  tbia  and 
otfaei  systems  of  the  body,  I  repeat  that  they  manifest  their  peccant 
26 


' 


TBEATMKNT  OF  DTSKASK3  OF  THE  NKRT0TT9  STSTEU- 


Qotivitv  upon  the  economy  in  other  ways  thoti  i&  the  CELusation  of  neu^ 
matbenia- 

The  relatioD  of  auto- in  toxical  iiin  to  the  development  of  neurasthenia 
IS  a  queatiou  to  which  much  atteittiou  has  bean  givaik.  Many  writers  be< 
Ueve  tfiat  undue  retention  in  the  Edimentary  truct  of  partially  digested 
foodstuffs  atid  the  aubaequent  absoiplion  into  the  system  of  toxic  aub' 
stances  manufsiGturetl  thcrcfroni  la  the  starting-point  of  the  disotder  that 
erentoalJy  overwhelms  the  nervous  ayatem.  Oihefs,  amougst  the  most 
conspi4;uaua  of  whom  is  Haig,  maintain  that  the  disease  is  gt^nerally  due 
to  an  acc(imulation  of  urio  add  in  the  tiasuea,  dae  to  diuiiuiahed  excre- 
tion which  ia  brought  about  by  an  mcreaged  acidity  of  the  blood  on  ac- 
count of  the  presence  of  an  excees  of  acid  salts  and  other  products  of 
nitrog^iLOUs  metabolism.  The  im^HJrtance  of  theae  factors  lu  causing  neu- 
raathenia  is  gradually  becoming  discr^itei.  Disorders  of  metsboUsm  are 
rsrtily  the  so]e  cauAfl  of  neuT^stbenia-  Oftentimes  the  manifestations  of 
such  diaordei'  are  the  effect  of  iifurastheaia  through  tiie  sympathetic  ner- 
vous syatem  and  not  the  cause  &a  ao  mauy  writers  would  have  us  believe. 

The  effect  of  m&sturbatiou  (under  which  are  included  for  convenienoo' 
sake  other  irregular  forma  of  sexual  indulgenee)  is  generatJy  recognized 
as  being  very  important.     The  statistics  here  given  corroborate  this  view, 

Tn  a  few  iiistanoea  pelvic  disease  in  wnjiLen  and  disease  of  the  genital 
organs  in  men  hare  cleaily  au  etiological  leUtiouahip  to  neurasthenia. 
Occasionally  it  occurs  after  frequent  preenanciea  aud  prolonged  lactation. 
In  such  cases  it  is  an  expression  of  exhaustion. 

Of  the  various  causes  that  hare  beeu  etmmerated,  some  are  all^impor- 
tant  in  one  case,  some  hi  another.  They  are  not  by  any  means  of  equal 
neuraatheuia-causing  capacity,  and  no  one  can  say  beforehand  whether 
one  of  the  abovementioTied  factors,  or  all  of  them,  will  cauge  neurasthenia 
in  a  given  individuals  It  depends  entirely  upon  the  individual  and  upon 
his  resistance  capacity,  which  in  everyone  ia  subject  to  uneKplainable 
variattoos.  Certain  parsons  are  so  vulnerable  that  the  equilibrium  nf 
their  nervous  Hystema  is  quickly  upset  by  the  occurrence  of  any  of  these 
causes;  while  others  have  a  nervous  organizsLion  ho  stable  and  so  sua' 
ceptible  to  the  aid  of  reconstructivea  that  they  resist  suocessfutly  one 
and  all  of  them  during  an  entire  lifetime.  Therefore,  it  may  be  said  that 
the  etiology  of  neurasthenia  dapends  more  upon  the  individual  than  upOQ 
anything  else.  Thus  it  ia  that  heredity  plays  soch  an  important  role  in 
the  occurrence  of  ueuraathenia.  If  one  is  born  with  a  nervous  syfltem 
that  IB  deficient  in  the  capacity  to  produce  neural  energy  or,  what  is  the 
eame  thing,  to  maintaiH  a  proper  equilibrium  lietween  production  and 
expenditure  of  such  energy,  such  a  person  is  far  more  liable  to  develop 
neurasthenia  as  the  apparent  result  of  any  of  the  exciting  causes  that  I 
have  mentioned  than  ia  another  person  wLoae  inheritance  iB  a  stable 
ELcrvoua  organisation. 


THE  TRKATUENT  OP  WEURASTHENIA> 


403 


I 


Symptomi. — The  Bymptoms  of  neurasthenia  will  aoi  be  considered 
save  as  they  ara  indicated  in  the  foJlowiTLganmm^nes  abowing  the  relative 
frequency  in  percant&ges  of  aymptoma  that  areeu  constant  in  neuraHtheiiia 
tbat  they  mciy  bo  callod  stigmata- 

1.  Pnyckical  sginptomA:  Static  depresBton,  22.3  per  cent^  -variable 
depreasjon,  19.5  per  cent;  l&cking  mental  aoncentiatioQj  l^.S  per  cent^ 
iDectal  confuBLon,  10. S  p^r  cent;  imdeGnable  fear^  S.4  per  cent;  exoes' 
eively  irritable,  7-£  ^ter  ceot.  Eiaggerat«d  senaiiiveness  and  morbid  re- 
aetrer  5.3  per  cent. 

2.  Hfiodttche :  A  leading  aytnptom  in  55.8  per  cent  (occipitaif  10.8  per 
cent;  frontaliS.l  per  cent;  vertical^  7.^  per  cent;  dltfuae,  26,7  per  cent). 

3.  Sensory  sffmptoms:  General  pains,  30-3  pcT  cent;  vertigo,  14,1 
p«T  cent;  paina  in  the  back,  12.3  per  cent;  acropareesthesia^  12  per 
c^nt;  paricstbesia,  11.1  pec  cent;  epigastric  pains,  rt.l  per  cent 

4-  Shejt:  Insomnia,  70  per  cent  j  dyseomnio,  10  per  cent;  undisturbed, 
SO  per  cent.  The  oliuaifieation  inelndoa  two  forms ;  First,  great  lassitude 
and  profound  mental  torpor  after  eatingfoliowedby  reatlessnesa  and  eleep- 
leHBueas  afterono  or  twti hours'  sleepy  and  ftecand,  wakftfiilueaa  and  other 
phenomeua  of  diBtuibed  sleep  vithout  introductory  somnolency- 

5.  Moifirjitpii. ptarni  r  Myasthenia,  37.2  per  cent;  twitobiugSt  2.7  per 
cent;  tremor  (as  a  complaint),  3.3  per  cent, 

6,  Vnsontfitoi* spnpt/aits :  Palpitation,  22. S  per  cent;  cold  extremities 
subjective  atid  objective,  34  per  eent;  hot  flashes,  5,6  per  cent;  pseudo- 
angina,  1.5  per  cent;  pulsation  in  the  neck  and  head,  4  per  cent;  pul- 
sating, fluttering  feeling  iu  tlie  abdomea^  l.*S  per  cent^  episbaxis,  0-9  per 
centi  polyuria,  4  per  cent.     Profuse  aweating  paroxysmal ly,  3  per  cent 

7-  Digtstifc  ei/mptoni^:  Stomaohio  indigefltion,  lS-3  per  cent;  in- 
teatinai  indigestion,  13.3  per  ceitj  poor  appetite,  22-3  per  cent;  good 
appetite^  26.7  per  cent;  variable  appetite,  21  p*r  cent;  appetite  not 
notetl,  30,1  per  centj  oonstipation,  27.3  per  cent;  Etoola  regular  or 
loose,  2S,3  per  peotj  stools  not  noted,  30-1  per  cent;  coated  tongue 
(noted),  6-G  per  cent;  mucous  diarrhoea,  3>5  per  cent 

8,  ScjMial  sijmptvins :  Nocturnal  amiasionfl,  19-1  per  cent;  impotonoe^ 
3  per  cent;  partial  impotence  18.5  per  cent;  logs  of  seiiial  desire,  23 
per  cent;  loss  of  *' vital "  HuLi  on  urination  and  at  stoot,  5  per  cent; 
premature  ejaculation,  1.2  per  cent;  persistent  maaturhatora,  3.5  per 
cent;  eitremo  prostration  after  coition,  10-2  per  cent. 

!).  Initial sijtnptomt:  Headaoho,  27  per  cent  (vertical,  3.6  per  cent; 
frontal,  3-2  p&r  cent;  occipital  6.6  per  oent^  diffuse,  12,6  per  cent), 
(^neral  paina,  S.7  per  cent;  rayaathenia,  7.5  per  centj  epigastric  dii- 
tresB,  7.4^  per  cent;  inaomnia,  .'-l  per  cent;  meEauoholia,  3.3  per  cent; 
vertigo,  4.2  per  cent^  palpitation,  1.8  per  cent;  pains  in  the  back,  1,3 
per  cent;  acroparseatheaia,  1-f^  per  cont;  vindaasidedf  26.  J  per  cent. 

10,   Phyticai  nl^Mii :  Ketlexes— knee  jerk  fiKaggemted,  22.2  par  oent; 


404 


TBBATMKKT  OF  DISEASES  OF  THK  TSERVOUS  STSTEl*. 


kiiee  jerk  diminished,  3.3  per  ceat;  knee  jerk  QOtmaJ,  74,1  per  cent^ 
abfienceof  the  pharyngeal  refleK,  H.'i  percent.  Tremor — of  fingers,  30  per 
ceatj  of  eyelids,  8.4  per  cent;  of  lipE^  6  per  cent,  of  tongue,  1.8  per 
cent.  Weight — loss  of  flesh  in  30  per  cent  of  the  cases.  Skin — dermo- 
graphism, 35  fter  ceiit^  red  eara^  4  pet  cent,  pale  akui,  18  per  cert. 
Pulae^high  tension  small  volume  noted  in  01  caaea.  Evidences  of  arte- 
rial sclerosis  m  24  cases.  Displacement  of  some  ot  the  abdominal  vis- 
cera—enlePO^'oBis,  4  caaes.  Pupils — dilated  and  sluggish  on  expoaure  to 
light,  4  per  cent.  Neuromuscular  system — local  tendem^s  on  pressure, 
indefinitely  distributed,  27  per  lent. 

Treatment- — In  diiacuafiing  the  etiology  of  neurasthenia  the  coucluBion 
was  reached  that  the  individual  wbo  developed  the  symptom  complex  was, 
after  all,  6rat  iu  the  Beale  of  importance.  In  the  treatment,  as  well,  itidi- 
ddunli:^ation  \s  more  neoeasary  to  insure  aueceas  in  this  than  lu  almost 
aay  other  diaeaee.  Although  there  are  certain  ageneiea  of  reconstruc- 
tion— such  AS  dit^t,  hydriatics,  madsagOr  rest  and  exercise,  change  ef 
euTironmeub  and  climate — that  are  beneficial  m  almost  every  case, 
their  application,  at  least  their  most  successful  applicatioai  is  scarcely 
ever  the  same  in  two  eases;  bo  that  which  is  said  concerning  treatment 
must  be  tnkeu  to  mean  that  it  must  be  varied  to  meet  the  needs  of  eacb 
case. 

Prophylaotic  TrDatin«at. — Since  the  occurrence  of  ueuraathenia  has 
be&a  shown  to  st'ind  in  close  and  definite  relatioaahip  to  certain  predia- 
posing  and  esciting  conditions  already  named,  it  is  evident  that  the  pre- 
ventive treatment  ia  an  imporiaiit  con gi deration-  I  am  aot  of  those 
who  believe  that  neurasthenia  is  a  disease  of  the  epoch  or  thai;  it  Laa 
occurred  ouly  ia  modern  times.  Nevertheleas,  to  a  certain  extent  it  is  a 
eign  of  the  times.  There  cfin  be  Little  doubt  that,  although  the  esciting 
factoiQ  of  neurasthenia  have  always  e:iisted,  the  predisposing  causes  are 
mainly  of  more  recent  date.  Neurasthenia  has  become  more  common  as 
social,  political,  and  economical  conditions  have  made  the  struggle  for 
Piifitence  more  violent  and  the  prospectB  of  a  quiet  life  more  perilous. 
So  long  as  such  conditions  ezist  and  so  long  as  mankind  assumra,  thiongh 
choice  oc  necessity,  to  cope  with  them,  just  so  long  viU  oeuraathonLa 
continue  to  occur,  unless  by  progret>s  of  evolution  the  human  species  he- 
comes  more  able  to  resist  these  factors.  As  there  seems  to  be  little 
chance  thiLt  evolutionary  progress  wdl  liurl  itself  into  tiie  breach,  it  be* 
coDiee  necessary  for  the  individual  that  he  may  withstand  the  strife,  to 
adopt  measures  that  will  tend  to  fortify  his  neural  resistance  and  equi- 
libriuran  Such  fortification  ib  the  more  necessary  to  him  irbo  is  handi- 
capped by  heritage  with  an  unstable  nervous  organization.  The  preven- 
tive treatment  of  neurasthenia  should  be  begun  simultaaeously  with  the 
development  of  the  tiidividiml.  And  the  rules  given  for  the  general 
moral  and  physical  hygiene  and  training  of  neuropathic  children  in  Part  I, 


THK   TREATMENT    OF    IffKURAaTHTCMA. 


apply  with  particular  force  to  the  prereEitive  treatment  for  neuro^them^in 
Buch  individuals. 

,     What  ia  there  eaid  concerning  the  preveatiou  of  the  neuropathic  dia* 
th^ii  should  be  read  in  this  conD^4;tion. 

The  prophylaxis  of  uouraathetjia  consiHtSr  in  realily,  cnly  iii  avoiding 
these  factors  which  it  has  been  proTen  by  experience  cause  tlie  doTelopment 
(jf  this neutoeia.  Wheii  once  the nearaathenic  Btote  ia  developed  the  ph}'- 
sician  is  not  in  a  poaitioiij  ia  the  majority  of  cases,  to  advise  the  patient 
bow  to  attacgehia  life  and  labors  so  as  to  avoid  an  attack  of  neurasthenia. 
He  majT  however,  do  much  to  piBveiit  the  racurreQce  o£  th  j  attack-  Once 
the  diseaae  haa  occurred  and  boon  recovered  from^  it  ia  very  liable  to  re- 
lapse. If  it  ia  kept  iu  mind  that  it  is  not  so  much  pbyaical  and  mental 
work  or  overwork  that  oaiiaea  neurastheuia  as  it  ia  worrj^  anxiety,  de- 
pression, and  reaulting  sl^^pleaaneas  and  diaoi-dered  digestion,  the  patient 
may  be  shown  how  to  avoid  a  relapBi^  even  without  curtailment  of  the 
labors  aud  activities  that  are  necessary  for  eijstence. 

Treatment  of  the  Attock* — The  treatment  of  neurasthenia  after  the 
disease  haa  developed  requiies  for  its  sucoesaful  outcome  a  deeper  insight 
into,  and  understanding  of,  mankind  than  does  that  of  almost  any  other 
bodily  or  uieutal  disease.  The  physician  who  has  the  good  fortime  to 
inherit  or  acquire  such  dincernmeiit  will  be  iinmeaAurably  more  Bucceasful 
than  he  who  ia  without  it  and  at  the  same  time  master  of  physiology  and 
materia  medica'  Nothing  ia  more  certoiu  than  that  the  patient^a  mind 
requires  as  much  or  more  treatment  than  the  bo<ly  and  its  fuuctionSi 
Thttra  are  many  reasons  that  will  explain  this;  but  the  ti-uth  t>f  it  ia  evi- 
dent  to  all  who  imderataud  the  important  r^le  play&d  by  ihe  mind,  the 
stress  aud  abuao  of  it,  in  the  developiuent  of  neurastbetiiar  and  the  differ- 
^t  maniiostatioDS  of  mental  asthcaia  throughout  the  course  of  the  dis- 
eaae.  The  iutroepectivencsa,  anxiety,  indefinable  fear,  painful  forebod- 
ing, keen  sense  of  ineapaeity  dt'Spite  the  pressing  need  for  action,  the 
meutal  depression  with  its  train  of  morbid  tlimighu,  sl^eplesstieas,  and 
perpetual  unrest,  all  are  no  doubt  lessened  and  sometimes  overcome  by 
the  uae  of  physical  restorative  agencies  aloue,  but  they  are  much  more 
surely  and  frequently  eradicated  by  the  simultaneous  use  of  the  proper 
kind  of  psychical  and  moral  treatment,  Sueh  treatment  doea  cot  depend 
upon  the  u»e  of  means  that  ap|ke;j.T  to  the  patient  to  lie  svipernatural,  aueh 
as  hypnotism,  neither  ilni^s  it  necessarily  c^onwigt  of  explanation  ot  px- 
hoitation.  Of  the  very  greatest  importance  ts  the  con£denc  which  the 
successful  physician  inspires  in  his  patients  and  the  maLntenance  oE  hb 
authority  as  proved  by  their  obedjence  to  inatructions  and  amenability 
to  suggestions.  And  such  psychical  influence  can  be  made  most  effective 
when  used  through  the  medium  of  the  physical  measures  which  pvperi- 
ence  has  shown  ta  he.  so  serviceable  m  the  treatment  of  neurasthenia 
These  measures  aro  powerful  agencies  for  sujifgestion,  and  as  the  nea- 


406 


TREATMENT  OF  D1SEABEB  OF  THE  KKRV0U8  fiPSTBH. 


raslLeuic  is  m  a  pBycho-pb^isical  slate  of  iucrea«6il  auggestibilitj^  Xhty 
fumiah  fruitful  aoil  tor  al]  kinda  of  euggeatiou.  Next  to  the  influeuce 
of  the  physician,  the  moet  iiuporiaDb  meafiureB  for  tlie  treatmeDt  of  n*ni- 
raathfiiiia  may  be  considered  under  the  foilowiug  haadirtgs: 

(I)  Tlie  general  hygiene  cf  tlia  neurasiheuic.  (2)  Dietetics  ftD4 
alimaiitation.  (3)  Hydrotliera]»y  and  balueotherapy.  <4)  Electrioity, 
(5)  Heat,  eserciae,  massage.  (0)  ClimatotWrftpy.  <T)  Mode  of  tr«4t- 
njent,  disciplinary  or  moral  by^ene. 

Qeii«ral  Hyg^ienOp — The  general  hygiene  of  the  neu^asthenie  patient 
includes  the  avoidance  or  removal  of  everything  that  tends  to  emphuize 
or  to  remind  him  of  hi^  iufirmitiea;  i^hungo  from  aHsocdations  aod  aur- 
tonudings  which  seem  to  be  cauaiug  or  maiatauiLiig  the  neuraatLenjc  oon- 
dition  bo  others  that  will  favor  mental  equanimity  and  ^neral  quietia; 
of  miud,  aj]d  holp  to  restore  nutrition.  Without  thoscf  the  treatnLCnt  of 
neuiaatheniaf  especially  if  the  disease  is  of  a  severe  type,  is  often  forC' 
ordained  to  failure.  The  pliyaidan  vIjo  strives  for  the  fulRlment  of 
Ihfcse  iudiculjoua  l^efore  aUeiuptiug  the  ntethodical  treatment  of  the  pa- 
tient will  have  imme^uraUly  greater  uucceas  than  he  who  neglects  them. 
In  many  instances,  uufortun ate ly^  the  patient^s  social  and  financial  state 
olfers  an  unsurmountable  obatnclti.  In  fact  it  may  be  said  tliat  a  long,  well- 
tilled  purse  iH  a  powerful  theia-pentit:  factor  in  tlie  treatment  of  neuras- 
thenia, lu  diaponhaiy  piaobice,  where  neurasthenia  ia  seen  ofteuer  than 
are  nil  other  kinds  of  nervous  diseases,  the  problem  that  has  to  be  contin- 
ually met  13  bo  Hud  a  sukstitute  for  these  indications.  That  such  a  one 
has  not  been  found  accounts  for  the  fact  that  the  treatment  of  ueuiaa' 
nia  among  the  poor  is  still  woefully  nusulisfactoTy, 

IiolatioD  ami  BlscipUne.^ — The  indications  just  mentioned  retjnire 
their  fuliilment  lelatively  complete  iaolatioQj  which  can  rarel/  be  had  al 
home,  unleBH  a  part  of  the  house  can  be  set  apart  for  the  exclueive  use  of 
the  patient  and  the  attendant,  Evon  when  tins  is  possible  tlksre  are 
many  rt^asona  why  it  is  bt^tter  for  tlie  patient  to  be  lodged  m  a  boardmg- 
house,  hotelj  or  houBs  conduoted  for  the  purpose.  Aufrh  iralation  acts 
lieueBcially  in  many  nays:  it  removes  the  putient  from  the  sympathiz- 
ing family  and  friends,  who  nro  ever  ready  to  indulge  him  in  numberless 
aelfidh  acts  atid  deeds  which  are  iiivoriubly  harmful,  and  to  question 
solicitoiLbly  about  the  many  r^al  and  imagmary  ailmenta  thatmaka  up  the 
symptom  romplex.  Moreover,  it  takest  him  away  from  surroundings  that 
not  only  remind  him  of  his  illness  and  incapacity,  but  that  tend  to  make 
him  more  self-centred  and  aelfish.  It  serves  to  break  up  injnriona 
customs  and  pernicmus  bnhits,  and  more  than  all^  to  impress  him  that 
something  is  being  done  earnestly  to  bring  about  recovery.  Many  patients, 
especially  women  and  their  friends,  are  firmly  eouArinoed  when  Hiioh  a  5te|> 
la  proposed  that  carrying  it  through  would  be  iantamonnt  to  driving  theiia. 
mad.     The}'  argue  that  euch  a  plan  may  be  suited  to  others,  but,  noniid— 


e  TOT 


THE  TREATMENT  OP  NKUR ASTHENIA. 


407 


eriDg  tbe  pec.ulWitieH  oC  their  meutal  c<justiitution  acd  certatn  iiei^edBuriea 
for  the  contnLUonce  of  eren  3  xuiseraUe  exiatencef  the  step  is  uufeaaibJe 
bejojid  Uebate  in  their  own  gubc.  OftentiineB  this  ia  the  tirst  oppurtu- 
mty  for  the  physician  to  display  that  insight  into  the  hum&n  mmd 
which  1  have  already  spoken  of  as  being  so  essent]:il  in  the  treaFiment  of 
this  disease^  and  hia  power  U>  inspire  cui]hde:ice  and  setuire  obedieut-e. 
He  kBOws  from  eiperience,  and  from  the  atatemenb  of  others,  that  enob 
relative  isolation  is  aeldom  if  erer  injurious  to  even  the  ujost  scoaitiTely 
OTgaaized  person,  and  that  it  almost  filways  conduces  to  the  quietude^ 
peibcefulnesa,  rest,  and  improvemeDt  of  nutrition  that  are  needed  to  re- 
Btore  health.  Very  rarely  dues  the  step  increase  the  patient'^  introspec- 
tiveiiGSB  and  make  him  mure  ccmacioua  of  his  aymptomat  aoxietiet^,  and 
feaia.  Of  course  it  is  notnoceaaary  for  every  tjcuraathenic  to  be  isolated. 
In  many  cajies  it  will  be  sutheient  to  inaist  that  he  withdraw  for  certaia 
times  during  the  day  to  the  quiet  of  hia  oi^n  ehamber;  to  give  over  cer- 
tain of^enpationa  or  duties  which  eall  for  the  expenditure  of  energy  that 
cannot  be  wpared;  or  to  jwstpope  the  time  for  arising  uutil  niicHay.  In 
the  very  eevete  case,  however,  no  comprcmtse  in  tlia  matter  of  isola- 
tion ahould  be  made.  It  ia  au  rasential  feature  m  the  teat  cure*  which 
I  flhall  apeak  of  later  mtbe  treatm^ot  of  neur^tbenia,  but  here  it  is  being 
considered  aside  from  any  other  pnrt  of  the  treatment,  taolation  may  be 
carried  to  exces^H,  both  in  point  of  uoirpletciiefiti  and  in  duration^  There 
can  l>e  no  doubt  that  prolonged  isolation,  if  not  counteracted  by  other 
means,  is  of  itself  suiHcierit  to  cause  neurasthenia.  The  leaaon  to  be 
Jeorned  from  this  is  that  individualt^ation  la  very  oecessary  In  the  treat- 
ment of  nevirastheoia  in  regard  to  the  general  bygi0<ne. 

The  9eoarement  of  SUep^— The  neict  mo^t  important  meA9ure  in  the 
general  hygiene  eouRiats  in  securing  a  proper  auiouut  of  sleep,  and  as 
insomnia  is  one  of  the  moat  constant  stigmata  of  neurasthenia,  this  is 
often  a  dittioult  thing  to  aeeompliBh.  In  many  cases  the  use  of  means 
that  tend  to  improve  general  nutrition  and  physical  rest — ^such  as  hydria- 
ticSf  electricity,  massage,  gyninasticSf  axerciHe,  or  enfori^ed  rest— help  ma- 
terially tcj  overc'cme  the  insomnia,  especially  i'  th^y  are  aided  for  a  short 
time  in  the  beginning  by  the  administration  of  eulfonal,  trional,  chloral- 
amide,  or  one  of  the  other  modem  hypnotius.  As  a  rule,  the  patient  baa 
alrearly  exhausted  the  sleep- prod uti in g  napacittes  of  such  drugs  before 
coming  imdnr  treatment;  but  despite  this,  when  given  undf>r  the  auspicea 
that  are  being  described,  thfty  rarely  fail  to  have  a  degree  at  least  of  the 
desired  effect.  Often  the  pliysirian  is  ti^o  impatient  to  ^et  prompt  frffects 
from  the  use  of  sleep- producing  medicines,  or  from  such  measLirea  aa 
massage,  the  cold  pack,  and  drip  she^t.  It  ahould  not  be  forgotten  that 
less  sleep  is  required  with  absolute  physical  rost  than  is  necessary  under 
oidinary  circumatauoes.  Moreover,  jihysieal  measures  that  aid  sleep  may 
not  auDceed  fully  after  the  fir^t  few  trials,  while  sueceaa  crowna  their 


408 


TREA.TUENT  OF  DISEAfiCS  OT  THB  STS8VOUS  SYSTBU. 


repeated  use^  i.>f  tliA  hydriatic  uieaaurvs,  llta  most  Impoitaut  in  secur- 
ing sleep  arc  the  colU  w^ot  pack,  tlie  prolonged  woim  batb,  the  drip  eLeet, 
and  the  wet  comptees  known  as  the  Neptune  gitdle.  The  latter,  which 
oonsiBta  of  a  banda^  of  coarse  linen  reaching  around  the  eutire  lower 
part  of  the  trunk,  and  fastefied  in  front  so  that  the  abdomen  has  a  double 
covering,  ifl  wrung  out  of  wat«r  of  60°  to  Gb°  ¥.,  acd  corered  with  a  dry 
taudage.  Applied  on  retiring  after  thft  parts  have  been  bathed  with 
cold  water  this  airaplo  meaaa  is  often  euccessfnl  iu  producing  alsep.  The 
prolonged  warm  bath,  temperature  l^S"*  to  100^  F.,  the  patient  being  kept 
in  from  twenty  to  forty  minutea,  is  liiewjge  very  aervieeaUe  in  bringing 
about  relaiatioii  of  mind  and  body  preparatory  to  sleep.  The  drip  sheet 
— ^which  is  applied  by  throwing  a  lineu  aheet,  loosely  wrung  out  of  water  at 
65°  F.f  around  the  patient,  who  stands  in  a  foot  tub  of  comfortably  hot 
water  with  a  Turkish  towel  wruog  out  of  iced  water  about  the  headj  then 
bringing  the  sheet  iu  apposition  with  every  part  of  the  akin  by  a  few 
quick  rubbings  of  the  attendant's  hand;  the  sheet  being  then  removed 
and  tlia  patient  dried  and  rea<;tion  sided  by  light  maeajLge  or  rubbing — is 
of  ten  effective  in  overcoming  ixiaoiunia.  Theae  hydriatic  measures  should 
be  tried  in  succesaion-  When  one  does  not  succeed  it  is  very  likely  that 
another  wilh  Some  neurasthenic  patients  have  no  diflioulty  in  going  to 
sleep  early  in  the  evenings  but  awake  after  a  pnifoimd,  unreficshing  sleep 
of  two  or  three  hours,  to  remain  awake  for  the  rest  of  the  night.  In  such 
a  case,  tsapecially  in  women,  severe  inaflsage  of  the  entire  body,  of  about  an 
hour*a  duration,  eumetimes  causes  the  patient  to  sleep.  In  others  the 
bydriatio  measures  above  mentioned  are  successful-  Occasioually  the 
administration  of  from  Bix  to  twelve  ounces  of  warm  milk,  plain  or  pepto- 
nized, seems  to  have  an  effect  in  bi'iugiug  about  mental  and  physical  coTn" 
posure  whitih  aid  h\e*^p.  In  cases  of  this  kind  it  may  be  advisable  ta 
prevent  the  patient  from  going  to  sleep  just  after  the  evening  meal,  so 
that  the  customary  hnur  for  sleep  will  lind  him  more  ready. 

Dietary  of  NcnraflthenicB. — The  diet  of  the  neurasthenic  patient  will 
depend  largely  upon  the  slate  of  his  digestive  functions  and  upon  the 
type  of  neurasthenia.  Certain  n^urBHthenics  whose  Fears^  thoughts,  and 
anxieties  are  mainly  of  their  vincera,  and  iu  whirm  careful  physical  and 
chemionl  eicamination  show  no  great  abnormality  either  of  the  digeative 
system  or  its  contents,  are  made  more  self-centred  and  gloomy  if  much 
stress  is  laid  upon  the  diet  or  attempt  made  to  change  or  regnlate  it 
Such  patients  should  be  advised  tii  satisfy  their  appatites  for  food  as  if 
they  were  robu&t,  and  to  partake  especially  of  coarsei  green  vegeteblesi 
which  will  have  an  ei^ect  to  produce  large  and  ready  evacuations.  Thej 
should  be  urged  also  to  drink  water  freely.  In  other  patients  there  will 
be  found  alight  derangement  of  the  digestive  funotiona,  auoh  as  temporary 
excessive  acidity  or  diroinished  acidity  of  the  gastric  juice,  Htomaehic 
and  intestinal  fermentation,  sluggish  vermicular  action,  and  fialuleney, — 


THB  TREATMENT  OF  NEtRASTHENlA. 


409 


vhtch  easily  reapoDd  to  tha  administfation  of  the  indicated  syruptom 
medicmea,  partioulaHy  if  general  treatment  for  the  neurLSthenie  Htute  is 
^ven  a.t  the  sama  time.  pRtienta  when  firBt  comtng  under  obaerTation 
frequently  dwell  upon  the  fact  th^t  they  Lave  been  under  the  treatment 
of  a  number  of  phjaiciaas,  uaually  Bpccia.H3ta,  for  the  relief  of  first  one 
symptom  and  then  uiothetT  and  they  produce  a  peukage  of  preooriptiona 
to  shov  the  amount  and  variety  of  medicinee  that  they  have  taken  to 
overectme  what  seems  to  thetn^  and  apparently  also  to  those  who  hare 
treated  them,  their  ailmenta.  i^uch  efforts  may  ba  compared  to  ail  at- 
tempt to  mead  a  shattered  fence  without  first  repairing  the  foundation. 

In  some  neuraathenio  patients  the  general  aathenia  is  ehonn  chiefly  in 
thQ  digestive  tract,  and  we  hare  to  deal  with  a  gaetro- intestinal  atony, 
whose  prolonged  existence  leads  to  dilatation  of  the  stomach  and  the  in- 
testines. The  resulta  of  sueh  conditions  aro  that  tha  viseera.  are  unable 
to  pus  the  i^ge^sta  along  with  proper  faeility  and  thoroughness.  This, 
together  with  insufficient  secretion  of  the  digestive  iuice^  which  is  in- 
directly dependent  upon  the  atony,  leads  to  fcrmentatiou  and  to  the 
formation  of  substances  which  are  injurious  when  absorbed  into  the 
system.  Hiich  fermentation  and  auto- Intoxication  fause  Rymptoma  which 
the  patient  bellevea  to  be  very  serious,  and  this  adds  to  hia  meutal  de- 
pression and  strengthens  the  belief  that  recovery  is  hopeleas.  The  Lu- 
dicatiousfor  local  treatment  in  such  a  case  are  to  L>a  deterrnioed  by  means 
of  a  test  meal,  that  it  may  be  observed  how  long  it  takes  the  stomach 
to  pass  the  food  ioto  the  inte^tmeSf  and  that  the  contents  of  the  stomach 
may  be  removed  for  aiialj^Bis  t<>  Bhow  the  relative  pro[K>rtiona  of  the  con- 
stituents of  the  gantric  juioe.  After  this  information  has  Ijeeu  obtained, 
and  after  the  stools  have  been  ouhjccted  to  scrutiny  to  determine  whether 
they  contain  undigested  foodatuffs  or  ere  of  shape  aiid  si:^e  pointing  to  im- 
paired  activity  in  different  parts  of  the  large  bowel,  the  phyaioian  is  m  a 
position  to  d^de  what  local  or  symptomatic  treatment  is  required.  To 
name  the  different  Hubstauces  that  nui^t  be  used  t.o  fulfjl  spenial  indica- 
tiocfl  in  certain  c^es  would  nob  be  proBtable^ 

The  most  important  step  m  overcoming  the  gastro'intestiiiai  asthenia 
which  LS  primarily  at  the  bottomof  all  digestive  disorders  ia  the  use  of  [ihyi- 
ical  measures  which  exjwrienre  has  shown  to  be  so  valuaUe  in  the  treat' 
ment  of  neurasthenia.  The  patient  should  he  asHure^l,  repeatedly  audcnn- 
vincingly,  that  he  has  no  organic  or  incurable  disease-  Careful  observation 
ehould  be  made  to  find  out  what  foodvtutf  disagrees  with  the  patient,  and 
this,  with  all  things  that  are  difficult  to  digcet,  should  be  forbLddea.  Asa 
rule,  a  mixed  diet  is  best  for  the  neufafithenic  patient^  but  meat  should  not 
l>a  given  more  than  once  a  day,  and  then  only  in  the  most  digestible 
forms.  Cereah,  anch  as  tit'e,  sago,  cracked  wheats  green  vegeUiiles.  such 
as  spinach,  string  beans  and  oeleryi  peaa,  fresh  bcaus,  and  putatoeSi  in 
pur€e  form,  can  be  taken  by  almost  every  neurasthenic.    As  a  rule,  white 


410 


TBEAT^ 


OF 


1BA8B3  OF  THE  I^BVOCB   BYSTEU. 


vegetableA  ara  to  lie  avoided.  Breail  is  to  be  t^ken  in  moderation,  and 
preferably  iu  th&  sli&pe  of  bread  made  from  the  whole  giaiu,  toaat^  and 
zwieback.  Frequcably  rcguIatioD  of  the  amouut  of  bread  is  of  the  great- 
cat  importance,  aa  a  coneideiable  proportion  of  these  patienta  liare  starch 
indigeEtiGD.  Care  mit^t  always  be  had  in  estimating  the  amount  of  fata 
that  can  be  given  to  a  neuraatbenie,  because  they  not  only  tend  to  dis- 
order the  liigeHtioii,  but  by  causing  aatiety  they  etainl  hi  t!ie  way  of 
other  and  more  important  foodatuffd,  such  &s  thd  vegetable  proteids. 
Sufficient  fata  can  usually  be  given  in  the  shape  of  milk,  buttei,  and 
cieam.  Patients  who  believe  they  have  an  idiosyncrasy  for  one  or  two 
of  \h6S6  may  he  able  to  take  the  cither.  The  best  way  to  give  ereaiu  is  in 
the  form  of  cream  toast,  wbich  is  prepared  by  taking  a  piece  of  thoroughly 
toasted  bre&d^  sprinkling  it  with  a  few  drops  of  water  aiid  a  pmcL  of  saLt^ 
and  then  pouting  over  it  a  thick  layer  of  creaui  fresh  from  the  ic«box, 
tthenic  patients  can  usuallj  tako  this  once  op  twice  a  day  without 
cference  with  their  appetite  or  digeatioa.  When  the  patient  can 
tolerate  it^  milk,  or  some  preparattou  of  it^  should  be  given  to  supple- 
ment regular  meals-  Persoually  I  have  found  the  best  Iiidg  to  admiais- 
ter  milk  to  bo  one-half  hour  before  eatiug  or  two  hours  after  a  meal. 
When  it  is  given  a  half-hour  before  a  meal,  aod  the  patient  is  told  to 
keep  absolutely  quiet  until  meal-tiiue,  it  very  often  seems  to  have  no 
effect  whatever  in  depreciating  the  appetite.  Mauy  writers  on  neuras- 
thenia contend  tliat  three  times  a  day  ia  often  enough  to  feed  □enrastbenio 
patients^  but  this  is  not  my  experience.  Many  of  these  patients  bave 
their  only  nunut^e  of  well-being  for  a  short  time  after  each  meal,  while^ 
on  the  other  hand,  they  are  nsuELlly  much  depressed  by  going  without 
food  for  several  hours- 

The  dietary  indications  that  have  thus  far  been  spoken  of  fipply  to 
the  neurasthenic  person  wbo  is  not  afflicted  with  other  disturbtmces  of 
tlie  gas tro -intestinal  tract  than  those  named.  Unfortunate]yf  from  five 
to  ten  per  cent  of  all  sufferers  from  this  disease  present  some  graver 
form  of  gas  tro- intestinal  atony  and  its  aecompaniments.  These  require 
very  particular  treatment,  as  the  disorder  of  general  nutrition  which  tliey 
bring  about  Htamls  obstinately  in  the  way  uf  regaining  the  neural  pcpti- 
librium.  The  most  uncommon  of  these  graver  forms  of  digestive  tiouble 
ia  that  kown  as  by  perch  lorhydiia,  associated  with  slight  or  considerable 
dilatation  of  the  stomachs  When  this,  associated  with  tbe  neuraatbenic 
alntej  occurs  in  elderly  persons,  it  is  one  of  the  most  difficult  conditions 
to  overt'onie-  It  should  be  treated  by  regulating  tbe  diet,  by  cutl.ing 
down  the  animal  proteids,  and  increasing  the  vegetable  proteids  and  easily 
digested  Suirches,  by  giving  milk,  preferably  at  bed-time,  in  connection 
with  some  alkali,  such  oa  bicarbonate  of  aodium  in  from  twenty  to  sixty 
grain  dosesr  and  by  alkaline  drinks  such  as  natural  Vichy,  Tntestinal 
fennentation  shotild  be  counteracted  by  occasional  small  doses  of  calomel, 


THE  TEEATMENT  OF  NEURASTHEI^IA. 


m 


follDved  by  one  or  more  dos^  of  Carlsbad  ealts  tind  hy  the  uumterntpted 
adiuiniatraLion  of  icbthjoJ,  ona  of  the  bismuth  preparations,  reaorcm, 
etc.     A  aauJiL  formula  b  tho  foUovrmg- 


^  Xtletiaji.  aaiicylbi^, 

PuLv.  rbui, 

IchLEiyol,     .-.,.. 
M.  £t>  capH-  No,  jcxiv,    S.  One  capflnle  XAA. 


flA  ^  ill 
1  i. 


■f'y 


Despite  all  that  has  be«n  aud  id  still  claimed  for  the  modern  antifei- 
mentfltives,  in  my  own  espeneiice  -^  to  y^^  gr,  of  calomel  two  or  three 
times  a  day  19  by  all  means  the  moat  reliable  subatance  to  prevent  lutes- 
tioal  putrefaction  H 

The  moat  important  elements  in  the  treatment  of  so-called  neuraathenJa 
gastrica  are  regulation  of  the  diet  and  the  administration  of  a  suitable 
amount  of  alkali,  except  where  the  (Condition  be  one  of  hyperchlorhydria 
when  such  alkaline  aduiinistratioti  would  be  decidedly  iajurious.  fii  ad- 
dition to  the  geut^ral  treatment  to  overcome  the  myasthenia,  the  galvanic 
current  may  be  applied  to  tho  fitomach  through  the  abdominal  parietee, 
or  better  by  the  intragaatrie  method  of  faradization  or  galvanization. 
In  my  own  experienoe  the  latter  mei-hod  ha^  shown  itself  of  greater  service 
than  the  former.  Very  little  beuolit  ta  to  be  had  from  the  ime  of  floice 
t'onstituents  of  the  digestive  fluid,  artificially  j^rf  pared,  such  as  pepsiu  and 
pancreatin.  If  they  are  iiaad  ab  all,  it  should  lie  for  only  a  few  doaes, 
Many  neurasthenic  patients  come  to  tho  physician  with  tlie  history  that 
they  have  been  in  the  habit  of  waeJ^ing  oat  the  stomach  regularly  for 
many  months.  On  genei-al  principles  it  msiy  be  said  that  such  practice 
should  be  stopped  at  once.  Also  it  may  be  said  thai  the  only  t^oTidition 
that  juatiBes  lepeated  washing  out  of  the  stomach  is  one  of  chronic  gastric 
catarrh,  with  an  accompanimentof  considerable  secretion  of  macua.  Even 
m  Biich  a  caso  it  should  be  alternated  with  intragastne  electrization  and 
frequently  intermitted  and  large  draughts  of  warm  or  hot  water  given 
instead. 

Constipation  accompanies  the  disease  in  the  majority  of  oaaea-  Xa 
about  five  per  cent  of  all  cases  there  is  a  history  of  symptoms  that  leads 
to  the  diagnosis  of  mucuu^i  enterititi,  the  prominentaccompanimentif  being 
irre^lat  diarrhoea  with  variable  aiuoiii^t  of  muc<iua  discharge.  To  over- 
come the  constipation  is  not  ujsualJy  adilhcult  task,  if  the  physician  keeps 
in  mind  that  tho  two  main  causes  of  it  are  sluggishness  of  vermiculai 
actioDf  a  manifestation  of  myasthenia,  and  deticiency  m  the  watery  con- 
stitiienta  of  the  stools.  To  overcome  these  it  may  be  necessary  to  em- 
ploy, in  addition  to  tlce  general  treatment  for  neurasthenia,  abdominal 
massage,  such  drugs  as  strychnine  and  belladonna  that  cause  contractiou 
of  unstriped  muscular  fibre^  m  connection  with  laxatives,  while  the  second 
factor  Lu  causing  coustipjitioa  is  thwarted  by  having  the  pati&at  take  freely 
of  water  and  of  substances  that  lend  bulk  to  the  stools.     If  this  is  not 


TREATMENT  OF  I>TBBA:^S   Or  THK  NKRVOUS  8TSTKK. 


BufficUntf  my  experieiico  h^  taught  me  to  reJy  upon  euemttta  of  olive  oil 
or  cotton-seed  oil,  Qdminiatered  to  the  patient  in  tbe  knee-chest  posLtioD, 
thrtiuijli  a  tubewhii'h  is  carmd  beyotid  tlie  junrtionof  tbereoinim  and  the 
culoa.  From  hLx  to  eight  ouucea  of  oil  are  iuLroduc<ed  yer^  alowlj,  ami 
after  the  patient  hna  become  somewhat  accustomed  to  tho  procedure  there 
i^  no  diHiouItj  iu  rctainiug  it,  It  should  be  repeated  about  erery  fifth 
day-  The  ph^nomeoa  of  mucous  enterttia  are  best  combated  by  the  osa 
of  the  Neptune  girdle  externally,  ai)d  by  copious  fluahings  of  the  large 
inteatiiies  with  plain  water  or  with  water  to  which  some  alka.li  or  anti- 
aeptic,  Buch  as  boiio  acid,  has  been  added.  These  caaeo  teciuire  careful 
aelectiou  of  the  diet  and  reguJatioo  of  the  amount  of  food  that  can  be 
profitj^bly  gi^eu.  In  somo  cases  in  which  the  taking  of  food  is  immedi- 
ately followed  by  B.  desire  to  go  to  stool^  with  the  voidanea  of  a  smali 
amount  of  fibres  Rnd  a  lai-ge  amount  of  mucuB,  the  occaeioual  administra- 
tion of  one  of  tho  bromides  is  Leuefioia!. 

Neurasthenia  occurring  with  eKoessive  foTmatdon  of  uric  acid,  or  rela- 
ti^eiy  defective  elimicetion  of  this  substance^  requires  spocial  dietary 
treatment.  The  details  of  Kuch  treatment  will  not  be  given  here,  as  it 
differs  in  no  wise  from  the  approved  dietary  Irealmeut  of  any  of  the 
mauifestatioiis  of  the  uric-aHd  diathesis-  The  uioat  im^KirtAUt  thing  to 
be  borne  in  miud  is  that  too  strict  iusiatence  on  au  anti- uric- acid  diet 
may  prevent  the  recuperation  of  nutrition  upon  which  recovery  irom 
neurasthenia  dt.«pend6. 

The  Interdiotion  orstlmtlants. — Tha  physician's  oourse  in  determin- 
ing whether  or  ii<it  alcoholic  drinks,  tea,  coffee,  and  tobacco,  shall  be 
taken,  is  shaped  very  largely  by  the  patieut^s  habit  and  reactiou  to  these 
substances.  If  the  development  of  the  neucaathetiia  stands  in  any  rela- 
tionship whatever  to  such  indulgence,  they  ahould  be  absolutely  exoluded. 
If,  on  the  other  hand,  the  patient  boa  been  aeoustomed  all  bia  life  to 
taking  a  small  quantity  of  light  wine  or  beer  at  meal-ttmea,  and  if  such 
iudulgence  aeems  to  help  the  appetite  and  digestiou,  the  indicatioos  favor 
the  coDtiiiuance  of  the  habitn  Nevertheless,  it  may  be  etated  as  a  gen- 
eral rule  that  all  of  these  enbatancee  tend  to  derange  digestion  rather 
than  to  aid  in  restoring  it,  and  they  should  therefore  i>e  avoided,  Malt 
liquors  especially  seem  to  have  the  capacity  to  start  fermentation-  I 
have  not  bt^en  able  to  convince  mystlf  of  the  reputtd  recoiistr active  and 
nutritive  qualities  of  any  of  the  malt  extracts.  Tb^y  mziy  aoiuetimea 
help  to  create  an  appetite,  but  they  can  be  satisfactorily  replaced,  And 
withont  any  of  their  di  sad  vantage  s,  by  the  use  of  simple  bitl(*rB, 

HydriatiD  Treatment- — The  value  of  hjdriatica  in  treating  neuras- 
thenia [\an  easily  be  or^reatt mated.  They  are^  nevertheless,  perhaps  tJie 
most  important  of  the  physical  measures  upon  which  ex|«rieuce  has 
taught  UB  to  rely.  It  owes  its  good  effect  to  the  powerful  appeal  that  it 
mahee  Btiko  to  the  body  and  to  the  mind.     It  greatly  aids  ooufltructiTo 


THB  TREATMENT  OP  NBU11A9THENIA. 


413 


metBrnorpliosis  fay  stimulating  the  peripheral  and  deep  circulatory  fiuida; 
it  js  EUJ  iuiporlaut  ageoc^  to  eicite  &iid  lo  tpiiet  the  peripLeial  uervea  and 
their  central  aud  peripheral  distribution;  its  use  almoL^t  alnajs  gives  at 
least  a  temporary  feeling  of  well-being^  caused  by  reaotion,  and  this 
makes  an  impression  upon  ttie  patieot^a  mind  helping  to  restora  the  lost 
con3den('e  and  tu  oven^ome  the  mental  depression  which  play  Eiich  a 
leading  part  in  the  diBease.  In  the^e  ways  arid  others  it  overcomes  the 
myasthenia,  it  promcitea  the  appetite  and  facilitates  digestion,  it  aids 
rest  and  sleep,  and  it  tends  to  overcome  the  niim^roua  par^sthosi^t  which 
form  SMch  a  uooapiuuouu  feature  of  the  patient's  complaint. 

The  method  of  luiug  water  to  advantage  in  the  treatment  of  neurastheiiia 
Taries  with  the  individual,  aitd  particularly  nith  his  abllil^  to  re-att.  It 
therefore  varies  with  tlie  same  percjon  in  difTeJ'eut  stagea  ol  the  diseaae. 
There  is  no  such  thing  as  a  fised  hydrlatio  pieacriptioDr  because  what  may 
be  good  for  one  patient  will  very  likely  be  injurioua  io  the  next.  When 
the  conveniences  of  a  hydriatie  institution  are  to  be  had,  thd  physician 
tihould  avail  himself  of  iheiii,  bei^^use  there  watercun  be  applied  more  care- 
fully and  accurately,  while  the  seetaingly  complex  apparatus  makes  a  lead' 
ing  appeal  to  the  patient's  nupd,  a  result  at  all  times  to  be  stiiven  for  in 
thetreihtmentof  neuiaathenia-  The  possession  of  such  hydriatic  apparatus 
is  ond  of  the  most  imporUnt  oUima  in  favor  of  eauatoria  treatment  of 
neunuttbenia.  Much  benefit,  however,  may  be  gamed  froiii  the  uee  of 
cold  water  with  no  uther  apparatus  save  the  attendant's  hand,  a  pitcher, 
and  a  sheet.  The  usual  hydriatic  measoree  in  the  treatment  of  neui'as' 
thenia  are  cold  abluliorjs,  tho  dripping  sheet,  the  sprayj  and  the  simple 
do-t<>he.  Of  these  the  latter  is  by  far  the  most  important.  In  order  that 
the  douche  may  be  used  successfully,  a  certain  amount  of  pressure  which 
can  be  readily  graduated  xa  neceasary.  For  the  average  neurastheuic 
person  of  the  depressed  type,  the  customary  method  is  to  prepare  Lim  for 
the  douche  by  a  few  treatments  with  cold  ablutions  (80*^  to  60'*  F. ),  tho 
water  being  applied  from  the  attendant's  hands,  accompauied  by  brisk 
frietiou,  while  the  patient  stands  in  warm  water,  with  a  cold  eompresa 
about  the  head.  If  the  patiej^t  reacts  well  after  being  dried  and  made 
to  Lake  lii'ely  exerC'tse  in  the  opeu  air,  ur  after  having  iieen  put  to  bed, 
the  cold-douche  treatment  may  be  begun,  When  the  patient  is  seat  to 
an  institution,  some  Buch  method  as  the  followiug  ia  used-  the  outaueouB 
oirculation  in  stimulated  by  encasing  the  patient^ii  body  up  to  the  cLiu 
either  in  a  hot  bot  or  in  dry  hot  sheets  for  a  few  minutes,  bat  neuer  ap 
to  the  p<rint  of  considerable  perspiration,  except  iti  the  irritable  varieties 
of  ueuraetbenia  and  in  those  accompanying  the  uric-acid  diathesisi  the 
douche  is  then  applied  all  over  the  body  with  from  ten  to  fifteen  pounds 
preAflure,  and  WLth  water  from  S5°  to  55"  Y.  The  treatment  is  then 
ended  by  the  application  of  a  spray  (called  the  ^Fleiiry  spray,  after  its 
French  originator),  with  water  of  about  the  same  or  a  little  higher  tern- 


414  TKEATMRNT  O^  DISEASES  OW  THB  »IEUVOCS  BVBTKV, 

peraCuro  and  with  equal  or  aomewhat  greater  prcoaure^  Tbe  patient  i: 
tlien  quickly  dried  and  reac^tlon  aided  in  tb^^  usual  way.  It  depends 
entirely  upon  the  degree  and  completeueHB  of  reaction  wba.t  th«  formulary 
icT  the  n^xt  treatmeat  will  he.  If  reaction  is  satisfactory,  ths  tempera- 
ture of  the  water  is  diuiiuished  on  each  eiK^ci^ailiikg  day  aDd  the  [iresnure 
somewbat  ipcreaaed,  but  never  ahove  eighteen  0£  tweuty  pounds.  The 
Soottisb  doucho  ia  rarely  used,  unless  it  bo  for  tlic  purpose  of  counteract' 
ing  neuralgic  paina  and  painful  parasEthesia- 

When  the  hydriatic  treatment  niust  be  carnsd  out  at  bom«,  cold 
ahlutloiLs  and  tlm  dripping  shtMit  are  moat  aecTic^abte.  The  former  may 
be  applied  in  two  wajA,  either  of  wbioh  ia  very  simple-  A  lin«n  sheet  ia 
wrung  out  of  water  from  "5°  to  C5°  Ft,  and  thrown  about  the  patient*  who 
is  standing  upon  a  warm,  dry  Eiirface  or  In  warm  wat^r  ^  then  the  attendant 
mukea  friction  for  from  thirty  to  ninety  secunds  through  the  sheet,  which 
13  then  cbauged  for  a  dry  sheets  through  which  frictions  are  kept  up  nntil 
tlkC  patient  begins  to  react  thoroughly.  The  reaction  ia  then  kept  up  by 
uae  of  the  customary  nieaaurefl-  The  dripping  sheet  15  often  more  naefnj 
than  the  one  juet  described.  The  linen  sheet  la  thoroughly  saturated  id 
water  of  the  same  temperature,  hut  is  not  wrung  out-  It  is  applied  in  the 
■RHie  way  after  the  patient  lias  been  given  a  brief  ablution  with  water  of 
the  same  or  somewhat  higher  temperature^  ajid  taken  off  after  from  thirty 
to  aisty  SQConds,  daring  which  time  friction  is  hcpt  up  through  the  cheet- 

Tbe  other  applicationa  of  water,  snch  as  the  prolonged  lukewarm  or 
warm  bath,  th^  balf-bath,  the  local  and  generaJ  cold  pack,  may  bo  used 
to  meet  s})?oia1  indications.  In  the  forma  of  neurasthenia  cbaract«med 
byerethiaiu,  mental  exoiteinent,  motor  imrest,  and  contiirnal  expression  of 
disaatiafaetion,  the  general  cold  pack  repeated  ojice  or  tirice  daily,  aud 
kept  on  from  two  to  four  honrs,  ia  a  very  important  and  helpful  meaBuro* 

The  Use  of  Electricity. — 'I'he  usefulness  of  electricity  in  the  treat- 
ment of  netira^sthenla  is  nnich  lena  than  that  of  water.  A  discussion  of  the 
mode  of  ita  beneficial  action  does  not  seem  necessary.  The  belief  fieema 
to  be  growing  that  its  power  for  good  depends  largely  upon  its  effect  in  mak- 
ing a  psychical  appeal  to  the  patient.  Ita  unknown  nature,  ita  wondrous 
mabifestations,  it^^  attributed  heal th-reato ring  qualities,  all  tend  to  impress 
the  patient  with  its  power  for  benefit.  It  really  matters  not  how  it  acts 
or  u]M}n  what  it  at^ts,  sn  long  as  it  may  be  utilized  for  the  jiatient's  gi'iod. 
Hot  does  it  matter  particularly  in  what  form  electricity  is  naed.  The  form 
that  appeals  most  powerfully  to  the  patient^s  emolioD  and  that  is  lEiven  from 
the  mostcompUcatedaiid  elaborate  apparatus,  aci'urdinglu  the  most  studied 
plan  and  with  the  greatest  care,  is  the  cue  that  will  have  the  beat  effect- 
It  IS  because  these  easeutiala  are  beat  provided  by  thesiatic  apparatus  that 
the  appIicatJQii  of  this  form  of  electricity  seems  to  be  of  more  beae€l 
than  either  the  fatadic  or  galvanic.  The  next  most  useful  form  of  elec^. 
tiization  ia  the  electria  bath-     I  ilo  not  mean  to  deny  that  lar&dic  and 


THE  TREATMENT  OF  KECRASTE]EX1A> 


I 

4Lfi 


vaaic  electricity  art^  samutiuieA  uaerul  in  neiua^theDi^  by  virtue  of  cei't&in 

pQveieal    properties  which   they  possefis,  to  aaaist  in  overcomiug  certain 

coaiitiociSt  suck  1x3  pJtia  and  tuyasthenia.      Kcr  matauce,  geQeral  faradi2a- 

Xvm,  If  Dot  carried  to  the  point  of  Fatigue,  laay  be  of  confiidciable  help 

to  giving   t<^ae  to  the  relayed  musolea.      On  the  other  hand  the  rapidly 

uiterrtipt«d  ctirr«^ut  may  aometiiues  t)e  uned  ac^vautageoLiely  ta  counteracb 

pain  aad  pariEathesia,  while  the  poaitirep^k  of  the  confltant  current  Is  now 

■nd  then  lueful  in  overcoming  local  pain,  such  as  rachialgia.     The  latter 

cnrtent  should  never  be  used  about  the  head,  because  oi  the  vertigo  that 

H  it  liable  to  caafie,  which  may  l>e  fastened  upon  by  the  patient  as  a  nev 

tymptoiDt  and,  sinking  into  a  morbid  memory,  will  hut  add  to  his  suf- 

ering.     Formerly  the  uae  of  faradio  electricity,  to  produce  miiscular  c*m- 

tnclion  and  therefore  make  for  change  of  tissue,  waa  thought  to  be  very 

Asseutiial  in  the  rest  cure^   but  it  id  gradually  being  given  up  in  favor  of 

xuuge*  passive  eierciBe^  and  graduated  active  exercise,  atthougb  it  ia 

juLl  "lied  for  its  etfect  as  an  indirect  psycho- therapeutic  agency. 

Bttl,  Exercise,  and  Ocoupatiou. — Thts  use  of  rt^st,  exerciee,  and  massaga 
iQ  L'ifl  treatment  of  neurastheuia  will  depend  largely  upon  the  individual 
ntdtbe  t\pe€f  the  disease  from  n hi vh  he  suffer s-  In  some  cases  absolute 
Tdt  m  bed  for  a  number  of  weeks  is  a  very  essential  part  of  the  treat- 
n«Dt.  Particularly  ia  thi»  true  in  the  ease  of  women  who  are  run  down 
fpun 8i»<'ial,  maternal,  or  household  duties,  nnd  in  that  of  both  men  and 
Tdineii  ia  whom  neurasthenia  follows  Home  such  eiliausting  expBrie]it:e 
u  pTi»tonged  aufiering,  repeated  illness,  protraated  attention  to  the  claims 
ADii  vranta  of  otbers^  especially  when  associate<l  with  antnmia  and  moro 
M  lesB  loss  of  flesh.  In  my  own  e>:perience  the  rest  pian  of  treatment 
It  ippUcable  to  a  relatively  small  proportion  of  all  nptiraatbenics,  when 
carried  otit  in  a  radical  way.  A  modific^atioii  of  it  is,  to  be  sure,  one  of 
tlttt  uecesaary  features  in  the  plan  of  treatment  which  I  auv  atbcjuptdng 
bo  outline*  But  in  many  cases  it  ia  better  to  prescriboeome  exerciso  that 
IS  oonsistent  with  the  patieut'u  strength  and  puree,  in  connection  with  a 
ovrtain  amount  of  enforced  refit  in  Wl.  In  beginning  the  treatment  of  a 
sffvere  caae  of  tlie  anxious,  depressed  type  of  neurastheQia,  it  is  as  a  rule 
a^lvisable  to  keep  the  patient  in  bed  for  two  or  three  weeks,  during  which 
time  the  use  of  masaago  and  resistance  movements  give  the  exercise 
pooeaaary  to  combat  the  myasthenia  and  to  aid  tissue  recouBtruction, 
Aftt*T  sueb  a  time  the  patieut  is  kept  m  bed  from  fourteen  to  eighteen 
boura  out  of  the  tweoty-four,  the  remainder  lieing  taken  up  in  hydiiatie 
electrical  treatment,  walking,  cycling,  golfing,  riding,  fencing,  bo£- 
m^  rowing,  etc.,  whichever  is  moat  feasible  and  auitable  to  him.  The 
kind  cf  exercise  that  is  beet  in  neurasthenia  depends  somewhat  upou  the 
type  of  the  disorder,  but.  more  upon  the  mdividual>  The  greatest  diffl- 
-  culty  is  met  in  finding  the  exercise  that  is  most  suitable  for  women  who, 
I    froai  one  end  of  life  to  the  other,  have  never  taated  the  sweet  weariness 


41B  TREATMENT  OP  DTSBAS&e  OP  THE  NBRVOCB  BYSTEH. 

thftt  fo11u\4's  accustomed,  toil  cr  whcse  age  precludes  thcrra  from  iadiilging 
)>ecoiuiiigly  in  the  varieliea  of  eierciae  tliat  1  liave  mejiuoned.  For 
Ibeiu  walkiDg  ia  tedious  and  lends  ibaelf  to  intrcspection ,  cycUog  in 
Icoked  npcn  aa  untittiag  their  yeara  and  dignity;  guJ£ag  is  too  Hpec^Uvu- 
lur  and  \iolent;  and  so  on  through  the  Ji£t.  It  is  iii  Guch  n  CAAe  that  the 
patient  flhould  ba  sent  into  some  new  couiitry,  espe<^ially  a  billy  or  moun- 
UlIuuus  oil?,  whose  FLttractious  iuvite  exploration  which  ueceuitatee  walk- 
ing, <:liiul>L]j|^f  und  riding. 

The  etTect  of  exercise  on  the  mind  of  the  neuroflthenic  pati«nt  can  b« 
eaaily  eKplaiQed.  In  a  normal  individnalT  the  mind  o^gtb  a  barrier  be- 
tween ini|trf^£sioQfl  received  thxongh  the  flenses  and  all  external  and  in- 
ternal mauLftibtatious  of  them.  It  thita  closes  the  g^ia  through  whicL 
they  voiild  paa9  into  the  sensorimotor  areas  to  find  eiprCflsion  In  the 
motor  system  and  in  disturbance  of  org&nio  function.  When,  through  tho 
inhibition  of  the  wtll^  the  mind  no  longBr  intcrveaes  between  tbe  mental 
iiupreseions  and  the  exprossion  of  tliero,  the  result  la  those  antottiatic  and 
uncontrollEibld  a^^ts  which  we  call  rel^ei.  Siirb  are  niaiiy  of  the  aot9  of  thfl 
nervous  patient,  mvoluutary  luovementa,  luauifeBtations  of  the  eaiationar 
and  the  keen  interpretation  and  resH^tiou  of  aeusations  and  ideas  over 
which  the  putieut  had  ni^  control.  This  loi^s  of  equilibrium  between  tho 
sensations  received  aud  the  power  of  reaiHtance  which  the  mind  ia  able  to 
oppose  against  their  spintaneoiia  manifefttDtion  constitutes  what  ie  called 
lack  of  inhibition,  wbii^h  is  iUa  burden  of  the  neurHSthenir,  Unable  to 
resist  them  he  becomes  a  prey  to  the  dark  thoughts  which  his  condition 
invitesi  and  in  thi^  morbid  state  the  1(k^  of  voluiitary  energy  or  r-<>siEitiinoo 
is  the  gravest  obstacle  in  the  vr^y  of  recovery.  Tho  hrat  ohjecl,  thfireforOi 
IS  to  restore  this  power,  so  tliat  the  mind  will  be  enabled  to  react  against 
these  depressing  influences  and  thus  l^giii  to  le^'ain  its  ctiuilibnuni.  Sys- 
tematic and  iuteiligeut  purposeful  exeruiae  is  an  important  means  to  this 
end  from  the  simplo  fai^t  tliat  tinch  mu:]culai'  effort  is  impossible  without 
some  effort  of  the  will,  and  the  will,. like  the  body*  develops  by  use.  This 
purpose  should  Ite  kept  coustantly  in  mind  iii  deciding  upon  the  form  of 
exercise  to  be  tried  in  each  case,  with  the  view  of  making  the  strongest 
appeal  to  the  will  of  the  patient.  And  this  should  be  applied  carefully 
at  first  CO  AS  to  overtax  neither  the  body  nor  the  mind^  then  gradually  in- 
creased as  the  patient  gains  endurance  and  resietEmoe. 

The  safest  t«st  in  the  aeLectiun  and  inaistance  on  cert&in  kinda  of  ex- 
ercise is  the  effect  that  they  have^  not  the  effect  that  the  patient  says 
they  have.  If  exercise  tends  to  make  him  accept  the  eufoiced  rest  and 
isolation  more  gracefully,  to  increase  the  appetite  and  facilitate  the 
action  of  the  bowels,  to  promote  a  feeling  of  relaxatioo  and  sleep — then 
it  la  beneficial  and  should  bo  continued,  increased,  and  varied.  If,  how- 
ever, it  has  the  opposite  effect,  it  abould  he  curtailed  or  ectirely  stopped 
for  a  time  and  rest  rigorously  enforced,  while  the  exercise  necessary  to 


THB  TKBATMEK-t  OP  KECHASTHKNIA. 


417 


{■Touiote  tissue  metamorphosis  ia  got  by  passive  muTemaTitH,      It  ii  often 

ell  fcr  a  patient  who  is  isulated  and  who  is  takiui^  a  iiioiU^ralu  rest  cnire 

%o  iadulge  m  certain  cccupatious  which  help  to  pass  the  time  und  to  di»- 

ttftCt  Uie  mind.     VVomea  should  be  encoitraged  tt>  sew,  to  kuit,  ami  to  piky 

cuds,  while  men  shoald  be  allowed  to  play  billiards,  baokgainmoii,  and 

t3ift  like,  providing  these  are  rot  looked  tijHni  as  taskn  aiid  do  nut  cut  me 

fabgae.     H«covery  cam  oftea  be  much  expedited  liy  etLECuragini;  the  pa* 

IwQt  to  indulge  moderately  in  aome  occupation   suitable  to  his  atreuyth 

md  tfllents.     if  this  occupation  t^suJta  in  tliti  producticu  of  something 

tugil>ls  and  useful  so  much  the  better. 

Ei«i(*ise  iri  the  open  air,  particularly  when  it  holds  the  interest,  is  of 
dwidiN]  benefit  to  those  wLuse  neuraj^theiiift  is  apparently  the  result  of 
Ndfiiury  work,  abgorbmg  menUil  occupatton,  worry,  care,  and  aoiiiety. 
Ix  IS  also  very  ncccBsary  for  those  who  have  the  urit'-acid  diathesis  and 
tbiidGQi?  to  catarrhal  oondition  of  the  buwels.  lu  the  fortns  characterised 
bj  iDiiS^T  vasomotor  mantfeatatioiis,  and  profound  myasthenia,  and  m 
s;iiQeruss  with  conspicuous  disturbance  of  the  sexual  sphere,  iL  is  tjot  md 
nJuabk 

llusage  is  oftea  overrated  as  a  them|>eutic  aid  in  the  treatment  of 

MvutheELiAy  and  perhaps  eometimes  underrated-      It  in  oeedleset  to  say 

thil  it  has  no  specific  virtue-      IJke  all  physical  agencies  that  are  uaefol 

IB  tie  treatment  of  this  disease,  it  owes  its  good  effects  to  the  aid  which 

it  (ires  to  professes  of  metabolism,  and  to  the  appeal  which  it  makes  to 

m  mind  of  the  sufferer.     The  latter  overshadows  the  former.      Massage 

lA  tlerefore  oftentimes  more  beneficial  when  it   is  gireii  aooordlang  to  a 

MUphcaced  system,  in  which  all  ihv  details  are  strictly  carried  out,  4Ad 

vken  It  ts  girenvitli  ccmplicafaid  mechanical  appuataa.    Thrnarfnhnwa 

of  abdominal  massage  la  orercomiiig  ccnatipatioa  Kaa  alnadj  bem  nun- 

tmc^.    Ho  definite  ralea  can  be  giTca  for  the  nacof  ma— jt^  for  i>  nonch 

depeada  npou  the  penoa  and  upon  the  tyjic  of  Jua  diecosc,     Some  pa- 

Eittti,  particularlj  laen  and  those  with  anaie^  ty|i«  of  Um  nnuoWf  do 

B0t  l»l*B  tUA  it  al  an ;  vhilo  othiera,  voimen,  drprrfd  Deoraithentet,  aad 

fit  iadiTiduala*  enjoj  it  and  iitqiM^tij  aleep  after  a  sdance.     llaa>a|;e 

spoatora  aar  tbat  the  efficacy  of  aaaaago  dqk^>da  lar^ly  upcD  the  maa- 

aerof  gmng  it  and  thaayateu  with  whiieh  it  la  carried  out.     Theu  riew 

^  tka  laattar  ii  an  mtefted  and  a  beaaMd  ona.     It  may  ba  osed  advaft- 

tiypMiiy  to  nTniiiaiw  eotfttpttkai,  rtiifm—  ^td  wjumas  at  tkm  jokou 

ad  aJwHssa^  teadennw  tif  tfas  ■■■des^  ^id  ■yarth—ia.     Immmtdm 

hOD  or  aoce  jnit  haFoie  tatmafr  or  bf  donvard  aifoltkf  «f  t^  isdat 
ladbacfcof  thoM^    Ihaa  ptoeadafo  Mcasa  to  taivaM*  Ae 
hf  ^B&M^  Ao  io«  atf  yood  in  tha  1VM, 

is  met  my  pca^     TW  noaaaiAndc  pstt—t  roevrew 
57 


d 


413 


TKEATMKNT   OF   I^ISEABES   OP  THK   NERVOUS   BYflTEM. 


quickly  ill  a  olimata  that  allows  hiin  to  spend  comfurt&blj  ^l  portioa 

tliff  time  ilk  tlie  open  air,  and  to  have  pleuly  of  thia  iiii portent  ekmeDtin 
a  pure  fitate  in  hia  living  apartiueut-     A  riimate  that  id  so  moiat  Aa4 
irarm  that  it  tends  to  genital  euervttion,  oi  one  that  ia  sa  cold  and  liiy 
that  a  great  deal  of  enejgy  i^a  tii^ecled  to  witUstaad  it,  is  contraindicatvd. 
The  advantage  iuuhange  of  rlimate  in  utoi-e  often  i\\xv.  Li)  the  newenvtron- 
nient,  with  it«  freedcm  From  strife  and  diatresaing  annoyances,  and  tha 
attention  to  diet,  rest,  exercise,  and  hygienic  rules  which  it  entaiU,  thui 
to  oliinatii^  conditions.     A   fitny  la  the  hilla  or  mountaitis  for  those  oa 
whom  the  a^^aBideor  plain  palls  oa  account  of  loa|}  aEsociatioa  is  best,  and 
vice  versa  for  the  fiaine  r^Haons.      The  inlluence  of  beautifal  Eceuerjr,  in- 
spiring uurroundiugd,  and  the  wonders  of  nature  may  impreas  upon  the 
seEf-centrcd  patieitt  liow  trivial  and  unint^reating  he  ia  when  com  pared 
with  it  ail,  and  help  to  Uft  him  ont  of  himself.      Like  everything  elae  in 
the  treatment  of  neurasthenia,  very  much  depends  upon  the  individual. 

The  question  of  travel  for  neurasthenia  patients  is  not  a  very  diflii^ult 
one  to  depide.  F<ir  the  many  it  i&  impracticable,  and  llie  few  are  better 
off  ^^ithout  it.  For  one  neiiraabhenic  patient  who  is  benefited  by  aimleoB 
'*  travelling  for  health  '*  ten  are  injurod  by  it. 

Drugfl  In  the  Treatment  of  frearaatheDia. — The  medioinal  treatment  of 
neuraathenia  is  the  least  impcTtant  duty  of  the  phyaician,  though  it  ii 
often  dillli^nlt  to  convince  the  patient  of  this^  and  phj^aiciaiiA  aa  welL 
Bei^pite  the  reaui^  of  paper  that  have  been  consamed  m  di»em;Dating  the 
information  that  ^^spermin," '^nuoleini'' animal  extracts,  and  emuleiont 
of  Derve  aubetanoe  are  epecitios  in  the  treatment  of  nLmrasthenia,  it  ia 
palpably  evident  that  none  of  these  eubataiii:^eB  has  advanced  the  therapy 
of  tha  affection  a  particle.  Symptom  niedicitiea  are  invaluable  to  meeu 
cert^ijn  ludioations,  and  disease  medicines  assist  in  overcoming  certain  or- 
gaaio conditions,  such  aaanaf-mia^  but,  despite  this,  the  majority  of  nniiraa- 
thenie  patients  would  roach  the  ^^oal  of  rvuovery  just  as  surety  and  quickJj 
if  drugs  W9.TQ  entirely  discarded-  At  leaat  it  may  be  truthfully  said  that 
it  ia  nftf^ii  as  important  to  forbid  the  patient  all  medicine  iw  itls  to  prescribe 
it.  Neurologists  will  probably  agree  Ihiit  the  majority  of  neurasthenic  pi- 
tients  that  oomo  to  them  after  having  been  treated  by  their  family  phy- 
sician or  desultorily  by  a  number  of  physieianSj  aro  bo  thoroughly  brozai- 
dized  that  this  state  demands  treatntent.  I  do  not  mean  to  say  that  the 
bromine  salts  aie  not  often  of  signal  use  to  relieve  certsio  difttresaing 
symptoms,  such  as  head  pressure,  palpitation  of  the  heart,  and  abfh»minal 
fluttering;  but  they  should  never  be  given  contiuuouaty,  promieciioasly, 
or  without  flpecial  indication. 

Although  the  phatmacop<]eia  oontaina  no  drug  that  has  special  virtue  to 
"  atrengthen  "  the  nervous  Bystem  or  to  restore  its  equihbrium  wh^n  the  bal- 
ance is  once  disturbed,  still  there  are  certain  drugs  which  create  an  appetite, 
aid  digestion  and  usaimilatdon,  force  oxidation  and  elimiiiatian,  and  add 


THE  TKRATUENT  UF  NEU&ASTHENEA, 


419 


la  litt  D(rafltita«uU  of  the  blood  aud  are  therefore  uaeful  ^vheu  each  iadica- 

lion}  exist.      The  simp  Id  bitters  iind  al^maubicB,  given  fi:>r  a  ahott  time, 

viU  l«  pretty  suro  to  cau&e  greater  relish  far' food.      AraeniOj  nox  vomicft, 

jjld  qainine  often  not  only  in<rrea3«  the  appetite,  but  aeem  to  h&ve  &  gen- 

enl  tonifyiog  effecc,  [lartioiilaily  ujton  the  muaculaj'  syatem.      Cod'liTBr 

oil  which  13  supposed  to  bo  of  special  aervjcts  in  the  tre^tmeot  of  neu- 

nai^9QL&,  has  no  other  virtue  thiio  to  provide  ao  easily  digeatcU  carbonB- 

oee<u  food.     In  aiuemio persons  auLtable  prep&riLtioDS  of  iron  aud  aTsenic, 

tlteruted  or  eombintd  with  the  simpte  bitters,  iniist  be  given.      In  giff- 

inj  iron  it  should  not  be  forgotten  that  it  has  been  proven  by  expertment 

tbit  the  quantity  whicti  the  blood  will  take  up  Btands  in  no  relationship 

tolheammint  given-     Not  infrequently  good  effeota  follow  repeated  ia- 

kikUoa  of  oicyg^n-     It  not  only  giv«B  a  general  fiUip  to  the  Bysteni  bat  it 

Its  1  desirable  uieotal  effect-      In  the  use  of  aFsenic  and  quiuine  it  is  well 

10  hau  in  luin  J  that  tbe  former  haa  a  tendency  to  canae  diaturbaoce  of 

'JiRBUfiaach  and  intestiuesT  which  may  be  very  dlstreasing  to  the  patient 

ind  ttnd  lo  mako  hiiu  more  aeLf -centred;  white   the  latter,  if  given  in 

sShitr  ihan  very  amiJl  doses,  ia  sure  to  eanse  rmging  in  the  ears  and  ver- 

U^  vtiah  he  will  iie  likely  to  interpret  as  moat  disaatroua  manifefitationa. 

Thi  idministration  of  aphrodiiiiBcs  in  secnal  neurasthenia  ia  couoeived  in 

em?i,  aud  fihould  never  bv  tried  eic'ept  for  the  mi^nlal  efTects.     Druga 

duloiake  i>ovvetful  appeal  to  the  mind  by  insulting  one  of  the  apooial 

KJ1IB3— such  as  valerian,  for  example,  particularly  wheD  gLven  with  aa- 

funace  thai  it  will  he  b^nefietal — are  often  of  great  comfort  to  the  pa* 

tient^  a.nd  thereby  useful.     Hypnotics  are  rarely  necessary  when  rest  and 

aeK\se,   hydrotherapy,  aD<l  massage  ore  pro^ierly  aitJ  f^thfnlly  uaed. 

It  is  often  necessary  tu  give  one  of  the  simpler  hypnotics  a  few  times,  in 

inder  to  secure  sleep,  uutil  the  physical  measures  just  mentioned  have 

time  to  take  effect.     They  should  be  given  in  large  enough  doaea  to  make 

Umn  effective,  so  that  the  patient  may  be  impressed  that  a  remedy  ia  at 

iLsnii  which  can  easily  cope  with  the  iiisoiiiuia. 

Local  Treatment— Reference  boa  alteady  been  mads  to  the  absurdity 
of  depending  upon  local  treatment  alone  to  cure  neuroatheniar  whether 
such  tre&tment  be  directed  to  the  prostate,  the  eye  mnscleSj  the  nterus,  or 
tEie  iloniach.  A!]  of  thaae  organs  are  very  likely  to  Bbow  considerable 
disorder  of  function  in  neiimsthenia,  but  sa  does  every  other  tissue  or 
m^aa  of  the  body  in  varying  degree.  They  all  need  treatment,  and  thua 
it  isthat  hydriatica,  diet,  rest  and  exerciso,  etc,,  have  proven  to  be  tho 
reiJty  trustworthy  therapeutic  f^encieEi-  Occasionally  neurasthenia  occurs 
vlth  ur  follows  rectal  abacessea  aiid  fistula,  enlarged  prostate,  a  slugguh 
or  even  indaEadd  runditicn  of  the  aeniinal  vesielt^s  aud  e^ccssslve  use  of 
iU-balanctxi  eye  muaidea.  In  every  such  case  the  effort  should  be  made 
to  rid  the  patient  of  these  evident  infirmities.  This  is  tantamouut  to 
saying  that  thecausal  treatment  of  neiurastheuiaahouldQever  be  neglected. 


420 


TEBATMEMT  OB"  1*1SEA8B8  OF  THE  NEBVOUB  SYSTEM. 


If  such  treatmeDt  aufliuasj  tlio  pjfctiuDt  and  the  phyaici^n  have  good  Chqbo 
for  luutual  coDgratulatioD.  Uufortninately,  however,  ib  does  not  suEic& 
in  about  niuetj  per  cent  of  tho  ca«efl,  aitd  it  is  unwise  to  neglect  i.he 
ninety  motely  to  roach  the  ten.  The  picture  i&  more  enticing  when  re- 
versed. 

The  Plan, — From  d.11  that  ha^  been  said  it  will  be  granted  that  the 
phjaiciau  hiiuaelf  U  t>£  first  importance  iu  the  treatment  of  this  uernr 
rosie.  His  auccdaa  in  handling  neurasthenia  will  etand  in  direct  propor- 
tion to  hia  power  to  inapirc  and  hold  the  oonfidence  of  the  patient,  and  thd 
thoroughneas  and  persistence  vith  which  he  makes  use  of  the  physical 
measiirea  that  have  been  detailed,  for  improvement  of  the  general  nutrition 
of  the  body  and  mind.  To  carry  euch  treatment  to  sLicceHsful  isaue  ro- 
qair^^a  great  iudindualizatioo,  stalwart  coDJidence,  tact,  peraevetance,  and, 
above  all^  atriet  peraoual  attention  to  detail.  The  physician  should  con^ 
tmually  strive  to  lift  his  patient  from  thd  quagmire  of  dread,  despair,  and 
deapundencty  into  which  he  haa  btteu  hurled  by  this  dreadful  infirmity^ 
and  implant  in  its  st«&d  aeutmicnta  of  hope,  confidence,  and  courat^c^  A.s 
a  nde,  it  may  be  said  that  a  patient  with  neurasthenia  should  be  ex- 
amined and  treated  nith  the  same  attention  to  detail  as  one  with  ty- 
phoid fever  or  endocarditis.  The  fact  that  careful  eiajuiuation  and  mts- 
thodical  treatment  elTect  a  cure,  in  part  or  largely  through  tlielr  appeal 
to  the  mind  of  the  patient,  in  no  way  detrai^La  from  them  aa  tangibly 
therapeutic  meaaurCH.  On  the  Gontrary,  that  is  all  the  more  rea^oa 
for  their  use.  The  more  often  they  are  employed  tho  leas  frequent 
will  be  the  reports  of  our^  by  Christian  acientists,  faith  curteta,  negro 
hoodoos,  osteopaths,  incantation  men,  and  other  fokira  and  mystery 
mongers- 

The  physician  who  has  neither  the  time  nor  the  inclinalion  to  devota 
such  care  and  attention  to  the  neurasthenic  patient  should  have  the 
frankness  and  moral  coura;;e  to  say  go,  and  not  keep  the  patient  on  bj 
pTomisPs  of  recovery  which  he  cannot  back  up  with  results;  while  ihft 
physician  wha  feels  that  he  ia  dischargiiig  his  duty  by  telling  the  patient 
that  hia  mifferiuga  are  "imaginary,"  "mental,''  "  trillings"  can  aiarcely 
be  said  to  hiivo  the  modern  conception  of  this  neurosis,  and  is  therefore 
not  fitted  to  deal  witb  it.  Aa  the  plan  of  treatment  is  so  important  in 
neurasthenia,  the  physician  and  the  patient  will  have  to  decide  whether 
it  is  feasible  to  carry  it  out  at  home.  If  it  is  not  entirely  so,  it  tiad 
better  not  be  attempted,  as  each  failure  lessens  the  patient  *  s  chanoa  of 
speedy  recovery-  No  compromiae  ahould  Ire  made  with  the  patient  or 
with  the  family  in  the  matter  of  conformation  to  inatructiona.  If  he  ia 
unwilling  to  do  all  that  the  physician  assures  him  is  necessary,  be  will 
Boon  come  to  view  the  matter  m  a  differeot  tight  when  told  that  the  treat- 
ment of  his  case  cannot  otherwise  be  undertaken.  Occasionally  it  will 
be  necessary  to  avail  one*s  self  of  the  fatulitiea  of  commercial  aanatoriA 


THS  TiUUTlfKNT  OP  NKriUSTBS^flA.  411 

fbeh  ue  tallf  equipped  with  hjdrutic  kud  ui»ehftnii>«l  devioea  for  th^ 
ue  of  Tftter,  mAssage,  Mad  psssire  exercbe.  There  18  much  to  be  eftid 
utioAt  and  but  little  in  favor  of  aucfa  iostitutioDs.  Aa  a  geueral  rul«^ 
^ma;  be  said  that  inatitational  treatukeot  ia  opposed  to  ibdividualiia* 
tioiL,  Hnd  ahonld  rarely  be  recammended. 


CHAPTER  XXVm. 


THE  TItEATMENT  Ol'  HYSTERIA. 

Htstekia  ig  a  psycbo- neurosis,  t^haractemed  by  disorder  of  th©  wi31, 
perveraii>D  oi  tbe  mliibitorj  powers  of  couscioustneaH,  hjlJ  hy  purttal 
cesaation  or  exaltation  of  individual  fuuctiooa  of  the  bTaio<  A  diaeaaa 
ih&t  ia  thus  charitoterized  must  uacesaorily  be  atteoded  in  its  clinical 
couraa  by  a  great  variety  cf  aymptcms.  It  is  this  variety  and  divereity 
of  symptoms,  comuioaly  called  proteaii,  tbat  distinguiahes  it  from 
other  nm'voua  or  mental  diseases.  Tbt  ancieot  coDception  cf  tlie  Jiseasa 
made  hysteria  an  attribute  of  tbe  reproductive  organs  and  restricted  its 
ocaarreacetotbe  female;  a  mote  modern  one  locked  upon  it  aaa  contcmpti- 
ble  B^ortcomiug,  and  placed  it  in  tbe  category  of  eoooeit,  a^eetation,  and 
other  attributes  of  puerility  aud  of  int^ompleta  development-  The  most 
modero  Tiew  cousiderg  it  a  psycho -neurosis,  and  associates  its  genesis 
with  profound  iieuropatbio  or  pBychopatlilu  heritage  asi  a  predisposing 
cause,  and  with  psychical  trauma,  ai^d  all  thinga  contributing  to  it,  a^  the 
most  important  exciting  cause. 

Utiology. — Aside  from  what  has  joat  beoa  said,  little  is  known  of  the 
etiology  of  bysteiia.  It  occurs  most  often  in  women  during  the  period  of 
their  fecundity,  but  it  is  by  no  means  rare  in  children  snd  in  males  of  al- 
raoatany  age.  When  tbe  disea^^eoccurs  in  men  its  manifcstationa  are  likely 
to  bd  more  Bcvere  than  in  women.  The  profounder  forma  of  the  disease 
ate  relatively  luicommon  in  thia  country.  TbJa  contraBts  very  strikingly 
vitL  its  frequency  in  the  Latin  conntriee  and  in  thuae  immediately  Ad- 
joining such  aa  Austria  and  Switzerland,  In  its  minor  forma,  it  is  not  so 
iiLConimon  lu  tliH  Anglo-Sflsou  race  wherever  they  have  emigrated,  and 
the  manifestations  of  it  are  not  infrequent  in  their  literature,  art,  and 
politics,  and  sometimes  even  in  their  religion.  Thehiatonea  of  witob- 
craft  in  ffew-  England,  and  of  fanatio  religioua  revivals  and  practices  in 
the  South  and  West  of  our  (country  give  ample  proof  that  the  moat  pro- 
found forms  of  hysteria  hava  oc<nirrad  in  this  country  from  tha  time  ot 
its  civiliKatton.  lu  later  yeacs,  it  is  a  relatively  common  dlsoriler  in 
hospital  as  well  aa  in  private  practice  cf  onr  iarge  citiesn  This  ia  due  to 
the  enoTiuoaa  influx  of  the  Jewish  raoo,  whose  membera  are  partioularl/' 
prone  to  the  manifestations  of  this  as  weH  aa  all  other  hereditary,  de- 
generative, nervous  diseases. 

Hysterical  individuals  are  degenerates,  hut  a  larger  number  belong  ia 
the  category  of  superior  degenerates  than  cf  inferior  degentratoa.     (Je- 


THIS  TREATafE:»T  OV  HYSTKRIA- 


423 


nerioaUj,  the  disease  i a  closely  allied  to  Qeutafitleuia  and  hypochondriasis, 
especially  the  fornis  of  tht-ee  neur^wea  that  are  not  enlirely  acijuirad. 
Hysteria  is  rarely,  if  ever,  purely  an  nciiuired  neurusia.  AlUiougli  there 
ire  a  Dumber  of  factors  which  B^m  to  play  ^n  important  r&le  in  the 
unmediate  occurrence  of  hj'steriot  these  agencies  could  not  cauae  the  phe- 
nomena of  the  diBease  were  it  not  for  the  inherited  peyehopathic  predia- 
poBition,  The  i^auses  of  the  neuropathto  and  psyohopathic  dispofiition 
have  beeu  cooaidered  in  Part  I.  The  most  iniportatit  of  the  provocative 
agencies  are  unqaestionahly  mental  and  moral  traujiiata.  rhysloal  In- 
jury also  playa  &  very  conapicuous  part,  but  its  iiijumuaneHS  ia  in  direct 
relationship  to  the  paychical  iojury,  b&  it  pain,  fright,  or  anxiety,  ^nth 
which  it  ia  accompanied.  In  the  same  way  ifl  to  be  explained  the  ap- 
parent capacity  fur  misohief  of  masturbaLion  and  comparatively  alight 
sexual  exi^Ptts  which  play  a  conspiruous  rOle  in  the  etiology  of  n^rae  cases. 
It  i«  uot  the  depreciation  of  nutrition  and  vigur  caused  by  these  which 
13  responsible  for  the  psychopathic  couditio.1  that  develops,  but  the  im- 
presBion  that  they  make  upon  the  mind  of  the  inUividua]  whose  sag- 
geatibility  ia  pathologically  increaaed.  Toxic  aiibstances^  sue h  as  alcohol, 
tobaau,  and  those  encoaiitered  in  ocGupatiunB^  aa  well  aa  some  of  the 
acuta  iufeotions,  atid  syphilis  ocr^asioaally  seem  to  have  a  Ifcariug  upon 
the  immediate  ot:iinrren<:e  of  hysteriap  They  do  so  by  depreciating  nu- 
trition and  by  making  a  profound  imppoasion  upon  the  patient's  mind. 
The  phenomena  of  hysLerinare  often  eti  fie  rim  posed  on  those  of  organic 
nervous  disease  siii<U  a.4  brain  tumor,  and  general  disease  such  aa  amt^rola. 
It  should  not  bo  inferred  from  thia  that  hysteria  always  w^cura  in  those 
whose  general  nutrition  is  depraved-  On  the  contrary,  the  victims  of  thia 
ueuroaifl  are  often  ruddy  and  well  nourished  and  apparently  Tigoroua, 
The  provocative  agent  oftentimes  seems  incredibly  trifling  when  con- 
trasted with  the  results  that  it  produces.  The  profouodeat  caaeof  major 
hyateria  that  1  have  eirer  met  occurred  in  a  piilhohjgicHlly  Bensiiive  law- 
yer on  hia  failing  to  be  elected  cuunsel  to  a  society  which  he  bad  prcvi- 
onsly  served. 

Symptoms. — The  eymptoma  or  phenomena  of  hysteria  are  so  uuuierons 
and  varied  that  it  ia  difficult  to  portray  th^m  in  a  few  lines.  They  are 
referable  to  all  of  tha  systema  of  the  body^  the  moat  important  l>eiiig  the 
psycliiL-id,  motor,  sensory,  and  secretory  ayiuptoms. 

The  leading  psychical  symptoms  are  weakness  of  the  will  poweo  defec- 
tive inhibitiou  of  mental  and  emotional  eKtemalization,  capriciousueaa, 
moodiness,  irritability,  desire  to  attract  attentiou  and  to  elicit  aynipsthy^ 
and  exaggeration  m  statemeiit  and  in  Bctioo. 

Tha  syinptoma  on  the  side  of  the  motor  sphere  maybe  paralytic,  spas- 
tic>  convidsive,  or  tremulous.  These  may  be  revealed  in  any  part  of  the 
body  whose  function  it  is  to  cause  movement-  Hysterical  paralysis  may 
he  monoplegie,   paraplegic,   or  hemiplegic.      Thi!  last  mentiDned   ia  the 


4U 


TREATMENT    OF    DlF^EASES    OP    THE    NERVOUS    SYSTEM. 


rareat  form-  It  id  diflttngui&hed  from  the  orgouio  variety  by  non-iiiLpU- 
cAtiou  of  tho  face  aud  ton^e.  Although  hyatericaL  paralysis  may  be 
flftocid,  it  is  almoat  invariably  aaaor^iated  witb  contpactura.  Paralysia  of 
the  peripheral  vocal  apparatus  is  not  um^iimion  and  causes  mutism  or 
aphoaia.  Coutracturo  ia  the  commonest  motor  symptom  of  byateria,  Ibe 
upper  «xtreinitioa  being  eapecially  liable  to  affetitioQ,  It  may  develop 
suddenly  after  an  hyflterieal  apaam  or  elowiy  with  hyateriufll  pam.  It  dis- 
appeara  when  the  pati^dt  is  aoEeathetized.  Hysterical  apasniB  or  eonvul- 
aioos  may  affeet  any  part  of  the  body-  They  are  usually  d on ioo -tonic 
but  CH-Vasioiiully  tonic.  Spasm  of  one-half  of  the  ton^e  and  lips  ia  a  not 
UQaommoQ  nianifestatioUp 

Hyaterioal  tremnt  may  be  rapid  or  elov,  and  may  parallel  tremor  of 
any  origin.  A.  comparatively  rare  motor  toaoifaatation  of  hysterisi  ia 
aatasia'ahaaia.  Thia  ia  the  name  given  to  a  condition  in  which  the  pa- 
tient ifl  unable  to  staud  or  walk  iiotwithatanding  thHt  all  movements 
CEUi  be  easily  done  when  lying. 

The  aenBory  aymptoms  of  hysteria  constitute  the  moat  important  and 
oonatant  atigmata  of  the  diaease.  They  i^ousist  of  depi^aeiOD  which  may 
amount  to  absolute  IobBj  ot  «xaltAtiou  of  the  functions  of  thd  special 
Benflea,  and  common  sensibility.  The  functional  sburtcomingaof  the  spe- 
cial senses  msiy  show  tbemselvea  as:  1.  Thoso  referable  to  virion:  am- 
blyobiaaud  amavjrosis^  concentrio  limitations  of  the  vjflual  lield,  caperially 
marked  for  colors ;  achromatopsia,  and  varioua  manifeatationa  of  micropsia 
and  megalopaia.  2.  Those  referable  to  amell :  partial  or  complete  EUJOEmia 
associated  with  aniT"<thesia  of  the  nasal  mucous  membrane.  3.  Those  ref- 
erable totaste:  ageusia.  4.  Those  referable  to  hearing:  a  varying  degree 
of  deafneas,  especially  for  high  notes.  The  perversions  of  common  sensi- 
bility which  occur  in  hyateria  fire  irregularly  distributed  areas  of  anjFS- 
thesia  and  analgesia,  and  hyperesthesia  and  hyperalgeaia,  Hemianiea- 
theaia  may  be  of  an  entire  half  of  tha  body  or  of  a  small  area.  It  is  the 
result  of  a  loss  of  Jtssociation  of  impreaainns  conveyed  to  eniisfiousress, 
Hyperitathesia  may  Vie  of  one'half  of  the  Iwdy  or  uf  only  a  small  Hngment 
of  the  cutaaeoufi  surface.  It  \a  manifest  by  e^resaivo  sensitivenesa.  It 
ia  apt  to  hare  ^nal  distribution  :  hy attsrogeiiio  zones,  pressure  on  which 
will  often  CQuae  an  hysterical  attack. 

The  aubjectivo  aenaory  phenomena  of  hysteria  are  also  referable  to  the 
various  9p6ftial  senses  and  consist  of  Hashes  of  light,  noises  in  the  eara, 
Btrau}fe  taabes  and  smells,  tingling  and  formication  of  the  extremilies  and 
truuk,  a  ft^eling  of  constriction  and  of  a  lump  in  the  throat,  knovrn  as 
glotma  hystericvuB,  and  peculiar  boring  pun  in  the  top  of  the  head  known 
■a  olavufl  hyBtericua,  Paina  of  every  kind  and  of  any  lw>ation  at*  Also 
often  present  in  hysteria. 

Vasomrb^r  diaturhances  of  hysteria  consist  of  ilermographism,  eyano' 
ara,  and  (tdeota,  the  latter  of  a  peculiar  variety  known  as  blue  o^enia. 


THE  TREATMENT  OF  HY9TBBIA. 


425 


flweUingoflhe  joints  constituting  hyaterica]  nrthropfithy,  ajid  hemorrhages 
from  Uj9  akin  ani  inuooua  uiembpaiiPH, 

Ttid  cutuii«cu3  r«i]exea  &re  uhiially  dimliiiahed  or  abaeul^  wlillo  tiiQ 
deep  refiexea  are  not  infreiiuentJy  normal.  It  wovild  aeem  to  li&ve  been 
definitely  proveu  that  not  only  uiay  exaggeration  of  the  deep  reilexes 
occur  with  hysteria,  but  true  clonus  as  well. 

The  vegetative  procefises  of  the  body  ure  often  enormously  perverted 
in  their  fuactiona,  Diatnrbances  in  the  digeative  trai^b  Euay  ahoMr  them- 
aelvea  as  anorejcia,  spasm  of  the  tesophagus,  vomiting,  indigestion  (so- 
called  nervous  dyspepaia),  boiborygmusi  meteorismus  &nd  abdominal  dis- 
tention constituting  paeudo-cyesiH.  Symptoma  of  hysteria  referable  to  the 
respiratory  aystem  may  ha  manife^^t  as  spasm  of  the  laryni,  dyspn^^ai 
tachypuma,  apaamodir  ii:iugh,  and  hiccough.  The  must  common  hyateri- 
oal  symptoms  referable  to  the  cardiac  system  are  palpitation,  tachycardiai 
and  psendoangina,  Those  referable  to  the  urmary  system  are  anuria  and 
polyuria,  and  to  the  eutaueoua  fysteia  exoesBive  and  diminifihed  aecretion 
of  sweat. 

Grand  or  major  hyateria  manifests  itself  irregularly  in  attanks  known 
ae  hysterical  couvulaions,  Tbege  are  trritaliojL  aymptoms  of  coDtrul  origtu 
which  appear  in  varioaa  fornts  and  combinations.  They  consist  of  clonic 
and  clonico-tonie  oonvulsioQa  of  the  extremities  and  body,  which  pro- 
du<Te  in  a  wild  mincer  the  moat  bizarre  positions  of  the  body,  ronatituting 
clownism,  arc  de  cercle,  triamvis,  convulsive  movements  of  laughing,  cry- 
ing, swallowing,  and  breathing.  Attacks  of  grand  hysteria  are  usually 
divided  into  three  abagea,  the  £rat  stage  con  si  sting  of  epileptiform  twitch- 
lags  or  spasrasT  the  second  stage  of  gi-oss  movementa,  and  the  third  stage 
of  passionate  attitudes  and  plastic  positionB. 

The  treacnient  of  hysteria  will  be  considered  under  four  headings: 
first,  the  prophylactic  treatment;  second,  the  treatment  of  the  disease 
itself  or  treatment  of  tho  psychopathic  state ;  third,  the  treatmeut  of  an 
attack  i  and  fourth,  the  treatment  of  individual  manifeBtations- 

Fiophylactio  Treatment. — Like  all  nervous  diseases  developing  on  a 
neuropathic  or  psychopathic  state,  the  treatment  of  this  psychoneurosis 
shonld  lie  begun  before  the  birth  of  the  ehild  who  is  heir  to  it;  that  is,  it 
should  be  begun  before  coui^eptioii.  Hysterical  part^tu  on'e  it  to  ifaeir 
children  that  their  mode  cf  life  shall  conform  to  a  plan  that  contributes  to 
the  highest  degree  of  physical  and  mental  oquilibrinm.  They  shoidd 
be  instructed  to  avoid  conception  at  times  when  there  are  any  manifeata- 
tiona  of  disorder  in  neural  equilibrium.  The  necessity  of  the  proper 
direction  uf  an  hyalerieil  woman's  life  during  pregnancy  cannot  be  too 
atroDgly  urged  upon  phyaicians  who  have  the  card  of  families^  The  end 
to  be  kept  in  view  is  to  maintain  an  uneventful  course  of  her  mental  life 
during  this  period  in  order  that  she  may  bring  forth  a  child  with  a  Biable 
nervous  organization.     This  can   in  a  measure  be  aided  by  stiidiously 


THEATMEKT  OF  DI8BAflE9  OP  THB  HUBTOrS  STgTEM. 


arraoging  her  envirunment  go  that  eyer^lbhLg  is  in  endeoce  tbat  makes 
far  m^Dtal  ^quanimitj  and  sclf-restraiuL  Pajopering  of  vicifrus  taster, 
Belf-mdalgencer  all  forma  of  eicilement,  particularly  tboee  tbat  appeal 
to  tbe  emotitjna,  sources  of  fear  and  Trorry  and  pbyaical  injurj  are  to  be 
BToided. 

Tho  children  of  hysterical  pare&ta  should  be  lemoved  from  tbe  care 
andeapionage  of  the  family,  cspeoially  if  the  mother  is  hysterical^  as  sono 
as  {rtjssiblti  after  tiie  actufil  foiiuatiTe  eta^e  of  Llje  (!btbra  character,  tbat 
is,  from  thd  Gixth  to  tho  tenth  year.  Thia  ia  eapeci&lly  incumbent  whoa 
the  child  shows  suoh  evidenceB  of  an  unstable  Lcrvoua  system  aa  nigbt 
terrors,  disoidered  sleepy  marked  «retbism  without  apparent  cause,  ab- 
norma]  seTisitiTeQess,  restlesgneas,  deatrnctiveness,  precocity,  and  mani- 
fest di^Hire  to  elicit  the  fiympathy  or  wonderment  of  those  about  it.  Such 
a  plan  coutributeH  nut  alone  to  tbe  welfare  of  the  parent,  but  ia  highly  im- 
portant to  the  child.  A  child  who  at  this  period  ia  allowed  to  aee  the 
various  TDaaifoatattons  of  hysteria  in  the  mother,  be  they  eiplosioLks  of 
temper,  uncontrollable  emotional  display,  convulsions,  or  other  terrorisung 
symptoms  of  the  disease,  will  be  almost  sure  to  develop  simitar  manifesta- 
tions sooner  or  later  if  allowed  to  reTiiaufc  in  such  eiiviromneiit.  Naturally, 
it  ia  oftentimes  impcesible  because  of  social  and  financial  reasons  to  take 
the  child  from  such  auspices,  pernicious  tboiigh  they  are.  In  such  cases 
the  best  compromise  must  be  made,  so  that  the  chi]d  ia  kept  as  mavh  as 
poBsible  from  the  sinister  inflneuee  of  the  hysterical  person  at  the  time  of 
the  attatzks.  When  no  other  resson  than  one  of  seittimeot  is  given  fcr 
refuBJi^  to  permit  the  ciiild  to  be  taken  from  tlje  influence  of  an  hys- 
terical parent,  the  physician  should  use  all  his  tact,  parsuasivcnesa,  and 
authority  to  carry  out  the  plan  proposed,  Si>  much  miaoi^  and  suflering 
may  thus  ba  spared  that  the  end  jui^tifi^  rather  drastic  measures. 

When  such  children  are  taken  from  their  parents  in  order  that  their 
education  and  bringing  up  may  be  carried  out  under  more  ij^orous  and 
favorable  surroundiugs,  the  intelligent  teacher  and  caretaker  to  whom 
they  are  entrusted  must  be  fully  told  of  the  desired  objects  in  tho  forma- 
tion of  their  oharacters.  The  education  of  children  of  hysterical  parent- 
age calls  for  the  same  intelligent  co-operatioQ  pf  physician  and  pedagogue 
as  does  that  of  defective  children.  Their  lombined  i?ffona  sbtnild  be  u>  de- 
velop aud  mai[itaic  a  high  de^eeof  bodily  stren^h,  vigor,  and  nutrition, 
No  attempt  should  be  made  to  force  the  development  of  the  mind  by 
thrusting  upon  it  inconsideTately  tlio  various  compooents  of  modern  edu- 
cation and  modern  scr^r^mplishmeuts.  All  manifestations  of  premeious- 
nesa,  mental,  sexual,  und  nioial,  should  be  discouraged;  chiidish ooquetry, 
self-ijidulgence,  and  eioessive  sensttiveneGS  eiterminaled;  romsuLic 
sentiments  and  disquieting  imagery  bauished;  ajjd  puerile  love  attach- 
ments and  associations  absolutely  forbidden,  The  epochal  periods  of 
roenstination  in  the  girl  and  of  maturity  in  the  bfiy  are  to  be  jealously 


THK  TKEATMENT  OF  nYSTEBlA. 


427 


guardeJ.  Not  a  few  cases  of  bysleria  ha^e  been  provoked  by  fright, 
flbante,  or  convictioEi  of  tbe  aecesBLty  for  coacealmeot  of  tho  occurrBooG 
CI  ihcho  Qoriual  fuitclions  iu  those  who  have  not  been  carefully  and 
properly  warned  of  their  advent. 

The  trend  of  modisliDeas  in  this  country  happily  is  toward  the  devel- 
opment of  ths  body  by  encouraging  out-of-door  sports  for  both  aexoB- 
Phyaical  prodigies  are  nowadays  very  mu^^h  more  io  evidence  as  display 
cljildroD  and  youth  than  the  wonder  child  and  intellectval  marvel  of  a 
generation  ago.  Indulgence  in  such  3|icrta  for  children,  abundance  of 
refreshing  sleep  in  well -ventilated  roomSf  iind  total  interdiction  of  tea, 
ooffee,  alcohol,  aad  stcriea  of  the  bogleiuan  are  inimical  to  the  develop- 
nient  of  hjHteria-  Tneulcation  of  the  precepts  of  ael f -con trol,  generous 
feeling,  altruistio  sentiment,  and  intolerance  of  Tiiawkiah  ayjiipabhy>cliiLd- 
iah  jealousy  and  puerile  introspectiTenefia  do  much  to  stay  the  hysterical 
tendency.  The  psychical  traumntu  which  start  tha  dynamic  defeeta  of 
hysteria  into  e^Liatonce  are  not  infrequently  traced  to  sentimental  love 
alfaira  which  the  raodein  girl  ia  often  permitted  to  take  seriously,  and 
to  the  separation  that  parents  awakening  tn  their  responsibilities  feel 
obliged  to  make,  and  which  she  considers  violent  and  unjustified.  Later 
in  life,  it  is  sometimea  syocnymous  with  the  fright  and  plight  aesociatt^d 
with  the  assumption  of  marital  obligations  by  persons  totally  unfit,  and 
to  abnormal  sexual  indulgenceg  such  as  coitus  reaervatuSf  and  aruficial 
prevention  of  pregnancy.  Still  later  in  life,  it  sometiEiea  occurs  at  the 
period  of  the  menopause  without  any  provocative  agency  which  can  be  de- 
tected.  In  these  latter  cases  there  are  no  fipecial  indications  for  prophy- 
lactic treatment  save  in  those  instances  in  which  the  neuropathic  person 
bua  safely  reached  the  period  when  the  meuopauBo  is  to  be  expected; 
then  particular  t?are  should  be  taken  to  carry  her  through  this  eventful 
period  without  unusual  demands  being  made  upon  mind  or  body. 

The  Treatment  of  the  Diiease  Itself  or  the  Faychopathic  State,— The 
general  treatment  of  tbe  psychopathic  state,  the  baet4  of  hysteria,  must 
be  conducted  on  the  plan  that  the  disease,  althcngh  etrictly  a  psychical 
one,  may  nevertheless  be  very  much  influeneed  in  its  manifestaiicns  by 
physical  conditions.  Very  nften  tbe  measures  necessary  successfnlly  to 
eombat  the  collective  mBnifestaLioas  tliat  <^natitute  the  state  hysteria 
muat  be  applied  handm-hand  with  those  taken  for  the  relief  of  aomo  oqc 
symptom  or  stigma  of  hysteria,  such  as  contracture,  paralysiSf  Jicmiac- 
netheaia,  or  bluntuig  and  obscuration  of  some  epecml  sense.  But,  on  the 
other  hand,  not  infrequently  orie  or  more  of  tbpse  sligiuata  is  the  sole 
manifestation  of  the  disease.  The  mistake  bus  often  been  made  ^>y  writers 
cf  giving  entirely  too  mnch  attention  to  a  consideratioD  of  the  ape- 
rific  bysteriDil  symptom  or  attgma  because  the  general  psychical  con- 
dition of  the  patient  seemed  to  be  quite  nnalfeoted  It  should  not  be 
forgotten  that  suoh  manifestatioas  as  so-called  hystenoal  stigmata  are 


428 


TRKATMENT  OF  DISEASES  OF  THE  NERVOUS  SYSTEM, 


ODiy  an  expression  cf  tlia  geueral  paychopatliiu  nbDorcnali^,   and  tbat 
this  Btate  calla  for  tre&tment  juat  a^  urji^Qtly  aa  do  tbo  indiridaal  pbe- 

Tbe  first  and  niont  mportaut  abep  in  the  treatment  of  an  ti/^berioaJ 
patient  1^  for  tlie  pb|~si4;iaii  to  put  hiiuaetf  entirely  eit  riApport  with  tbc 
patient  OlwA  completely  iu  authority  with  the  family  of  the  patient-  Tb&t 
is,  he  should  eocure  the  confidence  of  the  former  and  the  obedience  and 
co-operation  cf  the  latter,  Nothing  is  more  deleterious  to  the  proepectH 
of  overcoming  the  manifestatioTJs  of  hysteria  than  bo  attempt  to  make 
light  of  the  occurrnnres,  as  being  niprely  trivial,  unleHS  it  be  to  msignify 
tbo  sjinploma  in  snch  a  way  that  the  patient  will  not  only  become  more 
Bclf-centred  and  indulgent,  bnt  that  she  may  have  a  lien  upon  thoao  auF- 
toundiiig  bet,  b©  they  of  the  family  or  attendantfi.  Often  it  \%  neoeflMtr; 
to  undo  the  work  of  charlatans  and  EcientiSc  impostors  who  have  at* 
tempted  to  ciiire  the  diseaj^e  in  bome  bizarre  or  supernatural  manner,  and 
thereby  Bucceeded  iu  makiug  the  patient  more  invTjlnerable  to  the  right- 
eona  and  authoritative  influence  which  the  honest  phj^ician  should  bare- 
Ae  the  treatment  is  mainly  peyebical,  even  though  a  great  variety  of 
phygieal  agencies  are  iised^  tbe  plan  of  treatment  should  be  so  arranged 
that  every  step  tahen  should  count  in  a  forward  direetiou.  Some  writers. 
whose  knowledge  of  the  clinical  history  of  byateria  is  seemingly  based  on 
Tory  eligbt  puraonal  experience,  try  to  maintain  that  a  detailed  plan  of 
treatment  defeats  its  own  object  by  centring  the  paticDt  upon  bia  or  her 
own  ailmentSn  This  is  an  entirely  erroneous  view,  providing  the  detail* 
of  tt'eatment  exclude  everything  that  partalica  i>f  roddling.  Another 
mistake  tli^it  tbe  phyHiciao  iihiiiuld  tr^  to  avoid  ia  promising  the  patient 
leaults  that  he  cannot  be  at  Icjkst  nioderat<-]y  sure  of  aectiring,  for  in  no 
way  can  the  palient^a  ounlidciicij  be  more  thoroughly  shattered  than  by 
diHnppointiuent.  The  ultimate  object  in  the  treatment  of  an  hysterical 
patient  should  be  to  develop  the  patipnt*a  will,  so  that  it  will  regain  the 
domiuaiRTy  over  mental  pos^tPHHiona  ami  cnm]iuUiona- 

The  general  dietetio  and  physical  treatment  is  not  unlike  that  cf 
neurasthenia^  (jreater  iudiviiluali^ation  in  the  details  cf  liestmerit  va 
necesiary  in  the  treatmaut  of  liyflteria  than  in  almost  onj'  other  nervous 
disease-  3t  need  scarcely  lie  said  that  there  ifl  no  speeilic  medication. 
In  the  severer  forniH  of  thediseuse  a  innst  important  dis^-jjtlinary  and 
hygienic  ineasiirot  as  well  as  one  that  contriijutes  to  a  rehabilitation  of 
the  f^eneral  nutrition,  is  complete  or  relative  iaolaticn.  Tbe  patients  as 
well  as  the  familyi  is  apt  to  look  upon  this  measure  as  an  unnecefi^ary 
cruelty  directed  against  one  who  has  been  able  to  exist  only  trecause  of 
tbe  tf'nder  care  and  continuous  sympathy  that  have  been  lavished  upon 
him  or  her.  Even  in  the  milder  forms'of  hysteria— and  by  tbts  1  mean 
any  hysterical  manifestations  ahoil  of  grand  or  major  hysteria  auid  tbe 
clinioal  conditions  uii fortunately   called  hystero-epilepsy  and   hystcro- 


THK  TRBATSIKIfT  OF   BVSTEHIA. 


^9 


tmlepay,  it  often  becoiD«s  absolutely  necessarf  to  »epuate  Uie  patient 
(rom  the  previous  social  and  family  envi^OQmetl^      In  tLis  vay»  not  otily 
fill  tlie  ixJmpaTfttirely  aiild  maaifeatAtioiia  of  the  diaeaae  be  surety  ores- 
auBf^  but  the  psychcDeurosis  will  be  preTtuited  from  getliiig  &  firm  aud 
«kdiftlod^bl9  hoM  upon  the  patient.      In  mfuiy  iitfltarieea  thia  isolation 
Btut  be  eairied  out  in  the  palleDt's  home;  bat  wLenei'er  fe^ib^e,  it  \s 
bist  BfCoiupli^heil  away  frtiin  home  in  a  boai-iliDg- house  or  hotel  where 
ttt«  (aticat  am  be  under  the  phy&iciaii*a  direct  supervision  and  aloue 
lUh  the  DUTM  to  vhoin  he  eotrusta  her  core.      lustituiioQ  treatment,  and 
pirt^culAfiy  that  of  large  sanatoria,  cannot  be  recom mended,  except  in  in- 
stances in  which  speoial  provision  ia  made  for  the  complete  iaoktion  aitd 
ladividual  treatment  of  the  (vitieut.      The  mutme  trf^Htrneiit  of  Kueh  in&ti- 
tuLicws  and  the  atmosphere  of  inralidLsm  which  they  neceeaarilj  hare, 
]i«  »  speak  of  the  are^a  which  they  offer  for  the  exchange  of  emotional 
ajomioiiities,  render  them  extremely  antipodal  to  the  overcoming  of  tha 
bjsEencal  state  and  ita  manifestatluna.      In  latter  years  there  has  been  a 
deride  incliDatiuD  on  the  p^rt  of  some  physicians  to  lusiHt  upon  institu" 
im  treatment  for  Jiystericai  patieutf^^  at  least  of  patieuLa  whoae  aymploma 
ibiiotyield  to  more  or  leas  desultory  and  toatine  treatmeot.      Thia  idea 
hsa  beeo  borrowed  in  a  measuie  from  European  practice.      lu  Germany, 
fof  in^tance^  it  is  no  uncommon  thiug  for  a  patient  to  go  to  a  sanatorium 
of  tUEue  kind  before  he  consults  a  physician.      Institution  treatment  is 
amleubtedly  better  than  treaimetit  at  hume,  but  best  of  all  is  tlie  i^mpleta 
iftoUtiOD  of  the  patient.    Aa  haa  been  said,  the  patient  and  family  usually 
offer  ^eat  objections  to  thia.     The  morEil  victory  of  getting  a  patient  iao- 
laud  IS  very  miportanlj  and  often  it  is  the  first  decisive  step  in  the  pay- 
ducal  treatment  cf  the  disease^ 

Thft  psyrhical  or  meutal  treatment  of  liyetena  la  s]Joken  of  an  if  it 
vera  some  formula  to  be  applied  in  a  rather  definite  nay.  Thta  \»  not 
the  sense  m  which  I  desire  to  be  anderatood.  It  ia  quite  impoaaible  to 
pal  in  words  what  conatitutee  p^yohioal  treatment.  It  not  only  means 
the  attitude  of  the  phyaician  toward  hia  patient,  including  his  eapufiity 
Ut  bajure  auoh  faith  that  the  ^latleut's  defective  will  ()ower  will  be  stimu- 
lated to  action,  and  the  plan  of  iaolabion  with  its  eutaiUuents  already 
apokeu  of,  but  it  embracea  aa  well  tbo  proper  application  of  such  me- 
fhnical  therapy  as  water,  electricity,  massage,  esertise  and  occupation. 
Tieae,  although  they  have  specific  beneficial  action  by  virtue  of  indiuid* 
ral  posaeaaiona,  often  accomplish  more  through  the  meubd  ifnjiraaaion 
that  they  make  than  through  their  specifi^i  effecta.  The  immediate  re- 
sults attending  the  use  of  many  of  tliem  serve  to  inspire  auU  inspirit 
tha  patientB,  It  ia  admitted  by  every  one  that  these  measures  are  often 
effective  in  increasing  the  patient's  nntrition  and  vitality.  Hysterical 
patients  are  often  ana^mic^  with  sluggish  Pirndatiou,  faulty  digBStioii  and 
Bxeretion,  all  of  which  are  important  factors  in   maintaining  the  hys' 


4m 


TRBiiaiENT  OP   DI3EA9Ea  OF*  THK   NERVOITS  STSTEM. 


terioal  state ;  theiefoi-e,  theHe  muHt  be  itmeuded  as  Boon  and  as  thoroughly 

The  moat  important  of  the  oiechuucal  measures  in  the  ttej^tmeiit  of 
hjateria  ia  undoubtodly  hydiolhoiBpy,  The  generai  plan  of  bydric  pro- 
cedure in  this  difle&se  la  very  E]iu4.'h  thd  aaoie  as  that  fcr  neurasthenia. 
The  details  of  application  vajy  with  tlie  type  of  disease  arid  with  the  idio- 
syui^rasi^sof  the  pftUent.  The  most  important  methods  of  applying  water 
in  hysteria  are  by  the  douche  aud  apray,  by  the  drip  sheet,  ajid  by  ablii- 
tiuua  or  the  plunge.  Cold  water  is  the  niofit  potent  ageooy  to  stimu- 
late the  Girculation  and  to  facilitate  metabolic  changes  that  are  necessary 
foT  the  preservation  of  ^orma!  Dutritiou.  It  has  likewiBe  a  powerful 
effect  a8  a  sedative  on  the  sensory  nerves  of  thfi  nkJu,  anil  as  there  is  fre- 
t|iient[y  in  hysteria  xiot  only  a  peripheral  bub  a  ceutral  hypenestheaia,  some 
of  the  beneficial  results  of  the  application  of  eold  crater  in  hysteria  may 
he  attributed  to  the  sedation  which  is  one  of  ite  most  ^conspicuous  after- 
etfeota.  Indeed,  the  two  purpos^y  that  hydrie  {procedure  is  mtended  to 
subrterve  hi  the  treiitmeut  of  liystprla  ace  b^nie  and  sedative.  The  tonic 
effeot  of  Dold  water,  aa  has  already  lieen  pointed  out  in  the  chapter  on 
hydrotherapy*  is  coequivalent  with  the  reaction  that  follows  the  applioa- 
tion  of  water.  ThereforOf  it  birhoovee  the  phy&ictn&  to  observe  eloeely 
how  complete  this  teaetiou  ia  in  eaoh  patient,  and  to  employ  the  moans 
for  facilitating  reaptinu  which  are  deMcribad  on  page  05  et  gtf/. 

Of  all  the  hydric  proceduresj  the  most  important  in  Ijysteria  is  the 
tonio  bath,  which  may  be  given  benefieially  in  this  disease  at  a  much  lower 
teru|>erature  tlmn  in  neurasthenia.  For  instance,  iu  neurasthenia  it  is 
uaiially  advisable  to  b^gio  a  courae  of  hydric  treatment  nitlj  a  tempera- 
ture of  S5°  F. ;  while  in  hysteria,  if  tlie  patient  has  no  profound  depravity 
of  the  vaacular  syateuiT  th*i  doocJie  maybe  used  in  the  beginning  at  a 
teiui)eratm"o  of  froui  60*  to  55°  F,  Indeed,  in  some  cases  that  are  rebel- 
lioQH  to  treatmeut  the  most  eatiafaotory  results  follow  the  appUeatioD  of  a 
doucha  of  from  10"  to  J5°  F.,  under  from  fifteen  to  twenty  pounds  press- 
ure for  five  or  bSk  seconds,  foHowed  by  a  Fleiiry  apray  of  80*  and  similar 
piesaure  from  oue  or  two  auoondB.  It  should  not  lie  forgotten  that  the 
lower  the  temperature  nf  the  water  the  shorter  should  be  the  time  of  its 
applioation.  And  as  the  reaotion  is  usually  very  much  bettor  when  the 
douche  ia  applied  for  a  vsry  few  seoouds,  it  ia  the  most  eatiafaotory  pro* 
t»edure.  It  ia  neeesaary  to  eay  one  word  of  warning  concerning  its  uao. 
Tht)  dashing  of  eoM  water  u^vm  hysterogenic  7ones  may  precipitate  an 
attack  of  hysterian  This  can  be  avoided  by  a  a^-areh  for  auch  ai-eas  Ixj- 
fore  the  water  ia  applied,  and  then  if  the  douche  ia  directed  toward  them 
at  all,  it  should  be  under  very  mut^  lessened  pressure  than  on  other 
l^irts  of  the  body.  In  some  patients  reaction  wiJl  l>e  aocompanied  by 
headadio  and  frontal  fulness,  vvrtigo^  great  latitude,  cold  extremities, 
etc.     All  of  these  can  and  sbouh]  be  avoided.     To  preveLt  the  headache 


TBK  TREATUKKT  or  HVSTEIRIA. 


431 


s&ii  folnefiSt  ^  ^^^  ^'  uecessarj  asuaJly  is  to  havo  tlie  patieut's  koai 

codoctd  m  k  towel  wrung  out  of  iced  water,  and  to  ataoi  tba  paiienl  in 

a  foot'tub  of  hot  walier  fliiniig  the  apiilkatioii  of  the  doiLclifl^     Similar 

resulta  cAn  be  oblaLued  by  rigorous  percussion  aud  slapping  of  the  feet 

after  the  douohe  or  by  directing  a  stream  of  hot  water  agaiiiat  them  for 

tvu  cir  thr^o  &i>coQdB.     If  tlie  patient  oomplaina  of  distreaaing  seusatiou 

M  fultieaa  in  the  ehest  and  of  palpitation,  a  cold  oomprcaa  ahould  be 

||Ueed  over  the  precordium  drtring  the  applieaCion  of  the  douche.      It  haR 

\tm  my  ejtp«rteui.-e  tliat  this  ftsvliug  ia  iiwtv  likuly  to  orcur  iu  those  vrho 

nke  the  tonic  bath  BOOD  after  a  couaiderable  meal,  auch  as  luncb.     It 

uf  thcT^fore  be  said  in  thia  connection  that  the  beat  time  for  any  tome 

Ijdnc  procedure  la  in  the  forenoon^  fmm  one-haJf  tii  tivu  houra  after  the 

utiflpt  has  had  a  light  breakfast.     At  the  end  of  the  half-hour  or  so  fol- 

Icpwuig  the  bath,  which  is  taken  up  iit  walkuig^  gyiuua4ttcs»  or  po^ire 

oerdAe  to  facilitate  reaction,  depending  upon  the  oue  that  the  patient 

a^ble  to  take^  substantial  uouiishiuent  should  be  given. 

Whea,  for  auy  reason,  the  douche  and  spray  constituting  the  tonic 
bdr  do  nut  seeiu  to  be  widl  bi^nie,  or  when  Uieir  iippliraticiii  is  nut  fol- 
W«d  ly  tlie  derived  beue&t,  the  Scottish  douche  may  be  tried.     In  hys- 
UriJt  the  beat  results  from  thia  procedure  are  obtained  when  the  douche 
a  tucd  with  cold  crater,  and  not  with  sudden  thermal  trausitiona,  atich  aa 
m  ased  in  cases  of  Bciatiiia  and  ceurafltheuia.     The  stream  of  water  of 
from  95°  t*i  105'  y.f  tlepending  upon  the  toleranna  of  tlie  patienlj  is  di- 
mled  against  the  yaiicjua  parts  uf  the  body  for  from  one  to  two  secondB, 
Ihea  the  teiuperature  is  lowered  iri^  to  25^  F.,  not  too  abruptly,  atid  tlii^ 
Aflam  ia  kept  up  for  fiom  fi^o  to  tiftaen  eecouds.      Whea  the  Saotcli 
doiuihe  with  transition  is  used,  the  temperature  is  lowered  very  gradu- 
ally, ao  that  the  element  of  shock   which  enters  into  the  ordinary   u^e 
of  it   id  not  oprtiiitive.     When  the  patient  is   very  sensitive,  aiul  when 
there  are  areas  of  profound  hyperesthesia  of  the  akin,  it  is  often  advisable 
to  begin  with  this  procedure,  mid  gradually  lead  up  bo  the  use  of  the 
doache  without  tran^itiou,  or  the  tonic  bath. 

It  may  seem  to  the  reader  that  considerable  paraphernalia  are  necea- 
sary  in  order  to  carry  out  such  details  of  treatment  as  that  indicated  in 
ihe  boniu  bath  and  tlie  Scotch  douche.  Aa  a  matter  of  fact,  thJs  is  not 
so.  Wherever  suificieiit  pressuro  can  be  obtaioed,  it  is  comparatively 
easy  to  supply  the  rest-  All  that  is  really  needed  ia  a  tub  and  a  piece  of 
hoae  pipe  wuh  a  detachable  spray,  the  so-called  Fkury  spraj',  and  the 
Scottish  douche,  which,  of  course,  is  more  complicated.  When  it  is  pos- 
sible, the  physician  should  avail  himself  of  a  properly  ei^nipiied  hydriatic 
inatitutioa.  Even  here  it  is  necessary  to  give  each  case  personal  siiper- 
Tieioa  at  first,  because  no  t^o  patienta  react  alike  to  the  application  of 
water.  IVhea  it  is  impoaslble  to  uaa  waier  in  either  of  the  ways  that 
have  beea  d«cribe<i,  the  wet  sheet  or  drip  sheet,  aa  it  is  often  called. 


4'S2 


THEATUBNt  OF  DTBEAfiES  OV  TUE  SERVOUS  aVSTSU. 


fibould  be  ttieil.  While  tba  paUenl  Blends  on  a  dry  aurface,  a  sheet 
wruii^  out  uf  wutpOr  <ii  frum  45"  Uj  50"  ebuuld  be  thruivu  aruuud  tbo 
patient  flo  that  it  envolops  him  fiom  his  neck  to  bis  feet»  the  fafe, 
hekd,  And  ohest,  (lerhaps  the  entire  tnink  hariug  been  previouely  nioiA* 
tened  with  waT«r  of  the  fiujiie  temperaturd  applietl  by  ttie  hand  or  & 
B|Kiiige.  Aftt-r  the  t^heet  has  btwu  thntvii  around  the  pHtient^  he  should 
Tuh  the  vtieal  ftiid  front  of  tha  body  vjgmxiufily  thrfrugh  i^  fold  of  the 
eheet,  while  the  pei-^iju  who  h  applying  the  eheet  doea  the  same  vith 
tbe  palms  ef  liotb  hiinde  over  the  Ghoet^  to  the  posterior  pan^  of  the 
body.  Thia  frk-tjon  is  kept  up  for  from  three  to  five  laim^tee  uutj]  the 
ekin  gets  wt'll  recklened,  when  tbe  t^li^Pt  is  rpmoved  and  a  aectmd  dty 
one  IS  substituted  for  it.  rrictLoji  iu  a.  similar  way  is  tbt-n  kt^pt  up  for 
a  few  miuutcs  loogfir,  and  the  patient  is  told  to  dread  quickly  &ud  go  for 
&  brisk  walk.  Lusuilicieat  leartion  and  disagreeable  after-phenoxueua  U4 
overcome  by  nse  of  tbe  measures  iiiteoded  to  meet  such  eonditions  oerur- 
ring  after  the  tunic  luth.  The  rold  plunge  bath,  when  the  pfttleikt'a  circu- 
lation will  allow  of  its  uHe,  is  an  exeelteut  ((tnera]  ttinie.  Jt  shonld  not 
be  forgobtea,  however^  that  it  is  ueceasary  for  the  patient  to  bare  a  few 
minutes  of  phj-fliftal  activity  before  entering  tbo  tub  afid  active  frictioe 
while  in  the  water  &ud  after  getting  out,  m  order  tu  ineure  thorough  re- 
action. 

E]ei;tnr[ty  is  aiiulber  agency  of  \ery  uuisiderable  vaiue  in  tbe  tre&t- 
ment  of  hystoiia.  Like  wuter*  it  arts  upun  tbe  body  and  upon  tbe  mind 
to  improve  the  nutrition  of  the  former  and  to  make  a  powerful  impre»- 
eiou  upon  the  latter.  The  form  of  electrieity  thnt  ia  most  useful  in  thia 
pByehopaihio  BCate  is  best  decided  pftsr  trial,  Ab  a  rule,  it  is  either  (a- 
i^dic  or  static  eleotricity.  Faradic  electnolty  is  an  important  agency  in 
soothing  the  sensory  nerves,  and  when  employed  in  tbe  shape  of  a  faradie 
bruah,  ib  in  a  potent  measure  to  overcoute  byeterical  am^Htbeeia.  £^tatio 
eleutricity  is  often  frowned  at  nowadays,  aa  it  plays  Bueh  a  conapieuoua 
pfrrt  in  tbe  ariuamentarium  ct  tlio  diarlatan,  but  it  UJUst  be  conceded  that 
it  frequfiitly  has  not  ouly  a  commendable  uioral  etfei^t^  but  a(?ts  &s  a  pow- 
erful tonic  to  the  muHCuW  and  nervous  systeius  as  well.  In  fact,  ita 
action  is  not  unlike  thut  of  another  therapeutic  procedure  which  has  come 
somewhat  into  vogue  againf  vi;^.,  rapidly  re^>eated  and  niultLple  percus- 
sion, aa  Bc]viri>ated  by  Granville.  This  form  of  electria  energy  has  tha 
same  cbarai^ttinsiica  an  the  fnradic,  vir,,  high  tension  srid  slight  quan- 
tity. Ib  should  be  given  by  means  of  tbe  hull  electrudes  to  the  bmly  a4id 
by  the  coronal  brush  electrode  to  the  head  in  acaucee  cf  fixnu  ten  to  ^- 
teen  minutes  daily.  It  is  not  6o  uMiful  in  erethiatio  and  painful  etAtea  aa 
faradic  eleotncity  of  tlje  lung  coil  and  rapid  vibration.  Galvanic  elec- 
Iricily  ia  of  no  servicB  id  hysteria,  exempt  to  overcome  some  of  tbe  trophic 
oonditiuna,  such  as  muscular  atrophy  and  osdemai  two  ayniptoms  of  not 
very  common  oi^cuirence  in  thia  diaeu«. 


THE  TREATMSNT  OF  HTSTBKIA- 


4S8 


Maaaaget  Swedish  moTementfl,  calistheutcB,  a.re  often  beneficially  used 

U>  ?<raibat  muiifostattoiis  of  aathaoia,  to  inorease  muscular  tone,  aod  to 

overcome  Ljaterical  paralyses  aod  atroiihy,  particAtUrly  inlule  the  patient 

lA  hidergoiu  g  isolatica  treatment.     The  various  f citns  of  outdoor  ejieiciao, 

loch  u  goLfingf  bicycling,  aod  horacback  riding — whii;Ii  are  so  often  5er- 

neeAbk  not  only  to  ijnprovQ  the  patient's  generii]  oondition,  but  to  teach 

bm  lelf-Kliance  and  to  make  him  less  indulgent  and  introspectiva — all 

ttflj  be  made  to  play  a  Teiy  important  part  to  prevent  hyaterioal  parox- 

TDu.  and  to  a:^siat  in  rocoverijjg  from  them.      WLeu  there  are  no  apeci^ 

indio&ttona  to  the  contraryT  the  life  of  an  hysterical  patient  should  be  one 

dphyaical  activity.     Naturally,  such  an  arrangeiDetit  ia  not  incompatible 

vith  the  dtfiCipLiita  of  isolation. 

The  medicinal  treatment  of  the  psjchonenrosis  hysteria  does  not  call 
br  Teiy  extended  discussion,  for  the  truth  is  that  there  are  no  indicatdona 
ior  medicinal  treatment,  save  to  meet  certain  apecial  indications.     Unfor- 
toiutely,  the  salts  of  bromine  are  very  eitenairely  used  by  the  general 
prutitioner  aa  e^datire  agencies-     Thsre  are  more  dangerons  and  pemi- 
fimiq  metbiids  of  treating  bysterla  than  this,  but  bliey  are  very  few.     I 
ikinub  Diean  to  convey  the  impression  that  a  few  doses  of  a  bromine  aalt 
Are  ui)t  frequently  indicated  to  OTcrcome  special  manifeatationd  of  ere- 
thism and  excitement.      It  ie  tbe  routine  treatment  by  bromides  of  which 
I  paniculajly  apeak.     The  admin ist ration  of  foul-smelling,  pungent  mod- 
idau,  such  aa  the  valerianate  of  zinc,  and  tincture  of  valenao,  ia  the 
Isgtcy  of  a  barbarous  phammcology.     They  are  of  slight  service  because  of 
tZielr  povrerfol  odor,  which  makes  an  impression  upon  the  imagination, 
but  they  are  not  so  useful  in  this  direction  as  piLIa  made  from  methylene 
6lue,  which,  giving  a  decided  color  to  the  urine,  makes  an  enonoous  im- 
pfes^ioD  upon  the  patient.      In  most  cases  it  is  necessary  to  give  some 
fuedicines,  and  it  is  better  to  give  tho>^e  tli^t  can  ai^t  by  suggestion  than 
la  give  those  that  do  not  act  at  all.     I  have  often  been  convinced  of  the 
Ttiue  in  warding  otT  an  attack  of  a  capsule  containini*  vaTemin  and  com- 
pound  spirits  of  ethei,  taken  w ben  the  patient  had  premonitions  which 
Fere  indicative  to  her  of  the  onset  of  an  attack. 

The  regulation  of  the  various  functions  of  the  body,  such  as  that  of  the 
bowels,  the  kiUuer^  the  reproductive  organs,  and  9kiu»  requirea  no  other 
meotiwi  save  to  say  that  carefol  consideration  of  them  will  be  amply  re- 
warded in  the  treatment  of  this  disease,  as  it  is  in  every  other  in  which 
there  is  a  lack  of  balance  between  the  production  and  the  expenditure  of 
energy.  Reatoratiyes,  sach  as  iron  and  cod-liver  oil,  appetizers  in  the 
shape  of  the  simple  bitters,  and  occasionally  sedatJTes,  particularly  those 
acting  on  the  sympathetic  nerrons  system,  have  an  important  place  in 
the  therapy  of  hysteria. 

It  is  neceeaajy  to  say  a  word  concerning  the  aurgioal  proeednres,  par- 
ticularly on  the  generative  organs,  that  have  been  proposed  in  tbe  treat' 


434 


TSEATMSKT  O?  DI&KaSSS  OP  TBB  VBRV0C9  fiYSTBH. 


mem  of  liysteria.  Thv5«  operaiiouH  tn*-  ou|ili4>r«cii:i:iiy  or  the  removal  of 
the  normal  ovaries,  hjsl«rectoiQj,  clitoriiectomf,  snd  caetnttioii  iii  the 
toale.  No  tDvntiQD  la  moide  ol  oporftcioiid  oa  the  noa^  the  coccjx«  tb« 
TA^fiiift,  etc.,  b«c&aae  Ch^^  &r«  iusigni&caiit  compared  vtth  tboee  first 
tneutloiteiL  Tha  time  13  Lappilj  gone  by  vtieu  evich  op^rfttiooe  were 
rommunly  perfonDed,  although  oda  c:id  still  h»u  the  indications  for  their 
u&B  diacuased  nov  And  ihea  in  medioil  BOcitlies.  If  there  is  &nj^  one 
apeciaiist  more  than  another  whose  ftitl  and  comiael  shoidd  not  be  sought 
ib  the  beatmeat  of  hysteria,  it  b  the  gjnaetiologbc.  It  eeenia  an  uuneo- 
ectary  platitude  to  9M.y  that  hysterical  vi>[ueD  ara  aa  liable  to  iiterine  dis- 
order a^  iiua-hystt^rical  women;  but  they  &re  not  more  eg,  BK^ept  in  30 
far  aa  the  asdienia  oftentimes  asaoeiaUMl  with  hy^^teria  may  predispi>»a  to 
slight  diaplacoment  or  disturbance  of  functicm.  When  such  uteriito  dis- 
turbance occurs,  naturaUj,  meaaures  shuuld  be  taken  to  overcome  it;  but 
in  no  ciflo  should  th^ro  be  any  treatnient  from  a  gj'niccologioo-neurologi- 
ca.1  Btanilpoiut,  or  any  concerted  action  of  the  neurologist  and  the  gyrfeoDl- 
ogist.  The  saina  puiiishnient  should  be  meted  out  t<i  the  man  who  wil- 
fully TOnorea  a  nornial  uterus,  ovary,  or  tpstioldf  or  oae  not  so  far  diaeaaed 
that  it  cauuot  bo  nnraed  back  to  a  normal  coodJtioci,  as  is  judiciously 
given  to  bun  wjio  premeditatively  tnkea  deliberate  aim  and  maims  with 
.weapon  of  any  sort  a  fellow -orcatn re.  In  the  liglit  of  a  oompreheDsive 
knowledge  of  r^porta  of  cases  of  Lyateria  and  of  hyatero-epilepay  cin«d 
by  aargioal  proc-edure  upon  tbe  generative  organs,  I  say  that  1  refuse  to 
believe  that  one  example  of  true  hysteria  has  ever  been  cuied  by  auoh 
barbaroosj  uuacipatitii*^  uarighteoua  meaaurea. 

The  place  whioli  hypnotism  holds  in  the  therapy  of  hysteria  ha»  al- 
ways been  and  wiU  probably  always  remain  an  insignificant  one,  using 
the  term  in  the  only  seiiae  in  which  the  majority  of  the  profesaion,  in 
oominon  with  tlie  lai^,  will  use  it,  vii^,  that  of  carrying  a  person  into 
an  unconscious  bI^Ib  by  means  of  impreaaions  luade  on  that  individual's 
mind  through  the  medium  of  one  or  ujore  of  his  special  senaes,  Thi£ 
should  not  be  construed  to  mean  that  siiggeation,  whether  by  word  of 
mouth,  hy  prifcept,  or  by  o^^ular  demonstration,  may  rot  bo  used  ailvan- 
lageoiisly,  botli  to  orerctimo  the  stigmata  of  hystoria  and  to  aasiet  ii: 
counteracting  the  general  j)8yehopatliio  i^ondition.  Oftentimes  eutih  pro- 
cedures ars  &ttei]ded~by  brilliant  ami  striking  resulU,  as,  for  iustanee, 
the  diaappearaiice  of  hysterical  pain  or  hysterical  blindness  through  sug- 
gestion. I  cAuId  record  a  ]mut1>er  of  examples  cf  hysterical  treinor  and 
palsy  that  succumbe^l  to  a  few  miuut€S  of  suggestive  therapy.  It  bad 
been  pointed  out  in  tbe  chapter  on  psychotherapy  that  BUggcation  is  much 
more  potent  when  the  patient  is  in  an  hypnotic  condition,  aud  no  objec 
tioas  can  be  brought  forward  to  show  that  the  procedure  known  as  hyp- 
nosis should  not  be  indulged  in.  ThH  physician  who  attempts  to  sur- 
round the  prtx>esa  with  an  air  of  mystery  cr  to  flaunt  it  aa  an  indivi(3ual 


THE  TREATMENT  OF  HYSTERIA. 


435 


and  nntiauaJ  posaaHalon  plaaea  biiDself  dd  &  plana  with  the  charlaia.ii  and 
Degru  Loodoo.  It  is  fat  better  to  aTuid  thd  xx&e  of  hyyaoii^ai  eulireljr 
as  fi  definite  procedure  thaa  to  abuse  it  hj  borrowing  tbe  aira  o£  a  pro- 
fessional bypLotistp  UuqaeBtioiiably,  juat  as  much  good  couJd  he  accoiu- 
pUabed  in  rlie  treatiaeut  o£  hysteria  if  physiciajis  th9  world  over  were  to 
agree  never  to  meution  or  ^pply  it  agaiu. 

The  Treatmeat  of  an  H/sterical  AttauL — By  hyeterical  attadka  18 
meant  tratitiiLioaiaL  aUitea  between  the  oidiuarjr  meutal  cuitdition  in  hys- 
teria and  a  genul^io  hjetetioal  pajcbosis.  In  reality  thej  conaistof  more 
or  lees  brief  states  of  limitation  or  disturbance  of  con scioueiieB a  associated 
with  profound  inhibition  of  tbe  will-  Such  itates  are  attended  by  very 
difTemnt  texternal  manifestations,  such  aa  spaHinchlieH.Dduunviils]yemove- 
meDta  iu  difTerent  parts  of  the  body,  perbapa  afTeetiiig  all  the  extremities, 
taking  moat  often  tbe  form  of  affectation  jnovomente*  Such  are  the 
convulaivo  laughtoraJid  crying;  the  gestures  and  positious  of  fear;  and 
anxiety,  aeximl  excitement,  and  their  emotional  aceompaniments-  In  the 
less  severe  attacks  the  external  manifestalicica  may  be  i^reo-led  by  tremor 
of  the  eitrejn  i  tii^a^  tonic  spas^ie  of  the  bauils  ur  cf  tbe  faue,  neck, 
and  shoulders,  opisthoboaoat  jerky  and  spasmodic  respitation.  In  rer/ 
severe  hysterical  attaoks,  gronde  hjat^rie  of  the  French,  tbe  conrulsive, 
spasmodiCf  aud  afFectatiou  movements  are  most  profound,  Tbe  patient 
bounds  about  on  the  floor,  resting  only  on  the  heels  and  back  of  the  head, 
or  ahe  adsiunes  iioHitians  of  extreme  scstAny  ur  ^^t  \ioletit  p^L»ision,  while 
the  mental  eruditions  manifest  by  all  degrees  of  Incohereiicy  up  to  pru- 
foundeab  delirium  keep  pace  with  the  motor  manifestations.  The  pa- 
tient may  pass  into  tbe  dilTerent  cataleptic  conditions  atid  the  various 
forms  of  hysterical  sleep  and  uiiconaciousuefis  which  soiuetimes  closely 
simulate  death. 

Id  the  treatment  of  tbe  hysterical  attack,  there  is  rarely  need  of  great 
haste.  I  say  this  notwithstanding  tlie  fact  that  occasionally  the  cou- 
linuance  of  spasm  iu  the  respiratory  luuaolea  destrtiys  Iife^  because  of  my 
observation  that  tlie  most  common  proceeding  of  the  physician,  when 
called  to  a  patierit  in  tbe  apparently  agonizing  conditmn  of  an  hysterical 
parnxysra,  is  to  canciliate  the  family  by  cutting  it  ahtirt  with  a  hypo- 
dermatic iujoction  of  mctphine.  This  is  as  baneful  aud  ill-advised  an 
action  as  can  be  easily  imaginedf  and  one  that  should  rarely,  if  ever,  bo 
token.  Tie  first  duty  is  to  dispense  with  tlie  aid  and  presence  of  aym- 
pfttldzera,  buaybodies,  and  oth^r  unnecessary  element  of  tbe  gathering 
which  is  aure  to  be  about  the  patient.  The  physbiian  owes  lb  to  himself 
to  assure  the  f^imily  that  he  stands  between  the  patient  and  danger,  and 
thatt  although  the  attack  may  last  for  some  tiiue,  the  eventual  outcomo 
will  be  satisfactory.  The  conduct  of  the  physioiuti  ehould  be  Buch  that 
the  patient  is  impressed  that  be  Is  in  authority.  In  the  majority  of  in- 
stances tho  patient's  conscionsnesa  will  not  ba  m  obscured  that  ebo  is  not 


436 


TKKATHEffT  OF  mSKASEa  OF  TEE  NERVOUS  SYSTEM, 


awara  of  wha,t  ia  going  on  about  hern      Tho  "bringing   to '^  of  hysteri- 
cal patients  is  usually  a  very  simple  matter.     H  the  patient  does  Dot  re- 
spond to  &  vigoroua  comnmnd  to  wake  np,  while  at  the  Bame  time  ahe  U 
being  aaitisted  to  her  fseb^  tk  g]asa  of  tiold  water  dHahed  into  the  £jic^  a 
cold  doucho  applied  to  tbe  ba^k,  or  irritation  of  the  akin  bj  means  of  a 
foradio  curreut,  will  usually  succeed.     If  the  Bpasmodiu  attai^k  ie  very 
severe,  and  it  cannot  be  ended  by  the  meaaurea  spoken  of,  the  patieut 
should  be  given  a  few  whiffs  of  (?h]orr>forEBj  aud  in  the  traJisil.ional  period 
from  hysteriral  diaturbtuicBof  consciun^neaa  to  chlurofonnation  she  should 
be  commanded  to  wako  iip>     If  the  arousal  ib  cot  complete,  it  can  bo 
furthered  by  stimulation  of  tho  skin.     After  such  pfitienta  recover  con- 
at^ousness,  they  are  iiBually  kei-nly  awsire  of  the  epectaole  and  e^hibi- 
tioa  that  they  have  made,  and  their  feelinga  must  be  jealously  guarded. 
The  young  physii^iun  p^Elicularly  ahuuld  remember  that  aternness  is  effi- 
eaciaua  in  proportion  aa  it  lacks  rudeness  and  all  kinds  of  maltreatnienU 
la  youDg  children,  bodily  chostiBement  thoroughly  catiied  out  has  a  very 
legitimate  place  in   tha  pievention  and  treatment  of  hysterical  attacks. 
Happily,  it  does  nol:  lid  within  the  duties  of  the  physician  to  admintater 
tt.     In  Hevere  hysterical  attac^ka,  the  patient  should  he  placed  bo  that  she 
cannot  hurt  Ler&elf  or  do  violence  to  tilings  or  persons  about  her.     U 
there  be  neeil^  no  hesitation  should  be  had  in  giving  chloroform  by  inha- 
lation, cf  Gom-sa  in  very  small  quantities,  or  in  the  use  of  artificial  meas- 
ures  of  restraint,   such   a3  the   captive  sheet,   or  a  etrait-jacket-     The 
measurea  mentioned  as  eflicaciouB  in  the  minor  attacks  may  be  enipl<^ed. 
Sometimes  they  are  successful,   but  in  other  ca^es   they  and  all  othet 
measures  fail  to  bring  the  attack  to  an  cud.     The  ea^e  with  which  hys- 
terical attacks  can  be  terminated  by  pressing  upon  certain  areas  of  tho 
body  usually  hypetsesthetic,  such  as  the  ovarian  pegion,  the  breaste,  the 
small  of  the  back,  and  other  sensitive  areaa^  has  been  very  much  overesti- 
mated.    These  areas  being  hyijersensitive,  piesaure  uptm  tbem  causes  a 
powerful  mental  stimulus,  and  uudoubtedly  this  often  has  a  su^estive 
effect  upon  the  mind.     The  oftener  one  succeads  in  ending  attacks  in  tliia 
way  the  more  readily  will  Babacqucnt  attacks  yield  to  the  same  treatmenL 
The  Treatment  of  HyBterieal  Stigmata.— The  hysterical  patient  often- 
times cntiBtilts  thft  physician  to  apt^k  relief  for  snme  individual  symptom  or 
condition  sueh  as  pai'alysia,  contracture,  tremor,  atrophy,  oedema,  spas* 
moJio  cough  or  hic(^oiigh,  borboiygmus,  anoiexia,  h^matemesis,  aphonia, 
mutbm;  paiu  in  some  distinct  part  of  the  body,  such  ns  tiic  heart,  the 
abdomen,  or  head  \  hypereestheeia  aod  other  scijeory  disturbances  irregu- 
larly distributed  or  limited  to  one  side  of  the  body,  or  disturbance  ID  the 
function  of  auiiLC  of  the  other  special  senses,  such  as  partial  or  complete 
blindness,  deafness,  loaa  of  tlie  senses  of  smell  and  t'lste.      These  are 
knowu  as  the  stigmata  of  hysteria,  and  they  in  individual  or  more  or  lesa 
collective  oceurrence  require   particular  treatment.     It  is  important  to 


THE  TREATMRNT  01^  HYSTERIA. 


437 


remember,  however^  that  such  particular  trcatiaent  ie  not  to  itself  suffi- 
uii»iit.     The  general  pBychi>QemoB]B  should  Likewise  be  attacked. 

One  (jf  Uie  mOh^t  obatm&te  hjntbrical  aoutiupiLaiuietitB  to  overcome  is 
anorexia.  The  [liacipluie  of  iaolatioit  and  the  disagreeable  feat;uren  at' 
tending  forced  feeding  by  a  stonLadi  tube  and  by  rectal  alimentation  are 
usually  auflicient  to  make  the  patient  determined  and  willing  to  take  food 
naturally.  The  degree  of  emat-nation  which  hyfiterical  anoresia  inay  lead 
to  (and  indeed  it  may  lead  to  death)  is  asUnmding.  The  reprirts  of  fast- 
ing girls  are  heralded  by  the  seeolar  press  tljioughout  the  civilized  world, 
aud  they  rarely  fail  to  excite  greal  wouder  in  tlie  readers,  while  fortify- 
ing the  notorious  individual  iu  her  sinister  but  on  controllable  purposa. 
Probably  no  ease  ia  so  rebellioua  that  it  cannot  be  overcome  by  the  meas- 
ures qioken  of^  parti<]ularJy  if  the  direction  of  the  patient  is  in  the  hands 
of  a  firm,  nDtori**ty' despising  physician.  No  teniikomitig,  no  half-way 
meaaurea  should  be  the  rule  here. 

Hysterioal  hjcmatemeaia  is  another  symptom  that  frequemtly  requires 
strict  methodical  nnd  dlaoiplinaiy  trdatmeut*  The  patient  should  be  put 
upon  an  exclusively  milk  diet  and  subjected  to  absolute  isolation.  Natu- 
rally^  suob  treatment  can  be  cai-ried  out  at  home,  providing  the  family 
are  siilTlciently  amenable  to  suggestion  and  the  patient  be  put  under  the 
care  of  a  trustworthy  nurse.  Hysterical  salivation,  andsn'allowingsome- 
timea  associated  with  hawking  noiaca  and  a  feeling  of  spasm  in  the  ceso- 
phngua.  should  be  at  ouce  auhjccted  to  most  rigid  isolation,  for  when 
this  <<onditi^>n  becomes  chronic,  it  ia  in  my  experience  the  most  diffi^^ult 
hysterical  manifestation  to  dislodge-  Hysterical  ballooning  of  the  ab- 
domen and  borb(?rygnius  will  UBually  eui^oumh  to  the  application  of  tlie 
faradic  current  by  meana  of  the  brush  electrode  to  the  abdomen,  and 
the  Qustomary  hj'driatic,  mcchanicul,  aud  disciplinary  tteatmeuL  When 
the  ballooning  of  the  abdomen  is  so  constant  that  the  patient  is  convinced 
of  the  presence  of  a  new  growth  or  pregnancy,  no  time  should  be  lost 
in  eihariiing  or  chloroforming  her  in  ordi^r  to  ctjuvince  the  family  of  the 
tniQ  nature  of  the  symptom  and  to  imprusa  upon  the  patient  the  reality 
of  its  difl^ppearauce  under  such  conditiona.  Abdominal  paiiii  usually 
of  great  inten.iity  and  of  more  or  less  constancy,  although  subject  to 
paro^ynmal  cxaceTbation^  is  usually  aaaociated  with  the  existence  of  bye- 
terogcTiic  lonr^s  in  the  region  of  the  ovaries,  and  these  should  bo  overcome 
by  counter- irritation,  tJie  applioalitm  of  faradic  electrioity,  aud  the  use  of 
hydrotherapy. 

The  sueeesaful  treatment  of  hysterical  poralyaia  will  depend  largely 
upon  how  Fully  the  phyeiuian  realizes  that  such  palsies  are  in  reality  the 
outward  expressiona  of  a  diseased  will.  The  patient  hns  for  the  time 
lost  the  caparity  to  originate  or  trausmit  impulses  from  the  intellectual 
sphere  to  the  motor  areas  which  should  ho  externalized  by  luovements. 
No  treatment  directefl  toward  the  paralyzed  part  ibaelf  can  be  attended 


43S 


TREATMENT   OP   DISEASES    OP   THE    NERVOrS   SYSTEM, 


by  ivny  degree  of  aucoRaa,  except  ia  bo  far  fta  it  makes  an  appeal  to  aod 
overwoniGB  the  couUitiotiB  that  are  at  the  baaia  of  this  paralyaia.  Hyster- 
ical palsies  are  o£  various  diatribution  sjid  mtensitj.  The  Taricty  known 
as  Bstaflia-abaiiift,  in  whifib  the  patient  ia  absolntelj  unable  to  stund  or  to 
walk  Mid  to  lis?  tiha  upper  extremities  to  any  coasiderable  degroe  i^  the 
Djodt  remarkable-  The  patient  ia  doiuinated  h^  the  delusion  that  Le  caa- 
not  walk  or  fltartd^  and  Trhile  under  such  domioancy  ho  is  as  completely 
unable  to  do  so  as  if  he  were  paralyzed  from  organic  disease.  Yet 
wh«n  lyiug  in  bed  all  the  eitremitiee  cnn  be  used  ia  a  normal  and  por- 
poseful  way.  The  treatment  ul'  LyHtvrit^al  palsy  will  depeuil  Homewhat 
npoa  the  iiiunediate  provocative  agency,  "When  it  ia  due  to  Dvervork, 
such  as  in  machine  operators,  hand-workerB,  and  the  like,  ceasatioii  o£ 
Biich  labor^  the  nppiication  of  electriotty,  pattioularly  faradic  or  static  eleo- 
trioity  to  the  disabled  extremity,  and  the  ciiBtomai-y  thecapeutio  entail' 
mf'Tils  of  iflolation  and  fiuggestion  are  sufficient.  When  the  ptovoeatiTe 
agency  is  fright,  which  is  nut  rarely  the  case  in  children  and  in  young 
adulte,  I  have  not  infrequently  seen  the  paralyflia  completely  diaap- 
pear  on  engrossing  the  patient's  attention  in  one  way  or  another,  tuid 
then  abruptly  oonuuandiug  him  to  njove  the  extremity.  If  the  patieat 
ia  once  shown  and  convinned  that  movemeTit  is  not  impossible,  •com- 
plete fLiDctinnal  restoration  speedily  follows.  IF,  for  instancej  the  motor 
capacity  of  one  upper  ostremity  is  completely  aubjugated,  the  patient's 
two  hands  are  placed  in  front  of  him,  and  he  ia  asked  to  fix  hia  attention 
entirely  upon  the  paralysed  band  and  then  oommaDded  to  move  the  fin- 
gers  of  the  normal  hand.  When  this  is  done  the  procedure  is  reversed 
and  attention  ia  fixed  upon  tlie  normal  hand,  and  he  is  commanded  to 
move  the  fingera  of  the  paralyzed  hand.  Repeated  and  perRiiitent  efforts 
in  this  w&y  are  often  revrarded  by  the  patient  being  conrinced  that  it  is 
not  impcBsible  for  him  to  move  tlie  paralysed  extremity,  and  the  begin- 
ning of  recovery  dates  from  that  time. 

tn  the  majority  of  cases,  hysterical  paralysis  ia  aasociated  with  tin- 
hearalilo  pain  on  movement,  or  rather  a  faar  that  it  will  uanse  great 
suffering  if  the  parts  be  touched.  It  is  sometimes  feasible  to  overcome 
this  delusion  of  pnin,  which  can  generally  ho  done  by  suggestion  aud 
by  the  suggestivenesB  and  snothiog  poaaessioua  of  eleetrioity.  The  pa- 
tient should  be  convinced  and  BcboolGfl  in  the  conviction  that  the  pain 
ia  disappearing,  and  proportionately  as  it  disappears  tha  niotor  capacity 
will  return.  His  will  power  should  bo  stimulated,  supported,  and  re- 
inforced, and  the  physician  shonld  profess  to  be  completely  satiated 
with  small  but  continued  evidences  of  improvement.  Thus,  by  the  use 
of  physical  measures  which  are  directed  immediately  toward  overcom- 
ing the  complaint  and  which  appeal  directly  and  potently  to  the  pa- 
tient's mind,  in  association  with  the  disciplinary  and  hygienic  meas- 
ures directed  against  tfie   hysterogenic  etate,   the  prominent  stigma  or 


THE  TREATMENT  OF  HYSTERIA, 


439 


associate  aymiitom  cf  the  hysteria  for  'vhich  the  patieat  Beel^a  reliff 
disiippcapB  with  the  impTovoraeut  of  his  or  her  geneml  condition.  Aa 
the  patient  continues  to  develop  power  iu  the  parjUy^ed  eitremity  or 
PKtremitiea,  ha  shonM  bft  made  to  take  inRihodical  gymnastic  enerdse 
that  nill  appe^  not  oDly  to  Lhe  muBcIee  that  are  apparently  darelit^t  in 
their  function,  bill  to  tho  patient's  nind  as  rtclh  Ihia  appeal  can  be 
siipported  by  tbense  of  stimulating  Itnimenta  and  applloations  to  the  part, 
by  maBsage,  aud  by  various  other  measures  t^at  will  suggest  tbeuiBelves 
to  the  physician.  In  hysterical  aphonia  sometimea  the  voJoe  returus  after 
dne  s^nee  of.  the  electrii^al  and  BuggBHtiye  tieatmeut.  The  pntienC  is  in- 
formed in  a  positive  and  cocviucing  way  that  tlie  application  of  the  elec- 
trical current  to  the  vooal  cords  will  restore  his  voice.  He  need  not  be 
told  thiit  it  will  restore  it  oompletoly.  Then  a  moderately  strong  fa- 
radio  ourrent  or  galvanio  current  is  i)flS8ed  through  the  laryiiK,  the  elec- 
trodea  being  on  either  side  of  the  pomum  Adami.  At  the  moment  when 
tho  currisnt  is  pasHtrd  the  patient  Hhonld  be  comuiandBd  to  say  "nh/' 
This  convinoes  hini  that  he  can  produce  &  tone,  and  the  mental  alate  re- 
SkiltiuK  is  tho  one  that  is  being  striven  for.  The  repetition  of  this  will 
be  followed  by  gradual  gain.  It  may  asaiat  tho  patient  in  regaining  the 
will  power  to  speak  to  point  out  to  him  that  he  mukes  a  tone  on  eoughing 
and  that  ibi^  tone  is  aiuiilar  to  that  prodoeed  in  speaking. 

The  Ireatinent  of  hysterical  routraatuTB  ia  in  many  eaaaa  rather  nn- 
satisfactory  if  the  condition  has  lasted  for  a  long  time.  In  rt^cent  cases 
it  can  often  he  made  to  disappear  in  a  few  days  by  cler^trlcal  and  bydriatic 
tT^atment,  associated  with  method  ieu^l  psycholhorapy.  The  profound 
motor  irritation  which  ta  at  tiie  bas^s  of  the  hysterical  contrac^ture,  at 
least  of  the  repcent  uasea,  muat  be  ovtrnnme  by  snggeBtion,  either  by  word 
of  mouth  or  by  physical  means,  and  tlion  the  gk^ueral  will  puvper  restored 
by  the  uieaBures  that  have  already  been  detailed  for  the  tieatment  of 
the  psychopathic  Btate.  In  ancient  cases  a  secondary  contracture  residts, 
and  before  this  can  be  overcome  it  is  neceaaary  to  etherize  the  patient  and 
forcibly  to  break  up  the  adhoaiona  whieb  are  the  result  of  prolonged  ini- 
mobilizatioQ.  To  dothia  one  m;iy  becbligeil  to]>erform  single  or  multiple 
tenotomy.  Naturally^  after  any  such  procedure,  oithopBtKlic  apparatus 
must  be  employed  to  maintain  tho  gain  that  has  been  secured, 

The  treatment  of  hysterical  sensory  diaturbanccs,  aside  from  pam  and 
those  manifest  in  the  speolal  sensea^  dot^s  not  call  for  particular  discus- 
sion. Hysterical  anfesthesia  and  analgesia  Vd  usually  first  recognised 
by  the  physician  who  ia  consulted  by  the  patient  for  some  other  hys- 
terical symptom.  The  treatment  directed  toward  the  CTtrcomiug  of  the 
latter^  whatever  it  may  be,  atid  to  the  oouoteraetion  of  the  general 
psychopathic  Gtnte  iteually  suMcestu  relieve  the  ana^  thee  ia  and  analgesia. 
SometiiTje^  phyaiciana  amii3e  themselves  and  amaze  the  patient  by  dis- 
sipating Jiysterical   antustheaia  with    magnets,   a  procedure  dignified  ae 


440 


TRBATM&NT  OF  DISS  ASKS  OF  THE  NERVOUS  fiYt^TBM- 


metallotherapy.  The  anfflstheclo  ar^a  ia  covered  with  etripB  of  iron  or 
copper,  which  a.re  tlien  inHuenced  by  briaglng  a  nt^Qet  in  cootact  with 
them,  ivheiL,  lu!  the  aDsathesia  disappears.  To  apeak  of  Lhe  specific 
working  of  Huch  magnetizatioa  is  to  confees  aq  entire  igr^o^^iice  of  tho 
p^thogenesia  of  hysteria  and  its  rational  outb,  HjsterR'al  pain  is  somt- 
times  extremely  obstinate  and  ^]ow  in  its  reaponse  to  every  form  of  treat- 
ment It  la  of  great  importance  to  remember  that  motphiue  should 
not  be  uaed  for  Its  rtslief-  The  exueptiua  to  this  rule  is  that  a  ^ulTtcienL 
dose  may  be  giveu  intermdly,  that  the  patient  may  be  jiroperly  impreHsed 
that  it  is  withia  tho  easy  reach  of  the  phyfiician  to  cause  cessation  of  the 
pain.  Then  some  of  the  drugs  that  have  boen  mentioned  onder  the  gen- 
oral  therapy  nf  the  disease,  aitd  particularly  thoaa  thiit  appenl  to  the  im- 
Bgiuatiun,  either  through  one  of  tbe  apeci;d  eensea  or  hy  the  effects  thm 
they  produce  in  the  eicreliotis,  abonld  be  given.  XTuleRs  the  pain  delu- 
sion be  very  profound,  relief  will  generally  follow  the  cpplicatloQ  of  elec- 
tricity  and  the  use  of  sviggeatioo- 

Sufficient  has  been  eaid  eouoeming  the  treatmeat  of  the  sUgmata  of 
hysteria  to  indioate  that  the  succejis  of  such  tfesitment,  it  matters  very 
little  whnt  individual  symptom  the  physician  is  striving  to  overcome, 
will  depend  very  largely,  if  not  entirely,  upon  the  control  which  lie  gets 
over  hia  patient,  and  upon  the  wisdom  which  he  displays  in  enerciaing 
auch  eontrol  to  arouse  the  will  and  doterminalion  of  the  patient  and 
fortify  Gueh  awakening.  To  do  this  efficiently,  more  than  the  physician's 
menj  prcaeiic*  or  mere  contact  ia  necesaary,  it  matters  not  how  powerful 
his  personality  may  be.  The  aids  of  which  he  shoiUd  avail  himself  aie 
those  that  have  been  mentioned  in  the  section  on  the  general  plan  of  treat- 
ment. Of  all  these,  by  far  the  most  imporbant  is  isolation  and  its  dis- 
ciplinary entailment.  If  this  one  element  in  the  treatment  of  hysteria 
were  to  be  carried  out  completely  in  every  case,  tlie  world  would  be  hap- 
pily rid  of  a  colossal,  ever- increasing  literature  of  fasting  girls,  fatal 
hiccoaghs,  uaarousable  sleepers,  mliacalous  cntea»  wonder  doctors,  Lourdes 
literature,  not  to  apeak  of  theTclumes  of  incredulous  testimuny  furniabeU 
by  rendors  of  supeEoatuial  powers  and  mystery  medicines* 


CHAPTER   XXIX. 

THE  TREATMENT  OF  EPILEPflY. 

Tbk  t«ita  epilepfij  ia  applied  to  groups  of  Bymptoms  and  to  diseaeea 
vhich  aoatomicaJly  and  pathologically  ar^  extrejiiely  disparate.  In  fact^ 
at  the  present  day  itsboiiEd  nob  be  given  any  anatomical  si giiMcancfl  whut- 
Boevfir.  Tu  show  the  dJEBcultj  of  conTejiag  iu  a  few  worda  an  adei^uate 
idea  of  the  disorders  indicated  by  the  term  epilepsy,  the  leader  is  re- 
niinded  that  a  large  proportion  of  all  cases  of  dual  pcrsouality  are  luani' 
feslationa  of  epile[.>ay ;  that  most  cases  of  dreamy  Bt:iteB  of  oonsclousneBB 
are  in  reality  evidences  of  the  epiltptio  neurosigj  that  cortical  irritationj 
whether  it  be  due  to  growths  in  the  Buhat^ncflcf  the  cortex  or  to  pressare 
from  without,  is  mauifeated  by  the  pheuomeiia  of  epilepsy;  aiad  fiUiJly 
that  the  large  class  of  coses  which  wo  designate  as  genuine  or  essential 
epilepsy,  meaning  thereby  a  profound  neurosis  whose  moat  conspicuous 
symptom  ia  eclamptio  or  conTulsive  attai^ks,  ar-e  fill  included  under  this 
one  head.  When  the  term  epilepsy  is  used  without  qualification,  idio- 
pathic or  fio-called  essential  epilepsy,  that  i:^,  the  condition  iu  which  there 
exists  uo  deteotable  auatomical  Icsiona  to  account  for  the  symptoms,  ia 
always  meanL 

Tha  epilepsies  are  variously  claeailied.  A  radical  and  nsceasarj  divis- 
ion is  into  (Ij  congenital,  eHseiitial^  or  Bo-calied  idiopat^hic  epilepsy  -,  and 
(2)  aoijuired  epilepsy.  In  the  first  the  lesion,  whose  nature  and  seat  are 
unknown,  is  conditioned  by  factors  operative  i^pon  the  organbm  ab  &il 
early  stage  of  its  development,  probably  at  a  ticue  considerably  prior  to 
that  when  the  disease  liecomea  e»tabliahed  and  its  phenomena  mimifest* 
The  various  stages  in  its  pathogenesis  are  entirely  unknown,  and  the 
eventual  morbid  state  in  whieh  it  results  is  wholly  conjectural.  Rea- 
soning by  aualogy,  horn  the  auatomical  findings  which  have  often  been 
described  in  acquired  epik'tisy,  aud  from  the  facta  set  forth  from  a  study 
of  epilepsy  espe  rim  en  tally  produced,  the  theory  has  been  advaHctwl  that 
the  jjLorhid  anatomy  of  the  disease  is  a  sclerosis  of  cert:iin  parts  of  tha 
brain  cortex,  Tt  is  i^ntirely  liuprobable  tliat  this  explanation  is  at  all 
adequate.  Although  such  sclerosis  Las  been  found,  it  is  mdra  than  likely 
that  it  is  but  an  expression  of  changes  that  have  gone  oa  In  important 
parts  o£  the  brain  parenchyma,  and  that  it  is  entirely  secondary.  In  es- 
sential epilepsy  the  causal  ageuciea  act  upoTi  immature  protoplasm  or 
perhaps  even  upon  the  antw^edenta  of  protoplasm.     In  acquired  epilepsy 


442 


TRBATMEWT  OF  DISSASSS  OT  THB  NERV0TJ8  flTBTCM, 


the  causativ'd  fa^^tore  flct  injurionaly  upon  tiBBues  that  already  are  veil  de- 
veloped, perhaps  fully  no.  It  ntamla  to  T^aaon  that  tlid  teaioii  cbjet^tively 
DDUHiikred  will  mti  be  the  bouiq  in  botL  inatpaiiceB.  Ereu  the  coses  of 
eBsentiil  or  idiopathic  epilepay  that  develop  afl<?r  ftdolescent^e  are  CCO' 
aidcrod  to  be  the  result  of  cauaj^tiTe  factors  ef  remotely  anterior  ex- 
iaten'^e  aad  attivlty. 

Ksnantia,!  or  congenital  epilapny  ia  subdivided  into  u  niimbf-r  of  cli&i- 
cial  Tarietics,  a  oommou  diTEHiac  beiii^  llat  mguie  according  to  the  severity 
and  conatituticu  of  the  attAok.  Thus,  under  Cbe  Erst  subdiviaioD  we 
bare  grand  mal  end  potit  mal,  or  largo  and  emaU  attacks;  and  uitder 
the  second,  psyehicat  epilepsy,  dreamy  statPB  of  consoioaaiieaa^  dual  per- 
Borality,  and  motor  epilepsy,  the  conunon  variety.  Aeqidre^i  epilepsy  ii 
ofteu  subdivided accordiij^  to  its cnUHation  and  its  olicical  aiauifestatJouB. 
Etioli^iciilly,  ve  have  tiaumatic^  Byphiliti<',  alcoholic,  alK^inthiiief  end 
other  tojtie  epilepsies  i  epilepsy  of  the  onctphalopaLhies,  such  aa  that  re- 
Bultiog  from  lead,  and  the  very  doubtful  ckea  known  as  reflex  epUepsiee, 
Clinif^ally,  the  acrjuired  epilepsies  n:iB.y  manifest  themselves  in  the  saiDfi 
way  as  the  idiopathic  epUepHies.  Aa  ttiecrnmiionest  form  of  acquired  epi- 
lepay  ia  traumatic,  and  a«  tho  trauma  u^nally  cauaee  lesion  of  a  more  or 
less  narrowly  confined  and  Epci^ialized  area  of  the  hrain,  it  produces  what 
IB  hno^vn  aa  focal  or  Jncksonian  epilepsy.  In  these  caeos  the  display  of 
the  epileptlo  motor  phent^mena  bespeaks  and  indicatea  the  focue  of  the 
dieeaHB.  Thisj  fortunately,  often  allows  of  radical  treatment,  to  wit, 
eitirpatiou.  It  is  only  when  the  focua  of  disease  encroachefl  upon  some 
area  of  the  brain  to  which  is  allocated  pecial  function,  diaturbanco  of 
which  is  readily  recognized  and  clearly  interpreted,  finch,  for  instaDCCt  aa  a 
aegmect  of  the  motor  area,  that  the  symptoms  bespeak  nneqiiivcx^y  the 
seat  of  the  disease^  Moreover,  a  foeal  or  Jackeouian  epilepay  which  in 
the  lieginnin^  ia  attended  by  aymptoma  that  bespeak  the  eent  of  the  dia- 
eaee  may,  after  it  haa  existed  for  a  conaiderahle  time,  become  so  general- 
ized in  ite  convulsive  manifefilQtions  or  uccompanimenta  that  it  is  no 
longer  possible  to  determine  the  lociation  of  the  diaease  from  a  eousidera- 
tion  of  the  symptoms. 

All  epilepsies  are  also  divided  into  those  which  occur  in  early  life, 
and  those  which  occur  in  late  life.  Formerly  these  were,  referred  to  aa 
epilepsia  vera  and  epilepsia  tarda.  From  a  therapeutic  poiat  of  view 
this  distinction  \a  an  important  one,  for  almost  invariably  the  epilepaies 
of  late  life  rec|uite  very  different  handling  from  those  of  early  life.  The 
objection  to  such  classification  i^  that  it  seems  to  grant  that  genuine  idio- 
pathic epilepsy  never  ootsura  during  late  adult  life.  That  this  is  not 
true  will  l)G  shown  by  the  atatistice  which  will  be  cited.  Nevertlicleaa, 
moat  cases  of  ofiilepsia  tarda  are  of  the  acquired  A-ariety. 

Thus  it  will  be  seen  tluit  of  the  several  dilferent  patholo^cal  ooDdi- 
tious  for  whiob  tho  term  epilepsy  may  stand  some  are  deteetable  and  un- 


THK  TRKATHKNT  OF  KPILKPSV- 


4i8 


(iervtood,  wkile  otLera  are  oot.  It  ia  eaaeiitial  th&t  this  be  kept  in  muid 
in  «onsiderirg  the  etiology  of  ep^leps^,  arjil  tliat  alrnrp  dialtnctiou  be 
nude  betwec«B  eas^nti^  or  congenita]  epilepaj  anil  the  acquired  foruk 
VfMg  alLhcntgh  th«  same  factors  may  be  responsible  for  both^  th«  period 
of  tb^ir  adnTity  ia  quite  dilfereEt.  In  eflwntial  ppilnpay  Lh^y  Eire  ni^tivH 
before  the  developmeut  of  the  uidi\'idual,  while  in  acquJted  epilepay  the 
period  of  their  activi^  is  much  latcr- 

£tiolog7<  —  In  order  to  delsermme  at  lirst  haitd  all  that  might  bo  l^Amed 
of  the  etiology  of  epilepsy  from  a  consideration  of  one'a  own  exporienoe, 
I  hsTe  taken  a  comparatively  small  number  of  cn^aa — one  hundred  and 
fifty^of  which  I  Lave  detailed  histories  and  which  were  under  perAonal 
obserration  for  prolonged  periods,  and  carefully  analyze<I  them.  The  re- 
Eulta  are  m  maoy  respects  in  entire  accord  with  the  teaehinga  of  other 
writers,  bat  they  differ  in  some  rather  essential  particulars. 

Examination  of  these  statistics  shovs  that  96  (64  per  cent)  of  the  pa- 
tients were  male*  and  64  (or  3i>  per  cent)  of  them  females.  These  figurea 
ire  much  more  in  harmony  with  those  of  American  than  European  writ- 
en*  Almost  all  of  the  Eatter  ^d  a  slight  preponderancy  of  the  femaU 
t^x.  Of  the  acquired  ^pitepgies^  the  proportion  of  males  ia  even  ^eat^fn 
In  26  casefl,  IT  w^re  m^len  and  9  w»r^  females. 

No  age  is  exempt  from  epilepsy,  either  congenital  or  acquired.  The 
rut  majority  of  all  cases  luanifcst  themselves  dnrin^r  the  firdt  two  d^- 
adea  of  life;  indeed,  about  one-half  of  all  oases  occur  before  the  end 
of  the  firflt  decade.  My  own  statistioa  show  thai  ninety-seven  cases  (or 
about  two-thirdaof  the  entire  niimber)  occurred  before  the  fifleenLh  year. 
The  earliest  age  at  which  an  attack  ocH^urred  was  two  weeks,  the  latest 
ttH^-tbreo  years.  The  following  table  shows  the  relative  ages  at  the 
onset  of  the  disease  in  the  two  sexea*  and  sets  forth  graphieally  all  that 
need  be  said  as  to  the  influence  of  age : 


Viun. 

FttUlaL 

BdU. 

31  =  S0.7  per  cent. 
16=10         ■■ 

15=  e       " 

13=    «-7      " 
B=    4-4      ■■ 
8=    4-4      ^ 
8=    2         " 

*=    S          *> 
0 

»  =  3&7      « 
41  =  14         « 
17  =  ll.A      " 

917  =  IB     percenL 
3=1         ** 

y=  a       *■ 
7=   4.7      - 
4  =  a  J     " 

2=    1.4      - 
0 

1-1-6      « 
1=1-6      " 

a 

M 

89=  M         " 

11  =    7.4      " 

6=    M      ** 

&8==38.Tp 
1«  =  I3 

SI  =14 

»  =  ia4 

12=    B 

»=  a 

4=    17 
1=    U6 

IW 

tfT  =rW.7 
as  =  21,1 
11  =  U 

- 

M 

AenSOliiM... 

AtfoilSuBO 

U 

aa 

1- 

u 

H 

m^-—::: 

H 

Kpilepfly  oi  aD  kinds  is  more  common  among  the  poot  beeanse  of  its 


444 


TKKATHKNT  OF  DtSEAfiES  OF  TUK  I4^RVOT7a  ST5TEM- 


rolalionahip  to  dtpravitj  of  nutrition,  Buperfcptaticn,  aociclenta  to  the 
child  at  aud  after  liitth,  also  b«4.-auBe  those  fiise&aes  ood  habits  to  wUicIj 
it  hA&  some  relatioTiship  are  more  (!DiDmon  in  the  port'titd  in  this  class. 
So  far  118  tke^e  sLcLtisti^iti  ^a^  nabioa&lity  haa  no  iii£ueucB  wortli  men- 
tvoQiag, 

Heredity  is  tbo  moot  importaut  factor  in  the  causation  of  epilepsj, 
though  very  i^arelj  ia  direct  heredity  traceable  j  that  is,  epilepsy  oorur- 
ring  ill  the  immediate  ancesti-y,  either  llueal  or  collutBr&l.  It  might, 
thereforej  better  lie  said  lliat  the  neuioputhic  or  psjchopatbici  predispo- 
sition is  reallj  the  important  factor.  This  predisposition  may  be  defined 
here  as  a  diminiahed  reeistaDCe  to  physiologLca]  and  pathological  irrita- 
tion. Of  the  ir>0  cases  only  7  gave  a  history  of  direct  heredity.  lo  5 
of  these  thSE'e  was  epilepsy  on  the  mother^B  aide  and  in  2  od  the  father^s. 
It  is  usaaOy  Btatad  that  direct  heredity  ia  oftener  traeed  through  the 
maternal  aide.  TUeve  was  a  history  of  iadirect  neuropathic  heredity  in 
43  oases,  distributed  as  follows:  Alcoholism  in  father,  4  times;  in  the 
mother,  1;  hysteria  in  the  mother,  3  timea;  migroizie  in  the  mother,  3 
times-  insanity  in  the  father,  1,  and  in  the  mother,  1 ;  locomotor  ataxiOp 
1  ;  general  pareais,  1,  and  tio,  1.  In  the  remaining  27  cussi  there  waff 
a  histury  of  '^  nervoufinesa  "  in  one  of  the  parents  or  in  aome  immediate 
member  of  the  family.  Just  what  was  meant  by  this  term  it  is  impoa- 
sible  to  say  in  so  many  words^  but  it  may  be  taken  to  indicate  the  eTList' 
ence  of  hysteria,  neurasthenifl,  bypochondriasia,  headache,  and  the  like, 
with  aufflcient  prominence  to  make  it  worthy  of  mention  by  the  patient 
or  parent.  Twenty-sever  inf  the  4'A  cases  in  whieb  there  was  history  of 
a  neuropathic  diathesis  were  males  and  Ifi  femalea,  tbe  excess  of  the  for- 
mer beiug  scarcely  proportionate  to  the  calatiffe  difference  in  the  total 
number  of  caaea.  In  107  cases  thoro  was  absolutely  no  hifltory  of  a  neu- 
ropathic  ancestry-  These  Htatisties  show,  therefore,  a  history  of  neuro- 
pathie  heredity  in  aljout  thirty  per  cent  of  tbe  caaea.  This  is  slightly 
under  iha  average  of  most  writers.  In  only  one  inatence  was  there  eon- 
sidcrable  disparity  in  llie  a^es  of  the  parents,  the  father  being  45  and  tbe 
mother  If!. 

Alcoholism  in  the  ancestry  is  not  finch  an  important  factor  in  the  gen- 
esis of  epilepsy  as  the  writings  of  many  elinieiang,  eapecially  the  3Y6nehf 
would  lead  us  to  suppose.  Tii  itot  very  remote  times  muoh  stress  was 
laid  on  intoxication  of  one  oi  both  parents  at  the  time  of  conceptioa  as  m. 
causative  factor.  Naturally,  this  would  be  a  very  difficult  admission  to 
elicit  from  either  parent.  In  all  probability  it  plays  a  very  unimportant 
r^ICf  not  more  important  than  other  factors  acting  to  debilitate  profoundly 
at  this  time. 

TJudne  weight  should  not  be  given  to  the  caLi,ses  attributed  by  pa- 
rents and  patientSn  They  are  frequently  fright  and  injury,  but  both  artt 
often  consomitanta  of  a  £rst  attack.     This  is  well  illtatrated  by  a  re- 


: 


THE   TREATMENT   OF   KPILEPBY. 


445 


centLj  obBei'7ed  case.  The  fatLcr,  aa  iuteUigeut  man,  on  being  nekod  the 
oauee  of  the  diBeitso  which  dated,  according  to  his  Btat^mcnt,  frcim  the 
third  year,  said  that  it  waa  due  to  ft  prolonged  attack  of  aonvulsiona 
which  the  patient  had  abuiit  eexen  montha  before  the  epileitsj  began. 
Ha  had  b^en  informed  hy  Ihe  phyaii^iau  who  attt^iuled  thp  child  at  this 
time  that  this  attack  of  convulaiona  wa9  the  reault  of  conatipation.  It  is 
scaroeij  necfiaaory  to  add  that  the  oolamptio  attack  was  ths  original  man- 
IfHstation  of  the  epilefitic  neurosia.  In  the  majority  of  ca^ea  there  i9  no 
attrihuiable  c^use.  It  was  noted  in  53  crtsea  of  the  IcO  casca  here  Btud- 
ied,  the  attributed  causes  bt^ing  eimmerated  sua  follows:  Direct  injury 
from  a  fall  or  hluw  on  the  head,  22  ca»er^;  flight,  II  Gaae»;  shock  and 
oacitement,  5  caaea^  overwork  and  worry,  9  caeea^  teething,  3  coses, 
bathing  during  menatmatLon  was  the  attributed  canaoof  the  first  oonviil- 
Bion  in  3  cases,  This  is  worthy  of  not^,  as  a  number  of  writers  have 
remarked  that  the  orcurrenre  of  epilepsy  has  some  rehttlon  to  the  estab- 
lishment of  the  luefistpual  fum^tiona,  Casea  have  been  recorded  in  whieb 
tangible  cbstructiou  to  the  appeitrance  of  the  menstrual  flow  seemed  to 
Lave  osrused  aX  least  a  eymptoinatia  epilepsy.  In  16  oasea  the  epileptic 
attacks  were  the  reanlte  of  disease  of  the  brairi,  distributed  as  follows; 
Hemorrhagic  encephalitia,  5  ca*ies;  cerebral  apoplexy,  5  cases-  menin- 
gitis, 3  liiksss'j  and  brhiu  tuiuor,  3  cases. 

The  relationship  of  epilepsy  to  the  occurrence  of  acute  iafeotioua  dig* 
eases  ia  comparatively  insigui^cant.  It  was  noted  in  5  cases  only,  dis- 
tributed as  follows :  After  typhoid  fever,  1 ;  after  scarlet  fever,  2 ;  after 
repeated  attacks  of  msJ^ria,  1 ;  and  after  dysentci^',  1. 

Prolonged  and  dit^cult  labor  and  the  employment  of  anrgloal  aid  in 
delivery  does  not  adem  to  hsTe  any  definite  relationstip  to  the  oecurrence 
of  epilepsy,  judged  frum  my  own  histories,  although,  of  course,  epiltpay 
may  be  a  symptom  of  any  of  the  lufaotile  cerebral  palaiea  which  we  know 
to  stand  in  eonaiderable  relationship  to  dystocia. 

The  relationship  of  syphilis  to  the  occurrence  of  epilepsy  is  sometimeB 
quite  deteirtabEe-  [  am  not  H[>eaking  now  of  focal  epile^isy  due  to  a  sypli- 
ititio  neoplasm  or  syphilitic  inflammation,  [>ul  of  general  epilepsy.  In 
fonr  of  the  one  hundred  and  fifty  casea  the  disease  was  nonsiderod  to  bo 
due  to  syphiktie  diaeaae  of  the  blixid- vessels  and  resulting  luvolvcment  of 
the  parenchyma,  becaUise  the  histortea  showed  that  epilepj^y  had  foUoweil 
in  the  wake  of  ayplulia  within  Uve  years,  and  the  disea.se  proved  by 
its  response  to  antiayphditic  Lreatineiit  that  it  wjis  of  s>philiUc  origin. 
Three  of  these  patients  were  adult  males,  cue  was  an  adult  female. 
Throe  of  them  were  over  forty,  and  one,  the  woman,  was  twenty-three* 
three  of  the  acquired  cases  the  epilepsy  was  apparently  due  to  chronia 
alcoholism,  and  in  one  to  poisonmg  by  iead.  Gout  and  rheums.tism 
saem  to  have  ng  etiological  signt^cancej  although  in  a  number  of  fase^ 
in   this   scries  there   were  evidences  of  the  nric-acid  diathesis,    which 


446 


TRKATMRNT  OK  I>ISKA&KS  OF  THB  NERVOUB  BVSTRM. 


I 


was  iuterpreted  lu  a  pheDomenon  of  defective  metaboliBm  iccideat  to 
disease ^ 

Epileptic  coDvuUioTia  sometiJiies  oc«ur  in  connection  with  di^l 
but  whuther  the}^  are  de])eiiilent  upon  the  ktterur  t)ie  reverse  haa  not 
been  delermiued.  In  nut  ane  izaso  wua  there  nay  endeuire  that  ttt 
epilepsy  stood  in  causaJ  reli^Lionaliip  to  reflex  irritation,  aa  frum  the  ejos, 
earft^  gaBtro-intoBtinal  tract,  or  urugocital  apparatus,  although  in  nearly 
9VBTy  case  mention  wLia  made  tbat  tkia  had  been  ioquired  into,  I  do 
not  winh  to  ba  underf^bDod  that  there  wore  not  defective  cunditioiiB  of  the 
Bpeoid  »eiiiiG  organs  iii  &  intmbei-  d!  theKH  raaee^  ou  llie  I'ontrurjr,  ttere 
were.  These^  bo\yevor,  were  interpreted  aa  iKey  abould  be,  vii,,  aa  eri- 
dencea  of  disharmouioua  aomatie  dovelopmei^t :  stigmata  of  the  nearoatL 
The  intlueoce  which  maBturbation  ifl  said  to  have  on  tbe  occurrenca  of 
epLlepny  baa  no  light  Bhed  on  it  from  these  atatiAtica^  Many  of  the  pa- 
tiente  were  attdict^d  to  iuastarb»tioD,  but  this  ia  more  likaly  to  have  been 
a  result  of  tbe  epilepsy  tLiui  its  cause,  la  di:^uii^aiug  the  subject  of  th« 
so  called  refltx  epUepBieH,  it  muj,  therefore,  be  said  that  although  lieaj)^ 
all  writers  Btite  that  true  idiopathic  epdepsiea  may  bo  brought  out  faj 
reflex  irritatiuiif  this  surely  is  one  of  the  meat  uncommon  oaiiaes  of  the 
disease.  A  person  of  the  tieuropatliie  diathesis  may  be  thrown  into  an 
eclamptic  Doudition  or  into  a  condition  of  grand  hysteria,  fannerl/  called 
liyatero-i^pilepsy,  from  &oiqq  long-continued  peripheral  irritation;  hut 
07011  these  cases  are  rate.  It  would  bo  for  better  to  forego  ontireLj  the 
queatLoQ  of  the  reHex  origin  of  epilepsy  Chan  for  the  belief  to  be^-ome  en' 
geodered  that  such  oauaes  play  any  important  part  in  the  etiology  of  tbe 
disease. 

Careful  attention  and  study  should  be  given  to  tbe  eauaea  of  the  at' 
tack  of  epilepsyn  Errors  in  diet,  loading  to  indigestion,  constipation, 
hodily  and  mental  fatLgue^  and  exciteniant  of  all  kinds,  Imt  oepeciailj 
sexital  excitement,  are  tbe  OGinmonest  foreninuers.  The  importance  of 
obviating  thene  will  he  considered  iu  the  treatment.  Certain  exjierienecs 
would  beeni  to  have  some  indueuce  m  warding  off  atlocka  or  diniici^biDg 
their  number.  Of  these,  two  only,  the  occurrence  of  infectioua  diieasoe 
and  gestation^  require  mention.  It  has  often  been  uuled  that  after  aa 
epileptic  patient  has  had  a  severe  infectious  diseaae^  ench  as  typhoid 
fever  for  example,  the  attacks  of  epilepsy  will  be  very  much  less  fre- 
quent for  a  coaniclerable  time.  No  adequate  expluiiatioii  for  this  has  so 
far  lieou  suggested.  Occasionally  epileptic  uttpacka  are  very  much  in 
abeyance  during  gostatiun. 

It  will  readily  been  seen  from  tbe  disflusAion  of  tbe  etiology  of  epi- 
lepsy that  few  cases  ooneapond  in  all  importani  particulars.  Therefore 
there  can  lie  no  rule  of  thumb  in  the  treatment,  of  this  disease  Thia 
truth  unfortunately  seems  difficuU  fcr  many  lo  accept,  for  there  is  prob- 
ably no  diaeaae  in  which  routine  treatment  ia  more  closely  followed. 


THE  TEEATMENT  OF  EPILEPSY. 


44S 


tl«  first  e»seTitiaJ  Id  the  treaCment  of  npilepsy  is  individu&lizBtton, 
K»t  Ml  the  8cale  of  impwt&ncQ  come  p&tleuQe  liud  resourct^faliieaSf  bo1;ti 
oi  vliick  will  be  put  to  aerere  tesli  for  nft  wet^ka  &nd  mQitths  muHt  ba 
dtfTuted  Uf  the  treatment,  but  jeara*  We  may  not  even  then  be  able  to 
oreroome  the  diaeaee,  but  ^e  can  reduce  the  nutiih«r  of  Attachs,  and  u 
tbMe  aiand  in  direct  relationship  to  the  mental  aiLd  physical  M'elfare  of 
tlie  iadividu&l,  this  cousideTTjtion  ehoiild  be  fully  appreciated. 

Treatment. — The  bieatiueut  of  epilepaj  may  be  cona^dered  iindGr:  (1) 
Tlie  mtjiji  and  hjgienio  treatment,  which  inclLides  the  dietarji  diBc^ip- 
lioafy.  and  pedagogic  haadliitg  of  the  patientj  (2)  the  mediviual  treat- 
BOT.:,  urhieli  includea  not  only  the  drugs  CJiiployed,  but  tlie  time  »nd 
Dodo  of  their  adminiatratioD,  and  the  meafiurefi  taken  to  offeiet  their  dia- 
KgT^eabEe  effects^  and  (3)  the  propriety  of  surgical  interference, 

Tlie  therapeiiais  of  epilepsy  vari^a  according  to  the  form  of  the  dia- 
oue.  The  plan  of  treatment  that  is  applicable  to  primary,  idiopathic, 
ooogenit^  or  EO'called  essential  epilepsy  is  not  appr^ipriate  for  ayphili- 
^ty  trsiimatic,  and  accidental  epilepsy;  uar  la  the  treatment  of  either  of 
theae  the  same  oa  that  iudicaUrd  fL>r  epilepsy  >vhich  ta  dependent  upon 
purely  degoaerative  processes,  «uch  a^  parcoyphilitio  and  poat-inflamma- 
toij  degeneration - 

The  reason  why  phyaioiana  fail  ao  often  to  effect  such  pronounced 
tmehoratioQ,  ciot  to  say  cure,  of  epilepsy  as  to  satisfy  patients  and  their 
Eundica  is  because  they  neglect  the  moral  and  hygienic  treatment,  and 
depend  for  their  success  upon  the  admiaiatratiou  of  medicines.     Proper 
uii  aimultaneoua  use  of  all  givea  nuno  too  good  rasults,  and  no  ono  of 
tbem  shcuJd  be  neglected-     The  attitude  of  parents,  guardians,  and  care- 
tiken  of  epileptic  patienta  ahocdd  he  made  special  aubjecta  of  inquiry 
ind  inslnic^Lion  by  the  physician.      It  is  oftaotimea  aa  importanl;  as  the 
traaiment  of  the  patient  himsirlf.     There  ia  urgent  neces&ily  of  deputiz- 
ing the  entire  administration  of  medicines,  aa  well  ad  scrutiny  of  the 
diei  and  the  other  details  of  treatment,  to  some  intelligent  person  who 
it  devoted  to  the  inteTests  of  the  patient.     It  ia  wise  to  impress  upon 
pvHnts,  even  at  the  beginning,  the  nature  and  probahle  outeouie  of  the 
diaeaae.      Only  alniu'^  five  per  cent  of  all  cast^a  of  essential  epil^pey  are 
permanently  ouied,  even  when  treatment  is  carried  out  in  the  most  ortho- 
doi  way.     To  persist   in  this  protracted  and  oftentimes  discouraging 
tnatmeut  without  becoming  disheartened,  especially  when  no  oonaider- 
ib!e  progress  is  apparent,  is  often  very  trying,  and  parents  require  diplo- 
matic haniitiog  for  the  sake  of  the  patient.      The  pliyaician  who  foreuarna 
tod  ftt  the  flame  time  encourages  will  Lave  less  to  regret  and  he  teas  aub- 
ject  to  recrimuiation  than  he  who  does  not. 

Moral  and  Hygienic  Treatment.— The  moral  treatment— by  which  I 
trust  I  ahali  not  be  understood  to  mean  only  oonforiuation  to  canons  of 
ethica,  for  I  use  the  term  in  itg  broadest  sense— ia  particularly  adapted  to 


448 


TKEATUEMT  OP   DiBKASBd  OF  TUfi  NERVOUS  8VSTKH. 


the  tre&tinent  of  primary  or  esw^ti&l  apilepsy-  Thu  kind  of  epUepflf 
occurs  aaoot  commonly  at  %a  age  v]i«n  diaciplitiarj  lueoAured  aT«  re^kdily 
carried  out,  aad  are  moat  efficauious.  Habita  of  obedience  &ud  truthful' 
uesB,  the  testraint  of  paBfiione  aud  appetites,  the  mamteDance  of  enio- 
tioaal  efiuanimityr  of  temperate  lueutal  activity,  and  indiistrioos  applica' 
tioD,  fllLuiild  bfl  lastiUud.  The  educiLitiou  of  tlmtte  uiifartaDaLea  alioulil 
not  be  neglected.  Tliat  il  is,  however,  the  records  of  almost  every  town- 
ship  and  city  will  ahow.  Their  infirmity  rendeia  them  liable  to  self-in- 
jury, and  Its  mauiieatationa  ara  pn^judioial  to  the  happmess  and  welfare 
of  others.  Thus  they  are  the  pariahe  of  our  publio  and  private  schools, 
and  in  the  luwer  walks  of  life  tliey  soon  beecme  depeudenlji  of  the  com- 
luimity  or  tha  State.  Happily,  public  opiuiou  ia  being  properly  aioiued 
to  tbe  fact  that  the  State  ovtia  the  eame  duty  to  children  aBlicted  with 
epilepsy  that  it  does  to  othet  defectives,  and  id  many  States  institutions 
have  been  founded,  li^e  the  Craig  colony  in  New  York,  for  thd  care  and 
eduratitin  of  this  clasH  of  people.  In  truth^  the  institution  plan  of  treat- 
lueiit  for  epileptiRB  ie  the  idi>»l  one,  and  the  estHbliahment  of  such  epi- 
leptio  colooiea  in  many  of  the  States,  aa  New  York,  Ohio,  New  Jenoj, 
and  Ponasylvonia,  marka  an  importanl  etep  forwai'd  in  the  rational  and 
modern  treatment  of  Una  disease.  In  such  inatitutioua  epileptic  attacks 
can  be  reduced  to  a  miDimmn,  not  only  by  the  admiuistrution  of  anti- 
epileptic  mediciuea,  but  because  of  the  eaao  wid  thoroughness  with  whicb 
patients  can  be  made  to  couform  to  the  above- da  tailed  requlrementa. 
More  than  this,  the  patients  can  l>e  properly  educated,  mentally  aad 
physically.  Parents  who  are  uot  able  to  edaoate  thuir  epiteptio  children 
should  be  urged  to  entreat  them  early  to  the  salubrious  shades  of  sach 
iiistltutioTLfl.  The  educar^ion  should  be  uob  alone  of  the  mind,  but  of  the 
Benses,  and  parliculaily  of  the  hauda.  Many  epileplica,  if  properly 
ti-aiiied,  beeome  artiaana,  masters  of  handicraft,  and  Ubuiers  Bufficieatly 
skilful  to  earn  a  livelihood  and  oftii'n  to  compete  with  their  non-b&ndi- 
capped  fellow-men.  Now  aud  theu  an  epUeptio  ahowa  a  talent  for  one 
of  the  arts.  In  auch  cases  it  should  be  aafliduoiralj  cultivated-  Modem 
methods  for  the  educatiou  of  ba(;kward  children  whic^b  teach  maiiilj  by 
object  l^aons  are  the  best  means  to  this  end-  Such  details  may  seem 
pedantic,  but  thi>7  are  warrauted  by  the  hupeloesucss  of  these  coses  if 
allowed  to  go  on  without  other  and  more  intelligent  aurveillanoe  than  that 
of  the  unenlighteDed  parent.  The  carefully  trained  leaoher  and  the  in- 
telltgtfnt  pbysiciau  must  collaborate  to  make  the  best  possible  citizen  oat 
of  the  epileptic  child.  lusiituttonal  treatment  where  all  iheae  forms  of 
mental,  physical,  ond  moral  dcvelopmeiU  can  bo  engendered  ia  the  ideiJ 
one.  The  neceaaity  for  beginning  the  education  and  treatment  of  an  epi* 
leptic  «arly  in  the  rliseaae  before  the  formation  of  what  may  be  called,  for 
wont  of  a  better  mimi?,  the  epileptic  habit,  is  very  ImportanL 

The  hygienic  treatment  of  extilepay  is  embraeed  in  the  mode  of  life 


THE  r&C4TU£XT  OT  KPILBFST. 


449 


of  Utce«  pakiepta,  tLciz  hftbita,  indulgeiioes,  diet*  enrciw,  uid  iKcnp^- 
tUQ,  &ad  tb«  p<>aitioTi  whicb  the  pbjstcioD  t^kea  in  re^rud  to  theu  oa- 
ttU^itioD  of  GQch  fvnetioQB  or  obligatiooa  as  nifttniaoaj  tud  patefuity. 
Otoaatie  conditious  do  not  aeem  to  «iit^r  into  the  matter.     T!ie  mode  of 
llfa  of  an  epileptia  patieai  sboald  be  one  tb&t  icaurvs  &e«dom  from  bur- 
densome care  and  lauch  r^apocisibilit^,  aud  oue  tb&t  promotes  meutal 
rvcniieas,     This  is  mora  idealistic  thou  utOitftiiuL,  And  often  the  patieat 
suurt  perforce  make  a  <^>mproiiuse.     It  ia  needless  to  saj  ihsLt  L«  should 
be  urged  to  make  the  one  that  is  most  conducive  to  these  «Dds.      The 
contnetinn  of  all  habits,  unless  imifoTm  occupation  be  considered  a  halitt, 
is  to  be  deprecated.     Tobacco,  alojlK^l,  and  other  unnec^^&ry  Imuries 
■hich  may  be  injuriooa  to  the  nervoos  «j9tem  ehould  be  absolutely  for- 
bidden.    The  period  of  pubertjr  ahoiild  be  carefully  guiirded,  aa  epileptioB 
ue  particaliU-lj  prone  to  indulge  earlj  and  most  e:tces5ive1j  in  masturbft- 
ton,  and  as  many  of  them  lack  tbe  capacit:y  of  rvj^traint  &nd  are  mseu- 
sihle  U>  the  deleterrons  moral,  mental,  and  physical  effects  which  such  la- 
dol^enco  has,  the  gre^tf^at  care  should  be  taken  to  prevent  the-se  habits. 
Although  it  is  impossible  and  often  impolitic  for  a  physK^ian   in  any 
way  to  interfere  with  the  development  of  normal  paasions,  euoh  aa  htvB, 
marriage  for  the  congenital  or  essential  epileplir;  should  be  unequivocally 
advifted  against.     Every  neurologist  encounters  not  a  few  palieuts  who 
hare  been  advised  by  their  family  physioians  to  zuariy  bec&use  of  the 
supposed  miraculuus  influence  that  marital   obligattone   and   maternity 
vill  have  on  tliia  majestic  neorosis.      Such  advice  is  eonceived  in  dia- 
hsftrtcaiD^  error  to  the  enormous  disadrantage  of  the  ttu>s.     When  suoh 
individuals  imiist  u]Kin  marrying,  despite  the  advice  of  the  physician  to 
ths   TOotrary,  they  should   he  urged  to  avoid   procreation,     Jlaturally, 
tb^ss  strictures  do  not  apply  to  other  forms  of  epilepsy  than  the  easen- 
tiaL  variety,  unless  one  believes  in  the  tranamtssion  of  acquired  (.'haracter- 
isties;  but  in  every  case  the  neurally  aound  member  of  the  contracting 
parties  should  be  fully  tohl  of  the  obligations  that  are  being  assumed, 
and  be  made  to  see  them  through  eyes  uubJlndcd  by  It>ve. 

Reference  haa  already  been  made  to  the  selection  of  an  occupation  or 
profession  for  the  epiicptic^  Too  much  c^ire  cannot  bo  expended  in  aid- 
ing tbe  patient  in  choo^iDg  a  calling  which  will  not  be  attended  with  dan- 
ger, providing  attAcka  should  oi^Lir  during  its  pnrauiL  Unusual  oa?s 
\t  be  taken  to  maintain  tlie  bodily  beallh  and  tone  of  the  epileptic  pa- 
iti  therefore,  s<mie  form  of  exercise  is  of  prime  necessity.  Any  exer- 
cise that  is  Dot  attended  with  great  physical  effort  or  that  will  not  jeopar* 
diae  hfe  or  limb,  if  an  attack  should  occur  while  he  h  p&Ttii.'ipatiiig  in  it, 
is  to  be  allowed  and  recommecded.  Of  the  sports,  golfing  is  the  Ideal 
DDtt,  although  bicycling  may  be  engaged  in  if  ordinajy  precuuttors  ars 
taken.  Such  violent  aports  aa  riding,  teanis.  football^  and  rowing, 
iDostt  of  coorae,  be  avoided,  except  under  special  conditions.     What  has 


450 


TBEATMBHT  OF  DiBffiABBS  OP  THB  NBHV0U8  SYSTfilM, 


been  said  of  exercisa  applies  alao  to  amusemeoU^     Tbero  «r«  very 
unuflejiieuts  tlmt  aii  ^pileptiR  f^liould  be  prevt^uted  from  eujci^icjE-     T 
tie-goiug  iu  moderation,  6H|>ecLu]ly  lu  tLe  aft«rni>oni  eocial  iiLtercou 
if  the  meatal  etate  of  the  patient  allows  it;  parlor  gameB  and  tbd  U 
frU  lielp  to  lesseiL  tlie  mouotonj  of  wha^t  la  ofteutiiaea  oa  aJiiiost  intjo 
able  eiciat^nce.     The  asHiim[^tir.in  and  dieobarge  of  social  and  fiolit-:: 
fuTictiona  hy  epilepiif'S  will  vnry  with  each  iudividuaj,  and  will  liav^^ 
be  dsddEid  ac(;urdiog  t<>  tlio  meutal  ijevelopuieut  of  the  p^ienb  aniL      *. 
exigeiiuiiia  of  each  cjise.      In  n  word,  it  may  be  amd  that  a  ijer^ua    ^, 
haa  epilepsy  ahoold  be  advised  to  couform  hia  cotid^nt  and  iiidulgr^u^ 
to  those  of  a  normal  individual,  providiug  they  do  not  int^rfera  with  t^^ 
regularity  und  equal  arraiigeiueiit  of  liis  life.      TJia  exception  l»  tLia  nii« 
is  luatHmouy,  which  should  eLreuuouAly  be  adrued  aj^ainaL     Epilepiiy  ii 
adibea:^  the  treatment  of  w  hi  oh  calls  for  tlie  takiugof  lar^  quantities  of 
di'Liga  which  aot  ae  a  powerful  depressant  to  the  body  and  to  the  otuid. 
In  order  to  counteract  tlie  iiijurious  effec'ts  of  these,  tired  nature's  sweet 
restorer,  balmy  aleeji,  must  be  obtained  in  liberal  amount. 

Dietary. — Muro  important  than  all,  perhapa,  acd  vtry  much  mon 
important  than  any  one  of  them,  la  tlie  queation  of  diet,  It  la  probable 
that  more  bcnetit  would  follow  regulation  of  the  alimentary  canal»  main- 
teuauuo  of  digeBtion  and  nutrition  than  from  the  administration  of  the 
most  pnwerful  an ti -epileptic  dtwg.  Like  other  functioba  of  the  body 
in  epileptJcBr  thotie  of  digestion  and  aliiiL  en  ration  are  often  impaired; 
when  the  patient  ie  unablo  to  reatraiu  the  appetite,  diaaatroua  couae- 
quences  frequently  result.  At  one  time  it  was  generally  tauglit  that 
animal  proteidB  should  not  be  oonsuuicd  by  pereoaa  auSeting  from  epi- 
lepvyr  or  if  so  at  all,  then  in  tbe  greatest  moderation.  Those  who  r«<- 
ommended  such  a  plan  wtro  often  ahlii  to  fortify  ilieirclaims  by  eitatiatici 
ahowUig  tbat  the  uuiaber  of  epileptio  attacka  in  certain  indiridEiala  wii 
often  considerably  lese  when  they  were  not  allowed  to  eat  meat-  The  jw«f 
koo  pn/rtcr  koiy  of  tliifl  argument  is,  however,  n  most  fallaeioua  one :  cut- 
ting otF  the  animal  foods  ofttn  givps  the  overburdened  digeative  tr^ct  an 
opportunity  to  rest,  and  cauaea  a  partial  ceaaatioa  in  the  formation  and 
aooumnlation  of  Uje  pnidnnln  uf  incomplete  digestion  which  on  Lieing 
abaorhed  into  the  eyatem  exercise  a  pernicious  effect  npou  the  highest 
nerve  centres-  Moreover,  it  allows  oxidation  and  metaboliam  to  go  on 
more  vigorously  and  completely,  as  the  curbonaceoua  element  is  retativelj 
greater  iu  tbe  other  food  stuffs^  Thus  benefit  for  a  time  aeems  to  follow 
the  elimination  of  aoinial  protelds  from  the  dietary.  Far  greater  benefit, 
however,  ia  eecured  when  the  entire  dietary  i&  carefully  scrutinized  b>- 
the  physician, 

Tha  dietary  of  iheepileptie  patient  will  depend  largely  upon  the  patient 
himself.  For  young  epilepties,  milk  is  by  all  means  the  moat  important 
foodstuS,  and  children  should  be  timitf^d  to  It  and  to  the  ^a^ity  digested 


k 


THB  TREATMHKT  OF  BPILEPSY. 


451 


I 


I 


cereals.  On  the  other  band,  a  mixed  diet,  with  meat  cnce  b.  day,  tto  grBen 
ve^retableti,  (5CH»ked  I'm it4  and  easily  digestible  coreala  predouiiti^tlcig,  witb 
plenty  of  Wriber  between  ineabft  ia  beet  for  tbe  adult.  Nd  porticuliir  ad' 
vantage  is  bad  from  the  excessive  admiuistrdtion  of  fata,  unless  tbere  ia  a 
tendency  to  Bubnormal  bodily  tenipcrature.  Fermeuliblo  aubstanoes  in  the 
diet  and  those  difficult  of  digestion  are  to  be  avoided.  In  many  ca^es  the 
atarcbes  ^nd  engar  nre  partic^ularly  causatire  of  indigestion.  Yoracioiia 
appetites  are  to  be  restrained,  and  food,  takea  alowly,  should  be  properly 
masticated  and  insalivated.  Aa  a  rule,  tea  and  cofFee^  aa  ivell  as  all 
ctber  Qubfltances  that  are  not  partiotilarly  nourisblDg,  should  be  avoided. 

Jtedtoinal  Treatment  of  Spilepsy.^I  sball  speak  of  tlie  jrtedioinal 
treatmeut:  of  epilepsy  under  two  heads:  (1)  The  tpeaiment  of  the  neu- 
rosis^ and  f2)  the  T.reatnient  of  an  attack.  I  sball  keep  in  mind  the 
more  or  leas  typit:al  tafio  cf  priuiary  or  essential  epilepejj  for  this  ia  the 
form  in  which  medicinal  treatmeut  is  attended  with  Teiy  conflidtrable 
Buccoas,  and  beaauae  mediolne  is  of  moat  value  in  the  treatment  of  tbia 
variety.  The  reason  why  bo  many  eases  of  epilepsy  under  the  car^  of 
the  general  practitioner  are  not  vwy  uiucb.  benefiit-d  for  all  lime  by  treat- 
meat  LS  that,  although  the  proper  drugs  are  given,  yet  this  is  not  com- 
bined with  proper  attention  to  the  mode  of  admin iatration,  and  to  the  de- 
tails of  general  treatment  before  mentioned. 

The  one  great  drug  in  the  treatmi^nt  of  epilepsy  la  bromine.  If  all  other 
medioinea  having  reputation  aa  anti -epileptic  remedies  were  lost  to  the 
profE^Bsion,  treatment  by  this  drug  alime  would  give  a.s  goud  results  as  are 
had  from  all  to-day.  3iiiv:e  their  ialroductiQa  by  Laycock  half  a  century 
ago,  the  flalta  of  bromine  have  grown  steadily  in  favor  aa  an ti- epileptic 
agencies,  until  now  they  aie  universally  conoeded  the  first  place  by  those 
boat  fitted  to  judge.  That  tbey  leave  mnch  to  be  desired  in  the  treat- 
ment of  the  disease  goes  without  saying,  considering  the  prognosis  of  the 
disease  eveo  when  treated  in  the  inottt  approved  way.  One  of  the  most 
important  lessons  U^  bo  le&cned  by  the  physician  who  essays  to  trf-at  epi- 
lepsy IS  that  they  alone  do  not  exercise  a  eufficient  action  upon  the  dis' 
ease  whatever  ita  nature  may  be.  It  does  not  seem  to  me  that  the  seleo- 
ticm  of  a  partioiilai-  salt  is  <jf  sufBcient  importance  to  merit  couhiderible 
discusftloM.  hy  some,  perhaps  by  ■the  majority,  bromide  of  potaasmm  is 
cousideted  superior  to  any  of  the  other  salts.  On  the  other  band,  many 
prefer  the  bromide  of  smlium,  not  o^dy  because  of  its  higher  percentage 
of  bromine,  bat  because  it  is  more  agreeable  to  talce  and  Usa  apt  to  de- 
range the  stomach.  Bromide  of  strontium  haa  been  very  succeBsful  in 
the  hands  of  many  praetitioners,  and  now  and  then  some  one  dilates  on 
its  sujienonty  as  an  aoti 'epileptic  agent,  Roche  has  recently  repeatedly 
taken  such  a  stand.  Long  trial  of  it  entitles  me  to  tbo  opinion  that  it 
has  no  peculiar  virtue,  and  that  it  ia  less  reliable  than  either  the  bromide 
of  potassium  or  of  sodium.     As  a  matter  of  fact,  U  is  advisable  to  hegm 


452 


TfiEATMENT  OP  DISKASRS  OP  THE  NKRVOUfi  8TSTEU. 


U^^j 


the  treftlment  c£  epilepsy  with  one  of  the  latter  s&lta,  aitd   if   this  ia 
well  tolemted,  or  as  efficacious  a«  it  should  be,  auother  se^t  of  brumiiia 
or  &coi&b]ii&tioti  of  them  should  be  trieil-     Occaaiouoll^,  ouch  combioA^ 
tioUj  eapei^ially  if  given  wtth  aids  to  digestioB  Kod  with  hydrolrc 
ftoid,  seems  to  be  mote  b«ii«ficia]  than  a  flolutton  of  a  smgla  s&li. 

The  bromide  r^ui  be  iiJiiiinistered  lo  the  beut  ailvautage  if  some  defi< 
nite  solution  of  the  salt*  &uch  as  a.  tweuty-^To  or  a  ^fty  per  c«ju  waterj 
solution,  be  used  &s  a  staudard.     It  is  impoi^^ble  to  aaj  what  the  dose  of 
the  bromine  salt  should  be.     There  is  no  niiora  dosago  acoordinj*  to  weights 
and  measurts  than  there  ia  of  al(]ohol  for  a  patient  with  typhoid  fevei. 
The  doAe  ia  the  amount  the  patient  can  dispose  of.      For  one  patient  it 
ma/  ba  a  somplo  twice  a  day,  for  auother  it  may  be  a  drachm  or  tro 
drachma:  it  la  neceasary  to  mako  an  individual  study  of  tacb  cai».     It 
is  as  ridiouloua  to  j^ay  that  the  dose  of  bromide  for  an  epiJeptic   ia  a 
Aompld  four  times  a  day  afl  it  is  to  saj  that  the  doee  of  quiuine  in  malana 
is  fi'S  grains  three  times  a  day.     Xo  rational  person  would  think  of  giT> 
ing  the  latter  direcUons,  and  no  perauQ  who  baa  had  exjit^rience  in 
treatment  of  epilepsy  would  be  likely  to  contend  for  the  former. 
bromide  must  be  given  up  to  the  point  of  tolersoce,  up  to  the  complete 
neB3  oL  its  physiologica]  acbiouj  up  to  the  dosage  that  ooutrols  the  attack^ 
uid  then  Buch  doaage  maiciainedf  while  measures  are  taken  looking  to 
ths  maintenance  of  nutrition  and  to  the  preTention  of  the  doininancy 
toxic  manifestations. 

After  the  detaiU  have  been  arranged  to  the  Batiafaction  of 
physician,  he  should  study  a  chart  made  with  the  eud  in  view 
showing  the  frequency  and  time  of  the  attacks,  that  is,  whether  ih 
are  matutiual,  nocturnal,  or  periodic,  and  whether  they  have  any  r^Ia" 
tioTiship  to  the  occurreuce  of  physiologiea!  fuuclioii,  such  as  menstru- 
ation, sleep,  etc. ;  whether  they  are  of  a  petit  mal  or  of  liaut  mal  char- 
aeter,  and  whether  they  are  preceded  by  nu  aura.  If  the  attacks 
always  matutinal  the  large  dose  of  bromide  should  ba  given  ^>cfore  th 
patient  arises }  while  if  they  are  mainly  nocturnal,  the  large  do€e  shoul 
be  given  on  fetiring.  In  tliuae  cases  in  which  there  seema  to  be  no  deti 
nite  time  for  the  occurrenoe  of  attacks,  and  in  patients  who  are  occ 
pied  during  the  day,  it  is  my  custom  to  giro  a  aniall  dose  of  bromide  i 
the  morning,  eay  from  fiftenu  to  thirty  grains,  another  during  the  aftei^ 
noon,  and  u  comparatively  large  dose,  double  the  above  quantity, 
night.  This  plan  has  the  advantage  that  it  facilitates  sl^ep,  and  d 
nob  produce  sufEicient  aiupor  to  interfere  with  the  patient's  waktug  lime. 
As  a  rule,  the  drng  should  be  given  immediately  before  or  just  after  a 
meal,  unless  it  be  desired  to  get  its  immediate  effects^  when,  of  course,  it 
as  most  advantngeoualy  given  when  the  atomach  is  comparatively  empty> 
Seguin  has  called  particular  attention  to  the  advantage  of  giviug  the  salt 
welt  diluted^  in  some  alkaline  wat^r  such  as  Tichy^  or  for  poor  patients 


THB  TRBATUBNT  OF  EPrLEPSV. 


468 


I    in  viter  maile  aHghllj  alkaline  by  the  additicjii  of  bic^a^bol]&te  uf  aoflium> 
Tlwiuore  liberally  th©  doae  of  bromide  is  diluted  the  bettor  will  bo  ita 
effect. 

Aftdr  the   dosage  of  the  salt  o£  bromine  has  been  determined,  ita 

^■JodiUBtratioD  should  oot  be  loterrujtted  ud1^3s  special  conditions,  auch 

Hi  tbtt  occLErreace   of    acute    adjuaiuic    diseafit^,   demand   6uch   proi»- 

dmfl.    Statural  siatcs,  such  as  pi^^uancy  and  lactation,  are  not  ma- 

t«rullf  aOet-ted  by  the  tLdm-inistration  of  bromine,  although  the  effeote 

of  the  dnig  given  to  an  epileptic  mother  are  manifest  m  the  nuraing 

dull     But  as  epileptic  mothers  should  not  be  allowed   to  nurse  thsir 

ebildreOf  this  doea  not  reqaire  further  consideration.     During  preguiiiicy 

Bpeciil  oaf©  should  be  taken  to  prevent  the  occutrenco  of  epileptic  at- 

I  ttdifli  and  as  the  bromides  do  not  seem  to  have  an  injurious  ^ect  uj>oii 

f  ^  ("fitas,  tbeir  adnainiBtmtioQ  sliould  be  kept  up  in  the  customary  way 

during  this  periorl.     I  desire  to  rept^at  that  tha  desultfiry  and  irrationnl 

adiainistraLion  of  this  medic&Dient  is  wurue  them  no  brouiide  at  aX],  and 

pvticul^ly  as  euch  treatment  h^s  very  little  effect  upon  controlling  the 

utackdr  the  morale  of  the  patient  becomes  shattett^d  and  his  hearty  co- 

oppfatioa  is  diffieult  lo  aeeure.      If  satisfactory  results  do  not  follow  thi» 

plan  of  giving  the  bromifles,  they  should  he  withdrawn  and  some  other 

uti-epileptie   remedy  substituted,   or  used  in  conjunction   with   them. 

The  duration  of  the  bromide  treatment  will  depend  largely  if  not  entirely 

span  the  effects  that  it  produces,  aod  particulaily  the  extent  to  which 

the  actftoks  are  controlled  by  it>     There  should  be  no  thought  of  dimin- 

uhing  the  ijoae  that  controls  the  attacks  until  at  loast  two  years  after 

the  occurrence  of  the  last  attack.      After  suuh  a  period  tfie  amount  of 

hromido  may  be  diminished  from  one-third  to  one-half  duriug  the  eusu- 

ing  jear-      No  case  should  be  considered  cured  until  the  patient  has 

gone  at  least  four  y^nrs  witliout  an  attack  while  taking  the  drug  aud  an 

ftdditiooal  year  free  from  attacks  without  taking  the  drug. 

In  this  coniieclion  a  few  words  may  proGtablj  be  devoted  to  the  abuse 
of  the  bromine  salts,  I  know  of  uo  drug,  with  the  e:iception  of  those 
which  produce  habits,  such  aa  morphine  and  cocaine,  that  is  ao  enor- 
mously outraged  as  the  one  in  questiouH  If  the  tmtb  be  told,  the  thera- 
peutic use  of  the  bromides  is  very  limited,  and  tho  disease  under  coosid- 
eratioQ  is  the  only  one,  e^^-eptiiig  pos.'iLbly  migraine,  that  justrfiea  the 
oootinuoua,  persistent  administration  of  largu  quantities  of  any  of  the 
bromine  salts-  The  custom  frequently  followed  of  ptescribing  bromide 
ms  a  sort  of  piek-me-up  merits  the  same  c<mdemnatory  language  as  that 
need  by  temperance  advocates  against  the  prescribing  of  alcohol  It  is 
necessary  to  witness  only  ont^e  the  colossal  mental  and  physical  depravity 
which  sometimps  results  from  the  ignormit  administration  of  this  drug 
for  minor  ailmeuts,  and  sometimes  even  for  epilepsy,  fully  to  appreciate 
the  truth  of  this  statement- 


TREATMEl 


a.— 

i 


The  PlLeaomeaa   of  BTomide  IntoziistioD  and  Sromide  Cacli«xi&.— 

That  the  bromidoa  maj  Uq  givQQ  fiUGCCBsfully,  thg  plij-aiulijgk'^  act 
and  the  tQxJc  effeota  of  the  drugs  fihoutd  be  kept  ^vell  in  n^md. 
more  common  acatd  toxic  manifestation  a  of  its  uee  form  a  group  of  ey 
toma  which  has  been  described  &fi  bromide  iDtoxi(?atioii.  These  ^-ou^ 
of  TasoiuotoT  depression,  attntded  with  cold  extremities,  oJammT  skio, 
alightl/  depressed  bt*Jily  temperature,  aud  Icjweriugof  the  Tital  capacity'; 
coated  tongoe^  fetid  breath,  lo33  of  the  palatal  arid  pharyngeal  reflex, 
Btomaobic  catarrb,  depressioD  of  e^Kual  vigor,  myasthenia,  particularly 
manifest  iu  the  leg9}  unsteady  gait  and  station,  forgetfulnt-ss,  sJight 
greea  of  aphjisiu,  usually  eridemied  by  the  misuse  uf  words  and  th 
transposition  in  a  sentence;  slowness  vt  mental  rea^uBe,  inability  to  co' 
ordinate  complex  mental  processes,  and  often  a  considerable  degree  of 
dementia,  which  is  probably  due  botli  to  a  direct  action  of  thfi  drug  npoij 
the  protoplasmic  processes  of  tlie  eorttual  gajiglion  cells  and  to  a  eerous 
accumulatiriD  in  the  perivascular  spaces  like  that  which  occurs  occasioD- 
G.Uy  in  acute  alcoholism,  nud  fi-equently  in  chronic  alcoholiHrn^  forming 
the  anatomical  baaia  of  alcoholic  pseudo'^paresis-  The  poisoaous  eS'ects 
of  bromides  on  the  skin  ore  often  the  earliest  to  dcrclop,  They  couatit 
of  an  eruption  of  acne^  uauidly  on  the  face  and  shoulders,  and  cf  circtuu- 
flctibed  ul<^erations  'which  may  become  phagedenic.  In  acute  bromine 
poisoning  the  symptoms  may  develop  very  rapidly,  and  to  overcome  it,  it 
is  not  only  necensary  I^j  cease  giving  the  drug,  but  bo  adopt  most  vigorous 
measures  to  combat  the  evidences  of  lowered  vitality.  It  has  already 
been  said  that  □ccasionallj  the  symptoms  are  parallel  to  those  of  grave  ia- 
traoranial  trouble,  such  as  braiu  tumor- 

The  severe  manifestations  of  bromiam  can  be  counteracted  by  the  ad- 
mint  stration  of  restoratives,  cardiac  and  vaaomotor  tonics,  by  drugs  that 
havea  epecial  beneficial  influence  upon,  the  skin,  and  hydriatic  procedures 
that  contribute  to  the  integrity  of  the  cutaneous  ciiciilation  and  at  the 
same  time  improve  nutrition.  By  meana  of  these  measures,  a  daily 
dosage  of  what  would  otherwise  be  toK.ic  can  be  given  without  harm- 
ful results.  Tlie  avenues  of  ehmiiiatioii  of  the  bjdy  should  be  kept 
in  active  condition  by  the  use  of  warm  water  and  soap  on  the  skin^ 
and  by  the  appropriate  use  of  intestinal  antifermeDtatives  and  laxA- 
tives.  Urdinaril}',  the  vehicle  used  for  the  administration  of  the  bro- 
mine salts,  alkaCmated  waters,  gives  all  the  diuretic  e^ect  that  u 
requisite^  but  now  and  then  it  becomes  necessary  to  stimulate  the  kid- 
neys vigorously  for  a  time.  The  most  important  measure  to  overcome 
the  severe  acne  which  often  attends  the  administration  of  the  bro- 
mides, aside  from  the  maintenance  and  increase  of  nutrition,  ie  soma 
preparation  of  ardenic,  preferably  arsenate  of  soda.  Uulike  Fowler^s  so- 
lutiOQ  thiB  preparation  rarely  deranges  the  digestion.  It  should  b« 
given  in  moderately  large  doses  for  a  short  time,  two  or  three  weeki,  anct 


M 


THE  TREATMENT  OB*  ETO^PSr- 


455 


I 


then  iateruiitted,  and  tli©  patient  encouraged  to  diuik  freely  of  water. 
If  trophio  manifeBtationa  reveal  themselTea  by  ulceration,  the  patienii 
ehould  be  put  to  bed  acid  tbe  nlcera  treated  accoTdiog  to  the  principles  of 
modern  surgery,  while  the  patient's  vitality  is  enbaneed  by  appropriate 
food,  touioSt  aiid  atiiiiidaiits,  aiid  of  the  latter  opium  nould  eeem  to  be  tte 
beat.  The  best  all-araund  vasomotor  ianicj  stomachic,  aad  geiieral  resto- 
rative is  uux  vomica  or  its  alkaloid  atrjchnine,  which  may  be  adminis- 
tered eoinbiued  with  dilute  hydrochlorio  acid. 

If  the  flyiaptome  of  ckronic  bromism  become  dominant,  the  patient 
being  pale,  with  dry,  crisp'looking  membranes,  stuporous,  forgetful,  slow 
of  breath  aod  of  heart,  deprBflsfl{3,  suicidal,  auil  emaciated,  I  have  fimiid 
&  course  of  tonio  hydrotherapy,  associated  with  the  administiation  of 
opium  in  small  dofiee,  tho  bost  mcann  of  combatLng  them.  Opiuni  seems 
to  prevent  the  neural  protophii^m  from  wearing  itself  out  in  futile  endeav 
OTfl  to  overcome  the  rapid  waste  of  body,  and  to  stay  the  latter  until  rest 
and  nutritifm  can  reBtj}re  it. 

Wlxen  the  toxic  effects  of  the  bromides  are  manifest  by  inhibition  of 
aejtual  vigor  and  by  dcreUoticn  of  the  veeicol  sphincter,  belladonna  is 
often  of  real  eerviee.  It  has  In  its  fav^^r  the  fact  that  it  of  itself  is  cou- 
Bidered  no  mean  asti-epileptic.  The  most  potentaid  to  prevent  brom:sm 
aod  Ita  terrible  consequences  is  the  nse  of  hydrtatica.  Tte  patient  who 
loses  neight  aiid  becomes  EUi^miCf  baa  lowered  mental  and  physical  vital- 
ity, with  evidences  of  profound  vasomotor  disturbance  arid  glandular  in- 
activity^  is  often  started  in  the  opposite  direction  by  taking  a  rain  bath 
or  oo\d  ablution  in  the  morning,  followed  by  vigorous  rubbing  and  towel- 
ling, or  other  measures  to  promote  reaction.  Better  still,  whenever  it  is 
poMible,  these  patients  ahould  take  now  and  then  a  course  of  treatment 
in  some  one  of  the  hydriatic  iustitutee  wbich  are  now  found  in  most  cities 
of  any  considerable  ai^e-  They  may  be  replaced,  however,  to  no  mean  aii- 
vantage,  by  cold  ablutions  and  the  cold  splash  bath,  CJiution  should  be 
used  in  preeoribing  the  cold  pluuge  or  th&  cold  shower  for  these  patients. 
Their  impaired  vitality,  due  not  alone  to  the  admuiistration  of  the  bro- 
mides but  to  the  devit^i^ing  effects  of  the  disease,  often  prevents  them 
from  reacting  sufficiently. 

If  for  any  leason  it  becomes  advisable  materiaUy  to  diminish  the  dose 
of  bromide  that  the  physician  haa  determined  is  necessary  to  hold  the  at- 
tack nf  epilepsy  in  abeyarue,  I  cucisbler  the  safest  plan  to  be  that  of  ptit- 
ting  the  patient  to  bed  and  keeping  him  thereuntil  the  usual  dose  of 
bromides  can  be  administeted.  Naturally,  during  such  a  time  special  at- 
tention should  be  directed  to  the  alimentary  tract  and  avenues  of  elimi- 
nation. 

Ucdiclnal  Adjuvants  of  the  Bromides. — The  most  important;  adjuvant 
of  the  bromidea  in  the  treatment  of  epilepsy,  in  the  experience  of  tlio 
writer,  ia  opium.     Its  value  in  some  oases  of  epilepsy  haa  long  been  oom- 


456 


TREATMENT  OF  DISEASES  OF  TBB  NBRVOTTS  &YBrBU. 


mon  knowlodge,  but  rB(?.eutly  Flecbsig  and  (ithera  have  called  at!:«Dl 
anew  to  its  uElicaciousneaa  wben  giveu  according  to  a  certain  jilan  in  Bi 
caBCB  of  eflseulial  epilepsy  which  Bhow  theiuselves  tidud enable  bo  the 
midea  aloiiQ*  The  plau  ia  to  give  ordiaarj  extract  of  opiuoi  ia  from 
to  tea  griiins  daily,  the  maaimum  qLiantity  being  reaolied  boou  aftct  it] 
begun,  if  possible,  and  kept  up  for  six  weeks.  At  the  end  of  tbat 
the  opium  ia  stopped  abruj»tly,  and  oue  of  the  bromine  aalta  given 
ixiin[taratively  lur^^e  doses,  about  two  diachius  daily.  After  a  few  w* 
vBTjiug  Bci'qrdLiiff  to  thfi  evideiiceo  of  bromism  produced,  the  quanti^f 
reduced  ouo-halff  and  later  this  can  be  diminished  to  thirty  or  fi^rty  grain} 
a  day,  in  souka  instaucea  to  eveu  less  than  this-  In  my  own  experience 
the  attaeks  of  epilepsy  cnii  ba  materially  reduced  in  this  way  In  almost 
eveij  cafie  tliul  haa  shown  itdtlC  obstinate  tc  the  oriliaar>  bromide  plan- 
After  a  year  or  ao,  if  the  attacks  aie  not  kept  iu  abeyance,  the  opium 
may  be  repeated.  I  have  not  Been  any  deleterioua  resulls  follow  the  em- 
ployiuent  of  tUa  drug  in  this  fashion. 

The  combitiatioa  of  equal  parts  of  chloral  aiid  bromide  vhirrh  is  adro- 
oated  by  8e^iin  in  certain  cases  has  been  put  to  tho  hwi  of  considerable 
perscnsJ  experience,  aiid  although  there  can  be  no  question  of  the  Talae 
of  such  combination,  eapeoially  in  tlie  treatment  of  nouturnul  epilepsy,  I 
have  had  altogether  lesa  gratifying  results  from  its  use  than  from  that  of 
the  opium- bromide  plan.  The  danger  of  forming  the  chloral  habit,  it 
should  be  eaid,  diH^s  nut  avuin  to  \i&  bo  groat  when  the  thloral  is  given  in 
this  way  and  for  epilepsy  as  it  does  when  taken  merely  to  produce  aleep. 
Of  the  other  drugs  that  have  been  persistently  advocated  in  the  treat^ 
Pient  of  epilepsy  by  clinicians  whose  names  are  BycoDymoue  with  integ- 
rity, borax  atid  belladonna,  aud  possibly  adouis  vemalis,  are  the  taM\ 
important,  I  have  had  conaideraljle  experience  in  the  use  of  Ijorax  in 
epiVipHy,  but  I  have  never  been  able  to  conviure  mymM  that  its  effect 
upon  the  diseiuie  is  at  all  comparable  to  tliat  of  the  bromides.  Vei  Gov* 
ers,  who  introduced  it  as  an  auti-epileptie  agency,  haa  recently  testified 
to  ila  frequent  elfioAcy,  In  cases  in  which  for  some  reason  the  bromides 
cannot  be  given,  it  is  one  of  the  best  substitutes,  Tt  shf^nld  be  given  in 
powder  or  oolutioUf  6fte^n  to  thirty  grains  three  tujies  a  day.  As  a 
rule,  the  only  had  eSect  of  auoh  administration  is  an  occasional  attack  of 
pooriaaiB  which  can  b©  mmbatcd  by  givmg  arBonic,  but  bortix  haa  a  ten- 
denoy  to  derfinge  the  giatro-ioteBtinal  tract  and  to  irritate  the  kidneys, 

Belladonna  and  its  alkaloid  atropine,  digitalis,  and,  more  recently, 
adonis  verualia,  have  been  rt-c^mruended  in  epilepsj,  either  atone  or  in 
combination  with  the  bromides.  One  is  uever  juatiiied  in  giving  tham 
alone,  at  lea-st  not  in  the  hope  of  effecting  a  cure;  very  frequently,  how- 
ever, they  become  important  aida  to  offset  some  of  the  disagreeable  ac- 
compauimentB  of  bromide  administration,  to  restore  cardiovasrular  tenet 
and  to  aid  the  system  m  carrying  off  the  bromides.     The  preparation  of 


THB  TREATMENT  OF  EPILEPSY. 


4S7 


ftaas  drugs  that  is  usuuUy  tt^uifiunieiiiled  is  tha  tinotura,  the  Ursb  two  ia 
dostt  «f  ftQin  five  to  ten  drops,  nhile  adonia  vei-oaliB  ia  giren  in  from 
tall'  to  twkaQty-dtop  dosea.  They  have  the  advactai^e  that  ih^y  may  b« 
idiiuiufit«f»d  with  the  bromidea.  With  the  exception  of  borax,  none  of 
fikoa  deserrea  tha  name  of  fiubatitute  for  bromides. 

A  mimlirr  cf  other  BubBtauces,  such  as  the  Bdlta  of  zinc,  simulOf  anti- 
pjrin,  ftcet^ailid,  nitroglycerin,  ELitrite   cif  amyl,  borae  Bettle  (eolauiun 
4arolmenscr)r  antirabic  ii^jectiona,  aod  eo  on  to  a  lireaome  euomeratioD, 
have  be«n  uodes^rveiUy  pr^iaod  ftnd  bailed  as  cures  of  epilepsy.     With 
the  exception  of  hjiquIo  and  autirabio  injections,  each  of  these  haa  a  place 
in  the  theraj)eiLn«'a  of  epilepsy,  but  only  to  fulfil  somo  nertaln  definite 
Bussion  and  to  be  used  eymptomatically.      For  instance^  in  cases  in  wliidi 
aoistinct  vtifloinotor  mauifetitation  precedes  an  atta^-k  iu  the  Bhape  of  Bn 
iiim,  the  adminiatration  of  nitroglyceriQ  witli  the  bromides  peems  to  have 
a  partiouUrly  beneticial  effent,  especially  in  peCit-nial  attK?ks,     M*iaanres 
d)it  have  bepec  extensively  written  of  S.&  a iiti -epileptic  agencies,  and  which 
1  believe  are  nob  of  the  alighteat;  valuer  are  hypnotiamj  electricity',  hy- 
dmftinine,  duboieine.  piorotoxin,  oonnahis  indic^   amydin,  oamie  acid, 
Bderutinii.^  acid,  and  eooculua  indtcua.      It  may  be  diflicult  to  believe  that 
any  of  theee  substances  baa  been  pmiaed  aa  e^racious,  but  a  review  of  med- 
ical periodicals  shows  such  to  bo  the  diatresshig  truth.     None  of  them 
dcsen'ca  a  triaL     Naturally,  the  salicylates,  beba-naphthol,  oil  of  pepper- 
Qiint,  hjdraatmine,  and  cannabis  indica  may  be  used  aymptomatically  in 
epilepsy,  as  they  are  in  innumerable  other  diaeaaes;  but  we  are  not  now 
eonaideriiig  the  symptpOmatic  treatment  of  epilepaj, 

Afttrr  briefly  referring  to  the  vnrioiia  BubEtancea  that  are  uned  in  the 
tKfttQieut  of  the  epileptic  ncurosea,  it  is  se^u  that  tho  ond  subataoce 
to  which  faith  flhould  be  given  ia  some  salt  of  brominoH  The  othera  that 
have  been  mentiuned  with  favor  aro  aids  to  the  bromides  or  aubEtaneee 
that  can  be  made  use  of  when  the  administration  of  the  former  is  denied. 
Tlie  surgical  treatmeiir.  of  epile^^sy  is  nob  referred  to  ht^re  because  there 
is  no  such  thing  as  the  surgical  treatment  vt  idiopathic  or  esHenlial  epi- 
lepsy,  I  shall  have  occasion  to  consider  thia  topic  when  speaking  of 
traamatie  and  accidental  epilepsy.  Here  there  remains  only  to  be  con- 
sidered what  may  he  called  the  moral  treatment  of  patients  aiid  parents, 
vbich  is  of  no  Ginall  importauoe  in  attaining  ths  desired  reaulta  in  the 
handling  of  the  epileptic  patdent. 

Now  and  then  we  encounter  patients  who  are  unwilling  to  undergo 
the  bromide  plan  of  treatment,  which  often  entails  considerable  suffering 
and  deprivation.  To  overcome  their  objectioae,  it  has  only  to  be  shown 
to  ihem,  or  to  their  parents,  in  a  convincing  manner  that  tJiey  are  afflicted 
with  a  disease  almost  uuiformly  progressive  in  its  course,  which  in  the 
majority  of  cases,  if  untrcatcil,  leads  to  the  pauper  or  insane  asylum,  or 
to  the  custody  of  a  caretaker  if  worldiv  circnmstancea  allow^     It  should  be 


4fiS 


TKEATM&NT   OB'    DISEASES    Off   TUB   NBKVOCB   STSTKU. 


impresaec)  upon  th&m  that  the  plan  of  treatment  advocated,  olthougkit 
dooa  cot  oft<?n  completely  cure  the  difleaee,  f  requeatly  ao  far  restor€ii  the 
pfiti^iit  to  health  and  freedom  from  attacks  that  be  is  able  to  diii4.-hftrge 
tb«  duties  of  citizenship  and  meet  the  r^uirements  of  Bodety.  The 
brumisiUr  mental  detialiOLS,  impaired  eui^r^,  and  the  other  a^mptomA 
vhich  loQg'cantinued  use  of  the  salts  of  bromme  Bometunee  prtxluce*  «nU 
be  looked  upon  ae  naught  wheu  ccntrasted  w;th  tho  mtaety  which  the 
continuous  jnaDifeBtationa  of  a  progreBfli^e  epilepsy  entails. 

It  has  often  been  remarited  that  new  plana  of  treatment  and  change 
of  doctotfl  Eire  as  beueficial  to  eome  epileptic  patients  a.s  change  of  air  and 
clime  aie  to  other  inralida.  This  ia  nob  difficult  to  explain.  The  iter 
physician  iuqinreB  njore  closely  into  the  diet,  girea  more  etruigent  direc- 
tions as  to  mode  of  life,  and  atkrts  the  administration  of  Dfe<1icinea  on  a 
definite  plan.  Similar  activity  and  Ciire  on  the  part  of  the  fir<t  pbysi* 
cian  would  havo  st^cured  equally  good  reenlts.  It  ia  thia  p«rsjat«iit  4t- 
tentton  to  what  may  setm  minoT  matters:  rej^Iarity  of  eatiQi;:i  Wbmg, 
giving  of  medicines^  and  auitablo  <lispotial  of  time  among  work ^  relaia< 
tio(i,  aud  rest,  and  all  that  hospitalizatiou  impliea,  which  makes  the 
result  or  iiiJJiiLntiuii  treatment  better  than  that  of  priv&te  praiJtice. 

Treatment  of  the  Attack. —  An  epileptic  attack  is  usually  very  alarm- 
ing to  those  who  witness  it,  and  the  family  of  the  patient  often  insist 
that  fiomethiiig  be  done  to  aasuage  it.  Unless  the  tonjc  epasm  id  very 
severe  and  continuous,  the  attjiclt  requires  no  treatment  save  to  place  the 
patient  in  such  a  position  that  ha  ranunt  injure  himself  or  destroy  tbingi 
about  biiii,  aud  swuit  the  ualtir^d  reesation.  It  is  uauaJly  necessaij  to 
place  BoiLietbing  like  a  piece  of  cork,  rubber,  or  the  fuMed  end  of  a  hand- 
kerchief between  the  teeth  so  as  to  spare  the  tongue  when  the  tonic  spun 
of  tlie  masticatory  uiusclea  forces  the  jawa  together,  IE  tlie  patient  it 
bound  about  with  clnthing,  it  should  be  loosened  so  that  reipiratica  and 
canliao  actiori  \tn  in  no  wr.y  impeded-  The  plan  of  giving  a  bypotlennic 
injection  of  morphine  which  some  physician:!  puiaue  when  called  to  a  pa- 
tiL'ut  in  an  epile^itio  attack  ia  unaoccssary,  and  should  be  diacoumged.  Iq 
some  oaF^es  it  becomes  necessary  to  employ  measures  to  cut  short  the  coo- 
TTilaive  part  of  the  attack^  panicularly  when  there  is  a  tendency  for  the 
patient  to  go  Into  the  candition  known  as  status  epiiepticus  in  whicli  con- 
Tuleive  phenomena  succeed  one  another  with  great  rapidity,  often  with- 
out nny  intprveuing  period  of  stupor.  The  beat  means  for  cutting  short 
such  an  attack  oouBists  in  the  inhalations  of  ohloroform,  given  alone  or 
combined  with  inhalations  of  nitrite  of  amyl.  This  procedure  sh'>uld  be 
done  in  every  case  in  which  tha  tome  ^pasm  is  prolonged  OcoaMioually 
after  a  prolonged  etatus  epilepticus,  or  after  a  uumber  of  abtaeka  occur  m 
rapid  succeasioii,  the  patient  goes  into  a  state  of  partial  or  complete  coma, 
and  tbifi  re^iuirea  vigorous  treatment.  The  most  useful  measures  m  suoii 
a  condition  are  drop  doses  of  Croton  oil  it  coDstipation  eaista,  followed 


THB  TREATMENT  OF  EPH-EPST. 


459 


hj  the  ftdmiiiiBtration  of  genemus  quantities  of  liTark  coffee  by  tlie  month 
GT  bj  }ugb  rectal  iujfcttDii,  possibly  also  of  otLer  BLimulaots,  small  doaea 
of  bellaidoDiia,  and  the  application  of  an  ice-bag  to  the  head-  OccaeioD- 
tilj  1  have  found  it  ueooeaary  to  uso  subovitaaeoiis  iujectiona  of  normal 
nit  Bolution- 

!□  almost  every  cas9  thosa  about  the  patient  have  something  to  aug- 
gwt  that  ia  said  to  bsuf  serrite  in  cutting  short  the  attack-     Causing  the 
payout  to  swallow  a  quantity  of  salt  or  s^lt  water,  to  ia  seemingly  often 
4oce,  ahoixld  nobbe  allowed-      Another  procediue  which  daaa  no  particular 
p>od  ordinarily  la  the  immersion  of  the  patient  in  hot  water,  especially  in 
lie  caie  of  children.     Whenever  it  13  EBcessarj  to  employ  means  to  cut 
ibort  an  attack,  the  way  already  meutioned  is  the  rational  as  well  as  the 
«$[:acioua  one.     It  ahoidd  bebomeinuiiud  that  attacks  arc  liable  to  occur 
it  night,  and  occaaionitlly  patients  suffocate  themaeWcB  by  crowding  the 
Inifiinto  the  pillow^  and  precaaCioos  must  be  taken  to  avoid  this-      When 
dfl  convulsive  part  of  Lhe  attack  is  over,  the  patient  should  bs  given  con- 
^ntrsled  lif^uid  DOiinbhrneikt  and  mild  stimulants,  Hitch  as  hUrk  f-ofFee^ 
tad  an  effort  should  be  made  to  prevent  h.im  Erom  going  at  once  into  a  stu- 
porous sleep,  from  which  he  awakens  after  a  vannble  but  prolonged  tim^ 
feeling  as  though  he  had  received  severe  corporal  caatLgation,  and  with  a 
smfused,  exhausted  feeling  In  the  head.     After  the  patient  has  fnlly  re- 
covered fnna  the  attack,  that  is,  after  conacioiiauesa  has  been   fully  re- 
■tored,  tbei'e  are  no  objeftiona  bo  his  going  tu  sleep.     Indeed,  Ona  is  the 
most  refrcftbing  measure, 

In  aome  cases  of  epilepsy  in  which  the  conTulaive  phenomena  are  pre- 
ceded by  a  wamitigf  particularly  in  those  vbo  have  a  sensory  aura  pass  tov- 
tfd  the  head  from  one  of  the  eihremitit^s,  the  attack  may  be  prevented, 
at  itfl  severity  modified,  by  subjecting  the  part  from  whlt^h  the  viaiuing 
aeosation  passes  to  a  smart  blow  or  other  sensory  impression.  Just  bow 
tlie  stimulus  note  to  out  short  the  attack  is  a  problem  in  neural  phyaica 
Cbat  no  one  has  adequately  explained.  The  waruing  given  to  the  patient 
ia  never  far  removed  temporally  from  the  OEHXiming  convulsion,  and 
therefore  the  sensory  insult  must  be  made  by  the  patient  himself.  To 
aid  him  in  doing  this,  it  is  suggested  by  Jackson  that  a  girdle  be  worn 
beneath  the  sleeve  al>ove  the  wrist,  the  usual  atarting-point  of  the  aura, 
and  ad  soon  as  the  patient  feeld  an  attack  coming  on  to  give  the  girdle  a 
powerful  Lwist,  or  if  a  loop,  to  tug  at  the  two  ends.  It  is  aetoniabinff 
how  often  this  arrests  the  attacks  iu  patieuta  who  have  this  kind  of  warn- 
ing. Unfortunately,  these  are  very  few  compared  with  the  entire  num- 
ber of  epileptics,  Occasionally  the  arrest  of  attacl»  in  thia  way  robs 
the  epileptic  phenomena  only  of  the  convulsive  part,  and  the  vertigo,  stu- 
por, and  feeling  of  prostratioa  are  just  as  eevere  aa  after  an  ordinary 
attaL'k. 

Treatment  of  Dreamy  States  of  Consc Jonineu. — The  gmeral  treatment 


460 


TREATHKJ^T  OF   DISBASES  OP  THK  NRRVOUtJ  SrSTKU, 


of  tliQ  differ-eut  Qlinic&l  varietiea  of  the  epUeptjc  ueuroflie  ia  practie^ly 
the  sjime,  it  riiAtterg  Lut  what  the  form  may  be,  exref^t  vi  tliat  rare  and 
iUuQderalot^d  ooudition  to  vvbLcli  tlje  naiucs  dL>>aiJiy  statoa  of  oocBcious* 
D«Bfl,  states  of  reititniscenoe,  eta.,  Are  given.  At  tlie  present  time,  this 
cortdltiou  U  locilceil  tipoik  as  il  form  of  Bpllepay  a^^ctmg  che  gensory  side 
ol  the  ori^aniam.  Cliuically  aud  palhologicoUj^T  it  baa  cot  rM^iTed  tha 
oonsider&tion  that  it  de8ei;ves.  It  LaA  uiany  of  the  features  of  epilepc^ 
of  thfl  motor  side  of  the  orgaDiani,  but  there  ia  one  very  radical  differ^oce 
ia  my  own  exj>?rietice,  and  that  i^  that  it  does  not  tend  to  beooine  mote 
pronooaced  or  more  frequent  in  iva  maiufeatationB  aa  time  goes  ou.  An* 
other  vary  important  fact  that  hu  been  iinpreased  upon  me  relative  to 
ttia  ootidilioD  is  that  the  bromides  aie  of  litUe  or  no  aervice  id  its  treat- 
ment. On  tho  contrary,  iodide  of  potassium  or  of  sodium  given  in  tonifj- 
ing  doses  seems  to  he  laore  BBrviceable.  Best  reaulta  are  had  from  resto- 
mtive  mea§iirea,  hygienio  aitd  dietetic-,  and  from  building  up  the  patient 
aooording  to  the  plan  detaih-d  in  the  cUapter  on  neurasthenia. 

Treatment  of  Epilepsia  Tarda.-— The  tre^Luieat  of  epilepsy  that  de- 
Tolops  for  the  first  time  in  later  Hfe,  so-called  epilepsia  tarda,  is  a  dif- 
ferent matter  from  the  treatment  of  esseirtial  epiJept^y  which  develops  at 
the  customary  period.  In  the  majority  of  cases,  this  form  of  epilepsy  ia 
an  expression  of  ayphilia,  alcoholic  poisonlngf  or  aoaie  diathetic  f^onditiaii 
wliich  lifts  existed  lung  before  the  epileptic  attacks,  and  it  ia  iiecoAUry  b> 
combat  ttis  while  treatment  ia  being  directed  to  the  guperinipooed  flymp* 
torn.  Jttst  what  the  indicated  medication  will  be  in  any  givets  ca«e  de- 
pends upon  the  diathesis.  It  is  Beoessary,  of  course,  in  these  cases  to 
employ  a  real  acti-epilf  ptir  drug,  such  as  one  of  the  salta  of  bromine.  Its 
beneScial  effects  are  euhniiced  by  giving  it  simultaneously  with  iodide  of 
potassium  and  perhaps  also  Eiti-eglyeerm-  Tordfyiug  metLAtirea  are  of 
great  importance  in  this  variety  of  epilepsy,  and  should  be  vigorously  em- 
ployed. In  thia  respect  the  treatment  is  very  similar  to  that  of  the  para- 
^philitio  variety  of  epilepsy-  The  danger  of  statua  cpilepticua  is  panic- 
ulorly  great;  artd  there  ehould  l>e  ito  hesitation  iji  attempting  to  cut  it  short 
with  clilorofonn  and  nitrite  of  aniyl  inhalatjooa- 

Treatment  of  Epilepaia  FrooarsiTaH — In  epilepsia  procursiva,  and  in 
Bome  other  oondjtio^is  iu  which  the  epileptic  e^juivalont  displays  itself  iji 
tlje  shjLpe  of  psychii^al  manifestationSr  it  may  he  neeessary  to  rtstmin  the 
patient  fmm  doiiij^  JTijiiry  to  himself  and  perhaps  tu  utliers-  Thia  is  par* 
tii^ularly  incumbent  whfU  tho  patient  dc^s  not  appear  to  be  devoid  of  hU 
fai^ulties.  Some  sleep  seizures,  usually  reckoned  as  somnambulistic,  are 
often  of  au  epileptia  nature,  and  their  occurrence  calls  for  etrin^ent  inca^ 
BUrea  taken  to  eoml)at  the  neurosis-  Lihewiae,  a  considerable  proportion 
of  all  cases  of  dual  peTsonaJity  are  to  he  interpreted  on  the  basis  that 
one  personality  ia  normal,  the  other  an  epiteptie  eijuivalent. 


THE  TaEATuasr  or  EP^LEPsr, 


461 


TrAFTCATIO    A3tt^    AcCtttK^TAL    EriliSfVTi 


C&der  tbia  beading  may  be  groups  all  the  case^  cf  epilepej  that 
4o  not  b«lcng  in  the  CAt^gOTj  of   prlTDarj  idiopatbio  or  e^^ential  «pi* 
lepnes.     They  sre  iistially  and  (jroperly  called  sj'iuptomHtiu  epileptues. 
la  the  LegimiiDg  the  true  epUeptio  neurosia  has  no  eziatenc«r  but  tlio 
lubitUA  epikpticiifl  not  on\r  may  but  does  develop  if  t3ja  diseaflo  con- 
tULcea  for  any  toaaiderable  length  of  lime.     The  terra  traumatic  epi- 
lepsy sufficiently  explains  the  pathogenesis  of  the  couditiou.     There  \m' 
taat  irrilatioci  of  the  moUfr  cortex  due  to  trauma  whirti  expressea  it* 
■elf  in  q^ileptic  att&cka.      The  accidental  epilepsies  are  tlioae  ejuipto' 
sutic  of  30iue  diaaaae,  the  mo^st  commou  b^mg  aew  growths  of  the  b»in 
(ubetance  or   of   Burroimduig   tiEtsuea^   cauaing  eQ^roaehiuect    u^ion   the 
brain.     Another  variety  of  accidental  epilepsy  is  the  parasypliiUtic  Ta- 
ri€ty.     Remotely  anterior  syphilia  produnea  epLlei>ay*SOToetii[ieB,  not  by 
OiUijing  syphilitif!  ]t!sluus  Ju  the  meiiini^ea  and  nortex,  but  by  setting  itp 
i£  the  parb  a  de^neratiun  comparable  to  the  lesions  of  tabea  and  general 
paresis — syphilitic  iii  origin,  but  nut  c haras teristiealty  syphilitic  in  na- 
ture-    Saoh  casea  are  rate,  but  there  cod  be  uo  doubt  a£  their  occurrence. 
It  would  aeem  that  the  treatmeut  cf  the  traumada  and  accidental 
epilepsies  might  l»  siiuimed  up  in  a  line:  overcome  the  dlseiise  or  relieve 
the  condition  upon  wbiob  the  epilepsy  is  dependent.     Tbus  the  treat- 
metit  ^rill  rary  with  the  causal  conditions-     If  it  is  due  to  trauma  that 
has  set  up  changea  of  an  irritatirig  nature  in  the  oortea  of  the  brain 
or  in  the  juxtaposed  ttssues,  and  if  it  can  be  localized,  the  appropriate 
CTflatment  and  the  only  one  tliat  should  be  at  all  countenanced  ia  to  ex- 
cise  it  at  once.      EiEpeiience  of  the  last  few  years  has  taught  that  tlie 
aknll  cavity  can  be  eutered.  if  done  with  gre^t  skill  and  cart?,  nithout 
materially  jeopardizing  the  patient's  life.     Therefore^  it'  there  are  any 
poaicire  indications  that  the  epilepsy  is  dependent  upon  a  focal  lesion, 
it  matters  nut  ils  natiira^  trejtannation  shutild  be  done  at  otic^.     If  the  le- 
aiotk  that  i^  the  cmisG  of  the  epileptic  attai^lu  is  found,  be  it  of  the  ealva- 
riiinj,  the   meninges,  or  the  cortex,  it  should,  if  posaible,  be  completely 
exciaed.     It  should  be  borue  in  mind  that  the  danger  to  tbe  pntient  ia 
not  materially  added  tt>  by  the  removal  of  a  generoua  p^eoe  of  the  oortes 
in  wbic?h  the  lesioTi  is  situateil  or  on  wliic-h  it  has  made  destructive  press- 
iire.     Of  coursCf  if   a   spemali^ed  area  is  excised,  there  will  be   corre- 
sponding loss  of  function.     Although  this  functional  loss  is  in  the  begin- 
aiag   proportionate  to   the  amount  of   the  cortex  exf^ised,   it  is   rarely 
pennanent.     The  reason  why  ao  many  cases  of  Jackaonian  epilepsy  fad 
to  he  cured  by  operation  ia  that  tbe  operation  is  not  undertaken  early 
enough.      If  the  dis^uoais  can  l>e  made  before  any  i^onstderable  amount 
of  pathological  chauge  goes  on  in  tlie  brain  to  form  the  anatomical  baaia 


4G^ 


TREATMKNT    OH"    DTSKASES    OF   THE    NBRVOUB   SYSTEM. 


of  genuine  epilepey,  tbe  cb&noee  of  sutroesa  are  goo4 — mucb  better  thui 
some  vriteis  aro  wiUiog  to  coiioede-  Thia  stateinent  holda  true  oaXy 
when  thfi  o^ecatton  is  undertaken  before  the  patient  has  h.ad  maiij  ai' 
tackfi.  I  have  had  two  caaea  that  fulfilled  these  ounditiona^  sacoeBBfuUf 
□per&tFd  upon.  One  patient  waa  operated  on  four  years  ago,  aud  a  con- 
aiderEiUo  area  of  cortex  -which  showed  striking  cLangoB  of  jneoiiiKo-euce- 
phalitia  exnieod.  He  is  etiU  freo  from  attockaH  Another  patient,  operated 
oil  three  years  ago,  for  localized  meningO'encephiUitis  de[>eiident  npon 
depresaed  fracturo,  has  liktviao  remained  free.  In  t,ha  firat  caae  the 
diagooaiH  viha  mada  ami  Um  i>AU6iit  opt-rattd  upon  after  the  bwouJ  i^ou- 
vulfiire  attack.  In  the  aecond  caoe  the  patient  had  not  had  morf  thaa  & 
balf-do^eu  attack!;,  perhaps  lesa.  An  important  point  to  be  remecnbered 
about  these  cases,  in  addition  to  what  Laa  beeu  SHid,  is  that  even  though 
the  operation  has  ameliorated  or  apparently  oured  the  diaeaae,  th«  patient 
ahould  1>a  kept  upon  moderate  doaea  of  bromidea  for  From  two  to  three 
years  after  the  last  attack.  When  the  duration  of  the  disease,  the  iia- 
tare  of  tba  Itsiou,  attd  the  character  of  the  attacks  indicate  that  it  is  be- 
yond the  pale  of  operation,  the  treatment  ii  in  nowise  dissimilar  to  that 
of  essentia]  epilepsy.  The  treatment  of  epilepsy  whieh  is  symptomatic  of 
new  growth T  pressure,  or  any  louali/ed  lesions,  is  to  remove  th^  source 
of  the  diaeaae  completely,  and  when  this  is  not  posaiblo»  partially.  Nat- 
urally^  there  are  many  organic  conditions  that  are  ia  no  way  amenable  to 
Burgieal  treatment  and  that  do  not  allow  of  surgical  iaterfcrenoe. 

Surgical  Treatment. — tt  la  necessary  to  aay  a  few  words  under  the 
caption  nf  the  surgical  trefttment  of  epilepsy^  this  being  the  mode  of  ex- 
preaaion  contuiually  encouutered  iu  tho  literature.  I  have  already  said 
that  there  ia  no  sufh  thing  &a  tho  aurgical  treatmeotof  epilepsy,  save  tho 
truumatic  and  accidental  vorietiea.  Thia  statement  must  naturally  peem 
paradoxical  in  view  of  the  amount  of  Jitarature  that  is  put  forth  eveiy 
year  iu  which  the  moat  irrational,  not  to  eaj  absurd,  surgical  procediina 
are  recoiu mended  in  ap[iarc^nt  eenauaneas  hb  justifiable  meaeures  in  the 
treatment  of  this  majestic  neuroals.  In  this  category  are  included 
Buch  procedures  aa  atrctching  of  the  pneumogaatric  nerre,  ensectioa  uf 
the  cervical  sympathetic,  oastratioUi  ligation  of  the  vertebniJ  art^iiei, 
ocular  tenotomies,  circumcision,  hysterectomy,  clitorideotomy,  castra- 
tiou,  removal  of  spurs  from  the  naaal  sRptiim,  ligation  of  the  verte- 
bral arteries,  and  so  on  to  a  most  distreaaiug  end.  Many  of  these 
operations  have  been  originated  and  have  come  into  vogue  becanae 
of  the  fonret  wideaprHad  acceptation  of  the  theory  that  epilepsy  is  often 
a  manifestation  of  reflex  peripheral  irritatioTi,  and  particularly  imtatioo 
of  some  special  sense  or  highly  endowed  organ  of  tactOe  sensibili^, 
Buch  aa  the  sexual  organs.  There  ia  do  doubt  that  a  ^jniptomatic 
epilepsy  may  occur  from  peripheral  irritation,  and  that  such  epilepsjr 
deserves  to  be  called  reflex.     But  this  condition  is  in  no  wbj  a  die- 


THE  TBBATMKKT  OF  BPILBPSY. 


488 


ootDparable  to  primary,  eaaaatial  epilepsy,  or  sven  to  a  toxic  epi- 
lepsy.     These  reflci,  ajmptouiatic  epilei'aies  are   very   rare,   compared 
■■ith  the  cases  of  orciinarj  essential  epil&pay.     Their  conaide ration  by 
flathodiastft  and  faddists  b^alri^ady  done  immeasurable  hu-m,  ajtd  th^  paat 
Usioty  &itd  titotfiture  of  reHcx  epilepsi^Si  as  well  aa  tlie  makers  nf  sut^h 
biltong  deaerTB  speedy  oiiliviou.      No  pmiierly  trairiM  pliysirian  ever 
bik  to  axamine  hia  patient  completely^  and  if  La  dUcovers  a  condition  of 
d»  foreskin  that  ia  iaterfermg  with  its  functions  Le  removea  it,  just 
u  he  vouM  remo%'e  a  thorn  from  a  man's  foot  that  interfered  with  walk' 
tag,  but  tbis  does  not  prompt  him  to  tell  the  profession  of  bis  fiucceBs  in 
Baking  the  lame  wait,  nor  does  he  desire  to  be  considered  an  ortbopje- 
dio  surgeon,     ^o  more  shijuld  a  phjaician  v/ha  releases  an  adherent  di* 
Coris,  anchors  a  falleu  womb,  or  balances  an  eye,  claim  to  he  the  diacovereE 
and  poMeaflot  of  a  new  method  of  treating  epUepey,  ]Uflt  becauao  sm^h 
resloiation  of  an  organ  to  its  proper  condition  allows  it  to  functionate 
Qormally  and  thna  to  overcumo  what  may  have  been  a  most  important 
vinrc0  of  peripheral  irritation.      Biicli  ooaditions  as  tbetfe  do  not  produce 
the  neurosis  epilepsy,  nor  does  the  overcoming  of  tbem  cure  the  neuroaia 
epilepay. 

To  frammaHze  the  status  of  suigical  iuterferenee  in  the  treatment  of 
epilepsy,  it  may  be  aald  that:  The  pri?senC  generation  has  witnessed  tbe 
most  remarkable  advances  of  surgery  that  have  e^rar  been  made.  This  may 
io  a  way  account  for  the  furore  that  seems  tpO  have  taken  bold  of  aurgooua 
tbo  civilized  world  orer  a  few  years  ago  of  operating  on  all  florta  and  con- 
ditions of  epilepey.  If  this  does  not  ericompasa  the  explanation,  I  am  un- 
able to  suggest  iL  Thst  sueh  a  furore  existed,  no  one  who  will  examine 
Ae  literature  can  deny.  Tbe  result  of  it  is  tf»-day  that  operation  on  tbe 
skull,  trephining  with  incision  of  tbo  membraueB  and  removal  of  the  cor- 
tex, a  jnstiBable  only  in  tha  traumatic  and  accidental  epilepsies  in  which 
tbe  leaion  can  be  localized.  Absolutely  nothing  is  to  be  gained  from  sub- 
jecting any  other  form  of  epilepsy  Ut  operation.  It  baa  often  been  notod 
that  Lq  almost  every  ease  after  operation  there  ia  a  temporary  cessation 
of  greater  or  lesser  duratioit  of  tho  attacks.  This  has  been  attributed  to 
tbe  effects  of  the  operation  per  se^  and  it  has  been  pointed  out  that  a  cor- 
nvponding  respite  follows  auy  o^^eration,  it  matti^^rs  not  on  what  part  of 
tbe  body  it  i^  made.  I  am  inclined  to  believe  that  tbe  operation  per  aa 
has  irery  little  to  do  with  diminisbirg  the  number  of  the  attacks.  The 
improvement  is  probably  due  to  hospitalization,  limited,  selected  diet, 
careful  nursing,  the  discipline  of  regularity,  enforced  rest,  and  increased 
sleep. 

The  Treatment  of  Syphilitic  Epilepay.— Genuine  eyphilitio  epilepay, 
that  is,  the  epilepsy  of  Im^tic  meningo-encephalitis,  gummatous  infil- 
tration of  the  meninges,  localized  syphlliiic  disease  of  the  blood-ves- 
icIb  in  the  Eolaudic  area,  and  o£  cortical  gumiuata,  a  condition  wbich 


464 


TBmATUENT  OP  D13BASEB  OF  TUfl  NERV0V8  6YSTEU, 


naturally  occura  after  adult  Hge  has  beeiL  reached,  except  id  rare  ca|^ 
of  LuliBfited  syphilis^  requires  vigorous  aDtis^pLiJiiic  treatment,      It  a^ 
pQiiJs   upon   tbd  nature  of   the  syphilitic    process,   and    the   time  xw^ 
liaa  olapst^d  between  the  initial  lesion  and  tbc  present  diaeasef  just  VK^- 
th&  n.titiByphilitie  treatment  ;vill  consist  of,     Th^  mlGB   ^vt^a   for  ^ 
treatment  of  syphilia  of  the  nervoua  system  in  the  chapter  on  thateujj, 
ject  apply  bfre,     Thia  form  of  epilepHj  often   ossuihwi  the  JackAttQigQ 
type.      When  auck  ca?*eB  ctm  be  diagnosticated  as  syphiliti?,  uaturaJlp 
they  should  not  be  subjected  to  operation  for  temoral  of  the  ni'tf^rin 
miM^  until  antisyphilitio  treatment  has  been  tried  and  found  hckiu^. 
But  tlie  mUtaka  of  allowing  such  pal.tents  to  go  on  having  epiWptia  at- 
tacks, especially  vban  tbo  indicationa  are  that  the  gumma  is  in  a  {im  ol 
the  brain  that  cau  be  easily  got  at,  should  not  be  made^  after  aBhon, 
vigorous  courao  of  antlsyphilitift  treatment  fails  to  ^ive  celiet     Tie  ww 
like  tiSHue  that  is  occasionally  left  after  absciTption  of  syphiloniii  soitiptiinoi 
keeps  up  symptomado  epilepsy  after  the  real  ^owth  ha^  disiLppeUTul  on* 
der  iii«<dication.     There  is  no  reason  why  siir'h  snars  should  not  be  s];niHd, 
and  tho  eurgeou  should  he  urged  to  undertake  it.     If,  on  opening  thf 
skull,  remains  of  the  ayphilitio  new  form&tion  are  found  they  shirald  bs 
removod  as  well. 

The  treatment  of  paraayphilitio  epilepsy  ia  entirely  different  fpoin  tti 
treatment  of  genuine  syphilitic)  epilepsy.  In  the  fomter  antisAphili^ 
mea^sLires  are  worthless,  if  ijot  worsa  than  useless.  If  it  be  granted  thil 
after  death  these  cases  do  nob  reTcal  loaione  in  any  way  of  a  syphilitio 
nature,  it  ia  difficult  to  euggei^t  a  reason  wbj  such  patients  should  be  sub- 
jected to  antisyphilitic  treatment.  Yet  this  is  the  treatment  which  cmnj 
of  them  reoeive.  The  treatment  that  th«y  require  and  the  one  that  ^ 
most  serviceable,  is  the  combined  tonie  and  bromide  plan,  the  nutrition 
being  kept  up  to  the  highest  posaible  point  all  the  time.  Thos^  oaaes  do 
not  tolerate  any  such  quantity  of  bromjde  as  a  case  of  essentia]  epilepsy 
dooa,  and  it  ia  neceasajy  to  bs  on  the  oareful  lookout  for  toxic  symptoms 
of  thiif  drug,  for  in  suoh  cases  sad  tesulta  frojn  careless  or  exoessive  bn- 
mide  administration  are  often  seeti. 


CHAPTER  XXX. 


THE  TREATMENT  OF  THE  TIC  NBUROSIB. 


Tkb  word  tic  meana  litenvlly  a  twiuhing.  It  is  applied  to  an  al>nipt, 
JCA^df  ftad  usually  uncoutroOaliiv  cuovement,  tho  leault  of  abuorrpal  cou- 
traction  of  individual  muscUe  or  groups  of  muacles  which  uotniEJly  act 
together  to  fulfil  some  pliy Biological  purpose.  T^e  designatioTi  "tic"  is 
a  most  appropriate  one,  though  it  lias  stood  iu  the  vmy  of  the  cooditlon 
boiug  mote  genorallj  understood  aa  a  pathological  entity.  It  haa  l*ecu 
diHicuLt  for  somo  to  believe  that  the  otdinarj  tics  are  not  in  xeali^  hab- 
ii3,  one  variety  having  bpco  d(?ftcnbed  aa  a  habit-spaam.  Utheca  hare 
unfortunately  considered  the  ti^ta  aa  atypical  luatiifestaiions  of  ehoraa, 
and  the  dread  phrase  "  a  kind  of  chorea  '*  has  l)een  applied  to  them.  Tic 
h^ta  no  uiore  iu  comnioii  with  chofea,  he  it  acuh?  or  chronic,  than  it  haa 
with  epilepsy  i  iudecd,  I  aui  inclined  to  betieve  that  it  has  much  less. 
The  atmosphere  of  the  tics  haa  been  very  much  obscured  by  the  uao  of 
tbo  word  choreiform  to  deacriL*  the  luovemeuts^  also  by  their  berng  con- 
sidered with  chorea  in  systematic  uiedioal  treatises-  We  cannot  drop  the 
terms  choreic  and  cboreifonnr  but  if  we  could  when  Hpeakiug  of  the  tica 
it  would  ba  a  decided  gain. 

It  ia  important  to  understand  that  the  term,  although  it  auggesta  only 
the  moat  prominent  symptom^  often  bespeaks  an  abnormality  of  tbo  ner- 
▼ouB  system  quite  as  demonstrable  as  ihat  to  which  the  term  epilepsy, 
hysteria,  or  migraine  la  applied.  When  the  latter  words  are  used,  a  cer- 
taui  well'dehucd  signifieauce  is  attached  to  them,  and  they  call  to  the 
B  Qiinds  erf  the  uaera  cleaily  cvit  clinical  pictures  and  well-known  data  con- 
cerning etiology  uud  pathology.  It  is  uofortunato  that  the  word  tic  does 
not  do  as  much.  The  only  reason  why  the  names  hysteria  and  epilepsy 
have  a  more  decisive  application  is  that  the  conditions  for  which  they 
stand  have  been  Tnure  larefully  and  persistently  studied.  A  similar 
amount  of  labor  expended  U[Kjn  the  tica  would  be  followed,  I  veuture  lo 
believe,  by  a  corresponding  amount  of  information. 

I  At]  ties  may  l>e  claasitied  primarily  into  (1)  senile  (acquired)  tic,  and 
(2)  early  tic^  the  last  ireiug  further  divided  into  two  vanetiesT  ^'^-i  ("J 
degenerative  and  (h)  arijuired. 
The  senile  variety  ia  a  convulsive  or  spasTzmdic  manifestation  in  one 
part  of  the  body  or  anuther.  usually  in  tho  fac^.  almust  uivariably  due  to. 
or  at  least  aeoompanied  by,  degeneration  of  the  blood' vessels,  arterio- 
30 


466 


TKEATUENT  Or  DlSEAfiBS  OF  THE  NERVOUS  STSTEH. 


capillary  Sffi'OAiB.  The  twitching  ia  uau&Uj  of  tbe  fructo-orbicul^i^  uf 
facial  iQusciiIatare.  P&tltoj^eTietically  it  is  &d  entirely  difFereot  oO^ 
tion  irotn  the  early  deg«u«rative  types.  lu  short,  it  is  usuEilly  tlio  ayra^ 
torn  of  ft  w4?ll-tmderfiiooil  patTiulo^ieal  coiiJiLion,  and  the  treatment  vbtt^ 
iu  TH|uirefi,  anide  Trom  tliat  which  ia  r^ymiktoiuatic,  ih  none  utlier  tliui  iJi^ 
treatment  of  thia  condition.  To  thia  form  I  ahdl  uot  therefore  ^lliA  ■ 
rpvert*  J 

Kai'ly  Uc,  degenerative  or  acquired,  may  he  dn-lded  into  two  ^;rou[i|^| 
[1)  Motor  tic,  which  may  l>e  further  divided  into  {a)  loealiied  lif,  fl^| 
geiLurjilized  tic.  &ud  (2)  psychomotor  tic^  vbidi  luay  alAO  he  furtbcr^H 
vided  into  (a)  tic  which  is  a  lestHinse  to  a  compvibory  idea  or  obaesKii^H 
(if)  tic  caused  by  co-ordinated  movement,  aasociated  with  intellectulttH 
emotioQiU  extern allEati on,  orderly  or  disorderly*  1 

The  motor  tics,  although  in  all  likelihood  often  the  eipressioti  cCfl 
Bimilar  ahtiormal  condition,  &Te  much  leas  complex  thaij  Uie  psyi.-homolS 
tica.     But  despite  tliis  fat^t  tliey  have  been  mach  lesa  studied.     Oae  rv^ 
aoiL  for  this  ia  that  the  localised  varietica  have  usually  been  regurdf^  u 
habit-spuEiQB  and  the  geiieralized  tii*H  as  forms  of  chorea.     The  paj«hO' 
motor  tics,  and  particularly  group  Ii,  have  beeo  rather  exteaaivtily  studied 
aince  Gilles  de  la  Tourette  turned  his  attention  to  them,  and  since  it  hu 
been  undersUKxl  tJiat  a  condition  very  like  the  ]>by^;hon]Otor  tics  orcurs  tn 
certain  parte  of  the  world  as  a  tribal  and  family  afFeotion,  and  under 
other  conditions  as  apparently   the   result  of  some  toxic   or  infectiooa 
Agent.      Such,  for  Inatauce,  are  tho  "  juntpera ''  found  U\  that  portion  of 
New   England   bordanng  Canada,  Myrachil  of  the  Siberians  and  Kan- 
chatkaitST  ^nd  Laiah  i.if  the  eastern  coast  of  Africa.     The  psyi-liomotor 
ties,  ©specially  iu  tljia  country,  are,  morBOver,  relatively  uncoimuou  when 
eom}>atetl  with  the  purely  motor  form. 

Motor  tic  may  be  further  t;laasLlied  topographically.  Such  a  oloiisi- 
ficabmi  facilitates  recoguiliou  of  the  coDdition,  Thua  we  have  (a)  frou- 
to- orbicular  tic,  (/i)  nasal  and  iiaao-orbif^ular  tiu,  (r)  facial  tic»  {tf)  niifhal 
tie,  sometimes  trailed  apa^modic  tortiioUis ;  (r)  tic  of  the  diaphragui,  oft«u 
railed  respiratory  tic;  (/)  bowing  tic,  ot  tie  tia  aa/attPtt  as  it  hofi  heea 
called;   {'/)  strmg  halt  tir, 

Etiology  of  the  Tic  Neureiia^Very  little  defiDit«  and  positive  in* 
formation  is  to  ba  had  in  regard  to  the  etiology  of  tJc.  Tirs  nf  all 
kinds  occur  in  early  life,  in  childhood,  and  lu  early  adoleacenoe.  The 
diseasd  adiicta  malea  more  commonly  than  feniaica,  and  the  victims 
frequently  have  neuropatliio  parents  and  hrothora  and  aistera  who  nimni- 
fest  other  forma  of  nervous  disease.  Ocoasionally  the  twitching  fol- 
lows emotion,  fright^  iiodily  and  menul  fatigue,  and  is  oft«n  assoeiaUd 
with  £omatio  arid  psychic  defe^^ts.  In  other  words,  tic  is  frequently  a 
possesBLou  of  Lht3  Huperior  and  inferior  degenerates,  and  it  maitifints 
itself  during  the  formative  period  of  the  person's  character.     This  moat 


THE  TREATMENT  Of  THE  TIC   NEUROSIS. 


467 


P 


Kt  b«  taken  to  mean  that  tics  are  invariably  stigmata  of  degeneration. 

Tbi  simpler   motor  tit's   may  occur  in   individuals  who  have  nothing  in 

ftDteoedenta  to  suggest  an  Luherent  nsuropalliic  coustitution,  and 

bodilj  or  mental   attributes  which    can   be  called   stigmata.     Thej 

be  merely  an   exprsBsion   of   Bome  peripheral    irritation.      For  in- 

ice,  froDto-orbioular   twitching   or  «Yen  facial   tie   ia  aometimea   de- 

penJent  upon  defect  <jf  the  visual  mechanism  or  Insa  of  ocular  baiance. 

Bttii  and  facial  tic  moveiuerLte  are  at  times  an  eKpTcasion  of  iTribotiou  of 

ibe  nafto-pbaiyn^al  passage  by  intlammationa  or  new  growtba.     Spas^ 

nniic  torticollis  may  bo  the  result  of  some  comparatively  alight  irritation 

Id  ihe  Gubstance  of  the  muscles  manifesting  the  GpaBm^     Many  of  these 

inap^e  tics  continue  after  the  original  cauae  of  their  existence  has  been 

oreitTome.     They  then  approach   babit  twitchings.     The  aimple   motor 

tifs  may  be  the  leault  of   many  difiarent  conditions  which  cause  Bomo 

fonctional  change  m  the  motor  areas  of  the  brflin  or  in  the  sulcortioal 

notcn-  BtSitionB.     Thd  immediate  antecedent  coudition  is,   in  all  likeli- 

bood^  a  depravity  of  nutrition.     This    harmonizes  with  my  eiperience 

Uiat  tic   is  not   infreciueully  seen   in    niL'bitic  children,   in   young  indi- 

ridoala  who  have  acquired  a  rbeumatio  diatbesis,  and  occasionally  after 

jkcata  diseaac.      Tics  may  occur  in  persona  who  have  Toluutarily  imitated 

tL«  twitching  movemonta  of  others,  and  if  such  are  not  possesaed  of  a 

vtfttile  nervous  system,  the  tic  often  develops  so  strongly  that  it  cannot  be 

fnntrotled.      Such  persuns  are  abnormal  when  considered  from  a  neural 

standpoint. 

The  departure  from  the  normal  indicated  by  the  word  tic  is  ii»  the 
majority  of  caaea  akin  to  that  indicated  by  the  words  epilepsy  and 
hysteria.  1  am  inclined  to  the  belief  that  tics  taken  aa  a  whole  be- 
tpeak,  with  greater  uniformity  tbau  any  other  one  condition,  a  state 
which  may  1>e  designated,  at  the  preaeiit  time,  only  as  one  of  degen* 
oncy.  This  ia  usii^g  the  word  in  its  biological  and  proper  eense 
iS  aigmfying  a  loas  or  impairment  of  the  qualities  p^uliar  to  the  race 
or  type^  and  not  in  its  pathotogical  sense  as  synonymous  with  decay- 
Tus  itself  is  not  inherited,  but  the  neuropathic  predisposition  may  show 
itaelf  in  other  almost  innumerable  conditions^  mental  or  physical^  show- 
ing a  departure  from  tba  normal.  Thid  ia  tine  of  all  the  degenera- 
tive nervouA  discajies.  It  ia  rare  to  loarn  that  a  patient^a  parents  or 
immediate  relatives  have  suffered  from  aome  twitching  disorder;  but  it 
is  not  uncommon,  indeed  it  is  the  rule,  to  find  that  there  is  some  allied 
DCUTOsia  or  psychosis  in  the  family. 

Particular  lavesiigation  of  the  cases  of  tic  which  have  come  under 
personal  observation  during  the  paft  tire  years,  since  my  attention  waa 
Gist  attracted  to  this  view,  baa  shown  that  tic  is  osaociated  with  somatic 
and  psychicjiJ  atigmata  of  degeneration  in  greater  proportiou  than  any  other 
nervous  disease.      I  have  fall  notes  of  fifty-seveu  oases  of  tic,  and  have 


168 


TRSATUKST  OF   DlSBAflBS  OF  TBE!  N&RVQUB  8Y8TBI1, 


Bean  a  much  larger  number  of  which  I  do  not  poaaeHB  iiot«a.     On  IooIuum 
LhroQgh  tice  historieaof  these  oaads  I  find  ihaC  sut^h  sdgmat&of  rle^n«i|p 
tioD  were  suScienUy  obr joua  in  thirtytnoof  Xhem  (about  aiity  percenn 
lo  call  for  epeciHo  notation.     1&  others^  I  recall  such  atigmato.  ev^g 
ihou^'h  thoro  is  no  Qote  of  their  exietaoce- 

AlmoaL  without  cTceplion  thoy  Luve  bhd  &cf*ompajiinientA  of  th&ije. 
^ueratfl  state.     The    bwitohing   movemaritf  the  tic,  is   an  outward  u- 
presBiou  of  fmch  degetieracy^     lo  one  caae  it  tftkes  the  form  of  im  qb* 
cuntrollable  gritiiace,  in  another  of  a  barking  aoutid,  and  in  a  thin]  ti 
pasaea  through  the  gradationa  of  a  rhythmic -like  spaam  of  tbe  idukIv 
of  tho  trunk  to  a  twitching  of  the  mu^les  of  the  head  xad  of  tho  uecl 
All  th&se  foriua  uf  ijc  h&ve  certain  gener&l  fe^turea  In  common,  Liit  ihett 
features  niergo  gtaduallj  one  into  ouothott  and  it  ia  quite  impoafiible  to 
flay  what  form  they  will  take  in  thia  caae  or  to  vhat  extent  thej  will  go 
in  that-      When  we  coma  to  analyze  the  psychomotor  tics,  we  ;il  onco  ei- 
perienee  great  difficulty  in  sepaxatiag  them  by  hard  and  fast  lin«ifrMi 
the  maniffiBtatioiia  pf  otter  diaeaaeH  of  deg^-nevacy.      It  is  difficult  ujwj 
jus&  wherein  they  differ  from  the  abortive  types  of  rndimentaiy  pantntni^ 
from  the  obscHBiona  which  accompany  tlio  neuraathenic  stato  develoinus 
ia  children  and  in  early  adult  life,  which  1  aia  inclined  to  belieraiiaa- 
other  manifest^tioD  of  degeneracy,  and  from  tiie  luanifold  psychicil  i^utti- 
pulaiona  and  aecompauimeDts  of  hysterin.     But  there  are  o&rUin  g^ijtnl 
features  accunijiai:ying  the  tics  which  one  bouii   Jeanis  to  assocmUftilta 
thia  condition  and  not  with  the  degenerative  disorders  just  meutiowdH 
In  the  first  place,  the  twitching  movementfl  theniselrea,  if  carefully  all- 
ied, are  readily  dilTerentiated  from  hysterical  motor  manifestntioaai    U  J 
the  latter  diBea.Be  the  motor  phenomena  are  tremor,  oomtraotura,  iaat  I 
convulsions,  or  l^accidity.      None  of  these  occur  in  tic      Abore  nil,  v« 
must  not  delude  ourselves  into  thhihing  that  it  has  anything  in  coiiuumL 
with  chorea.     That  term  when  used  as  a  descriptive  adjective  should  bd 
applied  only  to  an  acute,  infectious  disease  primarily  of  ihtb  blood,  aself- 
limitiug  disease  known  as  Sydenham's  chorea,  and  a  hereditai}'  ofaorta, 
dependent  upon  chronic  parenchymatoua  degeneration  of  t)ia  cortBi  of 
the  brain  and  kno^vn  an  Hnntington^s  chorea. 

Not  infrequently  tic  patiepta  have  certain  abnormal  bodily  coDdliiouB 
which  are  believed  by  some  lo  be  causative  of  the  tic.  Some  wrilera  harfl 
bMn  so  illogical  as  to  contend  that  if  these  were  remedied  the  ties  would 
OMse^  It  is  very  certjiin  that  patients  with  tic  often  have  iTiiaahapen 
eyeballs  wbiuh  citll  fur  corrective  glasaefii  that  the  miiBculatnra  of  theii 
eyes  is  sometimes  badly  balanced;  and  that  other  periphera)  aenee  organi 
may  show  departures  from  the  normal.  But  1  am  firmly  convinced  thai 
these  are  tbe  rightful  poBsessions  of  an  individual  whose  evolution  towanl 
the  type  which  is  now  loubed  upon  us  normal  has  been  imperfect.  Mots' 
over,  no  meaDS  should  be  left  untried  to  correct  these  shortcominga,  bu) 


THE   T&EATUfiKT  OF  TSR  TIC  KSUROSIS. 


4M 


Ul^j  ihould  not  be  Gaid  to  cause  vhat  is  re&lly  another  tiianrFestadoi)  of 

T*  aiimmarize  m  a  few  words  iDy  coDceptioci  of  tic,  it  maj  bo  sjud 
ttiL  leaving  out  acquired  motor  tic,  both  the  parly  and  iater  raf  ietie&,  it  ii 
cmt  of  the  diseases  of  degeneracy  ^  that  its  association  with  aomatiQ  and 
f^chic&l  stiginaUof  defeneration  eutitlea  itt^t  t>e  closed  in thiscategory; 
1^  it  coDforma  in  its  occuirenoe,  in  its  development,  in  its  progreHs, 
Uid  m  its  attitude  toward  treatment  with  all  the  degenerative  diseases; 
itwcors  in  tho  early  yeara  of  life  and  develops  gradually ;  its  unimpeded 
(ttdeacy  ia  toward  pro^freaaion,  and  It  reaponda  moat  tardily  to  thaca- 
JKJ30  meaaures. 

U  is  quite  possible  that  the  piiycliogeiiesis  of  coprolalia  anrl  tha  like 

(VOnamitantfi  of  psychomotor  tic  ia  that  the  words  oODBtituttJjg  it  have 

bsDn  heard  on  the  street  or  elaewhare  and  Arc.  registered  upon  the  auditory 

t»bi«tscf  thebraia;   but  they  never  become  apart  of  the  oooseious  vocabu- 

Jiiy  because  they  are  not  passed  through  the  speech  areas  oif  the  brain  to 

the  tat«]1ectuaJ  areas^     Nevertheless,  Uiej  laay  be  exti^rnalized  by  uncou- 

,trolIable  forces  in  a  way  that  makes  their  maoifeatation  analogous  to  tho 

ilcbiuf  morementa  of  tic-     Indeed,  the  motor  impulse  may  be  a  very 

{sioiilAr  oae,  acting,  however,  through  the  entire  artloulatory  apparatus  to 

ptodnM  words, 

la  estimating  the  prognosis  of  tic,  a  number  of  factors  are  to  be  taken 

iitD  cou&ideratioLi.     Tic  is  a  condition  vliich  disorders  life  but  does  not 

jedtioy  it.     When  wo  consider  the  prognosis  we  oonBider  in  reality  the 

<^c«s  which  tho  patient  has  of  ridding  hLmsclf  of  this  manifestatioti  of 

diDrtoomings  in  dei/elopment  or  evolution.      Like  all  elementary  troubles 

Ihi natural  teadency  of  the  tics  ia  to  progress,  and  it  is  this  progression 

thai  may  ruake  it  more  diSiruIt  to  preser^'e  health.     In  geneial  it  may  be 

ttid  chat  the  earlier  the  tic  develops  the  less  are  the  chanrea  of  ita  ameli' 

ontion  and  cessation-     Likewise,  it  may  be  Atat<>dthat  the  more  extonaivc 

tbe  development  and  the  more  vital  the  parts  in  which  the  tie  phenome- 

mm  Domrs,  the  leas  are  the  ehances  of  cure.      It.  ia  jay  f  iperience  that  a 

flPQeralized  motor  tic  is  almost  alnays  pri^gressi  ve,  no  matter  what  is  done 

tei^  ^^^  ^B.%  a  tic  of  the  diaphia^u  ia  mora  atulrlxim  to  treat  than  a 

rlllof  the  face.     Again,  it  may  be  said  that  tbe  greater  the  number  and 

the  intensity  of  the  stigmata  of  degeneration — in  other  words,  the  further 

the  paiierit  is  removed  from  the  normal — the  less  are  the  chances  of  aasist- 

iDg  him   to  approximate  normality.     And,  lastly,  Uie  longer  the  eymp- 

tuat  have  existed,  the  greater  is  the  difficulty  in  ending  them.     Patients 

with  tic  who  have  many  psychical  stigmata  rarely  beeome  normal  persona. 

They   may   be  bettered,  but  the  mental  aecompanimenta  are  every  now 

wad  iheo  likely  to  show  tb«ir  domLnancy-     In  reality,  there  are  few  dis- 

in  which  the  physiciarj  ia  obhged  to  temper  his  prognosiH  with  so 

aMar&Qce  of  recovery  as  in  the  psychomotor  tics. 


4T0 


TREATMBVT  OP  BISEASBS  OF  TBE  NERVOU9  8YSTEM. 


Treatment  of  the  Tk  Neuroiiin — Tbo  tre&tm^it  luuat  he  considered 
UDdei  two  headings;  (1)  The  treatmeiit  of  the  moBt  anaojmg  sjropcom, 
vi^.,  the  twitohiDg  and  its  psychical  ftcoompoQiindDt,  it  there  be  auj. 
(2)  Tha  treatmeat  of  thd  neuroHiB,  of  whioh  the  tnaui  symptom  U  bul^  % 
maniiestatian. 

The  treatmeDb  of  the  twitching  v&riea  accordiug  to  Hitt  nature  of  Uie 
tio>  that  ia,  wlieth^r  it  be  an  acquired  or  a  degenerative  condition*  If 
it  be  aij  acquired  r^ondition,  the  treatment  is  very  aimple  and  meuxi 
the  removal  of  the  oauHe.  tf  it  can.  be  remoT^d  thp  symptom  will  ubuiUIj 
disappear  with  it,  although  often  it  ia  iLtfceGsarj  to  iine  at  the  shtne  ttnii 
lueaHurea  which  will  build  up  the  nerrouB  s^Ateui,  imitii^ularl/  as  Mich 
simple  acquired  tioe  are  Diost  common  in  neiiiotio  aubjecta.  Urtbo- 
pmdifi  Aud  eurgioal  moasures  are  of  aorvice  ia  tba  treatment  of  eertab 
forma  of  bcth  aoqijir^d  and  degenerative  tic.  Spaamoijic  tortiooUis  le 
aometimee  overcome  by  methoilii^ally  snapending  the  patieai  liy  m^vaa 
of  the  head-piece  of  the  apparatus  made  U>  Huspend  tabid  pati«DU. 
Spasmodic  wryu^k  is  aometimes  alleviated  by  giving  laige  doses  of  &i\i6 
extract  of  (;i>uiuia,  aixty  dr<jpd  in  twenty-Four  hours*  and  by  the  hypo- 
dermic admin istratiou  of  aCrapiDO.  The  galvanic  current  applied  to  the 
Bide  of  the  neck  oftentimes  gives  relief,  partit'ularly  if  the  oonditjon  is 
paiufiil,  ami  iiiti8»nge  is  often  of  real  Hervii^e,  Stretching  of  the  fu-za] 
nerre  for  facial  tic  and  rej^er-tion  of  the  apinal  accessory  uerva  and  of  tb« 
posterior  branchea  oC  the  four  upper  cervical  nerves  has  been  resorted  to 
many  timi's.  If  the  procedure  is  Uioroughly  done,  nalurftUy  it  over- 
cam<>a  the  spasm  even  though  the  tie  be  of  the  degenerative  variety- 
It  will  be  underittood  that  none  of  these  meafiurefi  can  cura  in  the  degea< 
erative  forms  of  tic.  To  overcome  tbe  disease  in  these  cases,  it  is  ti^^esaarj 
logo  behind  the  aymptomi^nnil  to  direct  treatment  immediately  toward  the 
general  health,  eo  as  to  mamtain  a&  normal  a  state  of  health  as  the  neural 
conditions  with  which  the  patient  is  1x>m  will  allow.  The  neooasity  of 
putting  all  the  boiiily  fiinctiona  at  their  i>cst  is  apparent  to  every  one. 
This  is  so  plain  in  the  treatment  of  all  ohronic  and  dt-geti erative  dis^asea 
tliat  it  seems  trite  and  puerile  to  refer  again  to  it;  but  aa  tic  is  our  of  the 
diaeasea  in  which  tha  utility  of  such  measures  is  often  more  iiianifest  than 
in  othera  of  its  kmd,  it  is  perhaps  permiasible  to  mention  it.  No  one 
measure  can  auffica  to  accomplish  this  end.  If  the  patient  is  a  child  and 
in  school,  he  or  bUh  shimld  be  removed  jind  eut-ouraged  to  lead  a  ro^ick' 
ing  outdoor  life,  aud  be  given  a  course  of  tonics,  while  the  various  bydri- 
atic  and  hygienic  measures  for  the  betterment  of  the  health  are  employed. 
lu  some  inatonces  the  disi^tpline  of  partial  isolatmn  and  the  removal  from 
parents  and  members  of  the  family  is  of  considerable  service,  particularly 
if  the  tic  ia  ossociateii  with  an  emotional  £tat(>,  or  occurs  in  a  very  ner* 
Toua  pel  son. 

All  sources  of  pathological  reSexcs  ehoitld  be  investigated;  the  e^^ 


THE  TREATMENT  OF  THE  TIC  NEUROSIS. 


471 


■keearaf  tlie  nasopharjax,  aad  the  geitital  oigaos  should  be  passed  in 

^t*iew,  and  any  doviaCioa  from  tho  iiormfll  cortocted;   but  the  physician 

Tba  BM9  in  tic  one  of  the  m^nifcetationB  of  the  degenerate  state  will  not 

bfguile  tim^etf  into  th«   belief,  nor  mislead  others  by  the  promise,  that 

(ufih  pai4*hJiig  can  replni^e  the  evolutionary  work  of  ppnturieg.      He  will 

Iconi  lo  difftrt^ntiatti  the  simple  ties  which  are  syniptoinati^^  of  some  local 

^fparture  from  tho  normal  and  the  degenerative  tics,  and  shape  bia  'Brorda 

tad  course  acoordiiigly*      i^imple  fa<iial  tii;  in  children  is  often  found  as- 

foeitted  nritb  some  disease  of  the  naaopharyux,  and  treatment  direct^ 

Lameiiiately  to  this  condition  and   k^pt   up  persistently  will  overcome 

ifte  twitching  iu  the  musftlea  of  the  face.      1  have  nctca  of  a  uuuiber  of 

cues  in  which  suah  treatment  h&s  been  efficacious.     The  indications  for 

treatment  a.ic  as  direct  aa  they  are  iu  the  treatment  of  what  has  been 

cilleii   watchmaker' ii  tic,  am  occu^i^tioit  neutogie  manifest  in  the  orbic- 

aUf  museles  following  tJie  use  of  the  glass  vhich  these  artisans  hold  in 

iho  orbits      In  sboit,  the  source  of  the  twit<.^bing  being  removed,  and  the 

general  healtli  of  the  patient  caied  for,  recovery  follows. 

The  treatment  of  the  neurosis  of  which  the  tio  is  a  manifestation  is 
ptactTcally  tlie  same  aa  the  treatment  of  any  otht^r  degenerative  condi' 
Uon^  subject  to  individual  and  selective  varialiou.  The  measures  to  be 
utilised  are  h>'gienic  and  Tuedicinah  The  by^ieuic  ^hauld  have  in  view, 
first,  tbd  development  of  the  body,  and,  second,  the  development  of  the 
mind,  and  the  medicinal  should  Snd  its  object  in  increasitjg  the  poteu- 
tiali^  of  life  in  the  cellulftr  elemonta  of  the  higher  tissues. 

The  education  ol  c-hJldren  with  tic  should  lie  along  the  same  liiiea  ai 
that  of  children  who  have  hysteria  or  epilepsy,  and  vith  the  same  object 
in  view,  viz.,  to  inerease  tlie  staliility  of  the  nervous  aystem  while  tl^fl 
Qutriticual  state  is  kept  as  ijcar  to  perfection  as  possible. 

MedicinaUy  there  arc  few  drugs,  aside  from  those  that  contribute  to 
,aHtOTation  of  nutrition,  that  are  of  any  service.  Two  of  the  minerals,  sul- 
^^dbaieof  copper  and  nitrate  of  silver^  are  given  empidc^liy  and  baveofteti 
been  recommeded.  In  a  niimL>er  of  iustaiic^a  I  havf^  seen  very  beneficial 
r«6ults  foUow  their  use.  It  is  impossible,  of  course,  to  say  bow  these  al- 
teratives act  or  what  they  do  to  intluence  the  progress  of  the  neurosis. 
If  they  are  admmLstered  in  a  desultory  faabioit,  or  if  they  are  given  for 
ft  short  time  only  and  in  a  move  or  less  bapha/ard  way,  their  use  will  be 
very  diaappoiuT.ing.  They  shouhl  never  he  alone  relieil  upon  to  benefit 
the  neurosis,  but  should  be  employed  as  adjuvants  to  tlie  disciplinary, 
hygienic,  and  moral  treatment  which  has  already  been  xcferred  to- 

In  the  minor  forms  of  ti^'^  it  is  eometimi^s  po^sibk  for  the  patients  to 
ooutrol  the  tw]tchiiig>  partially  or  completely,  by  an  effort  of  the  will, 
and  they  should  be  encouraged  to  do  so.  In  the  more  severe  fonus,  and 
in  casea  of  generalized  motor  tic,  the  twitchings  are  materially  lessened, 
or  indeed,  they  may  cease,  while  the  patient  is  indulging  in  absorbing 


TRKATMBNT  OF  DISRASBS  OF  THB  KKRVOC8  BTSTEU. 

cxKupatioiL  or  sporU  I  liave  sveri  markied  [leuelit  fallow  the  uat  of  tUe 
bkjcle.  The  tio  luovemeDta  jfteu  stop  eutirelj'  at  aucL  tii^iaa  and  ths 
longer  they  cc&se  the  hotter  for  the  patietit. 

Baminaiy.— In  (roiictuatoa :  Tm  is,  ia  Lhe  majority  of  oaseB,  a  Uegen- 
efative  neuroaU^  its  most  prominent  outward  u^anifestatioo,  vu,,  th« 
tTilfhing,  tho  one  from  nbich  it  talcea  its  ujtme,  is  a  Btlgma  ot  de- 
geueratiou,  just  110  heiuiaiiiifatheBia  is  a  stigmn  of  degeneration  in 
hysteria^  ita  next  moat  common  stig'mata  are  psychical  and  conaiBt  of 
oompuJaioiis,  obecHsionoi  and  poaseBBionaT  tic  ocoure  m  individuals  wbo 
have  stigmata  of  degcueralion ;  and  it  in  one  of  the  d<?geDer&tiT«  die- 
eases  which  develop  early.  Simple  motor  tie,  let  ns  Hay  tic  of  th«  mus- 
culature of  the  seventh  nerre,  ofteatimeH  is  a  reRex  coudition  depeudnut 
upon  ittitatiou  of  some  of  the  brmchea  of  the  fifth  nerve ;  in  «Ukrly  per< 
sons  it  ifl  often  associated  with  di'geuoration  of  the  blood- vesseht^  aod  in 
the  young  it  ia  gometimea  seen  with  perverted  st&tcs  of  Dutrition,  aod  it 
oeasee  when  these  are  overcome.  Furthermore,  tiff  has  atisoliitely  noth- 
ing m  common  with  acute,  humornl,  Sydenham's  chorea,  nor  with  degen- 
erative, parenchymatous,  Huntington's  ehoi-ea,  and  the  term  chorea  should 
never  bo  thought  of  in  connection  with  thie  diBease.  Finally,  tic  beia; 
in  a  majority  of  int^tan^'es  a  degenerative  neuroai^,  it  confotuiB  io  occur- 
rence, in  development,  in  ppogresslou,  in  obstinaoy,  and  un  reaponsi  veoeaB  ^j 
to  treatment  with  other  dUeases  of  Jegenerai^y.  The  form  uf  tr^<atinsnt  ^ 
of  greatest  avail  \r  like  that  which  has  \teen  Hhown  to  Lie  cf  service  ia« 
the  daafl  of  diseiaes  of  whi<'U  it  ia  a  type.  The  aniae  principles  ahould^^ 
guidons  in  the  treatment  of  tio  as  i  a  the  treatment  of  hysteria,  of  epilepsy^  ^ 
and  of  congenital  defects  iu  general,  and  in  my  enperienfw  the  salts  ot^ 
eoppei-  and  silver^  when  given  in  comparativet)'  largo  do«es  and  for  k  ■ 
proloDged  time,  while  the  bodily  health  and  the  general  norale  are  care*  ^ 
for,  are  more  i^ilicacious  in  the  degenerative  form  than  other  therapeut^^^ 
meo^urca. 


CHAPTER  XXXL 


THE  TREATMENT  OP  SIlORArNE, 


I 


MiQRAiN'E — often  called  megrim^  hemior&ni&,  aick,  bilioaa,  or  blind 
beadache— 'is  a  degenerative  □eurcaia,  whose  moEt  confltant.  aad  cliaruc- 
teristic  ayraptom,  parosyainal  headache,  usufd.!/ confined  to  one-half  of 
the  head,  oocDrs  during  the  prime  of  life.  Like  all  other  degeaeratiTe 
neuroses,  practically  nothing  13  knowa  of  its  etiology,  save  that  it  is  lio- 
peditary  in  more  thao  one-half  of  the  cases.  When  direct  iuheritanee 
cannot  be  traoed,  Bearch  of  the  ancestral  and  faiuily  relationship  will 
often  elicit  a  history  of  the  existence  of  some  other  neurosis  of  a  degen- 
erative type,  such  aa  epilepsy,  hysteria,  tio,  periodical  inebriety,  or  rudi- 
meotary  neuraBtheuia.  For  instance,  1  have  at  present  under  obsef  vatiun 
two  sisters,  aged  respectively  thirty-t^o  aad  thirty;  one  haa  epLlepfly, 
the  other  migraine.  It  is  aliout  as  common  in  males  as  in  females,  and 
it  chooses  its  vk-ttios  from  all  walks  of  liffi.  Tde  wage-pamer,  tlie  scipn- 
tist,  the  statesman,  the  man  of  letters  and  of  leisure,  all  furnish  their 
quota  of  cases-  Many  men  eminent  in  their  colliuga  and  professioiLs  have 
Studied  the  pbenomeaa  of  tlio  disease  subjeotively  and  objectively  as  it 
has  been  revealed  in  theiaaelves,  and  this  accounts  for  the  tvtdespread 
belief  that  the  iliaease  is  most  common  in  those  of  great  iaipellectual  pos- 
session. The  immediate  antocedeuta  of  an  attack  of  migraine  arid  the 
associated  symptoms  which  go  to  make  up  the  phenomena  of  a  paroxysm 
are:  faetors  contribntiog  to  fatigue,  depresaion,  enervation,  and  ejibaus- 
tiQji  of  the  soma  and  the  psyche- 
Symptoms —The  paro^iysnifl  of  migraine  occur  with  great  irregularltj. 
Some  patients  ai-e  so  fortunate  as  to  bave  only  one  or  two  attacks  a  year^ 
in  others  they  are  of  such  frequent  occurrence  that  the  patient  scarcely 
baa  any  time  of  complete  freedom  fr'im  the  attacks  and  their  conse- 
quences.  The  headache  is  usually  preceded  by  symptoms  which  the  pa- 
tient leamH  to  interpret  as  heralilers  of  an  attack.  These  may  be^  (gen- 
eral depression  without  attributable  or  aptiai'ent  cause,  uncontrollable 
inclination  to  yawn  and  gape,  an  indescribable  feeling  of  confusion  in  the 
bead,  noises  iu  the  ear,  restless  sleep  disturbed  by  disagreeable  and  ter- 
ToriKiDg  dreams,  obscuration  of  rision  by  flashes  of  light,  phajibasmagoriai 
and  patches  of  obscurity  of  ebungeabla  shape  and  position  in  the  visual 
field  known  as  scintillating  scotomata,  and  occasionally  by  more  nr  less 
complete  transient  unilateral  amblyopia.  The  visual  phenomena  are 
more  often  ancillary,  while  the  others  may  etist  for  some  hours  before 


474 


TREATMENT  OF  IHSEASES  OF  THE  NERVOUS  BVfiTEM. 


th«  attuck.  1q  iai-«  iDstanc^eH  the  nttaclc  ia  pr^c^dei)  by  a  filing  of  veil- 
bebg,  such  aa  increaaed  bodily  tone  and  considerable  mentai  «ia.Ltation. 
The  preliminaries  of  mif^niine  have  often  been  likened  to  those  of  itorm 
in  which  the  masBing;  of  the  Dlouds^  the  obacuration,  and  the  violcuoe  of 
the  elemoDta  gather  their  forces  and  concentrate,  then  the  downpuut  oc* 
ciira.  Aftar  a  variable  period  the  rain  gradually  or  euddenly  ceases,  the 
acpompanying  pherioniBna  receiie,  and  the  whole  world  or  the  immediate 
en  V  iron  in  en  t  »emns  brighter  and  clearer  by  nun  traat  than  it  wai^  t>efi>re. 
Thua  the  pain  and  attendant  pbeuomena  of  migraine  uiay,  Eifter  the  warn- 
ing given  by  the  aymptoitia  aifove  enumerated,  oonceDtrate  th<'ni8elre3  to 
one  £ido  of  the  head,  and  be  of  intolerable  severity  and  of  protrocled  ex- 
istenne-  but  on  the  other  hand  they  tnay  be  ao  iuBignificant  and  of  luch 
brief  duratUrn  that  the  paiirnt  cimtinuen  at  his  wi:iit>»tion  or  pleasure, 
Aa  a  rule  Lbe  pdin  is  on  one  aide  of  the  head,  the  left  more  often  thaji  the 
right.  AVhen  it  huH  more  restricted  lucalt^ation  it  ia  liktrly  to  be  of  thfl 
forehead  and  temple.  Very  often,  however,  it  ia  on  both  sides  or  it  may 
ehift  from  one  to  the  other.  It  ia  Uestirihed  differently  by  nearly  every 
patient,  ilepending  largely  on  their  deHcriptive  powers  and  capacity  far 
BJmile.  Aa  a  rule,  it  is  increased  by  eicitatiou  of  any  of  the  special 
eeoaes,  and  by  anything  thitt  distuihs  the  patient's  body  or  roind.  It  i« 
ameliorated  aoniewhatf  on  the  other  hand»  by  darkneas,  stilJness,  t\uie- 
ttide,  nnd  ceEHation  of  thought.  After  the  attack  the  patient  exjievienoet 
an  indearribable  feeling  of  r^lief. 

The  phenomena  that  may  preoede,  ai'innnpauy,  or  follow  an  attack, 
aside  from  those  mentioned  above,  are  nauaea,  anorexia,  vomit  of  the 
bilc-ataiiied  couten'ta  oF  the  stomaob,  great  prostration,  bypencfithesia  of 
the  special  senaefl,  and  general  irritability-  The  loeal  accompaniments, 
which  are  by  no  meann  »o  <ronatant  as  the  general,  are  paleness  of  tha 
shin  im  one  side  of  the  fai-e,  eulnrgement  of  the  pnpil  of  tbe  same  side, 
increase  of  salivary  secretion^  ncLriowue^s  anil  liriuLieASof  the  temporal 
blood -vesselat  contracted  retmnl  blood-vesaeta,  revealable  by  the  ophtbal- 
moBOOpe,  and  lowei-ed  surface  temperature  over  the  pale  areas  of  the  face 
— pbenomeim  that  nan  be  prchdui.'ed  artiiicially  in  maLi  and  In  animals  by 
irniationof  the  cervical  ay ta pathetic,  VVlieu  these  symptoms  are  accom- 
panimenta  of  the  headache,  the  name  of  angiospastic  migTaiue  is  giveo  to 
it,  >>nGh  attacks  are  sometimes  attended  by  transient  motor  aphasia  and 
slight  motor  pareais  of  oue-half  of  the  body,  and  very  rai-ely  transitory 
pajatysia  of  one  oeuiomotor  nerve.  In  other  caaea  phenon^ena  ooour  that 
may  lie  proihiced  in  the  ftVin  of  the  face  and  ear,  pupila,  and  salivary 
glands,  by  section  of  the  cervical  sympathetic  such  as  redurss  of  the 
akin,  dilatation  and  pulsation  of  the  temporal  arteries,  elevatiort  of  aoT" 
face  temperature,  umhiteral  facial  hypendrosiSt  narrow  pupih  AttackA 
thus  attended  are  called  angioparalytic  migraine.  They  are  extremely 
rare  compared  \vith  the  angiospastic  variety^      When  the  attacks  are  pre- 


THE  TB£ATME.vr  Or  HmiUIXK. 


m 


«»dad  ftod  accoiDpuu«d  by  «ubj«odTe  Mnntioni  ibat  «vi  \m  nCirrvd  to 
Uift  AjM,  they  ar«  cftllfid  ophtfaalBuc  Bipwna^  alUnu^  Timial  dilaiA  Im 
nry  liuk,  if  inj,  ceUtMoalup  to  thftir  oocnrra&c*  or  cttttMtiou.  Aa 
ittftck  of  migraine  IasU  frqta  a  f«v  houis  to  sercf^  days^  ftuil  &s  k  riil* 
fBdfl  grwliiaJIjf  often  atteoded  by  rotuiutig,  copious  CTa<>aUioB  fn>»i  tbt 
bowels,  ftnd  <H*cAsionft]ly  by  pmfiis^  p^npiratioii  or  dmnais.  Then 
tfttr  a.  deep,  protrarted,  l«th&rgio  slmuber,  th«  pstiuit  em^rgti*  wjlh  k 
feeling  of  reaewt^d  vitality  ajid  ambitioii.  AttAck6,  howT>vrri  otwaya 
IriTO  A  memory  of  pain  and  anguiab  whidi  protupla  Ui<?  initivtiliinl  lo 
^Tapulously  gu&td  against  what  he  believes  to  daum  or  proonle  iw  out- 
burst- 

Tb?  coiEirrfe  and  outcome  of  the  (liaeAse  are  tho  same  us  in  moitt  tif  th« 
tjfgeficrative  neuroflfts.  Left  alone,  their  moat  striking  iiianifeatJitionfl 
We  a  tcBilencT  to  increase  in  aererity  and  ft^qiietiry.  I'tiliko  aoqiiirod 
diseases,  they  have  do  inherent  tendeniry  to  grow  less  or  to  dii^iippfiar. 
Occasionally  the  disease  pheiLomeua  seem  to  undergo  a  tTAiufuriimtion^ 
and  appaar  as  vertigo,  g^'nt,  epilepsy^  ur  other  pjironjHmaT  eoiiiiiti'm. 
iJana  has  recently  reported  a  caee  iu  which  Uio  trauaitioa  from  luiKraina 
to  vertigo  characteristic  of  paendo-M^n i^re'a  diaerise  was  very  etnkiun, 
while  the  attsociation  of  migriune  aud  epilepsy  lb  uufortvmatLjIy  not  v&ry 
rai«. 

Treatment.— The  treatment  of  migraine  may  be  roTisidareil  under  two 
headings:  (1)  the  treatment  of  tha  patient  or  tha  dbaaae,  aud  i^2)  tba 
Ucatmeut  of  an  attack.  To  the  patient  himaelf  the  Utter  neema  by  far 
the  mt-re  importiuitr  bat  the  physician  knows  that  tuort^  can  bo  dotw  to 
shape  the  coiirae  of  the  iliaeai^e  and  to  diminish  the  Luttilil^'  ol  hun'rrna^ 
by  care  of  the  patient  in  the  interval  of  the  attaeka  thau  by  any  amount 
at  medication  at  the  time  of  the  patuiiyam^  The  treat Liieut  of  the  migrrii* 
noua  patieat  should  be  begun,  tike  tliat  of  all  other  disea.'^eA  of  (lvgeiierai:yf 
before  the  patient  is  horn.  1  caunot  here  revert  to  the  duty  of  tha 
phvGician^  whose  advice  may  be  asked  coneeroiii^  marriagM  for  thoao  who 
are  burdened  wiih  hereditary  and  famitiary  taint,  further  than  to  aay  \uiw 
difficult  It  is  to  act  the  part  of  satisfactory  guide-  (See  Tart  l.)  The 
phyeiciaa  ahoald  alwave  rooGDO  himself  to  showing  the  way,  aud  not  biBiat 
apcm  aoL^ompanjing  to  ace  that  his  deiiaion  o  reepectod.  ConalderioK  tho 
lAdabtedaessof  the  world  to  migrainous  pereons,  it  would  bu  an  ■atomptioii 
on  tha  part  of  the  physician  to  advise  agaiavt  marriage,  for  ha  Blgbt  ba 
depriving  poatority  of  a  Sir  John  Henchell,  a  fin  Itoii-Bejmoad,  or  ft 
WoUaaton.  ??evertheteaa,  if  be  be  more  altiuistie  than  utililaruuL*  hm 
nnut  be  tnio  to  bu  ideal  and  prevent  soffermg  whenever  po»tible,  Tba 
aJttcation  of  ebildraa  bom  of  mi^ramovu  porvcta  *bould  be  ooDdaet«d 
m  fAiD  BUBulai  to  that  of  thoae  «bo  tnhent  a  tcndcory  b>  tbat  pro- 
nmavmn  known  af  hysteria-  In  brief^  ^r^  effort  iboiiU  be  faeait 
to  makr  Kick  patiait  a  mixtaat,  rigoroai,  bealtby  aun  or  womb.     Thuf 


■476 


TRLATUBNT  OF  III8RA8S3  OF  THE  N'ERVOCS  SYSTEM. 


should  aeither  be  subjected  hot  allowed  to  subject  themselves  to  tbe  fore* 

ing,  [-mwiliiig  iirooesses,  cocgloinerated  uniler  tbe  name  of  eJiicaiion  or 
acL^uuipliabmeDt.  that  the  modoiti  boy  aud  ^1  has  to  go  tbiou^fb  At  the 
pr«ENmt  day.  When  the  age  \b  reached  that  fiuch  a  peraon  must  muke  a 
decision  as  to  bis  future  occupation  or  preparation  iox  cieetiay,  the  phjGi' 
cian,  i  f  given  an  opportimity,  should  again  b©  ready  to  act  Ibe  part  of  tbe 
sigii-pust.  It  is  unnet^Hsary  to  say  that  au  active  life  out^f-doora  coo- 
tains  much  le^ft  poteuttality  of  migraine  than  a  sedentary  life  within 
doora.  Tbe  purniciousneas  of  alcoholinsT  tobacco,  tea  and  coffee^  overeat- 
ing, sexual  aberrations  aud  ex^eases,  late  houi'S,  and  strife  of  411  kindi, 
should  be  dili^iitly  iuonbated  and  constantly  kept  before  the  patient 
until  be  oomes  to  rbcogui^e  their  ini[K>rt}Uice.  The  patient  should  learn 
«arly  that  fraedoin  ftoni  pain  stands  in  uizra  or  less  definite  relationabip 
to  meutal  eqiianimily,  evenuess  of  diaposition,  imeveutfulnesfl  of  life, 
and  nornk:Ll  state  of  the  digestive  apparatus,  and  that  he  ehould  atriva  for 
the5e.  He  should  so  avrango  his  time  that  at  least  ten  hours  may  be 
given  to  aleep^  while  two  or  three  of  the  rematning  twenty- four  should 
be  apent  iu  tbe  opea  air,  taking  some  sorb  of  ej^arcise  that  will  incrauB 
the  n&uromuacalar  totiQ  and  maintain  a  high  degree  of  nutrition.  Thii 
may  bo  impoasiblo  for  the  great  majority  of  bread-winnora,  especially 
vomen,  in  whom,  unfortunately,  migraine  is  not  rare^  but  in  these  caM« 
some  shift  must  be  made,  either  by  uae  of  hyilfio  procetlures,  massage, 
gyiunaaium  practipe,  or  by  sharte-ning  tbe  day's  work,  to  compensate  for 
the  health-giving  indulgences  above  mentioued.  It  is  in  this  class  partic- 
nlarly  that  so  much  con  ha  dona  by  teaching  the  patient  that  worry, 
aiLXtety,  and  antLci|ration  of  want,  or  conviction  of  bability,  do  far  more 
harm  than  the  actual  fuIHIment  of  their  daily  dutisfl  aud  labors. 

3u[>ervision  of  tho  diet  iind  regulntiorr  of  the  bowels  are  of  them- 
Belvea  oft^a  very  influenltiil  to  dimiuish  the  fretjuen^  y  ;ind  severity  of  the 
attack.  As  a  mie,  a  mixsd  diet,  vegetablee  predominating,  with  com- 
paratively little  meat,  ospeisiolly  red  raoat,  supplemented  by  milk,  com- 
bined with  on  alkali,  such  as  bicarbonate  of  sodium,  commercial  or  natural 
Vichy,  is  moat  suitable.  Whenever  possible  the  bowels  should  be  regc* 
lated  by  the  admixture  to  the  diet  of  substances  that  are  known  to  have 
a  laxative  eCFert,  and  by  tbe  uae  of  abdominal  massage,  and  gymnasttos 
that  strengthen  the  walls  of  the  abdomen.  Simultaneously  tlie  tonus  of 
the  intestines  is  increased  by  the  u^e  of  vegetable  laxatives  with  bella- 
donna or  nui  vomipa,  cofd-wat**!"  injections,  and  sit^  baths.  The  mis- 
take should  not  be  matin  of  giving  salines,  such  as  sulphate  of  soda  and 
Carlsbad  ?alts  in  large  doses,  or  other  suhstaQcea  that  deplete  tbe  system. 
The  patient  shmdd  be  subjected  to  the  moat  scmtinizing  medical  survey, 
and  any  departure  from  normal,  either  in  the  orgau9  of  the  body  or  in 
the  tissues,  repaired  or  attempt  made  to  overcome  them,  Oecasiooally 
such  scrviti[ky  will  reveal  abnormalitiea  of  the  eyes,  eara,  cavit]er<  of  the 


THE  TRKATlfBXT  Or  JnGEAlTE. 


47T 


tad,  or  of  the  uteiina  otgmns,  vlueh  saj  <v  m^j  not  hftrv  «i>j  betuing 

0B  tbe  neurosis  itself  or  en  the  fimjpuBKj  of  its  VKKt  pronmvt  muiifc^* 

titioas.     Thej-,  DevertbdesB^  shontd  bs  marcciBC^  if  1***"^*^.  mnd  for  the 

maan  that  all  pbvsic^  ahortcoiamgs  ftct  fts  »  drain  upoo  tk«  ^nersl 

hlslth.     The  physician  who  aeeks  fJi«  jgionodiAtp  >nt<«ed«ntol  ui  attack, 

be  It  latoiicatJon  from  without,  suoh  «•  pmoutBg  bf  oim  of  the  SD«taJ^ 

evenwtingi  esperially  of  mean,  antD^bniettlnni,  uric  arid,  fitigQe,  Me., 

ud  adopts  a  plan  cf  traalmait  to  *"■*"***•■  or  oouolcnrt  it,  ia  miuih.j 

sore  worthy  of  hb  hire  th^a  he  who  nei^Iceta  to  do  bo.     It  ia 

iQXWceaaary  to  t«ll  migruiuma  pMuata  how  thfj  ahall  lire,  what  ihvf 

Bij  do,  and  whxt  they  moftaroid;  txpenmc*  is  by  far  a  better  tc*eii^ 

tbiA  role  of  thumb.      Th^y  qoid^  Inm  the  dlsaitroos  ^ect  of  lato 

boon,  crowded  moms,  iDdiacntkna  of  diirt,  OTcnxflrticB,  aod  atca— bb 

of  different  kinds,  and  avoid  I^bbl     If  uipvAO  iB  aaBodatod  witii  aadk 

italea  aa  anfiemia,  diaplaoeisciitB  or  diaeaae  of  the  ntenu^  <JLrtMiie  niddl^ 

Mir  diaeaae,  disease  of  the  itaaal  paaaagcat  dyapqaia,  Bte.^  theaa  n- 

qoire  special  txeattaenL     It  ia  when  tka  latter  exitta  that  lara^  «f  the 

stomach  and  inteetiiiei  is  oftm  uaeftiL     The  Taleriaiute  of  menthol  in 

two-  to  Sve-graiu  dLises  baa  teoanUj  beea  retoou&eikded-     I&  era;  aao 

the  dig«atioti  and  state  of  the  iatcatiDea  ahoold  be  iaqiBRd  teto.     Whes 

the  aJimentary  trvt  ia  diaordeeed,  a  ccxme  of  Carlabed  w«t«r  laay  be  of 

serrice.     The  following  pieecrtptkn  will  efien  give  good  resnlts : 


9  CaSaias  citrati% 

HotthoL ea  p,  -fill. 

QiiEnlns.   ._         ^        .....         .        ft.  XT. 


^^■^  It  ia  QQiMoeasajj  to  ipeak  in  detaO  of  the  tiae  of  each  mnaBnine  ai 
[  hjdriatics^  oiasjfage^  tJMiMBliiia,  and  erea  elecftneitr,  for  the  perpaae  of 
incieaamg  the  paliaD*'*  cemera]  nnbritiacial  loce  and  rcriiflance,  Fiacta- 
cally  they  hare  the  nme  application  here  »  they  hare  ia  ikearafftheiii^ 
ereo  in  the  accjured  form^  of  the  latter  diMaae.  Theoe  agBPcien  haTo  &o 
niecafio  Tirtoe  in  niaaiiM^  and.  the  i^t*i*n*  of  endnciaala  foe  the  pftfail* 
tag  efficacy  of  ooe  or  other  of  th«flB  in  the  tiealBMnt  of  aiigtaine  aje  not 
mime  a  travesty  on  physiukigical  th^nipentica,  Imt  an  epitome  of  aneh 
^Bthoaiaata^  igoorance  «»eemiag  the  geneaia  of  the  diefBo  aad  iatsiprs- 
Iftliofi  of  its  pbeENMBCBa.  Tbey  ate  all  of  serriM^  and  for  the  leaaoa 
that  they  not  aloEW  inereaoe  the  paticiit^B  vital  fore^  bat  they  givie  him 
a  ffleling  of  ceKfidswe  liwt  inp"**TTiTig  ia  being  dooe  for  bin,  the  rflcLta 
of  which  aiv  **'*g^*J*  apid  beDB&aaL  No  moie  ia  it  bonmisg  for  ihoea 
wbo  do  pot  fnlly  recognize  the  benefts  to  be  had  from  the  methodical  oae 
of  thcBo  Mc— nrra  to  deery  them.  Their  piooe  in  the  therapeotica  of  mi- 
graine ia  DO  eohed  oo^  but  they  fill  an  iu>oeeii|t4ed  niche.  Having  eaid 
Ihia,  I  do  not  feel  impellad  to  reeonnt  ia  detail  the  modea  of  applying 


r 


478  TREATMENT  OF  HISEASES  OF  THE  NEHVODB  SY3TBM- 

or  of  utilizing  maseagei  cr  of  indulgmg  in  gvmnaaticB.  A  word,  how- 
ever, in  regs^rd  to  electricitr  is  iieceBsaTy-  G^s^fljii^tutiun  of  the  c?rvij?aL 
syrapathetin  lias  iirobably  more  rijerit  theoretically  Uiaii  any  other  proce- 
dure. But  W9  liave  aeeu  from  the  brief  description  oF  tlie  &y m  ptotaAtot- 
ogy  of  migrftine  that  tbe  ayjupathetic  plienomena  mny  hv  those  of  irriU- 
tion,  or  of  relaxation,  and  the  foTW  of  eleotridty  tliat  i&  good  for  th«  one 
eannol  surely  be  good  tor  the  othec.  EmpiricUts  may  contend  that  th* 
irritating  or  negative  ptile  should  l>e  usfld  in  the  angioparalytio  variety, 
aiul  the  cathode  or  aeilattve  pole  in  the  aogiospastic  variety;  but  experi- 
ence will  soon  convince  that  they  apeak  uot  out  of  the  fulness  of  their 
kiiOTrledgC.  Ah  a  matter  of  fact,  electricity  in  the  shape  of  galvanism  t*> 
the  cer^cal  sympathetio  or  to  the  head,  faradism  in  the  shape  of  g^iieral 
faradi?.ation,  cr  the  application  of  the  rapidly  interrupted  cirrrent  from 
a  long,  closely  wound  cull,  the  static  douche  or  sparks— *in  short,  any 
variety  of  electrical  applieatiou — has  its  eutare  usefulaeas  in  tho  treat- 
nient  of  migr:Lme  in  impTOviiLg  the  paticTit'e  general  health,  and  in  in- 
epiring  hiiti  with  a  feeling  that  something  beneficial  is  being  done  for  him. 

The  drug  adtninistratLoa  under  this  eaption,  namely,  the  treatment  of 
the  patient,  r^hould  cunsist  in  giving  siiuple  hitters  tocouut^eraetanorexiif 
alkalies  aracids,  de^vndent  u|ton  the  reaction  of  the  coutents  of  the  atom- 
ach,  laxatives  to  overcome  constipatioo,  iton,  arsenic,  and  quiniiie  u  tis- 
sue  recouatruetn-es,  and  the  fulfilment  of  the  other  requireniente  thattaay 
be  apparent  or  discoverable  in  ear<h  indi^idtial  naae. 

There  are  a  f(*w  dnigs  that  undoubtedly  have  a  decided  efTeet  in  di- 
lainishiiLg  niigrainoiis  potentiality.  Among  these  the  first  place  is  bj 
common  consent  given  to  the  broniideB.  originally  Bugges1«d  by  Liveing, 
who  wrote  so  illuminatiugly  of  this  dit^ease,  and  brought  into  wide  uaage 
hy  the  reL^ommendation  of  Chari'ot.  The  etiological  and  oliiiical  resem- 
blance whit^h  the  disease  hiia  to  epilepsy  suggested,  no  doubt,  the  uaefal* 
ness  of  the  mo.sl  iiuijortant  anti-epileptio  medipament  in  migraiii*.  Thft 
mode  and  plan  cf  its  adniiniatratiun,  ad  >*ell  aa  the  ruled  for  the  avoid- 
anoe  of  ita  injurious  effects,  ar&  the  aame  as  those  given  for  epilepsy. 
The  dose  depemEs  upon  tbe  idiosynernasy  of  the  patient  more  than  upon 
any  other  condition;  and  tht«  must  le  deitrniiued  by  experienoe.  The 
selection  of  any  partioidar  snlt  of  bromine  is  of  do  impf>rtanpe,  one  being 
about  as  serviceable  as  another.  After  the  piitient's  dosage  has  been  de- 
termined, the  quantity,  he  it  a  scruple  or  a  tlrachni,  should  bo  administered 
in  large  quantities  of  water,  plain  or  alkalinated,  at  t)edtime.  Aa  a  rule 
It  is  not  advisable  lo  give  it  during  tbe  day.  It  should  be  given  for  a 
prolonged  tiiire,  providtid  the  patient  does  nut  los^  weight,  and  tli^re  Is  no 
disturbance  of  digestion  and  nutrition  which  is  not  easily  corobiLted, 
When  these  occur,  the  measures  that  are  serviceable  in  combating  the 
phenomena  of  bromism  should  he  utilized.  The  admmiptratioa  of  the 
bromides  is  almost  invariably  followed  by  a  lengthening  of  the  inter- 


THE  TREATMENT  OF  UIGRAIKB^ 


479 


fVEung  period  of  health  and  bj  diiuiaulion  in  seveiity^  of  the  lieadAche 
ind  aQcillarv  [uigraiuoius  pheiiomeu£i- 

Treilmcnt  of  an  AttEUik.  ^During  the  attack  some  pam-reliever  miiBt 
b?  ^ven  in  sulficient  dosca  to  relieve  p^ui,  cepeoiaily  m  ttsvere  ciifl«B. 
Before  ihp  discov^ery  of  tha  modem  analgesins^  l*'^  phyaimn  hail  very 
btUa  choLo«  alioat  using  morphioe.  TUe  putient  (leiij^Eided  it,  rt^|mrtid 
1^  and  got  it,  arid  very  properly  so.  OflentimBa,  oveu  yet,  it  ib  n©o«i- 
iisy  lo  administer  morphiDe,  either  by  the  rectum  or  subcutanoouily,  and 
irhen  used  under  control  of  the  phyaioiau  there  ia  little  danger  of  enlnb- 
jj^hing  the  laorphine  habit,  providing^  of  drrtirse^  that  the  patient  In  not 
m  a  statiaa  oiigrainosuB.  As  a  rule,  howeT*r,  Huffloient  relief  to  enabla 
i\\f  patienL  to  ^t  through  an  attack  is  olitained  from  pbenacetiu,  autipy< 
rin.  antifebrm,  c^ie  of  the  salicylates,  caffeiae,  eytiain,  UctopheoiUt  etc,, 
or  oombiDations  of  them.     A  uaoful  preocriptioa  )»; 

^  BiciLoL  EalioyliUe.  ....,,,  gr.  x. 

Cafleine  talicylate,        ..,.,..  «T- U' 

^lietiacetia,  ...,....,  gTr  I. 

Td  be  uken  wiUi  boiniUi,  or  bo(  Wfttvr  tnd  whi^ktrj. 


This  formula  seems  to  be  partieularly  sorrioe^le  in  aq-eallad  opbthaliiiL4 

mi^raiDe,  associated  with  pallor  of  tbe  face.     On  the  other  hand,  vhm 

tjere  are  flushing  of  the  face  and  the  othor  amompanimetiUi  ahore 

tioaeii  I  hare  used  a  eapsole  cMHamiof  camphor,  ^aleriac^M  of  mm^tak, 

and  salicylate  of  raffcinc,  of  ea<ch  two  gr^na,  the  doae  bei&g  repeat«4j 

arety  bov  for  thr«  doaea;  tbe&  e^^rr  fovr  ho<u%  if  reqnified.     Tt  U  im- 

pDWihWf  to  gire  in  detail  all  the  eombuiationi  of  tbna  p«iD-rrii«Tera  that 

J  be  naed  vith  beoefit-     PatMuta  vaiy  lo  in  tbvtr  ■nan^bility  to 

dmga  tittt  it  rfl^nisea  kibm  ^ntfiiii— ■talinii  lo  find  the  bu^mI  mi- 

ofte,     AifctiMmi  fires  in  fi¥e-giaiift  doac»  aod  f'>llo«ed  ^ 

drftocbta  of  pan  hiaefc  coCm  hoa  bna  noit  ■t>Tinfa)ila  m  wj  ovn 

ri— w.     Itii  veQ  ID  baar  ia  ^ad  dst  whs  it  m  ■fiMnijTii  gm«a«^ 

of  tlwA  hypodawaraDy,  aaijfyi^  la 

kH  a  teadeacy  b»  dcmca  Iks  AfHtin 

Uigniaa  attm^d  by  *yvplttM  of 

baneitad,  altk>^  tha  atMk  at  sat  natemUy  ibovtiMd,  by  ^ 

istiaiaaa  of  aM  of  tba  ttUtav  tfe  iabalMiMaf  liferteci  i^ 

voat  rii^bk-    TW  dfxvfaa^  te  te  aaa  ia  4aa  te  aetiaa  h  vcfly 

of  ainagajtaiij^  p^»€*uj  ift— ■iaaiaa— tfl  tta  fiynognii  fc^twaa 


TREATMENT  OP  PISHA9Efl  Off  THE  »KRVOU«  8VDTKU. 


When  LliQ  (^uiicoDiitAQt  T&aoiiioior  maDifeataticrna  &re  of  a  pftr&lyttc  tjl' 
TKtyt  ^hicli,  ashaa  lieforebeen  aaid,  is  extremely  laie,  it  baa  been  adria«d 
to  givd  ergot,  but  my  experieuce  haa  been  that  very  little  reliatice  can 
be  placed  upcjn  this  dnig,  Od  the  other  hand,  1  har*  found  promjjt  re- 
lief,  peraonallj  and  in  a  mimber  of  patients,  by  light  manual  compres< 
aiuii  of  the  carotids,  or  bj  a  folded  haudkerchiflf  pinned  tighttj  aroimd 
the  tiQiik,  The  applicatiou  of  an  ice-bag  to  the  head  is  alao  aometimea 
uaefuL  and  floothiiign 

The  autotoiwmio  theory  of  migraine  haa  beaa  more  widely  ac^iepted, 
the  writer  venturei  to  believe,  than  it  deserves.  Nnmeroiis  plana  of  treat- 
ment baaed  u^ion  thin  theory  have  been  devised  and  pn^mulgaLed^  There 
can  be  no  doubt  that  there  is  a  state  of  profoundly  disordered  fuDctioo 
of  the  digestive  tract  ditriug  an  attaolc  of  migraine.  If  the  euutenls  of 
the  stomach  or  inteatinea,  removed  duting  an  attai;k,  are  examined  cbemi' 
eally  they  will  probably  be  found  to  contain  a  small  amoont  of  tox.io  snb- 
staniva.  But  this  perversion  of  function  aiul  the  immediate  €ODsequ«ncet 
are  caused  by  the  pi-ofoiind  disorder  of  tlie  sympathetic  nervous  system, 
which  is  at  the  bottom  of  the  attack  of  migr^ne;  they  are  tbe  reeulta, 
not  tlie  cause,  of  the  migrame.  No  doubt  the  digestive  disturbance  and 
its  entailments  acting  vipon  an  already  overwhelmed  economy  will  help 
to  retanl  the  eatablislmient  of  dquilibiriLm.  Therefore  measures  should 
be  taken  to  oven-^me  theelfects  of  su^^h  iutoxiratioJi  and  to  counteract  the 
formatioiL  of  the  tuxio  subatance.  If  this  can  be  accompli^ahed  by  having 
the  yfntisnt  drink  copiously  of  hot  water,  by  the  administration  of  a  Aoap- 
Buda  enema,  or  by  lavage,  these  uhoutd  be  used.  They  are  aidE  oaly  in 
facilitating  the  leatoration  of  neural  eqiiiltbTinin, 

In  the  majority  of  fasus  it  is  umieuessary  to  enjoin  abaolule  rest  and 
suprema  quiet,  with  freedom  from  every  form  of  irritation  and  excite- 
ment, during  an  attack.  The  patteut  voluntarily  embraces  these  tneaa- 
urea,  for  one  attack  is  suftieient  to  apptiao  him  of  the  comparntLve  com- 
fort they  give.  After  a  severe  atcaek  the  patient  ahonld  rei^eiv^  the  same 
attention  as  in  epilepsy.  The  inroada  which  the  suffering  has  made  upon 
his  strength  and  morale  should  bo  combated  by  the  use  of  readily  absorb- 
able and  highly  nutritious  food,  and  preparation  should  be  made  to 
strengthen  any  vulnerable  points  in  the  general  health  previous  to  the 
oecLirrenoe  of  thd  jiSKt  attack. 


CHAPTER  XXXn- 


THE  TREATMENT   OF  CHOREA, 


The  term  chorsa  means  literally  a  danoe.  When  used  ivitbcut  qiiali- 
ficatiou^  Sy(]eiiha.iii^a  t^horea^  oi  St.  Vitua*  dauce,  ia  alwaja  meajit. 
SydeoLam'a  chorea  is  on  infection  or  a  poat-infectioua  intoxication, 
whioh  od(;urs  predominantEj  in  children  and  iB  characterized  bj  inrolun- 
tary,  uncontrollable,  abrupt,  bJTarre  dance-movemeuts  of  the  extremi- 
ties, face,  and  occasionally  of  the  ti'uiLk  muscles;  myasthenia;  and  men- 
tal slugglsbnes^.  The  iliseasa  i»  a  ttelf-limiting  one,  and  usually  runs  its 
course  io  from  two  to  four  mouths.  It  has  nothing  id  comiuon  with 
chrouic,  degoQarative  chorea,  or  Huntington's  chorea,  save  ono  symptom, 
the  choreic  movements  or  twitching^.  It  has  absolutely  no  relationship 
to  the  tic  neuroBis  which  ia  accompanied  by  manifold  choreic  movemeuta, 
nor  to  the  so-called  habit  choreas. 

Por  purpoaea  of  conreoience  the  choreiform  distiaaes  may  be  clasniGed 
15  f oUovFS ; 

I.  Acuta  Infeetious  Chorea  i  Sydenhi-mU  Vhorf^n. — A  toxie  or  infeo- 
tioufi  dieeaaa  mauifesting  its  most  pernicious  antirity  on  the  central  ner- 
voua  flj'stem  and  occurring  pi-edominautly  in  an  acute  form  before  pu- 
berty, but  occasionally  in  adult  life.  Rarely  ia  it  subacute  oi  chrouic. 
Cliaicaily,  there  are  two  TEirietiee :  the  twitching  form  and  the  limp  form. 

IT.  Chr<nth  TMgf^nerativA  Chorea;  Ilvntin^ott's  Ch'/rea. — Aji  heredi- 
tary, progressive  degeneration  of  the  cortei  of  the  brain,  characterized  by 
symptoms  of  mental  and  physical  irritabiUtyj  followed  by  mental  decay 
and  physical  exhaustion. 

IIL  Ehctric  Chi/rea  ;  Dubini^i  Chorea.  —  An  acutu  choreic  affection 
pursuing  a  progreaaive  couiae  and  terminating  in  death  in  upward  of 
nino^  per  cent  of  the  caees.  The  disease  ia  endemio  to  northern  Italy, 
and  probably  depends  upon  some  BpecLfic  infection,  though  it  may  be  pel- 
lagrous or  malarial. 

IV.  Tic  ChortnLs. — Dance  movements  Hymptomatic  of  the  degenerative 
nearoBts  known  as  tic^  manifesting  themseWes  ad  laryngeal  chorea,  dia- 
phragmatie  chorea,  saltatory  oUoreo,  geetieulatory  chorea,  festioating 
ohorea,  and  procursive  chorea, 

V.  Habit  Choreii. — A  condition  whose  pathogeuesis  is  indieated  bj 
its  name.      It  is  sometimes  an  occupation  neurosis. 

VI.  Senile  Chorea^ — A  choreiform  disorder  occurriDg  during  the  la- 
ter part  of  liFe^  dependent  upoa  degenerative  changes  in  the  brain  i&ci- 

31 


482 


TKEATUftNT   OP  T>iaEASEfl  OF  THE  NEBTOU3  BYSTSU. 


dent  to  BeoJlil^,  The  diaaase  runs  a  cbronic  coiiriie  &□<!  never  ends  in 
recovery.  It  is  to  he  difTereiitldted  from  clironic  Sj(leDTuuD*s  cliom, 
which  occuioiLally  occurs  io  the  sen  ilium* 

YII.  Stetmditrj/  Chorea. — Irregular  nioveineDts  seccDdary  to  and  sym  f>- 
tomatic  of  gross  organic  lesion  of  the  brain- 

The  Beparatiun  of  acute  i^jdeuhaiii's  chorea  from  the  different  varie- 
ti«B  of  tio  and  from  the  hysterical  cboreaa  seeuia  to  have  be»i  at- 
t^oded  with  much  difficulty,  For  even  uuwadajs  ve  r&ad  of  hammcTUii^ 
rhorea,  laryngeal  chorea,  diaphragmatia  chorea,  etc.,  diaouafled  under  the 
trcLLtmeut  of  Sydeufaam'a  chorea.  It  is  now  generally  admitted  that 
th«se  latter  conditlona  are  manifestatioDS  of  the  tic  neui-oeiaf  and  that 
aimU4  Sydenhaiii^a  uhorea  is  a  blocjd  disease  whose  peoi^aut  artjvitics 
are  xaaLifest  ]>riiicipally  on  the  cortex  of  the  braiu  to  produce  manj 
symptoraSf  the  moat  striking  of  which  ate  choreic  moTemeoto,  Just  u  it 
would  not  be  considered  acientilte  to  diacuss  lung  fever  wheu  writing  of 
typhoid  fever,  eo  is  it  illegidmate  to  speak  of  chronic  degenerative  chorea, 
tic  choreas,  and  habit  nhureaa,  when  diacusaiug  Sydanham's  rhorea. 
Tet  lung  fever  and  typhoid  fever  have  vastly  moro  in  comnjon  than  haw 
«ny  two  of  these  diseases.  The  moat  interesting  features  of  Sydenham's 
ehorea  are  ita  pathogenesis  and  causation-  Very  little  is  known  of  the 
former,  and  not  BuiG^^ieut  o!  the  latter,  although  much  energy  haa  been 
expended  in  an  endeavor  to  settle  mauy  of  the  mooted  points. 

The  following  remarks  on  the  etiology  of  tins  dtseane  are  baaed  on 
one  hundred  cases  recently  studied,  and  not  on  preconceiTod  ideaa  or  pr^ 
vious  knowledge. 

The  tirst  jfoiiit  worthy  of  CDnaideratLon  is  the  age  of  the  pabents. 
The  youngest  patient  waS'  three,  the  oldest  twenty^fivo  years.  The  aver- 
age age  at  the  time  of  the  first  attack  was  nine  years.  The  following 
table  shows  the  ages  of  the  patients  in  reference  to  the  school  period . 


Fflmam. 

M9lm~ 

TetaL 

AmI  to    7 

B  =    fl  per  cent, 
45  —  4fi        " 

ft=    8       " 

5& 

b  =    S  per  cant 

M2  =  32       ■• 
*=     4        " 

41 

11  perccaL 
T7       - 

12        " 

Tabulated  according  to  decndea  the  fignres  are  as  follows: 


Plml  dctwio, 
Seconii  decode. 
Third  decade, 


20  feoj&lM- 
2      *' 


S4maJea 
Ifl    " 

1  Lnale. 


Toul.  <       .       .       i       .        bO     "  41  malea, 

Examination  of  these  statistics  shows  that  the  school  jieriod  embraoer 


TBX  TESATMEST  Or  CBORKa. 


i  apviH  of  seventj-fiT?  per  trsnt  of  ill  the  oaM«,  msd  that  th«  fir»t  Mn 
I  jeir^  of  1if«  claim  £hy  per  r^nt  of  dw  cftsea.  Choraft  oooura  pradoaii* 
L  fiuUj  becv«cD  the  MT«nth  tad  £Lfte«bUi  ytm^x  ^lLo«|^  bo  isAtaWM 
I  tf  Sfdenhun^s  chorea  in  idr^nced  life  are  cited  in  these  atatistiM,  euoh 
I  mtKt  ue  eococntered  oo^Ta^iouaJlj. 

ft       Sex  is  an  importsjkt  ^tioIogicaJ  factor  of  oborea.      Of  th«4e  10l>  oei»e, 
HU  were  iiLJiles  and  59  w^re  femalas,  the  ratio  being  therefore  about  aa  'J 
Fto  3.     This  does  not  correspond  with  the  figures  of  moat  writen.     For 
I    iutsnce,  S^   gi^ea  ihe  proportion  aa  1^6   to   74,  ^tnrgia  2i   to  76*  and 
I    WoUenherg,  one  of  the  moet  recent  writers  on  the  subjoot,  29  to  7L 
I    Sdcne  intdrdgting  facta  are  obtained  from  an  investigation  of  the  uatloti* 
I    iJAy  and  rai^  of  i>ur  patients.     Seventeen  yier  Kent  of  the  patients  w«r* 
I   loreiffQ  born.     Of  these  Bussia  contrihuted  8.  Oeruiaiiy  ^,  Anstrin-Hun' 
I   fBTT  3,  and  England  3.     Thitty-eoven  per  cent  of  the  i^isee  were  of  for- 
eign «-itTaction,  the  vast  majority  being  ei.ther  German  or  Irihh,     TUi» 
frcponderanco  of  the  Russian  in  the  foreign-bora  etatiatioft  uinl  of  the 
frish  and  Germans  in  the  foreign-eitraction  statistioa,  ia  very  ewily  ei' 
pliined.     The  ICuHsianB  emij^rabo  to  this  country  with  families  nf  aiiidll 
etildren,  while  thd  vast  majority  of   Irish  and  Oernian  euii^riiLDta  are 
dagle.     There  weic  no  negroes  amongst  the  LOi)  caaea.     A  fact  worthy 
of  DOte  ifi  that  27  per  cent  of  tha  eases  were  Jews.     Thin  is  particularly 
remarkable  in  view  of  the  fact  that  the  clientele  of  the  clinic  vt  not 
Urgeiy  Semitic,     The  predia^ition  of  the  Jew  to  the  ao-called  fuuo* 
tiooal  nervous  diaordera  ie  very  generally  recognized- 

The  relationahip  of  chorea  to  aeaaon  has,  during  the  past  few  yeari, 
been  carefully  studiedn  Twonty-nino  per  cent  of  thoae  oasei*  ooourred 
in  the  aniamer,  29  per  cent  in  the  spring,  26  per  cent  in  the  winter,  and 
16  per  cent  in  the  autumn.  The  gn^atest  ntiiul>er  of  easen  ooaiirrod  in 
July  and  M&rchr  and  the  minimum  niunher  in  October.  No  rtilatiuu- 
ahip  in  the  occarroaca  of  chorea  to  hygrometrie  conditiona  could  bo 
eatahlished. 

Th^t  chorea  has  some  relationship  to  overwork  in  school  and  partiou- 
tarly  at  the  time  of  examinations,  is  mentioned  by  moat  writera,  although 
my  own  obaervationfl  aro  tion-committal  on  this  point,  ft  may  tic?  tliat 
the  frequency  of  chorea  in  the  summer  may  be  in  noine  way  rclotod  to 
school  examin&tiocis.  Very  little  information  eonoeming  the  oooorraiM 
of  chorea  in  children  of  different  stations  in  society  is  to  be  got  from  A 
study  of  diapenaary  patients.  Nerertheleos,  it  is  worthy  of  romark,  tliat 
the  vist  majority  of  caaea  oocumd  in  what  may  be  callod  tbo  bettrr  c]a4* 
of  di«penaaiy  patienta. 

The  Important  H)le  played  by  heredity  in  the  RttMlf  of  aU  so-oalUd 
ftmctioaal  dctvoqs  diswisi  if  viU  neognuod  bj  acaiolDgists.  UtmCi- 
gfttion  iiiid»tmk«D  to  ibov  tbo  mi««B«o  of  Ixrodi^  on  the  dorolpp— t 
of  chorea,  rvreale  that  in  the  iukedtato  and  coUatetal  anccotofB  27  per 


484 


THEATMKNT  OF  BISEASBS  OF  THE  NERVOUS  STflTfilM. 


cent  were  neuropatphic,  21  per  ceat  rbeumatio,  12  per  cent  choreiio,  3 
per  cent  aardiovascular,  and  2  per  cent  tuberculous,  la  35  per  cent 
of  tbe  cases  the  family  hisr-ory  was  negative.  Theae  figiirea  bio  v^tj 
uiLicb  at  variaucQ  with  tlio»e  of  obh^r  writers-  Eultoburg,  for  LnsUare, 
Btatca  that  a  iiGuropatbio  tftint  vna  found  in  the  majority  of  hia  cvt^v^'^ 
and  Koch  found  that  about  eighty  per  cunt  of  Iiia  cases  8hove<L  a  neuro* 
pathio  family  history.  Sturgis,  on  the  other  hnud,  could  ©licit  such  % 
history  in  only  about  twenty  per  cent  of  his  oa^es.  Direct  chore le  or 
similar  heredity  cun  rarely  be  elicited.  When  it  c&n,  it  may  b«  con- 
sidered aacidcntiil- 

The  intiuenL^o  of  rheumatiom  ou  the  development  of  chorea  ia  still  i 
d«bfl.tabk  topic,  despite  the  fact  that  an  enormoua  amount  of  care  hu 
been  ('Kpendefi  iu  an  endeavor  to  prove  the  LntierTelationHhip  of  these  two 
oauditionH.  I  hava  long  bsea  of  tho  opinion  that  the  relntioiiship  <i 
chorea  to  rheumabiam  ia  more  important  than  okight  be  inferred  from  the 
Btatistiea  of  9ome  recent  writers.  The  dUcrepaiicy  in  the  stAtisticB  of 
different  writers  in  regard  to  tha  Influence  of  Theumatisni  can  be  ei- 
ploineil,  in  part,  by  the  different  meiLning  or  interpretation  pat  upon  the 
term  rheumatiBm  by  differont  writers.  Without  in  any  ivmy  attemptinga 
definition  of  rhcLtmatisra,  and  without  refcrent'e  to  its  pathofEcny,  it  may 
be  said  thnt  three  types  of  rbeumattam  are  distrnguished :  1st,  tonaillar, 
otangioous  rhdumatisTu  ;  2d,  flrtisular  rheumatism;  and3d,  cardJAxr  rbcu- 
matism,  including  rheumatic  pericarditis,  endocarditis,  and  myocarditis. 
A  hintory  of  repeated  attacks  or  a  acnes  of  attacks  of  toxisillitLA  oc 
currini:  during  the  rheumatic  seasons  and  yielding  to  antirheumatic  medi- 
oation  has  been  looked  upon  as  evidence  of  a  rhoumatio  constitution. 
It  was  found  that  tonsillar  rheumatism  oeeurrsd  in  23  cases,  articulai 
rheumatism  in  Ifl  cnaes,  and  cardiac  rheumatism  in  t'^2  oases.  In  1 
caae  all  three  varieties  were  pr^eut.  Fourteen  cases  showed  the  tonsil' 
lar  and  cardiac  varieties^  5  cases  the  articular  and  cardiac;  and  2  raM« 
articular  and  tonsillar.  There  were  iilso  4  cnsea  of  rardian  involvement 
lA  which  no  rheumatic  history  eould  be  obtained.  Tliese  statistics  seem 
to  show  that  there  is  a  definite  relationship  lietweeu  the  rheumatic 
dyBCraai4i  and  the  occurrouco  of  chorea-  It  is  jioBsible  that  chorea 
is  a  meErarheuiLiatio  manifestation-  During  the  occurrence  of  rbeuma' 
tiflm  toxio  anbatanoea  are  developed  in  the  blood,  and  these  act  dele- 
terionsly  upon  the  nervous  system,  whi^^h  may  be  more  or  less  unstable 
through  heredity,  to  produce  the  well-known  clinicai  picture  of  Syden- 
ham's chorea. 

Careful  examination  of  the  heart  in  chorea  showa  the  frequent  occuz- 
rence  of  hypertrophy  and  dilatation,  with  accentuation  of  the  tirat  apical 
and  second  pulmonic  sound.  These  it  is  believed  are  very  frequently  the 
indicators  of  a  previous  rhenma-tic  dyscrasia.  Cardiopathies  roay  exist 
without  the  oceurr^nce  of  cardiac  murmurs,  and  a  careful  examination  by 


TBK  TREATMENT  OF  CHOREA. 


4S6 


I  pMtfvuioi]  iB  oftentimes  more  serviceable  to  show  the  leal  atate  of  Affa^irs 
tjun  is  auscniltatiuiL. 

Some  wtiU^rs  mountain  that  churea  oLi^ura  fiequeDtiallj  to  infectioii>| 
it.,  thftt  it  ia  a  aecandar^  diflea.so.  These  stati^tica  are  opposed  to  auoh 
iviev.  No  dideaae,  yave  rheumatiBiu,  aeemB  to  have  particular  causal 
rthtJOTiship  to  chorea.  In  none  of  the  cases  did  there  aeem  to  be  auy 
leiitiotiahip  to  the  eruptire  diseases  of  childhuod. 

The  attrihiited  exoitiDg  causes  iif  chorea  are  aome  variety  of  pHjchical 
utuma,  such  as  frifiht,  acute  worrj,  and  highly  wrouglit  anticipation, 
Verj  rarely  does  it  seem  to  be  gastro-inteatinal  irritation,  as  from  the 
presflDco  of  worms,  aud  stTaiii  of  a  special  sense  organs  fiurh  as  the  eye- 
Aa  ^lamination  of  the  cases  relative  to  the  attributed  i^ause  as  giveri  by 
khe  parentor  patient  shows  as  follows:  Fright,  IG  cases ^  injury,  9  caaea^ 
rheumatism,  9  cases,  overwork*  4  cases;  cjicitementi  il  oase&i  and  bil- 
1003  attack,  whipping,  school  eiauLiuationi  esce^sive  ropti-jumping,  sim- 
pie  fe^er,  an  attack  of  grippei  each  1  cose-  In  one  patient  the  original 
ittaek  and  the  rekpse  w^re  directly  traceable  to  an  attack  of  malarial 
fever.  Temperaiiieat  has  been  s|iokeii  of  aa  an  otiologicaL  factor,  hut 
fiom  A  £tiidy  of  theae  caBes  I  am  led  to  the  belief  that  it  ia  not  a  matter 
of  any  ccDfiiUerable  importance.  That  chorea  is  more  coiomoD  in  excit- 
able  ohildrenT  as  suggested  by  QaletT  has  not  been  corroborated  by  this 
itudy.  the  rarity  of  t«fiex  excitation,  miaturbation,  imitation^  eye- 
strain, and  the  like,  in  the  causation  at  chorea,  either  predisposing  or 
eiciting,  ia  shown  by  the  fact  that  la  none  of  these  cases  could  such  his- 
toiy  or  relationship  be  traced. 

Chorea  is  a  disease  that  ia  particularly  liable  to  reourrenoe  or  relapse* 
Forty'Gve  of  the  IIK)  patients  had  more  than  one  attack.  Of  these,  15 
were  males  and  30  females.  The  relationship  of  rlnjumatisin  ta  the  recur- 
ring attacks  was  praiitii^ally  the  same  aa  thatgiven  for  the  original  attacks. 
Sixteen  of  the  45  individuals  who  had  recurrent  attacks  had  some  variety 
of  cardiopathy.  The  recurteLcea  were  rather  evenly  distributed  amoiieat 
spring,  summer,  and  winter.  The  average  age  of  those  who  had  relapses 
was  llj  years,  which  is  seen  to  be  considerably  higher  than  the  aver- 
age age  of  the  oi'igiuul  attack.  Tlie  average  time  t>etween  the  original 
attack  and  the  recurrence  was  20  months,  the  shortest  interval  being  2 
months,  the  longest  'J  years. 

It  IB  well  kno^vn  that  a  peculiarly  severe  form  of  chorea  occurs  occa- 
flionafly  during  pregnancy,  especially  in  primipar:^.  It  is  impossible  to 
estimate  tlje  frequency  of  this  variety  of  rhorea,  but  that  it  is  not  com- 
mon may  be  inferred  from  the  fact  that  no  case  of  this  kind  has  Ijeen 
seen  in  the  clinic  during  the  past  six  years.  Chorea  gravidarum  is  more 
likely  to  occur  in  those  who  have  previously  had  chorea  and  m  rheumatic 
persons.  Although  not  necessarily  of  a  severe  clinical  type,  it  IB  often 
accomjianied  by  iciental  symptoms  of  a  maniacal  character,  eleTation  of 


m, 


TRECATMSNT  UF  DlBEAfiEfl  OF  THK  NERVOUS  SY8TKU. 


temperature,  &nd  great  physical  agritatiot].  Chorea  of  adulta  is  alw&yi 
a  more  serious  diBease  thaQ  chorea  of  cbildreu;  and  the  variety  under 
diBOuaaiuu  is  one  of  the  gravest  varieties. 

The  signiGc'-Biice  of  au  attack  of  c^hcrea  la  moie  thaji  mere  tenure  oF 
\he  sjniptoiu  rxomplei  indiciatea.  In  the  first  place  the  diaease  occurs 
more  fiequeuUy  in  those  whose  heritage  ia  oeuropathic,  id  thoee  w1id3« 
bringiug  up  ha^  not  been  euch  aa  to  promote  Belf^rcab'aiDt,  hut  rather 
permit  the  indulgence  of  paseionB  and  appetites,  aud  in  those  vbo  ut 
unameTjable  to  disoiplinnry  measiirea.  An  attiick  of  chorea,  be  it  ever  so 
slight,  ill  a  V/&J  points  to  the  eiiatenre  of  a  neuropathic  diathesis,  bdJ 
iuJicateA  that  the  poaaeaaor  ia  more  honestly  entitled  to  succumb  to  iLa 
harasements  of  life  than  are  his  more  stably  organised  felJows,  Tbis 
should  prompt  the  endeavor  to  make  the  treatment  more  far  reacbmg 
than  through  the  weeks  when  dance  movementa  ore  presents 

TreatmenL-'The  treatment  of  ohnreji  ia  a  very  simple  matter.  The 
vast  majority  of  patienta  would  recover  juat  aa  quickly  if  thej  were  put 
under  the  proper  disciplinaryi  hygienic,  arid  Jietetic  nie&Aures,  aa  thej 
do  when  subjected  to  the  most  orthodox  plan  of  treatmetit.  Heat  is 
by  far  the  moat  important  measure  in  the  treatment  of  ohorea,  and 
the  more  complete  the  re^t  the  speedier  the  cure.  Choreic  children 
aboiUd  be  at  onoe  takeu  out  of  BchooL  and  the  parenta  urged  to  put 
them  to  bed,  and  keep  them  there  if  possible.  It  ia  difticult  to  coQ- 
vince  parnnts  of  the  neceBoity  of  tliia  seemingly  too  heroic  meaaure» 
Rcd  much  more  difficult  still  to  keep  the  patient  in  bed  willingly  or 
unwillingly.  The  physician  should  make  the  closest  compromise  pee- 
Bible.  A  moBSura  of  what  is  desired  in  this  direction  can  be  had  by 
having  the  patient  slay  in  bed  one  or  two  hours  later  ui  the  morninf 
than  is  liabitaal  and  lie  down  for  an  hour  or  two  in  the  afternoon. 
No  infricgementB  of  the  ruJe  that  choreic  patients  should  be  in  bed 
before  dark  ia  to  be  t<:tlerate<1  -  Many  of  the  patients  are  in  a  run- 
down, mentally  overwrought  i.'ondition*  the  result  of  the  rheumatic  dyv 
craaia*  impropei  nutrition)  and  prolonged  application  to  studies,  Conae- 
quently,  re:$t  and  freedom  from  all  aorta  of  excitement,  combined  with 
careful  attention  to  the  diet,  is  the  most  rational  prescription. 

Children  who  have  been  aerustometl  to  a  inixed  diet  should  be  put  ttt 
orce  u]K>ii  an  exclusivB  niilk  diet,  wliJch  is  to  lie  given  up  to  the  paint  of 
tolerance.  Older  children  and  young  adults  may  Lie  allowed  a  miitei^  diet 
which  contains  a  comparatirely  small  amount  of  animal  food.  In  &lniast 
every  case  the  bxilk  of  the  food  eliould  be  milk  and  cereals-  Fatty  foods 
have  ne?er  seemed  to  me  to  be  of  particulnr  serrice.  SweeU  aud  farina- 
ceous foods  should  he  eliminated  because  of  their  liability  to  cause  flatu- 
lency and  thereby  to  increase  rardia^^  jialpitatiou-  The  digestire  apf:<a- 
ratus  is  not  usnally  deratiged,  but  when  it  in,  meaauren  should  be  taken 
to  counteract  excessive  acidity,  fermentation,  and  conatipaticaLi     A  cold 


THE  TREATUKKT  OF  CSOftEA. 


«7 


net  compress  over  the  Abdomen,  kuocrn  aa  xh^  Ncpttinn  einlU«  1ia?  nob 
ffllj  A  beut^&ci&l  effect  upon  the  &lini«nUrj  tnct,  but  u^vy  ofl^u  rX' 
vdAM  A  fioothing  effect,  which  Aids  phjiknl  &itd  inentjd  n«i  juid  nir^p. 
OthAr  hydriatiG  measures  ntA}^  be  used  to  ov«rroine  uiotjtr  imnat,  niiil  M  j 
nntribute  to  the  maintenance  of  mctritiou.  The  ii&tivntuu  iiriiiitig  mhnulA 
be  made  to  stand  in  a  tub  or  baaiu  of  watm  wAter^  vhiLo  w&tet  of  frOQl 
7fi'  to  60'  ia  dashed  on  the  spino  from  the  hollow  hands  of  Iho  motbw 
or  aa  aitendanti  or  throvu  ai^ust  the  spine  from  a  dipper  or  pitcher,  ud 
then  followed  by  vigorous  rubbing,  with  the  baud,  a  floah  bmsh,  ta  t 
ooAiae  tocvd.  After  such  an  nbtutioii  the  little  patient  ujaually  te^U  ytrj 
mcich  refraahed  and  invigorated,  Wheh  ih&  motor  unreal  ia  verjr  i^reatr 
mlntary  reaults  are  often  had  from  the  u^  of  the  wet  pnck  A|>]ilii>d  be- 1 
f(ir«  ratiring.  The  moderately  cold  wet  pack  is  better  in  this  roajHS^tr 
paTti<iularty  if  tbe  patient  i&  asthenic,  than  the  warm  poek.  The  lauer, 
bowBTer,  19  preferable  in  the  beginning  of  tbe  diaeaai*,  and  specially 
when  the  agitation  ia  veiy  great-  Tho  pack  ia  not  only  Huothiiii^  to  the 
patient  but  contributes  to  refreshing  5teep>  It  ie  fur  better  than  hyp- 
noliesj  and  haa  the  advantage  of  not  being  followed  by  disagreeable  flft<*r- 
«S«cts.  After  the  first  one  or  two  applications  childr^^ii  do  not  rebal 
against  it;  in  fact,  they  eojoy  it. 

The  medicineH  that  are  of  stfrvi(5e  in  chorea  are  fevr  in  nujnl«r.  Tbii 
be^peaka  their  real  value.  The  most  importacl  drugs  are  arsenic,  aiiti* 
pyrin,  quinine,  exalgin,  iron,  and  the  bitter  tonics.  PoBflibly  the  brc»- 
midos  and  chloral  should  also  be  mentioned,  for,  although  they  liave  no 
aniichoieic  properties,  they  are  often  benefidally  used  as  flymptoiu  luodi- 
diie&  It  ia  diflioult  to  estimate  the  rfRl  value  of  araeuiQ  in  chorea,  fvan 
though  tradition  aud  experience  speak  so  louJly  iu  its  favor.  Molt 
wTiterB  agree  that  it  baa  an  important  iutlucnce  in  Bha;>ing  the  course  and 
in  modifying  the  severity  of  any  attack.  This  opinion  the  writer  abare*, 
though  not  with  great  enthusiasm,  for  it  haa  already  l>een  naid  tlint  undue 
favorable  conditions  the  vast  majority  iif  cases  recover  as  HunOy  aiM 
promplly  without  any  medication.  Areenic  may  be  given  in  the  aha^w  of 
Fowler'  a  solution  or  the  arseniate  of  sodium.  In  the  latter  fonn  it  baa  Im9 
tendenc)'  to  disorder  the  digestion,  and  it  aeems  to  be  quite  as  betiefirial. 
Segoin  taught  that  araenic  sbculd  be  given  in  large  dosee,  even  to  the 
produotion  of  such  toxic  effects  as  puffinesA  around  the  eyea,  eplgastnc  diA* 
tnsB  and  vomiting,  and  lacr^ination,  biit  I  am  £rmly  of  the  opinion  tliat 
■A  wxm  aa  such  aymptoma  appear  the  drug  should  be  withheld  uotU  the 
poieonoTts  aymptoms  disappear. 

Exalgin  la  a  pot«nt  drug  to  lesaen  the  aeveri^  of  the  ehoteie  movt* 
menta,  aud  it  aJso  teema  to  shortim  an  attack.  The  aenoua  otfjaotLOn  t^ 
its  uBft  Ia  that  it  cauiea  profound  hsmolfsia-  lU  sflecta  upon  tii«  pA- 
tieat*A  Appeaiuioe  ud  ritality  are  mAnifeat  very  promptly,  and  to  one 
mtAOcoAtomed  to  its  use  they  may  seem  very  alarviag.    T1>««e  lyasptPMi 


4SB  TRBATUSNT  OF  DISBA9EB  OF  THE  NERVOUS  STflTRU. 

&ri3  palbaesH  of  the  akia,  bltiUb  appearujce  of  the  extremities,  lowered 
aLirface  aud  general  temperature,  and,  if  pushed  to  &  greater  degree, 
epileptiform  convulaions  and  Byicptoma  of  collapae.  The  dru^  may  be 
given  in  doses  of  from  oDe'half  grain  to  t,hr?d  ^runs^  repeal^  every  fire 
hours,  to  children  under  ten  years  of  ag^.  It  nhould  always  be  given  m 
tHiQJUDoliou  nitb  large  dosua  of  some  aliBorbable  preparatioD  of  iron. 
Exalgia  is  of  greater  service  in  the  early  etAges  of  an  attack  than  later  in 
the  disease^  Were  it  not  for  the  profound  aujemio  and  collapse  symp- 
toma  whieh  It  causey  the  drug  could  be  recommeDded  more  ivarmly,  for, 
in  truth,  it  is  nothing  tesn  than  HHtoiiiahing  how  quickly  it  mitigates  the 
severe  niutor  imiiiifesUtdoiiH  of  the  ilis^ase. 

Antipyrin,  quiaine,  and  the  jwHcylatea  have  all  been  strongiy  recom- 
mended  in  the  treatment  of  ohorea.  hatisfaotory  reeults  often  follow 
their  use.  It  ia  supposed  that  quiuine  owes  it^  benehciaJ  eifect  to  its 
action  on  the  blood  in  contributing  to  hicmageneaia.  The  salicylates  are 
given  on  arrnunt  of  their  supposed  aiitirheiiujatic  effects,  and  when  there 
are  evidences  of  any  of  the  t^liui^al  varieties  of  thia  dysoraaia^  they  ahoold 
be  admlniatered.  Some  wiitf^rs  have  spoken  of  their  value  is  conCri  bating 
to  iutesttnal  antiaepais.  Speaking  in  general  terms,  intestinal  antisepsis 
is  a  myth.  If  evid^nues  of  ioteBtinal  fermentation  exist,  there  are  many 
more  eUtcaoiona  vnya  uf  coLtzitf?racting  it  than  by  giving  f.he  aaliiylateK. 

A  ooinhiuatiou  of  chloral  and  bromide  is  often  of  service  wheo  the 
motor  unrest  is  eJitreme,  particularly  if  il  is  associated  with  nakefnfness. 
They  should  never  bo  given  continuously,  because  of  their  malign  effect 
on  th^  Hood-  If  insomnia  is  GuHioleLtly  pronouuced  to  require  special 
n^dicatioTi,  it  can  easily  be  combated  by  hydrtc  application  cr  by  the 
ad m in isr, ration  of  amall  quautities  of  trional  vith  hot  luLlk. 

Bromide  of  cuuphor  in  from  two-  to  Hve-grain  doaes  in  capsule  form 
has  receauly  received  warm  reoommendation  in  the  treatment  of  chorea. 
After  cousiderable  trial  I  cannot  say,  however,  that  i  have  found  it  of 
any  particular  value. 

The  mental  disturbances  of  chorea  do  not  call  for  special  medication. 
The  meadures  taken  to  oouuteiait  tl^iieial  asthenia  and  to  combat  ex;«s' 
sive  tiaaue  inetiunorphods  will  auftire  Ut  overcome  them.  It  should  never 
be  forgotten  that  ohoren  is  a  generul  blood  diacase  in  which  the  brunt  of 
the  bfemic  deterioration  is  borne  by  the  central  nervous  system,  and  that 
measures  taken  to  overcome  the  general  eonditions  will  relieve  propor^ 
tiouately  the  locel  EuauifestationB. 

Chorea  occarriug  with  prepnancy  is  usually  much  more  severe  th 
the  acute  chorea  of  early  life.  It  demanda  aotive  and  vigorous  treatmeat 
from  the  start  Otherwise  it  wilt  result  in  such  a  condition  cf  bodily 
weakness  that  the  patient  will  either  abort  spontaneously  or  the  neces- 
sity of  terminating  pregnancy  will  become  paramount.  In  these  cases 
no  difficulty  is  experieoeed  in  getting  the  patient  to  take  to  her  bedj  but 


M 


TBE  TBEATMBNT  OF  CHORKA.  ^H 

(Acq  iha  qu«fltioa  of  f«eilu>g  b««oiu^  a  reiy  iiuportjuit  one!,  &■  it  is  not 
iafteqaently  associated  with  intractable  TotDitlng.  The  same  mnsuivs 
I  ^ooJd  be  used  ut  overcuiae  ihia  GjnLptom  th&t  are  of  service  vheu  ii 
tfcoi?  iTith  pregnaDcy  uncomplicated  vith  chorea.  Apart  from  tlu3,  the 
treatDjent  ia  not  iiDlikd  that  of  aininle  ohorea.  If  the  aeventj  of  th« 
ijiuptoms  13  mitigated  promptly,  the  patient  may  be  allowed  to  r^uiue 
bar  ordinary  duties^  and  the  prospects  are  that  complete  recorery  wiU 
ft)l]ow.  If  the  syinploms  are  so  severe  that  Ibe  life  of  the  patient  is  in 
jropardj,  there  should  be  n(>  hesitatioa  or  delay  in  reniovmif  Uie  coQ' 
toots  of  the  nterua. 

Chorea  in  the  adult  male  and  ohorea  of  advanced  life  do  not  require 
^iffer«'nt  treatment  from  chorea  of  the  youn^,  unless  it  is  dissociated 
vilh  o^anie  disease,  such  as  of  the  blood-vessels. 

It  has  already  been  said  that  chorea  is  very  liable  to  relapse,  and  a 
knowledge  of  this  fact  should  prompt  the  phyaiclan  to  adopt  nien^urea 
tiut  will  tend  to  prevent  the  recurrence  of  thia  neiiroaie,  particularly  in 
the  sprinf;  and  summer,  when  the  majoriiy  of  casea  occur.  Bearing  in 
mind  the  prediaposing  and  exciting  factors  of  chorea,  it  will  readily'  be 
seen  that  theae  indications  are  encompassed  by  attention  to  the  general 
cutrition,  proper  use  of  hydriatics  and  exercise,  interdiction  of  exeesstve 
mental  application,  and  by  the  maintenance  cf  intelligent  mental  and 
phyamal  discipline.  When  the  occrurreDi-'e  of  the  disea£6  eeems  to  have 
a  definite  ralationship  to  rheumatianiT  the  rheumatic  diathesis  should  Ii4 
particularly  cownteraeted. 

It  haa  been  B;ad  that  chorea  is  a  self -limiting  disease.  There  are  excep- 
tioDS  to  the  rule,  and  many  of  these  are  found  in  the  choreas  oGcurring  in 
late  adult  life.  Patients  who  do  not  recover  after  a  lapse  of  the  usual  time 
require  somewhat  different  treatment  from  the  acute  case.  The  treat- 
ment to  whirli  they  are  more  or  less  ami^tLaiiEe  is  similar  to  that  whirh  is 
of  tMnefit  in  neurasthenia-  Medication  is  the  least  important  factor,  al- 
though beneficial  results  are  sometimes  seen  to  follow  the  admiuiatratiun 
of  potassium  iodide  in  relatively  small  doses^  one  of  the  pTeparatione  of 
aojio^  eueh  as  the  bromide  or  valerianate  (two  to  eight  grains  of  the  for- 
mer given  in  syrup  and  frum  one  to  four  grains  of  the  latter  for  an  aduH) 
combined  with  general  tonifying  medication.  Electricity  has  been  rec 
ommended,  and  it  may^  by  its  appeal  to  tha  mind  of  the  individuali  have 
a  quieting  at^d  beueticial  influence,  but  aside  from  thm  it  has  no  thera- 
peutic value  in  the  treatment  of  this  disease.  Often  the  applioation  of 
the  actual  cautery  to  the  nape  of  the  n«ik  and  the  upper  part  of  the  spine 
makes  a  great  impression  upon  the  patient  aud  favorably  inlluences  the 
course  of  the  disease.  In  erery  case  of  tliis  kind  the  liability  to  the  ele- 
ment of  hysteria  and  habit  should  be  kept  in  mind,  and  when  thoro  are 
evidences  of  either  of  these  conditions,  the  value  of  isolation  and  Other 
diaciplinary  measures  not  forgotten. 


CHAPTER  XXXm. 


THE  TREATJIENT   OF   PAJlALYSIS  AGTTAlfB. 


pABALVfiis  agiteuB,  Gomtuonly  known  aa  Farkinson's  dtfteas«,  U  & 
diaeaae  wubont  knonn  fLD&tomical  foundatiOD,  characterized  by  tremor 
of  one  or  all  of  the  extreraitiee,  liy  rigidity  and  lessened  mobility  of  the 
TOluntaiy  musclea  vhit^h  co-msg  a  ch^ia<:teiiatdf  Etttitudeaad  %^it,  by  vaso- 
motor phanometka  and  Btiaycjgtbe&ia-  Dcapite  the  many  careful  inTeati- 
gationa  of  the  neTToua  ayr^tem  that  have  been  made  by  the  aid  of  modem 
methods,  the  nauir«  «f  the  diseiaee  is  still  [inknowD.  Although  clAssi6ed 
as  a  fuDi^tioiLal  nervous  itieeaae,  ^pathological  rhaogea  are  ulTtio>;t  mvari' 
ably  fomid  in  the  central  uervoua  system  after  death,  eapecially  if  the 
disease  has  esiTHted  for  a  long  time- 
It  IS  a  disease  of  tate  luatLirityH  The  vast  majority  of  oases  occur  be- 
tween the  ages  of  forty  and  fifty^  but  a  number  of  well-authentieated 
oasea  hd.ve  been  recordi^il  of  |kHtientB  with  this  diseai^e  before  the  twen- 
tieth y*:iy  of  age  and  after  the  sixtieth.  Women  are  afflicted  leita  often 
than  mcu.  It  is  more  coinmoa  in  the  Anglo-Saxon  and  Celtic  races  than 
in  the  Latin  and  Oriental  peoples.  Practically  nothing  10  kno^D  cf  ii& 
causation.  Now  and  then  its  dev'Eilopment  hn^  been  more  or  less  immedi' 
aiely  preceded  by  some  mental  or  physical  Bl.ram,  fiuch  aft  orerwofk  and 
iiidulgeuce  in  excess,  aud  by  fi^ight,  trauma^of  ten  times  th©  two  com- 
bined, the  former  being  far  greater  th^  the  latter,  by  exposure  to  cold 
ajul  wet,  and  other  encrrating  and  dcpravijig  iufiuencca.  These  are  the 
factors  that  are  apparent  la  many  forms  of  nervous  diaeues,  and  they 
probably  have  no  other  aignificauce  than  their  peroioiouaaesa  ia  lowering 
vitality.  Oec-asiuiiiilly  the  aymptouis  of  the  dlMeaBe  occur  tnore  or  1«4i 
remotely  in  the  ^ake  of  some  infection,  and  rheum&tiam.  Hecugaition  of 
this  fact  has  prompted  many  writers  to  theorize  concerning  the  probable 
relationship  of  tJiese  diaeaacs  to  the  one  in  question  and  the  manner  in 
which  the  pheuoinena  of  paralysis  agitans  are  brought  about. 

In  order  to  estimate  the  attributed  and  apparent  cauae^  the  relative 
frequency,  to  determine  the  iuitial  symptoms  and  mode  of  ouaet,  and  to 
learn  the  factors  that  in^ucnee  the  course  of  the  disea^so,  twenty-aia 
casee,  taken  fi^m  dispensary',  hospital,  and  prix-ate  practice,  in  about 
equal  proportion,  have  been  studied. 

The  accompanying  table  shows  the  relationship  of  age,  nationality, 
and  heredity  to  the  occurrence  of  the  diseiase: 


f 


or  rA&A2.TStt  A^ilVUW. 


m 


X&tWBt&UTT, 


t 

t 

t 

t 

1« 


Coitcd  Sub --. 

Bolbnd 

En^wi A 

G«nnHiy 

Iralaad 

AtMtriA..,.  

RiMU 

TottJ 

Thirty  to  fottj 

Ton;  to  hhjjmn 

Witty  U>akHj  7«w .......,, 

8ix^  to  MTimtj  yew 

BewWtf  XO«\^tj  jtaM 

ToUl 

Direct  beraditj 

lodlrvct  hei«dkty 

Ho  heredity 

ITnkBowD ,...,.,. 

Total 


rHMhVL 

1 
\ 


The  moflt  atriking  feature  in  reference  to  natioDiJity  U  tlie  wnftrkftblrt 
piedomiuaQce  oi  the  Iiiah  race.  Very  nearly  one-half  of  all  thn  an%P% 
wera  of  this  people.  When  we  conjiderthat  the  oonstitution  of  the  clhilo 
ia  not  c<ni8picuonaly  Irish,  it  will  readily  be  aeen  that  tbis  ijre;jf>»<leruir« 
u  not  to  be  explained  by  accident.  It  may  be  that  the  Jriih,  Mim  a 
TOy  emotional  race,  are  more  Tulnerable  to  the  attribiitf-U  excMkua  fMiuiinfi 
of  paralysis  agitane:  shock,  anxiety,  worry,  and  depruision.  ft  ij>  wii 
improbable,  however,  that  it  is  in  part  ezplaiiuible  by  the  ''iitirely  dlfT'rr- 
ent  mode  of  life  which  the  people  of  this  race  h&ve  when  tljpy  titke  up 
their  abode  in  this  country,  as  no  one  has  pointed  out  that  %\m  trtnU  are 
pftiticolarly  afflicted  with  paraljBis  agitan^  at  home.  In  otht^r  woriU,  it 
woold  seem  to  be  as  much  enrironm^ntal  as  inhi-ri-rit.  Auiithnr  jjAfigliitr 
feafcniQ  of  the  statistics  concerning  the  natjouality  of  thf?  j«tient#  ia  Um 
Felative  infrequent  of  the  disease  in  Irish  women,  f^mirwU'A  with  tfi# 
women  of  other  natjooalitiee.  For  ioHtaniv^,  the  Americans  and  O^tt/jSIvS 
fmsiab  an  eqnaJ  number  of  men  and  women.     Maay  0«!Tman  and  ^MrtMtfc 


493  TRKATUKNT  OW  DlSKASES  OT  THS  XESVorS  STftTEU. 

writer?  mftintaii^  that  there  is  very  tittlo  reUtdonahip  of  seik  to  the  ooour- 
reuce  cf  paralyeia  &giUns.  Jt  vill  be  seea  that  my  statistics  show  that 
the  ocou/rence  of  ibe  diseajie  is  tbre«  men  lo  on©  woman.  Gowers  give^ 
the  pi«p<irtion  in  his  eiperience  as  five  men  to  tliroe  women.  The  dis- 
use occurs  most  oOen  in  the  fifth  decade,  and  gradually  dimtiiishes  un- 
til tbe  eighth  decade.  Two  ^^picol  raaea  kft«r  the  seventieth  year,  and 
one  in  the  eighteenth  year  have  been  encountered. 

The  intiuence  of  heredity  has  be«n  considered  of  not  much  impor- 
tance, but  in  no  less  than  four  cases  was  tliere  &  straightforward  hiatory 
of  direct  inherirancc.  In  tme  cas«  tlie  &tber  had  paralyeis  a^iians,  wbUo 
llic  motUiT  and  a  uiatorna]  uncle  di^^i  with  some  form  of  poralysia.  In  a 
svktAnX  v»se  tiie  mother  had  a  disease  cinilar  to  that  of  the  patient,  the 
nbakuig  I'emb'  particularly  marked  whm  ^e  wia  exdte*l.  fn  a  third 
v&iftC  Uw  fatlkpr  had  exactly  the  same  disnoe  for  the  last  eight  years  of 
his  life,  and  it  ia  thoiigbt  a  paternal  vncic  was  sinxilarly  afflicted ;  while  in 
a  toiirtli  C'lW^f  that  of  a  woman,  tbe  father  aad  a  patcraaJ  aunl  had  exactly 
Uic  same  discvuo.  Naturally,  this  iufonnaticaL  waa  obtained  only  from  the 
patient  or  the  UesceTidanW  of  the  patients,  and  is  therefore  liable  to  aeri- 
nus  emr.  A  very  careful  inquiry  was  made  in  every  case  on  tliis  poiut, 
iriLh  the  above  rasiilt,  which  is  ao  at  variance  with  tbe  usual  teaching 
ML  Ut^  HubjMit  that  I  am  UDwilling  to  aceept  it  as  abaolute  fact.  A  his- 
lOft  of  initin«rt  heredity— that  is,  of  manifestations  of  nerroua  or  mental 
Alawmn  m  lb*'  fainily— waa  found  in  aixleen  per  cent  of  the  cases.  Up- 
vaM  vt  1kf\>'  r*^  ^*^^  ^^  ^^^  eases  gave  neither  direct  nor  indirect  neuro- 

In  Nga^i  ^  oc(iupation»  the  statiatics  show  that  the  patients  were  very 
«vwlv  »**Mt*buli>l  Ajtioujr  upbolaterera,  pl.isterers,  gardeners,  saddlara, 
taaiftfTT  rtnnter)^  lalxjrerfi,  sQ^ilors,  mill  ha:ids,  promoters,  Journalieta, 
d4li4a  m^T^anta.  and  faucy  workers.  Neither  the  mentally  hataesed 
toiw  l*T*  vKv*w**^^  ovorworltetl  are  especially  liable  to  the  iiofiurrence  of 
akii  «UaHh>*<  VWwkvra  mit  of  doors  develop  the  disease  as  frecjueutly  as 
^^^Hm  v>M%«^  I'li^  Ntabistica  further  show  that  tbe  disease  is  as  likely 
^.  ,wf  iiiade  iiF  niHJietyas  m  another.     Of  tJie  seven  wotnenf  four 

^,,v  -J-  '■*^'  ^'^^^  '"^■"^  widows,  and  one  was  Kiugle;  while  of  the  nine- 
at\M««  weraor  hud  been  married,  and  three  were  single, 
tu^^lt  lM«MMfiil<ka  the  alleged  causes  of  the  diaeaHo  did  not  give 
^MMMiAf*^  t»|w>matt^ir  Only  atwut  thirtj^-iive  per  cent  of  all  the  pa- 
^^^^  «afa  aM^  ^  It^^  ^  distinct  cause.  Tbe  attributable  caiises  were ; 
1  tMMMM  ^^  ileath  of  a  beloved  daughter.     2.   Excessive  and 

4MMat  riiatni  iueideut  to  supporting  a   family.     3,   Family 
^     k   i'^a^t)  at)^*^!^^  A'l^  becoming  wet^  incurred  in  oocnpa- 
V   k^kM^  Wff  ^^  Waiid  with  cold  stone  id  winter,  while  employed 
^w\  ifci  -ii-MV*     *    ^'»  attack  of  grippe*     7.  FriRhti  the  sudden 
.  ^^  Uaf^L  t^at  near  her  bed*     S>  The  discovery  that 


4 


THB  TRKATHEXT  OP  F^RXLVSIS  AUrtAXi^ 


«» 


an  uxuiATTied  daughter  wts  ptegoAiit.  9-  B«iiig  knocked  ijovn  by  m  t«* 
lucl«,  but  withoat  couaequeat  phjncal  iiijui^.  10.  Finding  Ut4l  lil  hit 
■■Tuigs  bad  been  loot  Thus  it  will  be  stea  ihAt  ih^  aUag^d  oaUMt  ^f 
psychic^  or  emotiouaJ  u&umA.  It  b&s  fi«qiieaUy  b««i  sW«d  th&t  MUt» 
uul  cbrouio  diMftSM  of  Tuioua  kinds  have  a  prediipoaiDg  iiil1u«Q«»  upon 
tbe  (XKurreiLcti  af  paTBljsis  a^iUns.  This  statemsot  w  ttnroboniUid  to 
ft  flight  extent  bj  this  study.  Of  th«  aix  vomen,  four  denied  any  pre- 
vious disease-  One  had  had  a  fungoid  groirth  ramovpd  fnnu  the  uUrua 
■liortly  before  the  oc^urreuoe  o£  pottUysta  agitans;  one  hnd  hud  ohrt>uio 
diairhtpa.  A  third  patient  had  had  yellow  fever  m  grtut  tnaay  yean 
before  the  Of^currence  of  the  disease  for  whicli  shr  nuiie  under  nhari- 
Tation.  Of  the  men,  ouo  gave  a  history  of  a  blow  on  tlie  hoail,  afL«r 
which  he  hftd  been  daliriDiis  for  three  months ;  but  tldn  had  occurred  no 
long  befora  the  manifestatioQa  of  ParkiDeou^s  discoso  Unit  it  i^ould  nol 
possibly  have  tad  any  inSu«D<^^.  Another  had  had  an  attuck  of  anitn 
articular  rheuniatiaiu  liefoi^  the  mariifestationa  of  the  di.s«ajte^  nhiln  u 
third,  in  whom  the  symptouia  seemed  to  fullow  an  attack  of  gTipir<i|  Los 
already  been  mentioned.  Two  of  the  tnen  had  had  yellow  fever,  ek^htoen 
years  and  forty  years,  respectively,  previoua  to  the  mimiferttiititms  of  pa- 
nljftis  agitans.  Uuly  Iwoof  the  twenty-fovir  patieiita  were  hartl  driukeri 
or  amokera,  and  in  none  was  there  a  hisb^iry  of  syphilis.  As  a  lualter  of 
fact,  the  moat  Titrikirkg  feature  of  the  peraonal  histoiy  of  all  thoBO  pA' 
tienlG  W33  that  they  had  Used  temperate,  wholi^aome  livee,  ap^iaicntly 
davoid  of  undue  strife  or  uuoommon  burden.  la  a  few  cases  the  patienla 
alleged  that  the  onset  of  the  disease  was  ooincident  with  some  annoying 
or  erciting  eipetien*je,  Tor  instance,  one  ulhu  was  qiiilo  poiitive  tliat 
the  diaease  uccuired  immediab^ly  after  leaviug  tho  witnrHH  l>ox,  whttrn 
he  had  been  auhjectcd  to  el  haraasing  cross-cxaminatbn.  Anothi-r  patirnt 
dated  the  begin&mg  of  the  tremor  from  the  mo^ir^nt  when  he  hr'Urd  that 
all  bia  savings  had  b«en  lost^  owing  to  the  failure  of  a  bonk.  Jiut  in  Iroth 
casea  close  inquiry  reveali^  that  ron^t^alar  rrj^idlty  luul  antadatffd  theao 
cixperimicea  Ly  a  nuKiber  of  months.  A  third  [^atii^ut  avurrtid  tluit  t}j4t 
tremor  developed  while  he  was  lyin^  ia  bed  convalesrioif  from  an  of>cra- 
tion  for  inguinal  hernia^  but  investigatiou  showed  that  th«  surgvon  had 
diagnostki^ated  paralysis  agitans  on  the  man's  admiavion  to  the  h<»ipita]- 

Thia  brief  n^vi&w  of  the  etiology  of  paralysis  agiiani  shows  L)iut  tha 
moat  important  factors  are  age,  aex,  nationality,  morality,  vjiiUfut  ruio- 
taoDa,  eapecially  depiesaion,  overwork,  direct  and  indirect  h«redtty,  awl 
infootiotu  diaaaaee.  Apart  from  tbe  peculiariti'^  of  BtatiatMA  bacwUh 
preseotad  which  bava  aJready  beea  mantioned,  relative  to  ihm^  fa^ttfn, 
Uia  only  point  worthy  of  not«  ia  that  trauniatitin  was  not  an  allegw]  c$ 
exciting  nuao  in  a  liiigle  iuaiance.  This  u  the  more  mtutrkah]*  aiiMB 
KAflt-Ebisg  finds  that  ia  110  caoes  tiauoA  wa*  tJ>e  came  in  aeveu, 

-The  diacaao  BnalJj  dordopt  in  »  »e«i  ioaidiwia  way. 


t 


TBEATUEIiT  OF  DISEASES  OW  THE   NEBV003   5TSTRM. 

The  first  cooipl&iDt  m&j  bo  of  profound  And  imattributftbU  we&riaeu, 
UAualiy  of  OTie  upper  eKti'cmity.  Tbia  may  or  may  not  be  ^sociate4  with 
trambliug  of  the  part,  but  the  latter  is  fture  lo  follow.  With  tiie  Eeoliog 
of  weight,  fatigue,  and  unwieldiresB  uf  the  eitremity,  a  peculiar  form  of 
muHcnlar  rigidity  develops.  Tbia  rigidity  is  mope  apparent  to  the  patient 
than  it  is  to  the  physician  on  puaiTo  moreuLCiit.  Although  it  uauallj 
develops  hrst  la  the  right  upper  extremity,  it  sooc  poaaes  inaidioasJy  to 
the  others,  find  eventually  is  manifest  iti  every  part  of  the  body.  It  u 
responsible  for  the  peculiar,  immohile,  expresMianleflBoaaDtenanceof  thd 
patieotj  fcr  the  bowed  coudittno  of  bia  bwly,  aud  for  tbi^  slight  flexion  in 
all  the  artioulationa  of  the  loog  bou«s<  Moicover,  the  coutractiou  which  u 
at  the  Lottoio  of  the  spoeticLty  condttioiia  the  patient's  gait,  with  ita  abort, 
ahulHiELg  steps  aud  toudeot^y  to  ruu,  called  featination^  mclination  to  fall 
forward  (propuUion),  aa  well  as  the  teudenoy  to  fall  backward  iretropul^ 
sIod),  especially  if  the  patient  starta  bo  move  in  tbat  dir«ctioD,  aiid  th« 
inclination  to  f^ll  Bidewiae(lateropiilsion).  It  is  refipocsible  likewise  for 
the  high-pit4^hed,  unmodulated,  moikototio^ia  voit^e,  the  tixed  manner  of 
speech,  and  the  apparent  hypertrophy  of  the  skin  whieb  ctLn  often  bo 
made  ouL  The  tremor,  whieh  is  eooaidered  an  eesential  feature  of  the 
disease,  may  never  develop;  but  usually  it  shows  itself  a  few  weeks  er 
moQtbs  after  the  rigidity  and  fatigue  in  one  hand^  ofteneet  in  the  lefL 
Oc<^a8icnalIy  it  precedes  the  occurreuoe  of  rigidity  of  the  muaHea.  It 
gradually  creeps  up  to  the  aboulder,  aooompanied  by  a  peculiar  subjocti 
flenBQtion  of  unreat,  and  passes  across  to  maurfest  itself  in  tbe  upper 
treiiiity  of  the  opposite  side.  Later  it  shows  itself  in  Che  lower  ext 
bieSf  and  £uilly,  as  a  rule  (alt)ii>ugh  tbb  is  contrary  to  the  tiaual  stai^ 
ment) »  in  tbe  cephalic  extremity.  It  has  three  characteriaticfl :  Firftt,  itA 
location,  usually  in  the  hands,  which  are  already  brought  into  a  pencil- 
holding  position  by  tbe  muscular  rigidity.  It  oftentimes  cauaea  a  forward 
and  haebward  movement  of  the  thumb  and  the  index  6nger  oompaiablo  to 
those  of  rolling  a  pillr  often  railed  a  pill'roUing  movement.  SeGond,  ita 
rapidity,  from  five  to  six  a  aecoJid,  therefore  standing  midway  between 
the  slow  tremors  and  the  rapid  or  fine  tremors.  Third,  it  continues  while 
the  patient  and  bia  esLtremities  are  supported  and  at  rest.  Although  it 
usually  lessens  in  intensity  when  the  patieot  attempts  and  performs  vol- 
untary movemeul,  it  oftentimes  does  not  do  fio,  aiul  may  ii^deed  become 
slightly  exaggerated.  Ocr^aionally  it  stops  without  apparent  cause,  but 
reappears  without  attributable  exciting  factors.  It  is  increased  by  all 
forms  of  psychical  exoitatiou  and  by  physical  indulgem:e.  It  may  involve 
all  the  eitreuiities,  and  usually  does  so  before  th&  patient  passes  into  tbe 
teimiual  stage,  wherein  tbe  rigidity  and  immohiliry  again  have  sway,  as 
they  often  do  in  the  begiuuiog.  In  addittou  to  these  symptoms,  which 
are  lookf'd  upon  aa  the  leading  features,  there  are  many  associated  phe- 
nomena, all  of  them  apparently  perversjona  of  the  sympathetio  nervous 


TVS  TmKATlCEXT  Or  r  AKAI^ 


AMVAm. 


v^icb  imfty  or  Bar  &at 

k«aft  of  the  pnpab  om. 


^iM^ 


The  wMOty^hm  li 


bawiftls  and  tlio  bUddo  nnwong  UiMr  fonckkft,  aarv  i&  Um  i»ilnt»lio> 

cf  homed  action  ta  tli*  sphisctt^  aiul  tha  di««o4i^  w^ana  r««ma  io 
turlj  good  workiBg  order.  The  patiaat  i<  Kwa-^notkBal,  aud  •KhiUU 
a  degree  of  cmtentmait  vhirh  u  strikinglj  si  vaHaiiv*  with  that  which 
ate  woald  expect  to  find  m  a  norioaJ  indtridual  who  had  be^i  depnvvd 
oC  the  capacitf  to  cajov  life  or  eam  his  d&iljr  br^ad,  and  who  had  ^b* 
■UybeeD  appridedof  the  eventual  oatoome  of  the  ctisea^,  Ni^vurthelaiBt 
there  U  do  demeuti^ ;  &(  Jeast,  not  u&ul  the  di^^ea^e  U  nearly  at  iXa  CAdf 
Aside  from  the  subjective  set: sations  of  Tatiguey  oppreuire  Whriiitti,  ful- 
nvaa  in  the  head,  and  difGcully  of  prehension  aiid  tcMfuinuliinu  thn  pa- 
tJenC's  [n«et  freqaeat  complamt  is  of  Bleepleaaneea  aud  luabihty  1o  gvl 
refreshing  reet^ 

The  course  of  the  disease  ia  uniformly  progrt^saitftv  In  thin  it  U 
stril^iiiglj  in  coDtr^t  with  a  diseitse  which  tradition  mnintiiiiirtil,  and 
which  aome  fltlll  teach  Is  freqiteatly  mistaken  for  paralyttia  agiULnii  -vlv,, 
diflsemijiated  iaautar  sclerosis,  which  is  almost  iuvariahlj  progreaiivo  atid 
retrogress  ire.  The  diaeaa©  lasta  from  five  to  thirty  joflrs,  \»  a  ml*, 
the  pstisnta  pass  iuto  a  bedridden  aud  asthenic  ooiiditii^n,  witirh  mahdi 
different  parts  of  their  body  vulnerable  to  infections,  such  ai  liibepoiilo' 

sis  and  pnenmunia,  and  they  die  of  thf^e  or  other  witerciirrenr,  r1ihf>i>(tu 

In  this  d/uuocUon  some  of  the  results  obtaii^ed  FmiLL  btudy  of  the 
symptoms  of  twenty-six  cases  will  be  gW&n.  The  distrLhution  of  the 
BytnptoniB  was  preponderantly  diplegio.  Thirteen  of  tlie  puarn  WHro  ih- 
plogie,  four  beiuiplegic,  and  three  tetrapLegic!.  In  three  uf  thti  reniAiiiiug 
cases  the  symptoms  were  more  pronounced  on  the  Ir^Ft  side  than  on  the 
ri^t-  ThiSf  howe%-er,  do^a  not  place  th»iii  in  the  li»[[ii|>lt-|(ie  oattigoty. 
Only  two  of  the  cases  were  of  the  monoplegia  type.  In  one  oaM  the 
lower  jaw  was  diaiinctly  affecttd.  Of  the  twenty-six,  one  only  was  de- 
void of  tremor.  This  was  a  most  typical  ease  of  I'arkinson'M  ihwase  in  a 
laborer  siity-one  years  of  age. 

Xo  general  statement  can  bo  made  concerniog  the  iiarllest  synij^tuin  In 
cTeiy  ca^r  of  paralysis  agitans,  ft  has  been  said  that  this  is  rarlabU 
with  each  case.  Although  trem ulottsneas  is  the  symptom  for  which  the 
patient  first  seeks  relief,  careful  inrjuiry  will  Qiuallj  allow  that  rigidity, 
amyostbenia,  and  diminished  agility  bare  antedated  the  tremtv  for  a 
hmger  or  shorter  time. 


496 


TKEXTHBNT  OT  Dt^EA^ES  OV  TUB  NERVOUS  BTBTCH. 


Studjof  tbe  00363  relative  to  theitftture  an<l  tht  rhytLinof  tbo  tremor 
goes  to  oorroborata  the  ouRtomary  teaobis^;-  The  rate  wag  lii  &]\  ctuieA 
from  three  lo  six  per  second.  The  aiuplitude  of  the  tr«mor  iacreawil 
with  tlieirrc^fressof  the  diseafle.  Tn  three  c&ses  the  tremor  was  dUtinctlj 
iDtentioual — tliat  isi.  it  VOA  iuereaaed  by  purpoe€fti]  movements^  In  80tne 
advanced  ataR^is  it  va3  noted  that  voluutaTy  actJou  had  decidedly  a  quiet- 
ing JnQvieDce  upon  the  tremor.  In  nenrly  overj  cose  the  tremor  waa 
iiioreased  by  excitement,  reproot,  and  mental  agitation.  In  two  cased 
only  was  it  noted  that  phyaica]  agitation  had  a  aoothfng  iDl^ueiife  npoa 
the  tiemor,  lu  sii  raaee  there  wt-ro  a  dintim'.t  tremor  of  the  cephalic 
extremity.  As  to  the  infiueuce  of  alo&p,  in  nine  ca«ea  of  which  definite 
inforinatieti  Dould  be  obtained,  the  treinoi- always  stopped  during  aleep< 
One  man  was  very  positive  that  toward  morning  he  vaa  awakened  by  a 
B]wntaiieous  Ht  of  ihaking. 

The  reapiratiau  was  studied  in  eleven  easea-  In  four  cases  it  waa 
regukt  and  deep,  without  particular  change.  In  fonr  casea  it  was  super- 
ficial and  of  mcreaui'd  f  re<iueiicy,  twenty-one  to  twenty-four  a  minute.  In 
three  of  these  last  eases  the  expiration  was  irregular  and  jerky,  while  the  in- 
spiration was  regular  anil  harmuniou8.  In  one  cjtw  it  waH  distinctly  noted 
that  tlioj^rkiness  of  the  expiration  coincided  with  the  tremulous  movement 
of  the  upper  extremities,  but  lu  the  other  two  cases  this  was  not  bo. 

In  fifteen  easoa  apeoial  impiiry  was  made  cotK'ornttig  the  existence  of 
propulsion,  retro  pulsion,  and  tat^rupuUmn,  lu  £«veiL  coaea  aU  knowl- 
edge of  its  etistent!a  WAS  absolutely  denied-  lu  t^ve  of  the  remaining 
eight  oases  tlie  fKttlents  Doiuplained  of  a  tendency  to  fall  forward,  tn 
four  patieuta  Uiere  was  at  the  aame  time  some  retropulsiou  and  lateropul- 
eion.  In  two  patients  of  the  hemiplej^c  type  lateropulaion  was  present* 
the  tendency  being  to  fall  toward  the  diseased  side. 

In  sixteen  eases  imjuiry  was  made  concerning  the  state  of  tbe  stom- 
ach and  bowt^l^-  Eight*  [latit^nts  cuiaplaiiied  of  obstinate  [^onsttpaTion, 
one  patient  had  chronic  diarthcea,,  another  had  occadional  attacks  of  diai- 
fhc^B,  while  the  remaining  seven  made  no  complaint  of  their  ^inatro- 
lntestina[  functions. 

Abnormal  heat  sensations  were  complained  of  in  five  cases  out  of 
fifteen,  in  wh.ieh  it  was  notBd  that  inquiry  had  been  mode  in  regard  to 
thta  couditionn  The  hot  Hashes  weio  usually  of  the  face,  but  not  inlre- 
quenbly  also  manifest  in  the  side  showing  the  tremor.  Particular  seaj^ch 
was  made  for  sensory  disturbances,  since  Karplus  and  others  have  mata- 
taJncd  that  some  disturbance  of  sensation,  hyperrestliasJa^  fayperalgefiia, 
hypulgesiur  parif^theHiar  or  spoiitaneoua  pain  ia  not  uufroinmou.  lu  only 
two  instfincea  wei-e  sensory  disturbances  elicited.  In  four  cases  sweating 
waa  a  very  disagreeable  symptom.  As  a  rule,  it  occurred  rather  late  in 
the  disease-  In  Otie  instance  atone  it  was  the  initial  symptom.  Uroolug 
wafl  a  very  distressing  symptom  in  two  cases. 


THH   TREATKBNT    Off   FAJtALfsm   AGITAN'S. 


497 


Th«  mODtal  conditioii  of  the  patiants  w&s  noted  in  ninoteen  oas^s, 
Et^Tea  vr&Te  choerful,  hopeful,  o£  good  disposition,  and  eoRj  to  get  aJong 
wi^,  TMa,  taken  in  winnei'tion  with  the  fact  that  some  of  therti  wece 
ttiiiLatifS  c>f  A  charity  hoapit^  where  the  inviroument  does  not  Qontrihiito 
to  euphoria,  luoana  a  ^reat  deiil.  In  nouo  of  the  patients  waa  there  anj 
pcnr^ptible  degree  of  dementia. 

Treatment.  —  Unfortunate Ij,  no  mediciunent  has  yet  been  diBcorered 
that  h&e  any  inSuence  in  shaping  the  course  or  clianging  tha  outcome  of 
tbi3  difleaae.  Begmnera  iu  the  art  of  therapy  ahould  keep  thin  in  mind, 
and  thna  spare  themselves  the  trouble  of  attempting  a  cure  by  any  of  the 
dtitg^ — &nd  their  name  ia  legion — that  have  bci^a  recommended  diiriug  the 
last  half  century.  Energy  of  thia  kiud,  and  zaal  for  experimeotatioii  may 
be  legitimately  eipended,  perhaps,  in  trJala  with  new  drugs  and  other 
health-rest onag  measurBB,  But  it  sliovild  not  be  forgoUeu  that  one  ia  not 
always  juatiCed  in  raising  the  hopes  of  the  tjatieuta  fur  recorety  so  high 
ir  so  often  that  when  the  promises  are  uot  fulfilled  their  □oofideuee  u 
ODmplotely  shattered  and  only  harm  results.  Despite  this  depresaing 
CGtimate  of  the  vLine  of  drug  medication  in  the  treatment  of  paralysis 
agitahs,  RkLich  can  be  dotke  ti}  alleviate  tlje  aymptoiua,  to  praloitg  the 
patient's  life^  and  to  make  him  loora  [^mfort.able.  As  iu  anothernervuus 
dueatfes,  dietetia  and  diaciplinary  modes  of  treatment  are  of  the  greatest 
impottaace.  Their  value  iflvery  con  epic  uously  seen  in  patieutfiwho  early 
in  the  eonree  of  the  disaaae  ate  obliged  to  ee^k  the  shelter  of  a  bospital. 
Although  they  are  apparently  and  realty  not  very  ill^  ^^  wage  earners  they 
are  incapacitated.  The  regular  ^ijode  of  life,  aad  all  that  ia  implied  by 
hospitalization  ia  couduoive  Ui  aroidance  of  wear  aud  tear,  and  such 
patients  cootinue  year  after  yeat  without  any  material  change  e&oepb 
alight  increase  of  rigidity,  tremor,  aud  the  other  cardinal  symptoms.  The 
first  LndicatiOD,  then,  is  for  the  arrangement  of  an  uneventful  life,  free 
from  care,  strife,  excitement,  and  soriidity,  in  a'coii^iiial  ercviroDment 
and  healthful  climate-  As  a  rule,  a  cool  climate  ia  far  more  grateful  W 
these  patients  than  a  hot  one.  Life  in  the  country  or  in  the  suburbs, 
where  a  maximum  of  fresh  air^  sunlight,  and  sleep  are  to  be  had,  with  a 
miniiDum  of  demand  on  the  mind  mid  tha  body,  meets  the  requirements, 
providing  the  vital  force  of  the  i>atient  in  net  put  to  a  severe  tent  in  with- 
standing extremes  o£  temperature. 

The  diet  should  be  of  a  aimple,  nourishing,  atrea^hening  kind,  and 
Gl<H?e  attention  must  be  given  to  the  functiona  of  digestion  and  of  absorp- 
tion, so  thai  the  bodily  weight  may  bo  kept  at  the  level  which  waB  nor- 
mal in  health.  The  comfort  of  the  patient  eau  tie  materially  added  hi  by 
regulation  of  the  bowels  and  other  elimiiiative  avenues,  lb  is  absolutely 
pecesaary  that  the  patient  has  the  personal  care  of  an  attendant  or  one  of 
the  family,  Disaatroua  accidents  have  not  mfrequeDtly  follon'ed  neglect 
of  this  precaution.  The  customary  measures  fo;-  the  maintenance  of  gen- 
eral muscular  tone  and  mitrition,  so  serviceable  iu  many  ftiuoLional  and 
33 


TftKATHKKT  OP  DtSSASBQ  07  THB  l«BRVOU9  ST8TSH. 


flll^MM  prrooi  diseoMfl,  ouch  ju  the  apj^Ui'&tioTi  of  water  and  eleotricitj, 

rilft  «•»  of  miaongq  and  gjiniiasui^  are  nut  so  appropriate  in  tliia  difiea^ 

«a  lliej  Are  in  many  others.     Nevertheless,  the  nae  of  lukewana  baths,  of 

iKwlweii^f  icinuteato  hiiH  &□  hour's  dunLtioo,  aj-eoftecttojesverj sooth' 

ui(«»th#|uitletLt,  and  have  a  t^adency  to  mak&  the  mus<;ulu  rigidity  lead 

4o«iauit.     Moreover,  they  eon  tribute  to  Auoder^te  fueling  of  well-being, 

■adald  InMCuriiig  rfffreahing  real  for  which  Uiri  |iaiieat  generally  d&in- 

01^     [n  iiatieEita  uuUer  forty  years  of  ag^  th«  application  of  water  from 

M*  to  T5°  F-  from  the  hand  of  an  attendant,  followed  and  &cconiputie<i 

ty  frictioD,    U  aometimea  et^rviceablo  in  combating  the  distressing    at- 

Iftoks  of  local  aud  general  heat  of  which  the  patient  complains,      TLk 

WMsura  cuTi  be  utilized  daily  with  patiejits  who  react  well  after  it.      Re- 

aolioa  may  be  fibcilitated  by  hariug  the  patient  wrapped  ia  a  hot  blaukel 

IpMTious  to  the  ablution,  by  having  hjja  atond  in  hot  water  during  the 

tehi  Vid  by  light  manage   and  eKtemal  heat  foilowing  it.     Ma£Gage, 

tpp^od  as  stroking  and  Light  kueading,  fuIfiU  practically  the  same  pni-^ 

povev  and  is  utilised  for  the  same  ends.     It  tends  to  lessen  the  spasticity, 

ti>  improve  the  gener^  nutrition,  and  to  ia<.TBaae  the  patient's  capacity  for 

nsL     Swedish   gymnaatioe   have  been   warmly   recooimandcd   by  some 

writt^rSi  but  X  have  never  seen  anything  but  detriment  attend  their  use. 

Th«  sAme  may  be  eaid  of  EULfpensien,   which  has  been  plentifully  tried, 

«a4  of  nerve  stretohlng.      They  are  mentioned  only  to  be  adv^ised  sgainat. 

A  few  years  ago  Charcot  noted  that  niauy  of  bis  pHtieula  mfh  paralysis 

i^tuui  were  more  oomfortable  during  and  after  a  short  ride  in  a  jultiug 

v^biole.     Asasuning  that  the  jarring  and  vibrations  had  a  eoothiug  effect 

Ott  tlie  oeive  centres  from  which  arise  the  tremor  and  rigidity,  he  had  a 

«kui  eo  eonatructed  that  the  patient  or  an  attendant  could,  by  puabing 

^pikir  of  upright  handles  bai;kward  and  forward,  communicate  vibrati<ai 

10  the  entire  body.      Such  a  chair  was  in  use  for  many  niouths  in  my 

rlini(%  but  nowadays  it  aubservts  only  a  single  purpose,  that  of  a  seat 

lb  ijueleasuess  is  no  greater  than  that  of  other  vibratory  apparatuses, 

futf^h  as  tl)0  one  for  the  head,  that  have  been  coostracted  with  a  similar 

«ut1  iu  view.     Electricity  baa  practically  no  place  in  the  therapeutics  of 

naralrsi^  agitans,  exccptliig  so  far  aa  it  is  a  potent  ageuoy  for  suggc<stion. 

OiM  of  the  most  striking  results  of  treatmcDt  io  paraEyaie  agilana  is  the 

Inmporsiy  auieliorabion  o£  all  tlie  eymptonis  on  undertaking   any  new 

form  of  treatment.      1  have  now  under  observation  a  man  in  the  advanced 

fUge  of  the  disease  who  some  years  ago  maintained  that  he  was  maten- 

tlly  improvad  by  some  meobanical  treatment  given  to  him  by  another 

iihjlitHau.     On  inr^uiry,   it  was  found  that  the  "treatment"   consisted 

of  lAking  a  few  tracings  of  the  tremor,     O^rfienhcim  states  that  he  La£ 

aeeu  eon^iderable  benefit  follow  the  eleotrie  bathj  and  especially  the  appU- 

eataon  of  the  dipolar  faradio  current,  but  It  is  not  improbable  that  the 

tiAth  aloue  would  havs  beea  accompanied  by  quite  as  much  improve' 

laent 


THB   TKKATHONT    OF    PAKALYSIB    AU1TAJ4B. 


499 


I 

I 

I 


t 


The  drugs  that  &i6  in  use  for  p&roi^aia  ^itanSf  and  fiom  which  oome 
beaeljt  in  dissipatiiig  srmptoma  and  fulfilling  pointed  mdioatiocs  tnaj  bo 
expected,  are  hjoaoyjimiis  aad  diiboigine,  Indiaa  hemp,  opitim^  biema- 
lo^noUfl  ageucieSf  suvh  as  arsenic;  and  iruD^  and  iiticaa  ion  ally  gelaemLmti 
uid  Teiatrum  viride.  Of  the^,  the  inoBt  LmportJLQt  by  far  are  Ihe  tno 
first  metitioDcd-  Given  bypotietmicailyi  wluch  ii  tho  prsfcr^blo  way 
wboQ  poeeible*  or  hj  the  moiitbi  they  promptly  mitigate  tho  Boverity  of 
the  tremor,  and  have  a  proaoimoed  tendency  to  Telas  the  muscuJar  rigid- 
ity. They  are  both  powerful  loxic  agenciea,  and  iiiuaii  tbernfuie  be  given 
witli  rare.  IIyt>acyauiiis  (liyosi^tue  hydfobromide,  one -une -hundred  and 
twentieth  to  one-eigbtietli  of  a  grain)  is  aaid  to  have  more  adrocatee 
that]  duboisuie,  bnt;,  peret^uaUy,  I  much  prefer  the  latter.  It  is  not  go 
l^t  to  cause  disagreeable  symptomar  while  the  effects  are  eoequaL  The 
Holphate  af  daboi^ine  ahcuM  be  given  in  from  one-nne- hundredth  to  one- 
aixiietb  uf  a  grain,  two  or  thrt^  tiine«  daily.  On  the  accession  d£  vertigo, 
cephalic  parsathesia,  diaturbance  of  Tiaion,  nausea,  dryneas  of  the  mouth 
and  tongue,  it  should  be  stopped  at  once.  lu  many  iuatancea  the  adjnin- 
istrattoa  of  either  of  the-se  iJruga  i^  followed  by  abitout  complete  cetiiiation 
of  the  tremor  for  a  ahcirtaror  longer  tiin(^^  but  uauaHy  for  aeveral  days.  Un- 
forluaately,  they  apparei^tly  have  flight  effecb  in  mitigating  aleeplessoess, 
^myosbheuia,  and  the  feeling  of  unrest  thab  so  many  patiente  complain 
of.  When  these  become  U'O  burdeoaoms  for  the  pationt  to  bear  unaided, 
opitimor  its  alkaloids,  preferably  morphine,  must  be  given,  and  especially 
to  cans^  i^est  and  sleep  in  advanced  cases.  Earlier  in  bbe  disease  ri^llance 
o&n  be  placed  on  tlie  less  baneful  sleep  producers,  buch  ai4  sulfonal,  trio- 
aal>  and  paraldehyde^  given  in  the  eauie  vray  aa  they  are  for  idiopathic 
iDaoniuia.  Alc^ohoI  or  wbiabej  in  hot  water,  when  taken  at  bedtime,  la 
oftea  bencticiol  in  overcomitig  the  maomnian  The  salts  o£  salicylic  aaidj 
particularly  those  of  «odium  aad  pobasaium,  have  been  widely  rwoiu- 
mended,  ej^peciully  during  the  last  ten  years.  They  were  probably  aug- 
gfiated  by  the  pabieut^»i  romplaint  of  rheumatic  paiu  aiid  by  the  occurrence 
of  other  moie  characteristic  phenomena  cf  rheumatiam.  After  thorough 
trial^  I  am  convincod  that  such  medication  is  quite  nsetei^s.  Conaider- 
inj;  the  profound  d^^ee  of  depression  of  neuromusi^ular  tone  which  patientG 
with  thia  disease  have^  it  Reems  incredible  that  the  LrGmidea  have  ever 
been  recommended  or  given,  bab,  nu fortunately i  they  have  been.  They 
Art  powerful  ageucies  for  hai'm,  and  the  thought  of  giving  them  should 
never  be  harbored.  In  aome  instances,  especially  in  those  cases  that  are 
Eiot  benefibed  temporarily  by  duboisine  or  byosoyamus^  the  tremor  and 
rigidi^  may  be  mitigated  to  some  e?cbent  by  the  adminiabration  of  gelse- 
mium  or  veratrum  virtde  bi  from  three-  to  five-drop  doecB,  three  timefl 
a  day,  The^  ilrugs  have  aerved  me  more  satisfactorily  aa  symptom  ntedi- 
oines  than  Indian  hemp,  which  has  the  reoonuikendatiou  of  Gowera,  and 
which  has  beeu  widely  uaed. 


CHAPTER  XXXIV. 


THB  TREATMENT  OP  ESOPHTHALMKJ  OtllTRE- 

ExoPHTHALnic  goitre  la  a  neuiosia  of  the  Hympathetic  nervous  system 
attended  bj  wcul^  and  interatitial  changes  in  tlie  thyroid  gland  which 
^ve  rise  to  iaoreaoed  thyroid  aeuretioni  Dhar£Lcteri2ed  by  tochjcardia, 
goitre,  prominence  of  the  oyebalk,  tremor  of  the  e^^tremitieB,  amyosCbenia, 
and  emotioD^ism.  Itoocura  moatfrdqiieTitly  iafemaJes  doi'ing  the  period 
of  their  faciindity,  and  especially  from  the  fifteenth  to  tho  thirtieth  yean. 

From  a  pereoual  study  of  flfty  caaea,  the  following  poncluaiGoa  con- 
cerning its  occorronce  have  been  reached.  The  proportion  of  females  to 
males  was  about  7  to  1,  ol-  HH  per  cent  of  the  former  to  12  per  eent  of  the 
latter.  Of  the  women  oL>  per  cent  were  married.  The  foUowiag  tAble 
indioaCeB  the  occurrence  of  the  disease  according  to  decades- 


1  to  10  yean, 
10  tq  20      " 
SO  u»ao      " 
S0u>4li       "• 
40  to  00       '- 


0  per  cant. 

so     " 

20       " 


Twenty-aix  of  the  niunber  were  between  the  ages  of  fifteen  and  thirty* 
The  oldest  w&s  fifty-eii  and  the  youngest  fourteen,  ^i  in  all  neuropathic 
coDditioQS  an  eiEajnination  of  the  patient's  heredity  and  family  history 
showa  the  eiistence  of  many  neivoua  affectdona.  Very  rarely  is  a  history 
of  direct  heredity  obtained.  Not  OLie  of  the  fifty  oaflee  gare  such  a  his- 
tory. Id  thirty  per  cent  of  the  oaeea  there  was  a  history  of  some  nw- 
voua  diaeaee  in  the  family,  and  in  oa&,  of  consanguiuity. 

The  f]u:tor»  that  so  ofteii  [ireeede  the  occu.rrence  of  the  ayniptoms  of 
the  diaeaae  that  tltey  may  be  coiiHidered  vaubative  of  ^2ophtha]nnc  g^oitie 
are  mental  acd  physical  sho<:k  and  exhaustion  and  everything  that  contrib- 
utes to  them.  Many  examples  occur  without  apparent  proTOcation.  Of 
the  attributed  caus^  a£  giyeu  by  the  patients,  thirty  per  cent  wero  doe 
to  psychical  shock,  fright,  worry,  and  excitamentj  eighteen  per  cent  to 
physical  injury  or  exhaustion,  and  eighteen  to  infec^tious  diseases.  The 
real  etiology  of  the  diaeaae  is  atill  verjohscure.  Stndy  of  ita  occurreaoei 
its  symptoms,  and  its  course  leads  one  to  tljc  belief  that  it  is  primarily 
a  disorder  of  the  sympathetic  nervous  system,  either  of  its  peripheral 
distribution  or  its  central  fepresertation.     This  is  in  turn  followed  by 


THE  TREATMENT  OP  BX OPHTHALMIC  aOlTBB. 


■loh  exoeesiFe  and  ocniaUnt  fuiictiotiiLg  of  the  thyroid  gland  that  it  leads 
not  alouo  to  hjpertbyroid&tiou,  wliich  iu  iUelf  la  peraicioue  to  the  ecoc* 
ony,  but  to  degenerative  changes  in  the  thyroid  glaod. 

Although  thedlfieoseis  attended  by  the  development  of  pathognomonio 
symptoms,  these  symptoms  are  of  very  vu'iable  severity  and  combination B. 
The  most  churactflristic  of  them  ars  tachycardia,  tremor,  eulargement 
of  the  thyroid  gland,  and  exophthaliuoa.  But  tlie  disease  may  be  present 
without  the  existence  of  the  two  latter.  Tachycardia  is  the  most  con- 
stant and  invariable  symptom,  The  pulee  ia  oauaLlj  small  in  voliune, 
regular  in  rhythm,  though  arrhythmia  often  occurs  when  the  disease  ifl 
wfM  marked,  and  from  one  hundred  to  one  hundred  and  sevf^nty-five  in 
frequency,  ll  ia  liabJe  to  poruiysmal  variation  irith  or  without  apparent 
cause  or  excitation.  It  is  associated  vith  cardiac  palpitation,  with  pul- 
Ution  in  the  arteries  cf  the  neek  and  head,  and  with  more  or  lesa  hyper- 
trophy. The  euLargemeut  of  the  thjrroid  gland  may  be  unilateral  or 
tHlateral.  OftentimBB  it  is  of  such  alight  extent  that  it  ia  to  be  detected 
ooly  on  careful  esaniinatiuu  Uuxirtg  the  act  of  deglutitioD.  This  ia  espe- 
cially the  case  when  there  is  considerable  deposition  of  fat  in  the  neck. 
To  the  touch  the  swelling  is  not  very  £nn^  and  usually  a  peculiar  thrill  or 
Tibraticu  is  given  to  the  examining  fingers.  The  tumor  may  beoome  eo 
large  as  to  encroach  seriously  ui>on  the  respiratory  tract.  The  exoph- 
thalmos is  usually  bilateral,  although  it  may  lie  of  one  side,  or  it  may  be 
more  prominent  on  one  side  than  on  the  other.  The  palpebral  fissure  is 
widened,  and  there  are  no  blinking  movements  (Stelwag'e  aymptoiD)  of 
the  upper  lid.  A\'hen  the  patient  moves  the  eyes  downward,  there  is  a 
perceptible  disaasociation  between  the  movement  of  the  eyeball  and  theeye- 
lid,  which  is  known  as  v.  Graefe*^  symptom  ^  and  when  the  patient  fotnisses 
the  eyes  on  an  object  held  close  to  him,  the  eyeballs  do  not  converge 
oqnallj  and  remain  fiied,  a  phenomenon  due  to  insufficieuoy  of  the  inter- 
nal recti  originally  deeeribed  hj  Mobiua.  CEdema  of  the  eyelidsT  infiam- 
mation  of  the  cornea  and  coojunctLva,  and  a  degree  of  ophthalmoplegia, 
are  of  rare  oceurrence.  The  tremor  of  the  extToriities  is  of  a  profound 
neuraatheuic  type,  fmm  teu  to  Sfleen  vibrations  per  second,  and  subject 
to  oonaiderablo  variation  in  intensity.  The  patient  is  n^ore  or  leas  pro- 
foundly myasthenic.  Thia  is  manifest  in  many  ways,  auch  Be  in  diminu- 
tion of  the  respiratory  capacity,  giving  way  of  the  knecs^  eiliaustion  from 
slight  effort^  aiid  insuflicieTLcy  of  soma  of  the  ooular  muscles.  Vascular 
and  trophic  symptoms  are  often  very  conspicuoua.  Of  these  may  be  men- 
tioned flushings  of  the  face,  and  rarely  of  other  parte  of  the  body;  sub- 
jective sensations  of  heat  and  burning,  hyperidrosiB,  which  may  be  unilat*- 
ral  or  segmental;  ooldnesa  of  the  extremities}  unattributable  attacks  of 
diarfhcea,  associated  with  ballooning  of  the  abdomen;  polynrii;  der* 
niitgraphic  skin,  and  rutaueoiia  pigmentation.  The  patient  fraqiieiitly 
oomplaina  of  insomnia,  of  a  feeling  of  profound  unrest,  of  great  irritabil- 


J 


603 


TREATHBNT  Ql-  bl^A&Efl  OV  TBK  NEKVOUa 


ity,  of  a  gnawing  feeUng  in  tlio  epigastrium  like  that  of  gejtutne  bunget, 
find  of  almost  any  one  or  moie  cf  the  aymplomacf  the  neiirasthenio  state. 
CliniDally,  many  forma  of  tba  diaeaae  ciigbt  be  described.  The  apical 
v&Tisties  are  in  reality  as  csminnn  as  the  t^'pit^a).  The  Rbortive  and  tha 
aevcre  tyiit^s  of  exopbLhalmiu  goitre  are  also  not  very  rare.  It  may  truth- 
fully bo  aaid  that  n  neurasthenic  atate,  plus  peraistent  tachycardia,  19  euffi- 
oieat  in  niue  ra^es  out  ot'  tou  to  juatify  the  dingnoeia  of  tbia  neuroiia. 
Tha  course  of  the  diseaae  ib  by  no  meatia  conatatit.  It  is  liable  to  spoa- 
tatieoun  t^overyy  to  proloDged  remissioDST  and  to  exai^erbadona.  Rarely 
tJie  diHeaae  ocoure  abruptly  with  profound  and  pmHtrating  symptoms 
which  lead  to  a  fatal  outcome  nithiu  a  few  ^eeka.  Such  caaea  ara 
attended  with  extreme  emaciation,  great  depreBsioD  of  the  vital  fiirtcs, 
and  delirium.  The  eliiitcal  picture  and  the  physical  signs  oiODBtitnting 
exophtbalmie  goitrd  vary  with  tha  type  mid  with  the  course  of   the  dia- 

Treatmeat. — The  succesaful  treatment  of  exophthalmic  goitre  depends 
largely  upon  the  physician's  ability  to  secure  the  patient's  full  co-opera- 
tion in  carrying  out  the  details  of  the  plan  looking  t>^ward  mfiiital  and 
physical  (tuietude,  and  restoration  of  the  nutriticmal  b&lauce.  In  my 
own  experience  there  are  few  nerpdus  diseaaBs  sn  unsatisfnrtory  to  treat 
in  dispensary  practice  and  few  that  are  so  amenable  to  treatment  in  hoa- 
pited  and  in  private  practice.  The  reason  for  this  is  that  dispensaiy 
patiente  are  not  only  beyond  the  ooDtrol  of  the  phyeieiana  but  are  aocially 
ao  ailuated  that  they  cannot  properly  use  the  measures  ;  Te^t,  gracluated 
exerciaea,  hyrlriatirs,  electrit^ity,  hygienic  nnd  dietetio  rules,  which  ini- 
meaaurably  outweigh  drug  therapy^  Many  varietieaoftreatmeut  and  plans 
nf  treatment  ha^ebeen  recommended.  Some  of  them  areha^edoii  (I)  em- 
piricism, others  (2)  are  claimed  to  be  founded  upon  capavity  to  thwart  the 
cause  of  the  dieease,  theoretically  established,  while  others  still  (3)  pur- 
port ta  meat  special  indicatlouSr  and  by  inhibiting  the  phenomena  of  the 
diHeaae  to  cure  the  disease  itself.  Under  the  6rnt  may  be  mentioned  the 
admiiiistratioQ  of  phosphate  of  sodium,  which  given  in  do^es  of  from  one 
to  four  drachma  in  twenty-four  hours  unquestionably  often  amoljorafee  the 
eymptoma,  with  BubjecUva  and  objective  improvement.  Here  alfio  may 
be  mentioned  operations  on  the  nose  and  the  naaophuri-ns.  Judging 
from  the  literature  of  so-called  curea^  operation  for  remmal  of  inrranaaal 
growtha  and  obstructions  is  sometimes  of  real  service-  Under  the  second 
caption  may  Le  iuchided  such  treatment  as  the  use  of  intestdual  antii^ep- 
ti<!s^  the  rationale  of  which  is  based  upon  the  belief  that  toi^io  products 
alisorhed  from  the  alimentary  tra^^t  have  a  periiieioua  effect  iipon  the  vaso- 
motor area  in  the  oblongata,  aod  are  thu^  responsible  for  the  genesis  of 
the  diaeawe.  No  one  will  dt-ny  that  a  disease  whose  symptoms  are  alraoat 
exolusively  manifest  through  the  vegetative  nervous  ayatem  in  always  aasc- 
oiated  with  disturbance  of  digestion  and  absorption,  not  to  ape^k  of  metab- 


THB  TKEATMKST  OB"  EXOPHTHALMIC  GOITRE. 


503 


oliam.  Therefore  cue  may  appreria&e  tlia  benefit  to  be  ii&d  Erooi  siriot 
regulation  of  tbe  diet,  and  tbo  xmreniittmg  use  of  BO-c&lled  intestinal 
antiaeptica,  without  leajing  towncd  Iho  theory  that  tho  diaeasii  is  an  auto- 
infection  of  intestinal  origin.  Under  the  third  heading  may  be  men- 
tioned tlje  use  of  ilrugB  that  reduce  tbe  frequentj  of  the  lieart  leala  or  the 
size  of  the  goitre.  Thean  include  digitalis,  fitrophantlmSf  belladonnii,  ai'O' 
nitpj  nitroglycerin,  the  iodides,  aiid  bromides.  The  two  firat- mentioned 
drugs  have  been  very  ^iety  rocommcridod,  and  they  could  hardly  b&Te 
secured  tbeir  reputation  in  the  treatment  of  this  disease  without  deserv- 
ing it.  Nevertheless,  T  am  unahle  to  say  one  word  in  their  hehalf-  Af- 
ter thorough  trial  of  tUeiii  it  only  renjains  to  say  that  tlie  eCf&ets  whJtb  it 
13  said  tbej  produce  can  be  bo  muoh  more  easily  and  saf«ly  obtaioed  by 
non-medioiQal  measutes  that  I  never  employ  them.  It  is  said  that  the 
admiuUtration  of  digitalis  slows  the  beating  of  the  heart-  It  dues  in  & 
normal  peTSon,  bat  not  in  one  who  has  Graves'  di.aease.  More  decided 
Hlowiog  of  tJie  heart  ran  ba  obtained  by  the  application  of  a  i;old-wai«r 
compress  to  the  precordium,  by  the  use  of  cold  douches  under  properly 
regulated  pressure  to  the  spine  and  the  estremitiesi  and  by  rest  than  by 
the  use  of  atrophanthus.  Belladonna  is  aupposod  to  act  henofieiolly  by  vir- 
tue of  ita  peculiar  property  of  stimnlating  the  unstriped  muscular  fibres, 
thus  giving  tone  to  the  vasrular  system,  and  overooming  arrhythmia. 
It  haa  been  used  externally  as  an  omtmeot  to  the  goitre  and  as  a  plaster 
over  the  heart.  The  results  of  its  us©  in  my  experience  are  not  ButK  as 
to  warrant  recommending  it,  save  to  meet  some  special  indication,  such 
as  hyperldrosis  and  polyuria.  Of  this  class  of  medieinCH,  the  one  that 
has  seemed  to  me  of  real  service  is  aconite^  given  in  the  form  of  McKes- 
son  &  Robblns*  pill  ar:Dnitia  aa  originally  rticomniended  by  thi^  late  K.  O. 
Segnin,  Qiven  in  gr.  -^^  dose,  four  timea  daily,  and  increased  until  the 
patient  is  taking  twice  this  quantity,  or  even  more  according  to  the  effects 
that  it  produces  upon  the  neurovascular  system,  it  seems  to  me  the  most 
iportaiit  medicinal  adjuvant  in  the  treatment  of  this  neurosis.  It  acts 
Lptomatically,  according  to  its  well-known  physiological  efFacts,  tfi 
lessen  the  number  of  heart  beats  and  to  lower  vascular  tension.  It  is 
recuirmended  merely  afi  an  adjuvant  and  in  nowise  to  bo  compared  with 
the  physical,  hygienic,  and  dietetic  measuTes  which  are  about  to  be  de- 
tailed.  Iodide  of  potassium,  when  given  internally  or  when  thoroughly 
rubbed  into  the  goitre,  helps  to  rpdnce  the  enlargement  of  the  thvmid, 
but  when  given  in  auMcient  doses  to  do  this  it  teudu  to  increased  cardiac 
pulsation,  to  disordnr  of  digestion,  and  to  impaired  assimilation.  Its  ad- 
ministration ,  therefore,  defeats  its  own  ends.  Pew  writers  recommend 
the  ayatematic  use  of  bromides.  Mobius,  however,  believes  that  the 
mental  and  physical  sxcitabilily  are  best  combated  by  giving  from  thirty 
to  sixty  grains  of  any  of  the  commoner  bromide  salts  in  wat'er  oti  retiring. 
Although  it  ia  refreshing  to  note  any  therapeutic  recommendation  from 


604 


TREATMENT  OF  DffiBASES  OF  THtt  NfiRVorS  STaTKU. 


this  writer  which  ia  not  Buppoied  to  act  "  pajchiofttly/'  it  is  to  be  hi 
that  his  ailvdcacy  of  thd  bromides  in  the  treatment  of  exophthdmio  go! 
will  not  lead  any  nue  to  their  Hyabematiti  use.  In  the  treatment  of  aim 
any  patient  there  are  occasions  when  one  or  a  few  doaes  of  bronjid© 
are  JDdbated  to  combat  epwial  aymptoma,  euch  as  profound  restless Eiesa^ 
uitremttting  a^itatioD,  8ubjoclL7&  feeliuga  of  heat,  aad  funotion&l  patpita- 
tioa,  but  Burh  a  drug  ahould  not  be  given  continnoiialy.  Nearly  eri^ry 
symptom  medioine  in  th»  phariiiaco|xi*i&  ha^  been  recommPTided  nt  ono 
time  or  aaotber  in  the  treatment  of  Graves^  disease,  bub  very  little  benefit 
is  to  be  expected  from  stryohniue,  pici  iLtO  of  ammonium,  picn^toxinT  ergot, 
araenic,  cactua  grimdiBorua,  eto.  Uii  the  other  band,  restorati^'eB  whose 
elfect  is  to  promote  oonatruotivA  metabolism  muy  l>e  given  ocoaaionollj 
with  good  reflultfl-  Ab  a  rule,  juLiietils  with  this  dise^ise  iki  not  tolerate 
iroiit  although  it  hoe  been  ajid  is  titill  given  very  exteuBively.  Theaimpla 
bitters,  muieral  acids,  and  aida  to  digestion  may  he  given  temporarily  to 
meet  spet^ific  indicutiona.  Dilute  snlphurio  acid,  ten  drops  three  timee 
daily,  has  raceutly  been  recommended  by  Vetlescik  of  Christiania. 

The  Uni  most  importAOt  matter  to  decide  in  be^nning  the  treatment 
of  a  patieut  with  exophthalmio  goitre  is  how  much  physical  exercise  caa 
be  taken  without  increasing  the  rapidity  of  the  heart  or  m  any  vr^y  ooa- 
tribiitLn^  to  the  patient's  irritability,  reBtlessness,  and  myastheaia.  If 
the  dissaRo  is  of  eonsiderabla  severity  or  well  developed,  usually  no  pbi3re- 
ical  exercise  f-Ln  be  taken  without  aggravating  some  of  the  symptoma. 
Therefore  it  is  necessary  in  the  majority  ofcasen  Loconline  the  patient  for 
a  time  to  bed'  A9  soon  as  the  neurovucular  ayatom  has  been  steadied  by 
enforced  rest,  and  the  tiontributory  measurea  that  should  be  employed, 
the  patient  should  be  allowed  and  enuouraged  to  take  suoh  exercise  as  will 
Bid  eonHtmetive  m^LabolisTu  without  increasing  tlie  heart  beat  or  in  any 
w[iy  adding  l/j  her  discouifart.  Sm^h  exemiae  will  exclude  everything 
bordering  en  the  violentf  auch  as  runDing,  ohmbing]  ridiugi  and  bicycling, 
but  it  may  include  graduateil  gymnasium  oxerciseT  walking,  golBbg,  and 
eroquet.  The  advisability  of  allowing  the  patient  to  exercise  will  depend 
entirely  upon  the  effwts  produced.  The  patient  should  be  in  an  environ- 
ment that  couE^ributes  to  mejital  ease  and  relaxation,  devoid  of  liability  to 
emotional  excitation  or  depresaiorif  and  net  dependent  upon  her  own  r9* 
aoutcea  for  amusement  and  reUhxation-  If  it  ia  found  unneceaaaiy  to  con- 
fine her  to  bed  during  tbe  entire  twenty-four  hours,  it  is  well  to  insist 
that  the  time  of  arising  be  delayed  until  near  Toidday,  and  that  the  reti^ 
ing  hour  he  early  in  the  evening.  The  dietary  should  be  one  that  is  at 
the  same  time  highly  nutritious  and  easily  digested,  FocHlahould  lie  taken 
^eqneutly  in  small  quantities,  and  nitrogenous  substances  in  the  shape 
of  meat  should  bo  taken  but  once  a  djiy>  For  the  majority  of  eaaesi  ftH 
exclusive  milk  di^t  ia  not  advisable.  Yet  oecasionally  when  gftstrto 
and  iateatmal  ferraentfltion  are  conspieuous,  it  is  advisable  to  restrict 


Tire   TBKATMBINT   OF    EXOFHTBALMIC   OGTTRE. 


tiie  diet  to  milk  and  milk  preparations.  Greeu  vegetables,  eBpeciaJlj 
thoae  of  co&rse  t«iture  sjid  easily  digested,  should  be  taken  freely.  The 
patient  shoiiH  be  ur^^  to  drink  freely  of  ivater.  Alcobolics,  tea,  coffee, 
and  tobacco  should  be  &bBo]ut«ly  interdicted.  The  safest  guide  in  dlreot- 
ht%  the  dietary  13  the  bodily  veight.  rrogreaaive  loss  of  BesL  and  tko 
occutrenoe  of  cachexia  dematid  the  tise  of  tissue  tcconstrucbi'^es. 

Hydrotherapy  li^s  the  same  im)}ortant  part  m  the  treatment  of  exoph- 
thalmic goitre  that  it  has  in  the  treatment  of  neurasthenia.  It  ts  impoa^ 
Bible  to  statpe  apecifioally  tphe  hydriatio  procedure  indicated  in  every  iiasa. 
In  othcT  words,  tbete  19  no  such  thing  aa  a  £xed  hydriatic  prcBcnpLioa. 
Every  case  is  a  law  uuto  itself.  Aa  a  ruler  ^'  ^^^J  he  aaid  that  tachy- 
cardia ia  heat  aombated  by  the  apphcatioD  of  a  cold  oompresB  over  the 
heart,  and  by  the  use  of  douches  of  from  SO"  to  70°  F.,  and  from  ten  to 
fifteen  pounds  pressure!  over  the  spinal  column.  General  vasomotor  to- 
nicity is  obUiutid  from  cold  ablutions  over  the  entire  body,  the  water  being 
applied  from  the  hands  of  au  attendant,  especially  after  the  oLirfaco  tern- 
perature  has  been  slightly  increased  by  wrapping  the  patient  in  a  warm 
sheet  and  blanket.  Lukewarm  half-batlia  answer  the  eame  purpose. 
Restleesness,  LrrlCability,  and  myasthenia  are  ooTabatecl  by  the  use  of  the 
wet  pack.  In  my  own  experience  the  latter  symptom  ia  more  amenable 
to  the  cold-water  douche,  applied  for  a  few  seconds  to  the  legs  and  feet^ 
and  the  hands  and  arms,  thiin  by  any  other  measure.  I  have  often  seen 
diarrbceai  cease  after  the  application  of  the  I4^eptone  girdle. 

Bahieotherapy  i&  not  of  great  importance,  save  as  it  serres  to  fiilfil 
the  indications  that  have  already  been  spoken  of  canceming  the  patient's 
environment.  Patients  vith  this  neurosis  seem  to  be  as  comfortable  at 
the  seaside  as  in  the  mountains,  hut  sea  bathing  should  never  be  indulged 
in.  PhysicLans  living  at  mineral  sprmgs  and  watering- pi  aces  have  ad- 
vocated prolonged  sojourns  at  such  places,  but  there  is  very  little  disin- 
terested tet^timouy  in  support  of  auch  a  plan. 

Electricity  haa  loug  been  of  good  tepnte  in  the  treatment  of  this  dia- 
ease,  and  there  are  few  diseases  in  which  its  reputation  is  better  founded. 
Mention  will  be  made  only  of  the  galvanio  current,  ae  it  would  seem  to 
be  the  eoaseneUB  of  opinion  that  faradic  electricity,  despite  Vigouroux's 
advocacy  of  it,  ia  of  vary  insignificant  aervice.  The  approved  method  of 
using  Uiegnlvauio  current  ia  the  stabile  application  over  the  cervical  ayui- 
patbette,  and  to  the  enlarged  tiiyroid  gland.  The  Urge  indifferent  elec- 
trode (anode)  is  placed  over  the  lower  cervical  vertebra',  and  the  small 
cathode  electrode,  from  two  to  three  centimetres  in 'diameter,  at  tha  inner 
border  of  the  middle  of  the  sterno-cleido- mastoid  muscle,  wMle  a  current 
of  from  three  to  four  milliamperea  is  allowed  to  flow  for  from  three  U>  five 
minutes.  The  same  procedure  is  repeated  on  the  other  side.  Then  a 
similar  current  is  allowed  to  pass  through  each  lobe  of  the  thyroid  gland 
for  a  corresponding  time.     This  procedure  should  be  repeated  once  or 


GOG 


TBS&TUENT  OF  DISEASES  OF  TBB  yCBVOUS   STBTEH, 


twice  daily-  Borne  authora  have  raoomjD^j'ded  very  much  stronger  <*tit- 
ranta,  but  pflrsonally  I  have  never  Haen  beDafit  follow  tbeir  iiae.  Stitic 
<dectricitf  may  b«  used  for  it&  generEil  tonic  and  inental  efFect^  but  care 
should  be  taken  that  it  does  not  excite  the  patient  or  make  her  moi^  list- 
less. The  electrioal  treatment  should  be  kept  up  we«k  tfter  week  for 
several  mouthfl  Jind  always  in  connection  with  the  other  physical  meaBures 
previously  sjwkon  of. 

Bnrgical  Treatment  of  Exophthalmic  Cbitre.^l>tiriiig  the  past  few 
years  the  aurgical  trcatmeut  of  esophthalniic  goitre,  conaistiug  of  liga- 
ture of  the  thyroid  arteries,  partial  or  complete  resection  of  the  thjroid 
gland,  bilateral  division  of  the  cervical  sympathetic  or  the  ganglia,  and 
simple  eipoflure  of  the  thyroid  gland,  with  consequent  retrogression  and 
atrophy  of  ita  tbrsuea,  bo-called  exothyrLipexyi  has  come  promijit^ntly  into 
vogue.  At  the  present  writing,  records  of  two  hundred  and  Forurtern 
cascB  are  to  haud.  The  operatioa  that  would  seem  to  be  moat  faroi-ablv 
considei'ed  ia  that  of  partial  thjT^idectnmy,  Judging  from  Uie  et^tisbce 
of  individual  writers,  auoh  as  Booth,  Putnam,  Saengec,  Eocher,  Kum- 
mell,  and  others,  it  wonld  aeem  legittinate  to  state  tliat  the  results  of 
operation  have  been  su^cienbly  favorable  to  warrant  its  recommendation. 
But  when  the  entire  field  of  operated  cases  ia  surveyed,  the  fact  that  the 
mortality  from  these  operations  is  greater  than  the  mortality  from  the 
disease  itself  (viz,,  from  ten  per  cent  to  fifteen  per  eant)  admits  of  no 
denial.  Until  this  mortality  rate  is  rpduced,  and  unHl  cases  reported  as 
cured  from  operation  are  ao  completely  relieved  of  oymploms  that  cthei 
physiciana  aside  from  those  interested  iu  the  operation  are  convinced  of 
the  cure^  surgical  procedure  cannot  he  recommended  ia  the  treatmeot  ol 
exophthalmic  goitre  until  after  the  general  plan  of  treatment  outlined 
above  has  been  thoroughly  carried  out.  and  has  failed  to  hold  in  abeyance 
the  manifeBE^atiouH  of  the  diaeaae.  Tu  reiient  times  upomtions  on  the  cer- 
vical sympathetic  nerves  and  their  ganglia  have  found  considerable  favor 
in  France*  Those  who  urge  them  aiMept  Ahadie's  views  of  the  patho- 
gencsLB  of  Graves'  disease,  namelyf  that  it  is  due  to  persistent  irritation 
of  the  vasodilator  fibres  of  the  sympathetic  and  cf  their  nui'lei  of  origin, 
the  gaitre  forming  ss  a  resnlt  of  vasonl&r  engorgement  of  the  thyroid. 
Although  the  results  of  operation  an  given  by  its  advoi'ates  Jaboulay 
and  JoiincscOf  and  their  followers  seem  gratifying,  the  real  value  of  the 
operation  has  not  yet  baen  proved.  It  may  safely  be  said  that  it  should 
he  tried  in  those  ^^aaes  that  do  not  yield  to  the  other  lens  dangei-ou?  plans 
of  treatment-  The  mortality  of  operations  on  the  cervical  sympathetic 
would  seem  to  be  less  than  that  of  thyroidectomy. 

Serum  therapy  baa  been  tried  with  some  apparently  beneficial  results 
in  this  disease.  It  is  generally  aooepted  that  at  least  some  of  the  mani^ 
featations  of  *^iophtha!mic  goitre  are  due  to  byperthyroidation.  It  wsa 
therefore   very  flatonishing   that  P'^porta  of  mres  from   lliyroid  feeding 


THB  TEBATHBNT  OP  BXOPHTHALIIIC  OOmtB.  507 

w«Te  recorded,  but  vhen  it  was  found  that  the  aubaUuee  ftdmiitinUrcHl 
waa  not  thyroid  but  thymus,  it  waa  thought  that  this  gland  of  unknown 
function  might  have  some  property  to  check  the  manif^atationa  of  the 
diaease.  With  that  end  in  view,  fresh  glands  of  the  aheep  liave  boen 
Adrainistered  by  a  number  of  eiperimentere,  but  the  results  have  not 
been  satisfactoiy,  nor  has  the  administration  of  the  serutn  from  dogs 
whose  thyroids  were  previouslj  extirpated. 

Bummary. — In  brief,  then,  the  treatment  of  exophthalmic  goitre  cod* 
sists  in  the  p^iper  utilixaUon  of  rest,  dietary,  environment^  water,  etoc- 
trici^,  exercise,  hjgieoio  and  disoiplinary  measures.  In  njany  r^aaes, 
certain  symptoms  will  call  for  particular  interference,  but  the  indioatioriH 
in  suoh.  conditions  are  in  nowise  different  than  when  the  same  orcur  apart 
from  exophthalmic  goitre.  (£dema  of  the  eyelids,  inflammation  of  the 
Donjnnotiva  and  cornea  due  to  exposure  through  the  retracted  lids,  hyper* 
idroeis,  insomnia,  diarrhcea,  etc.,  call  for  the  treatment  which  is  adapted 
to  them  when  oocurring  under  different  circumatances. 


CHAPTER  XXXV. 


THE  TRBATMBNT  OP  MYXEDEMA. 


MrzfBDKMA  ia  the  name  applied  to  a  progreasive  oaohexia  or  mucoid 
tMnafordiatioa  of  tho  ooocective  tiaeue  all  over  the  body,  btit  oapeciallj 
of  the  anbcutsneoos  tiaHue,  associated  with  mental  and  pbyaleal  flla^giah- 
uess,  deji€indeDt  uau^ly  upon  fibrciaia  of  the  thyroid  ^Land  with  atrophy 
of  the  sevxetiug  epithelium.  Occasioaally  it  is  due  to  sypbilia  and  to 
actinomycoaia  of  the  gland.  The  diBoase  is  identical  witb  that  which 
lefiulta  in  auimala  after  extirpatioD  of  the  thyroid  gland.  It  occurs  pre- 
dominantly in  women  dimug  the  later  years  of  fecundity,  between  thirty^ 
five  and  forty-five.  When  the  diseane  occurs  in  infancy,  it  is  known  as 
cretinLani,  which  nia}'  be  congenital,  prim&ryi  sporadic,  or  endemic-  Tlie 
prediGpoamg  and  oxcitiug  causes  of  the  disease  are  unknown.  The  an' 
ceatry  of  Buch  patieats  often  shows  tonaiderable  neuropathy,  but  rarely 
aimUar  disease.  Oooasionally  the  diBeaae  has  followed  in  the  wake  of 
Graves'  disease.  . 

The  diaeEise  ia  of  variable  intensity  dependiDg  upon  tbe  degree  of 
thyroidal  fibroais.  In  all  cases  it  ia  usually  of  slow  onset  and  grndual 
development.  The  skin  becomes  thick  and  dry,  and  ia  the  B^iaC  of  re- 
sistant a?^dema.  This  oedema  ia  noat  conspicuous  in  the  face  and  hands 
of  which  it  causes  conapiouous  and  profound  deformity.  The  eyes  are 
half-closed  and  expresaionleBST  the  cheeks  and  lipa  are  enjarged,  thick- 
ened, and  Homewh&t  pendulous.  The  face  has  a  full-moon  appearand 
lighted  up  by  a  bluiah-piuk  area  or  conglomerate  points  over  each 
malar  praccsa.  The  nose  ia  thickened  and  has  a  stunted  appearance. 
The  hair  of  the  head  and  face  has  a  lifeless  appearance,  and  soon  falls 
uniformly  or  in  patches-  The  gums  are  turgesceat,  of  bluish  color,  and 
blefd  fussily-  The  lingers  anrl  hauda  become  swollen  and  devoid  of  nim- 
bkueaa  and  dejtterity.  Tbe  naila  become  bruised  and  brittloand  oram- 
bling>  Such  patients  are  alow  and  delibeTate  in  all  their  moTementoj 
mentation  ia  very  aluRgish,  and  the  sufferers  betray  very  Jittle  latereat  in 
themselves  or  their  environment.  The  pulse  is  weak  and  slow,  the  tem* 
peratitre  Bonifwhat  aubnOTmalf  and  the  ^Htieat  complains  of  feeling  cold^ 
The  aecretioufl  and  excretions  of  the  body,  particularly  tbe  perspiration 
and  uriae,  are  very  much  diminished-  The  latter  often  contains  olbumio 
and  hyaline  casts.  Oocasionally  the  psychical  disturbance  aasnmea  tbe 
form  of  delirium,  but  usually  it  ia  manifest  as  deioentia.  Chapman  of 
London  has  reoeutly  called  attention  to  what  he  believea  to  I «  an  early 


THE   TREATUETiT  OF  MTX<EDEUA, 


fioe 


dJagi;oetio  sign  in  &ijxcedem&,  Tbts  (>ca^Bists  of  &  *'  certain  eloppinesa  of 
tiid  coDjuDGlivsa  best  observed  by  pushing  up  tbe  lover  eyelid  at  the  outer 
ugle  of  the  eye,  caused  by  the  presence  of  mucin/^  ^Vb^u  this  c^iiidi' 
tion  is  fijuud,  the  urino  being  of  normal  specific  gravity  and  devoid  of 
■Ibonkiik,  and  th^  patient  is  ^ucmic,  niyiocdema  should  be  suspected. 
Tho  oouraa  of  the  rliaease  is  slow  and  liable  to  frequent  tetnissiocfi.  Un- 
treated it  leada  V>  the  deyelopment  of  such  profouDd  depreaaioa  of  vital- 
ity and  deterioration  of  nutritioa  that  the  patient  sopciunba  trt  gener&l 
sstbenia  and  exhaufition,  or  to  eome  acute  intercurFeat  disease  which 
under  other  circumstances  vould  be  considered  trivial, 

Tttatment — The  tre&tment  of  myxGcdema  waa  for  a  long  time  lUMi 
QAfuooeesful,  although  a  fev  eases  vera  recorded  in  which  improremefit 
cmmed  under  general  tonic  and  eliminative  treatmeut.  Cases  of  myxoe- 
dema  that  are  due  to  syphilis  and  ai^tinomycosis  reicorer  when  these  dis- 
maea  are  enoeaufully  treated.  Not  until  it  was  abown  experimeu  tally 
that  myxcEdema  followed  extirpatioa  of  the  thyroid  gland,  and  that  Buch 
mvacedeinatoua  couditioD  disappeared  after  thyroid  implantation^  did  the 
real  tieatment  of  this  disease,  whicb  forma  sneh  an  important  eha^Aer  ia 
tiiB  hisGory  of  experimental  tberapentics,  begin.  It  was  soon  after  shown 
by  nnmeitHU  invcetagators  that  the  ed^Dtial  substance  of  the  thyroid  gland 
which  aoto  caratiTely  could  be  inboduced  into  the  body  by  grafting,  bj 
snbentaaeoos  injection  of  an  extract  of  the  thyroid,  through  feedii>g  of  tike 
raw  thyroid,  tliroagh  the  intmctioQ  of  a  thyroid  lanolin  cream,  and  by 
the  adminiatntiOD  of  the  dried  or  powdered  gland  in  the  shape  of  cap- 
RulasT  tablets,  or  pills.  Tbn  latter  has  come  to  be  the  way  in  which  1^ 
thyroid  extract  is  now  almoat  nnivci^ally  administered,  but  the  raw  glaod 
may  begiTen — fromone-eighthtoone-half  of  aaheep's  thyroid  daily.  Tlie 
tablets  are  manufactured  by  many  wholesale  chemists,  both  here  and 
ftbroadr  and  the  preparationa  of  one  seem  to  be  aa  useful  as  those  of  another. 
The  average  doae  to  begin  with  is  from  two  to  fire  giaina  of  the  deaiocatcd 
powder,  \he  dose  being  gradoally  increased  imtil  some  snch  ma&iCcsla- 
tiox>9  as  ocnpital  headache,  artioariar  aaiitMa,  Toauting,  dianhoa,  dc^ 
fibow  that  hyp«rtKjH»dbaAion  haabegan.  The  treatment  sboold  tbett  be 
tntefrtipted  for  wwal  day^  daringwhidL  time  the  patient  sbcnid  be  kept 
in  bed  under  vipportire  treatnosL  Whvi  math  symptoms  disappear,  the 
adnuDistntian  of  the  thyroid  extract  should  be  resoned.  After  froca 
foDT  to  tts^  weeks  of  treatment  the  beneficial  effeete  will  becin  tn  man- 
ifest thema^ree  by  disappearam^  of  the  sobjeetiTe  and  objeectre  ujx- 
ffidenkatoDa  wjm^notoB,  It  is  espeeialljin  advmneed  caass  that  tba  begm- 
ning  treatawnk  most  be  carried  oat  wHh  gnat  **■■'**■,  for  the  orgasBe 
eufeeblemeot  of  the  heait  which  almoet  always  exists  d«r»  not  tolerate 
mnch  etreee  being  pnt  npcm  it.  The  patient  sboald  be  kept  in  bed  for 
the  first  few  days  or  weeks,  and  if  symptouss  of  heart  failim  occur  th«y 
flboald  be  combated  with  MJ^aliita  and  digitalia.     THe  general  can 


610 


TKKATtfENT  07  DlSfiASBS  OF  TBS  NERVOUS  8T8TKM. 


and  trentrnfrnt  at  the  patiect  should  b«  moflt  rigoiously  carried  out  bj 
the  uae  of  a  EUtritious  diet,  ronaiBting  l&rgely  of  milk,  green  regetablw, 
and  easily  dig^^^teii  fats.  Tbe  uitrogenoua  aubstanc^a  in  tbe  aLape  of 
lean  msatpa  should  be  decreased-  The  p&tdent  should  bd  iDstructdd  to 
huabttnd  the  ener^ea  while  the  vital  forces  arc  stimulated  by  the  ad- 
ministration of  iron  and  stryohnine  iQ  small  quant:itieB.  Un fortunately j 
Lhg  thyroid  treatment  of  nijxoedcina  is  not  am-h  ac  unmitigated  stiecesa 
as  the  published  reports  in  tliB  beginning  would  seem  toindioale-  When 
tbe  adm  mist  ration  of  the  extract  is  stopped^  symptouia  of  the  disease  are 
sure  to  recur  sooner  or  later.  Diaappe&iaiioe  of  tbe  symptoma  of  myicr- 
dcma  indicates  tbat  the  first  Btage  iu  the  treatment  of  tba  die^aAO  Lu 
been  reached.  It  usually  sudir^ea  to  give  it  now  in  much  smaller  doses 
than  at  first,  but  tbe  dose  must  be  deteruniied  In  t^ftch  individual.  Thp 
second  aud  iiuporbaut  part  of  tba  treatment  which  should  be  impressed 
upon  tho  patient  is  the  daily  administration  of  a  doEC  of  thyicrid  equal  to 
tbe  daily  output  of  a  normal  gland.  It  eboutd  be  a  part  of  the  diet  juai 
tbe  aame  as  bread  is. 

Recently,  the  lodina-bearing  aubatance  of  the  thyroid  gland  knovu  at 
iodoi:hyrin  baa  been  ri^yfiuiueuded  Lj  plaoe  of  the  thyroid  eatract-  It  is 
claimed  that  a  grain  of  the  powder  is  about  equal  to  one  grain  of  the 
gland.  It  is  admiuiatered  in  from  fiv-e-  to  fifteen^grain  doaefi,  sometimefl 
even  in  twice  this  quantity,  and  the  results  so  far  obtained  warrant  its 
unequivocal  reoonuoeDdation.  So  far,  at  least,  it  would  seem  that  dii- 
agreeable  and  untoward  results  are  less  liable  to  follow  its  adminiatTation 
than  that  of  thyroid  eztraot.  It  is  an  import&ut  additiou  to  the  than- 
pcutics  of  this  disease,  as  it  oEers  a  substaace  that  can  be  given  alter- 
nately vith  thyroid  cEtract,  and  with  profipeots  of  euceess. 

The  treatment  of  cretinism  ia  not  materially  different  from  that  of 
myifedema.  The  earlier  the  condition  is  discovered  and  treated  the 
greater  are  tlie  prospects  of  care.  It  should  not  be  forgotten  that  good 
resitlts  are  often  had  in  the  treatment  of  cretlnisiD  of  long  standing — eighl 
to  ten  years.  In  such  ca^ea  the  body  is  more  improved  than  the  mind. 
It  is  only  in  eases  in  which  tbe  treatmeat  is  started  early  that  normal 
mental  development  can  be  expeeted.  In  starting  the  treatment  grad' 
ually  increasing  dows  of  tbe  extrar^t  should  be  given  uutil  the  symptoms 
disappear.  lb  is  of  thi^  greatest  importance  that  tonifying  measures  be 
administered  aimultaueously*  As  in  adults  the  treatment  must  be  con- 
tinued aa  long  as  the  patient  lives.  The  permanent  dose  must  be  deter- 
mined in  eaoh  case. 


CHAPTER  XXXVT, 


I 


THE  tbkat?o:nt  of  symmetrical  gang  reke— neuropathic 

flANQRENOnS  TROPHONEUROSIS  (RAVKAUD'B  DISEASE), 

Toe  symptom  complex  to  which  the  oame  Rajnaud'a  diae&M  ia  giTea 

oooaiALa  iu  the  occurrence  of  VASomotor  pUeiioiikend  in   the  extremities, 
uuallj  BycTLmetrical,  vatyiogfrom  subjeotiro  coldness  and  object  ire  pallor 
ud  Uvldi^,  through  local  asphyxia,  and  ulceration,  up  to  complete  jau- 
Sr^ne.     The  disease  occura  neatly  twice   as  frequently  id   males   aa  in 
tauales.     The  majority  of  ca^a  occur  b«tweeu   the  agea  of  twentj^  aud 
tasty.     It  is  of  rare  occurreuce  la  earij  childhood,  and  it  ia  never  encouu- 
(«red  durmg  late  genilitj'      It  ia  sometimes   mot  iu  patients  who  hai^e 
other  nervous  disaaaesi  such  as  hystoria,  epilepsy^  tabea,  mjelitia,  fiyriu* 
gOmyeLia,   neurasthenia,  and  acute   mania.      Its  existeuco  ia   somotimeB 
UMcialed  with  urticaria,  aclerodeima,  erythromelalgia,  and  other  d«rm&- 
toneurosea,      A  neuropathic  diathesis  is  to  be  mado  out  in  Jl  large  proportion 
of  uaaes-      The  patienta  are  not  infrequently  w«ak  and  anieaiic,  the  result 
of  inherited  conditioaSi  or  of  some  toxic  agency,  exposure  bo  cohl  or  inter- 
enrrcut;  diseases.     The  excitiug  caiisea  so  far  as  they  have  been  determined 
are  fright,  fii>at-hite,  profound  f^itigue,  uud  trauma,  especlaEly  to  the  sym- 
pathetic system,  as  from  blows  or  iujuxiea  over  the  abdomiual  plexuses. 

Symptoms.^The  symptoms  of  the  disease  develop  paroxysmally,  after 
fright,  ahock,  and  injury,  or  without  attributable  cause  and  show  them- 
selves as  paleness  and  glossiness  of  the  fiugers  or  toes,  rarely  the  noee 
and  the  ears.  With  this  there  is  a  seuaatioQ  of  tingling  and  twitchiji^ 
and  dimiuutiou  of  dexterity  aud  sensibility.  After  a  variable  duratiou, 
Uicse  phenomcua  may  disappear,  or  the  porta  may  bocome  exsanguinated, 
waxy,  and  colorless,  forming  the  so-called  deikd  fingers.  The  skin  may 
become  shrivelled  and  puckered,  aud  the  members  themselves  quite  use- 
IcM.  This  stage,  after  lasting  from  a  few  minutes  to  several  hours,  may 
pass  away  without  leaving  a  trat:e,  or  it  may  [jass  iattt  the  second  atage, 
that  of  iocaX  asphyxia,  in  which  the  parte  assume  a  bluish'hlack  appear- 
ance as  if  they  had  been  dipped  in  iuk.  The  epidermis  over  the  affected 
parts  may  show  small  blisters  which  often  contain  a  quantity  of  black- 
ish  blood.  Aftfir  from  cne  to  several  days^  the  skin  over  the  black 
portion  of  the  affected  eitremitiea  separates  from  the  adjacent  parts, 
tho  derma  becomes  trxtenaively  destroyed,  and  saiaJI  ulcers  can  be  seen 
eroding  the  subcutaneous  tissue,  while  the  terminal  phalanges  become 
fihrivelled  and  mummied.      If  the  gangrenous  process  is  limited  U>  the 


612 


TREATMENT   OF  D13BA3B8  Of  TEK  NKBV0TT3  8T3TEU. 


formatiDii  of  small  necrotic  areaBr  tliese  haal  bIowI}-  aft«r  the  tittadi 
has  parsed  off,  leariug  sioall  st^ara.  If  tlie  gangTt>noufl  process  is  tnon 
stivet'P.  the  ends  of  tlis  ftitremititiH  becume  dry  bdJ  shrivelled  aud  a  lino 
of  demarcation  formo  io  the  heiilthy  tissue  from  whicb  a  reftotive  procen 
IB  eeb  up,  which  separatee  the  di'-od  part.  The  process  of  separation  and 
cicatrization  it'  left  unaided  frequently  extends  over  many  moothe.  In 
the  majoritj  of  cases,  however,  the  gangrene  does  rot  go  on  to  this  ei' 
tent,  at  leaat  Lot  until  after  tbe  [jatieiiL  ha8  eiperienced  many  att^^lcB. 
Very  rarely  are  the  cheeltB,  Upa,  ton^e,  penis,  Tulra^  and  nates  the 
Beat  of  trophic  changes. 

The  eonstitutioual  symptoms  are  very  rarmble.  In  th«  b^tnning 
thftte  In  oftentimes  a  feeling  of  chilliness^  nansea,  anorexia,  and  great 
proBtration,  The  diseaao  is  au  afebrile  one,  the  surfaire  temperamre  be- 
ing often  subnunnal.  Intermittent  hteniogloUnuria  ts  rather  a  commoii 
symptom^  Mental  symptoma,  sueli  as  profound  depresaiou,  traQsient 
attacks  at  aphasia,  eonTulsions,  and  unoonsoiousneBB,  oooasiouaJly  oocur, 
They  may  be  attributed  to  regional  iseha^mia  of  tba  brain,  resulting*  froui 
ipaam  of  the  aiteiips.  The  first  and  second  stages  uanatly  last  from  a 
few  hours  to  several  days.  The  dnratioii  of  the  third  stage  depends  upon 
the  severity  of  the  process,  and  itsreflpoosiTenees  to  treatment.  The  dis< 
ease  is  very  liable  to  relapse,  and  succeeding  attacks  are  apt  to  be  sevore. 
In  children,  the  disease  runs  a  very  rapid  course  and  :&equently  there  u 
nothing  paroxysmal  about  the  attack.  The  child  may  die  within  a  few 
days  after  the  symptoms  first  hhow  tbems^lres.  On  account  of  the 
great  dei>ravity  of  nutrition  from  which  most  of  these  patients  Miffar, 
they  ai^  liable  to  the  development  of  intercurrent  infeotioua  diseases,  to 
whi<:h  they  miecnmb. 

Treatment.^ The  most  important  factors  in  the  treatment  of  an  at- 
taek  are  to  relieve  the  pJLtn  and  to  fnvor  reatoration  of  the  circulation  la 
the  affected  ejctromit}',  If  the  pain  is  very  severe,  morphine  should  be 
given  internally.  It  should  never  be  injected  into  the  seat  of  the  pain, 
for  irritation  of  these  parts  increasoe  the  liability  to  gangrene,  and  its 
intensity  if  it  is  already  present.  The  affected  parts  should  be  wrapped 
in  cotbjD  wool,  and  placed  in  a  position  that  favors  the  vascular  circula- 
tion of  the  parts.  At  the  same  time  dry  bent  should  1«  applieil  over  the 
abdomen  ajid  otbt  the  affected  extremitjH  It  is  thought  that  nitioglycerin 
or  nitrite  of  amyl  adminielered  internally  has  a  benelioial  effect  to  relax 
the  contraction  of  the  blood-veseels  and  to  favor  restoration  of  the  circula- 
tion. When  the  patient  is  seen  early,  ih^ae  medicines  should  be  given, 
and  at  the  same  time  an  attempt  should  be  made  to  stirimlate  the  cardio' 
vascular  apparatus  by  the  administration  of  Htrytihnine,  Blootrini^  has 
been  used  eitensively,  but  its  therapeutic  value  is  very  small.  It  la  rec- 
ommended that  the  positive  pole  be  applied  over  the  side  of  the  ne^^k  and 
the  negative  pole  in  a  basin  of  warm  salt  water,  in  whioh  the  extremities 


TBB  raMATMKST  OT  STKXKTUCAL  OAJ^QRENK.  Al^t 

m  immoned  in  toin,  «ikil4»  btmi  Gtia  to  fifteen  cells  gvuenbe  tax  «i1<totHfi 
Qunnt.  In  die  milder  manifeotktioiu  of  the  diaeftM^  light  ihmmi^  w 
teidedlj  bmefieiiL  Ko  mttempt  slioiild  be  m«de  to  ujte  i1^  hnv«VM, 
■fter  the  diaeaae  has  pwued  the  aeoocd  stage.  When  guigreii«  oc^orr^  it 
ihonld  be  treated  ftoootding  to  the  prindplea  of  modem  siiTfECry. 

Hoie  imporbrnt  than  the  symptomatic  treatment  ia  the  n?giiUUon  of 
tibe  patient's  life^  and  the  adoptioo  of  measurea  to  iuoreaae  his  nutriUon 
ad  strength.  If  one  is  saccessful  in  doing  this^  the  patient  may  tol«rate 
the  «2(nting  oaoMs  of  an  attack,  such  as  exposure  to  cold,  nienUl  Ahonk, 
ind  tlw  like,  withootanj  bad  results.  The  neuropathio  diathosis  aod 
the  othef  nerroufl  diseases  with  which  Raynaud^s  disease  it  associAtotl^ 
ihould  be  peraistentlj  oombated.  The  patient  should  be  tnat.r\irted  to 
fire  a  lif a  of  aimplioity,  tending  toward  bodily  and  mental  quietude  ^  to 
like  r«^ar  and  syHtematic  exercise,  and  to  avoid  fatigue,  deprensionr 
and  other  occonencee  leading  to  exhaustion.  When  it  is  imi)oaiib1o  to 
do  this,  the  tonifying  effects  of  hydrotherapy,  gymnastics,  massage,  and 
■0  forth,  should  be  sought,  while  the  general  health  ahould  be  supported 
by  the  adminiatration  of  restoratiTes  and  alteratives,  attention  to  tho 
dietary  and  the  general  hygiene. 
38 


CHAPTER  XXXVn. 


TUB  TREATMENT  OF  ArfQIONBUHOTlO  (EDEMA, 

A^iOTONEuaoTio  oKleuia  U  a  disease  characterized  by  the  appearajitc 
of  ciroumscribed  swellings  on  diCEereut  parts  of  tba  body,  particularly  Ibe 
face,  throat,  and  extremities,  usually  without  apparaut  cause  or  premooi- 
tion,  trausitoiy  in  duiatioEi,  aud  inju'infiaiuitiatory  iu  nature.  The  most 
important  factors  iu  ila  etiology  are  an  unstable  nervous  system,  maci- 
festins  itoelf  as  hysteria,  ueuTasthema^  or  in  direct  heieditaiy  transinisaum 
of  the  diaeaae,  and  overwork,  exhaustion,  and  toxie  intluenoes,  sueh  u 
thoaa  of  tobaooo,  tea,  and  infectiouH  diaeaaes.  It  ocoura  more  comTnouly 
in  early  adult  life  than  later,  but  many  cases  have  been  reportcfl  in  cbi]- 
dreu  and  esp^^iolly  thojie  riotinia  of  the  uutritional  disorder  known  u 
nbohitia.  Among  the  exciting  causes  are  eipoaure  to  cold,  g-astric  irn- 
tation,  trauma,  fright,  and  the  ingestion  of  alcohol.  The  exciting  oausea 
that  produce  urticaria  produce  ftngioueurotlc  <eilema.  It  h  highly  prob- 
able that  the  latter  differs  from  the  former  only  in  its  ^eater  intensity. 

The  uianifeatations  of  the  dlaeaae,  conAiBtuig  of  circnmaarilted  svfrU' 
ing,  aasociated  with  a  local  feeling  of  unwieldit^esa  and  tenaion  in  the 
part,  usually  present  themeelvee  without  warning  on  the  face^  lips, 
tongue,  pharynx,  forehead,  buttooks,  or  genital  organs  ^  in  eonie  in- 
staikcifi3  the  patient  oomplatna  a  short  time  before  the  appearance  of  the 
swelling  of  a  feeling  of  depresiBion  and  exhaustion,  aaaoeiatped  with  dia- 
treas  referable  to  the  tongue.  The  swelling  reaches  its  full  development 
iu  from  one  to  three  or  four  hours.  It  does  not  pit  on  pressure.  In  the 
begiuning  it  has  very  close  resemblance  to  the  swelling  produced  by  a 
mosquito  bite ;  the  color  ia  whitiah,  with  a  diatinct  rose  tinge,  but  in  sotn* 
ciiaes  tha  skiu  over  the  awelling  la  of  a  dull  roseate  hue,  with  a  whitish 
shading  orer  the  centre.  It  l&ata  from  a  few  hours  to  several  days.  It 
may  ot^aui  in  separate  purts  of  tha  body  flimultaneously,  but  frequently 
its  disappeaTauce  froju  one  Locality  ts  tJie  signal  for  its  appearance  in 
another.  As  a  rule  it  does  not  ahow  itself  iu  more  than  two  or  three 
loralities  at  one  visitation.  The  subjective  Befisatii>i]«  accompanying  th* 
swelling  are  tliose  of  e^haustiou,  providing  the  swelling  does  not  encroach 
apon  an  organ  enoh  ae  the  eye,  the  stomach,  penis,  etc.,  or  does  not 
block  up  the  conductivity  cf  a  paasag*?,  auch  as  the  motith,  pharyni,  lar- 
ynx, and  iuteatinea.  It  is  highly  probable  that  smiilar  o*dema  may  oocur 
in  the  suhstancQ  of  the  brain  or  in  the  pia  and  cause  symptoms  in  keeping 
with  its  localization.      When  the  mucous  membrane  of  any  of  the  pas- 


THE    TBEATUE^-T   OF   A^OIQVKUBOTIC    a:l>&MA, 


515 


I 


s^es,  esp«ciaUj  of  tho  laijrtx,  io  the  seat  of  svolliQe,  tLe  ajmptomB  maj 
be  not  only  distressing  but  inimical  to  Vile.  The  gaatro-iateatiQul  symp- 
toms whi(*b  occur  in  from  oae*third  to  one-balf  tbd  ca^ea  coDBistLog  of  & 
f#0liDg  of  veigbt  Id  tte  epigastrium,  caiiHea,  Tumitmg,  diarrbu^a,  and 
Mveni  colicky  pain,  are  undoubtedly  aasociatpd  with  an  cedematoua  state 
of  tKe  gaatTO-inteatinal  muccrua  membr&ue.  Tbo  attacks  occur  at  ';'ftriable 
periods,  ftud  in  the  interval  the  patient  may  be  in  c^atomuy  health, 

TtMtment, — Unlees  tbe  (edQm&  appears  in  the  laiynx  or  pbaryiuc,  it 
Hoea  not  call  for  any  particular  treatment  at  the  time  of  the  atuckj 
Although  tbe  Hnelliuga  will  duuippear  more  rapidly  if  the  patient  is  kept 
at  reet  in  an  equable  temperature  and  if  diy  beat  ia  applied  to  the  oedema- 
toos  area^  Compreaaiou  by  meana  of  a  flannel  or  an  elastic  bandage  ap- 
plied lightly  sometimes  seema  to  facilitate  the  disappeiranoe  of  the  svell- 
ing-  CEdema  of  the  epiglottic  and  laryni  should  be  treated  by  local 
applicadooa  of  warmth  and  scariScation,  while  the  physician  holds  him- 
Mlf  in  leadmesB  to  perform  tracheotomy.  The  indicationa  for  general 
treatment  are  to  discover,  removet  and  mitigate  the  cauaea  and  to  lonify 
the  patient's  neurovafieular  system.  Little  progress  \nll  be  made  in 
prdnenting  reourrenee  of  the  manifestations  until  the  cause  has  been  dis- 
eoTHred.  Tonics,  guch  as  strychnine  and  iron,  invigorating  batha^  par* 
ticalarly  those  beneficial  in  hyAteiia  and  neurasthenia,  and  exerciBo  and 
lounge,  are  the  most  important  uieafiures  in  tho  treatmeot  of  this  dioeaoe. 
The  dietary  aud  the  digestiTo  capj^Lty  of  ttc  patient  should  bo  carefuUy 
inquired  into,  and  derangements  of  them  corrected.  SpeciaJ  indications} 
■neb  BB  the  occurrence  of  excess  of  uric  scid,  intestinal  putrefactioD|  and 
gouty  manifestations,  require  specific  medicatioa. 


IlTTEBMirTENr   SwRtLIXO    OF  THK   Kl<lX. 


rP  Under  the  name  intermittent  swelling  of  the  knee,  or  hydrops  S^nu 
intermittens,  a  condition  of  accumulation  of  fluid  within  the  knee-joint 
(very  rarely  are  other  joints  affected),  occurring  wtthoul;  apparent  cause 
in  otherwise  healthy  indiTidnab,  has  been  described.  The  Bwelling  of 
the  joint  occurs  periodically,  uaually  with  fortnight  intervals,  and  lasts 
Crom  one  to  several  days.  It  is  not  attended  with  any  manifestations  of 
in^ammation,  nor  does  it  give  discomfort  to  the  patient  except  from  tbe 
meehjuiieal  effects.  It  Is  usually  considered  a  vasomotor  neurosis  very 
simUar  to  aogioueurotio  cedcma.  Tlie  etiological  factors  that  have  been 
spc^ea  of  are  not  unlike  those  that  are  believed  to  be  caijsativo  of  the  lat- 
ter affection.  Occasionally  it  alternates  with  some  of  the  ancillary  phe- 
nomena of  Basedow's  disease,  such  as  suffusion  of  the  face,  polyuria,  hy- 
pefidrosis,  and  urticaria. 

The  affection  is  supremely  unamenable  to  trt^tmeut.  Antirhetimatica 
appear  to  be  uselesa^  It  m&j  recover  spontaneously,  or  after  the  nso  of 
massage^  electiioity,  qQinine^  areenic,  and  general  tonio  therapy. 


CHAPTER  XXXVm, 


TIIB  TJtEATMBNT  OF  ACBOMEOALT, 


Acno>fR4;ALT  19  a  chrooio  diseiiBe  cbaraoterized  bj  great  inoreaoe  <rl 
Uie  extramittee  of  the  bodi^,  the  h^dB,  the  feet,  the  fuse  and  the  he&d, 
due  to  An  in^reaee  in  the  volnme  of  all  the  tiasuea,  kard  mid  8oft^  The 
disease  occuTH  in  evt^ry  race  atid  alTecta  nmlos  and  females  about  eqnatlj'- 
It  occurs  during  early  adult  lUtr,  but  in  must  frequently  diacoverod  be- 
tween the  agca  of  twenty  and  forty.  Congenital  cases  liavo  been  re- 
(K>rded,  Sohwoner  has  recently  described  the  o^^c-orreace  of  the  disease 
in  motbet  and  daughter.  The  cauaation  of  the  disease  is  imkiiown.  It 
oi^eurs  OGOBsionally  in  j^tienta  who  h^ve  syringoicyelia,  t&l>es,  hyper- 
ttcphic  osbeo-artliropELtliy,  gigantism,  and  the  degenerative  psydioses. 
Among  the  eitoi ting  cauacj^of  the  diaoaae  may  be  mentioDed  worry  aaij 
depreasioD,  fright,  exposure  to  cold|  injuries,  alcoholism,  rheumatiam, 
and  gout  It  is  generally  believed  that  acromegaly  is  ifi  some  way  de- 
pendent upon  lasioa  of  the  pituitary  gland,  aa  the  tissuea  of  this  organ 
have  lieeti  fouTul  iliHt^OKed  or  the  seat  of  new-growth  in  almost  every  cue 
that  lias  come  to  autopsy, 

Symptoms. — The  eymptoms  of  the  disease  are  of  insidious  onflet,  and 
freqn<^ntly  are  recognized  first  by  the  physmian  who  sees  the  patient  acci- 
dentally, or  for  some  trivial  complaint  The  patient  may  have  remarked 
that  the  eTtremitiBs  b;ive^nidually  tteen  getting  larger,  and  that  be  is  not 
so  alert  mentally  and  physically  as  he  was  formerly.  Headache  of  great 
severity  and  un amenability  to  medication  is  an  early  symptom  in  many 
cases.  These,  associated  with  general  neuraetheniij  symptoms,  consti- 
tute the  complaint  in  the  beginning,  When  the  patient  is  eiamtnedr  it 
la  found  that  he  has  a  peculiar  poetore,  both  in  atauding  and  waJking,  tbe 
neck  is  Iwnt  forward,  while  tho  bead  is  tilted  slightly  backward,  in  orrier 
to  bring  the  eyes  up  to  a  lerel ;  the  shoulders  are  rounded  and  stooping, 
the  chest  is  bvilging,  and  the  gait  is  unelastic  and  heavy.  The  patient's 
posture  is  acoentuatcd  by  the  prognathoLjs,  heavy,  projecting  lower  jaw. 
Tbe  lips  are  large,  the  month  ts  expressionless,  the  naso-labial  creases  are 
deepened  to  fiaaureH.  The  nose  is  enlarged,  proboscis'likef  freqaeDtly 
slightly  pigiaeritetl,  anil  with  wide  nasal  aperture;  the  eyea  are  deeply 
set,  and  overhung  by  thiakeuedaupraorbital  arches  studded  with  ooarae  and 
thickened  eyebrows.  The  lower  part  of  the  forehead  ia  bulging,  and  this 
gives  a  retreating  appearance  to  the  upper  part.     The  malar  bon^  and 


d 


THa  TBBATMCKT  OF  ACKOMaOALY, 


517 


zygoma  atand  out  prominetitly ;  the  oheeka  are  flattened-  the  ears  are 
enlai'ged;  thti  hair  is  coarse  aud  drj,  auil  the  skhi  fraiiupntly  [ligiueriled. 
The  entire  facuj  exprebsioa  i&  dull  &ud  uuauimated^  a  j^dti^'Ut,  gLievLug 
sort  of  l(X]k.  The  hands  and  feet  axe  enlarged,  but  there  is  no  deformity, 
that  iSf  the  enlargGinent  15  eymiiietrieal  and  all  the  tissuea  partioipate  in 
the  hypertrophy.  The  spinal  column  shows  a  cerrico-dorsal  kyphoaia, 
which,  with  the  anlar^ment  of  the  tltorax,  gives  the  patient  a.  hump  in 
fitjnt  and  behind-  The  eitpernal  genital  organs  are  frei^uently  hypertto- 
phied  iu  the  female,  while  the  internal  genitala  of  the  female  and  the 
.genital  organa  of  the  male  eltq  uRualJj  atrophied*  Impotence  of  tlie 
male  aud  ceaeatiou  of  menstruation  in  the  female  is  the  rule  to  vhieh 
there  are  exceptions.  The  Hpecisil  aenGea^  save  That  of  eighty  are  intact. 
The  iuipairmen^  of  sight  aud  the  eucraachment  of  the  visual  fields,  uao- 
ally  bttemporul  hemianopaLa,  are  proportionate  to  pressure  made  on  the 
optio  chiasm  by  the  pitvdtary  gland.  The  visceral  organs  are  as  a  rule 
normal.  The  voioo  is  profoundly  altered,  iow-pitehed,  resonant,  vi^Jumi- 
nous^  and  of  a  peculiarly  disagreeable  intonation.  Speech  is  alow,  gut* 
tural,  embarrassed  J  the  leflult  aeeminglj  of  uuwieldinesa  of  the  enlarged 
tongue  and  other  ti^aues  of  articulation.  The  urine  is  usvially  increased 
in  quantity,  and  bometimes  onntaina  sugar  or  albumin.  The  patients  is 
often  irritable,  dcpreaeed,  morbidly  saoBitive,  and  introepeotirei  foigetfiJ 
and  autipathio  to  mental  indulgence.  The  courae  of  the  disease  ia  pro- 
gressive, aud  iavuriably  ends  in  death  from  exhaustion,  suicide,  or  iu- 
terourreut  disease. 

Treatment -"The  treatment  is  entirely  symptomatic,  as  the  etiology 
and  pjithology  of  tho  disease  are  comparatLvely  ui^known.  Heaauns 
Abould  be  adopted  to  delay  the  less  of  strength  and  to  invigorate  the  pa- 
tient. These  are  massage,  hydrotherapy,  gymnasticflj  and,  if  pfissible, 
some  en^j  and  ab^orliiitg  occupation.  Although  these  may  have  little 
efficacy  iu  delaying  the  course  of  the  disease,  tliey  inspire  hope  and  con- 
fidence while  tending  to  inoreaflQ  the  patient's  strength-  When  poasible, 
the  mode  of  life  and  the  dietary  ahould  be  carefully  regulated,  especially 
if  on  examination  of  the  excreta  some  drain^  such  a^  albuminuria,  glyco- 
suria, and  iticompletely  digested  food  ai-e  found.  One  word  of  Taming 
maybesaid  iu  referenceto  the  dietetic  treatment  of  diabetes  occurring  with 
acromegaly.  Acromegalics  do  net  tolerate  deprivation  of  the  catorif  acients, 
as  do  other  diabetica.  Bulimia  aud  constipation  Gbonld  hoth  be  guarded 
against.  The  Jatler  should  be  counteracted  by  the  addition  of  coarse 
vegetables  to  tbe  dietary  and  by  the  administration  of  high  t^nemala  of 
oottou-seed  oil.  The  headache,  neuralgia  of  the  branrhfs  of  the  tri- 
facial nerve,  and  pains  iu  the  eitremities  are  beat  combated  by  tbe  use 
of  phenacetin,  antikamnia,  and  other  moderu  analgesics^  H^ad.n'he  that 
has  proven  rebellious  to  this  treatment  has  been  benefited  by  trephin- 
ing,    Extract  of  thyroid  gland  and  of  the  piiuitary  glaad  have  been 


E18 


TRKATMB>T  OF  BISEABES  OF  THB  J^ERVOUS  SYSTttM 


employed  empiiically,  and  many  writers  have  reported  b«Defioial  r«sulu, 
especially  from  the  use  of  tho  former.  Thyroid  extract  He^tna  to  have  the 
poivtir  to  TKiluca  obeaitj,  and  hy  bo  doing  it  may  seem  U*  eien'ise  a  beneS 
cent  action  on  the  diaeaae.  This  ia  iUusoiyt  howerer,  andita  admiiufitra- 
tion  may  add  to  the  muscular  'weaknesa-  Based  upon  thd  ground  thftt 
fuDcticual  destruction  of  tbe  pituitary  body  ia  the  cause  of  aoromogaly 
many  cliniciaua  have  employed  extracts  of  the  pitnilary  body  in  the  treat- 
ment of  tlia  diHuaae.  It  wotild  seem  to  bu  tha  conaensuB  of  opinion  that 
suth  treatment  has  failed  to  prodaue  beneBcial  reaulta.  Further  e&peti- 
mentation  iu  thid  direotion  is,  however,  neceaaary,  Todiue  has  btcu  used , 
Tery  extenaivi^ly,  both  externally  in  the  shapo  of  the  ointment,  and  inter- 
nally in  tba  aUape  of  iodide  of  potassium.  OccnaioDaUy  the  iodine  salte 
and  araeiuo  have  atfemed  to  \t&  of  much  beiieftt  in  stayieg  tha  pro^r^ss  of 
the  diseaae,  but  It  is  not  improbable  tbat  such  amelioratiou  baa  been  co- 
incident with  one  of  the  lemiasiona  natural  to  the  dtseaso-  Pv^Qthe^ia 
of  the  extremities,  hypendroais,  sleep lesaneea,  and  mental  deprtasion 
oftcntimea  oaEl  for  bjiecLfic  medication^  but  the  treatment  under  these  cii- 
cnmstances  is  not  unlike  that  appropriate  for  sunh  aymptoms  occurring 
with  other  diaeaaea. 


CHAPTER  XXXI X. 


Tax  TBBJLT5IIXT  OF  SCLERuDinaiA. 


ScLEhoDaKMA  ift  &  tuopboneviaaa  nmltiuf  in  iiKhumlirm  nn4  Mmyly 
of  the  akin  ukd  fttbentUbBou  tisKML  ClinkmLtjp  two  fOrm«  iM  dkithi* 
gnished,  tb9  diffoM  or  ajtamtfbnsal  rm^tj,  utd  th*  oiranunribtd  kikowA 
■9  moTph^-a,  ur  Addison's  keloid.  Pithcgenedoillj  th*  diaiMa  is  appftr* 
CDtlj-  Ik  caiAiieoQS  tnfiltr&tioii  wUch  givoa  rim  in  Uu^  btci&Dmg  to  avell* 
ing,  piftceded  and  accompuiied  bj  Tuomotor  diatarfauM«A|  «od  IftMr  by 
tfa^  absorption  of  tho  infiltnite^  ti^sn^  &nd  the  oomm*no<>  ^f  ft  vovlik^ 
atrophy,  Tha  etiology  cf  the  dU«4(se  is  iinknovrn^  It  oor^iirs  pr^pnnde 
>£]&gly  in  young  females,  and  eapeciallj  ia  those  who  have  bad  at  tcmifl 
more  or  XesA  recent  preceding  time  savh  infectious  disoaara  aa  prjaip«la% 
acarlatina,  pneutuoain,  malaria,  tuberculoais,  aud  tj-pbotd  f«T«r.  0|li<r' 
f&otora  whicb  seem  to  have  a  oauaal  rdlatioiiahip  are  «x]>osvLre  to  oo1d| 
injmyf  grief,  anxiety,  and  x^orty.  Th^  disease  ia  apt  to  o<^ur  m  neuro* 
pathio  indiridLialri,  &nd  occaalonallj  is  auperlmpos^d  upOQ  syrL]igi.itu)'elia| 
cbronio  myelitis,  and  Haynaud's  diaeafle. 

8ymptomB.^The  first  manifefitatiotia  of  the  diAea^e  arn  usimlty  looftlg 
consiating  of  a  feeling  of  stifTnesB  and  unwiddiiios^  m  tlio  piirta  iilTt^todt 
fframiratiop  then  reveals  different  ^^onditious  depending  upon  the  Btu|{« 
in  which  the  disease  is  ©uooTintered.  When  tlie  HcilonHlerninUmii  procnM 
baa  reached  its  height  tha  akin  ia  of  leatber-like  feel  aiid  consiatoi^cyt  lUid 
drawn  so  tightly  over  the  parts  thjvt  it  cauaes  iinmobiliziLtioiL  if  it  in  aLxmt 
a  joint,  or  atrophy  of  the  soft  and  hard  parts  over  the  oxtreTnitioSt  A.t- 
tetcpta  to  pinch  up  the  Bkin  or  to  pit  it  by  preflHura  iirct  iiot  HiMtioMfut, 
but  wh^n  the  fiuger  ia  drawn  rpit^kly  and  firmly  acrona  the  surraoo,  a 
wbitiab  line  with  a  pink  tnrder  reuaina*  If  thtt  fa<^e  la  aCTecttid^  tlio  fna< 
tnrea  ate  obliterated,  the  expression  beiug  that  of  a  death-iuask.  Wh^D 
the  skin  over  the  chest  is  involved,  the  latter  ia  flattened,  the  breuHtrt  pom- 
preased,  and  reapiratLon  often  impeded-  The  oeourrenoe  of  sclerorlemiA 
in  other  parts  of  the  body  produces  deformity  consonant  with  the  lliatioa 
and  muat^ular  atrophy  that  accompany  it.  The  oiruiimwTilied  variety 
of  scleroderma  preaeuta  itself  in  the  form  of  patchea,  btitids,  or  ntrojtka, 
-varying  in  size  from  the  end  of  the  iinger  to  the  pi*lnj  of  tb*  liand  and 
even  larger.  They  develop  gradually,  frequently  on  parla  of  the  l>ody 
that  are  not  easily  eeeu,  such  aa  Cbe  baok  of  the  udck,  but  more  ofton  tm 
the  chest  and  over  the  diatrl button  of  the  fifth  nerve,  najiecially  of  th« 
supraorbital  branch.     On  the  lower  extiemitiefl  tha  cutiu^eoui  aurfaov  to 


5a) 


TltaATMKNT  OP   DIBBABBS   OF  THffl  KKRVQUS  &Y3TBU. 


wliich  ihfl  lermiiiiil  Iwi^  of  the  short  aaphenouB  nerve  are  distnbiited  ts» 
favorite  H^at  of  morphc^^.  The  |>Atc.heB  are  of  a  de^  whito  f  r  jellowuh 
color,  often  boidered  by  a  pinkish  £oue,  aud  ou  superficial  etau» nation 
they  may  be  easily  miatakea  for  eoare.  After  the  disease  ia  fullj  d^ 
veloped,  recovery  may  lake  }il[w;o  without  leading  auj  traco  of  the  a^ec- 
tion,  although  imfortuDately  the  diBdaae  do«a  not  tend  tow&rd  rocorery. 
The  course  uf  the  disease  may  extettd  over  several  years,  and  although  it 
do««  not  itself  uftiru  lead  directly  to  death,  it  pradispoaes  to  acute  diaeafieq 
suoh  as  rheumatism  and  acute  iaflajnmatiooa  ijf  the  respiratorj  tract,  and 
tbceOi  bccauso  of  the  putieofa  emaciation  and  7ital  d&preaBioD,  are  v^ry 
apt  t,^  Jead  tu  a  fatal  termination. 

Treatment. — ^The  object  of  treatment  ehonld  l»e  to  unrigorate  th» 
patteut,  lo  pay  especial  alteutlcKi  to  the  nutrition  of  the  6km  aud  neuro- 
vascular systeuit  and  to  avoid  factora  that  are  kucvD  to  aggravate  thd 
disease.  Careful  attention  to  diet,  exercise,  and  hy^ene,  combined  with 
'the  admin iBtration  cf  such  restoratives  as  arsenic,  iron,  and  L^od-liTer  oil, 
and  the  utilization  of  massage  and  hydrotherapy,  will  best  meet  the  tint 
indifationH.  Eleclriciity  by  ineaiiB  of  the  raiistajit  current  of  sligbt  inten- 
sity, three  to  four  milliamperes,  over  the  aclerodenuatoos  areas,  followed 
by  an  appHcatiuu  of  two-per-ceiit  salicylic  vaseline  thoroughly  rubbed  in, 
sometimes  seeme  to  have  much  benetiuial  effect.  Life  in  the  open  ur, 
in  a  salubrious  ei^uahle  climate,  careful  avoidance  of  ciposure  to  wetting 
and  chilling,  will  best  obviate  the  oaiises  tti at  aggravate  the  disease.  Pa- 
tteuts  who  arc  subjected  to  the  discipliue  of  hospitalization  af-t^m  to  thrive 
YOry  W6il.  A  nutiil)er  of  cases  have  been  reported  in  which  the  adminis' 
tration  of  thyroid  extract  has  seemed  to  be  of  great  benetit.  But  like  La 
all  other  conditions  iu  which  this  subatauoe  has  been  found  ufieful,  the 
disease  recurs  soon  after  adminiatration  of  the  thyroid  ia  fltop]>ed,  Thft 
general  trealjueut  of  the  disease  may  be  said,  in  brief,  to  be  not  unlilte 
that  of  chronic  rheumatoid  arthritb- 


CHAPTER  XL, 


THE  TREATMENT   OP  PROGRESSIVE   FACIAL   HEBGATROPffT. 


i 


PBonasasivE  facial  hemiatTophj  is  characterized  by  a.  progreasive 
vaBHug  of  cue  side  of  tlie  face  in  which  all  the  structuras  participate  in 
1  Tuying  degree,  the  luuM^les  least,  the   akiDf  suhcutoueoiia  tiasuea,  aud 
hoDt  moatr  sometimes  OfSaociated  with  hemiatrophy  of  the  tongue.     The 
dtsease  oocura  in  children  and  iii  youths  of  both  sexeai  vetj  rarely  in  late 
uiolt  life.     It  has  followed  local  trauma,  exposure  tc  oold,  and  the  infec- 
tious disease,  Huch  as  influenza,  erysipelas,  and  typhoid  fever.     It  occurs 
moBtoftBD  in  people  who  have  some  inherited  or  accjuired  neuropathic 
condittoD.      It  maiy  occur  in  connection  with  aclerodenna  and  with  Addi- 
wa'a  disease,     lu  a  number  of  instances  it  has  b&on  associated  with  lesion 
of  the  fifth  nerve. 

The  disease  usually  logins  with  mor(>  or  less  pain  in  one  side  of  the 
race,  then  the  patient  notices  Due  or  more  whitish  spots  on  the  lower  jaw 
or  near  the  orbit,  which  gradually  becomo  larger  or  coalesce^  The  skin 
OTQr  these  patches  sinks  and  forms  pits  or  troughs  due  to  disappearance 
of  the  suboutaneous  fat.  Coincidently  with  this  there  is  pigmentaCion  of 
the  face,  irregularly  distributed-  The  atrophy  inTolves  the  skin,  its  ap- 
pendages, and  tlie  tii^suea  beueatli  it.  The  hair  of  the  face,  the  bead, 
and  the  eyebrows  loses  its  color  and  falls,  forming  irregular  areaa  of 
alopecia.  The  sebaceoua  glands  are  atrophied,  audtheirsecretioa  is  dimin- 
ished aud  eventually  suppressed.  Tho  amount  of  perspiration  is  normal 
or  incteast>d.  After  a  variable  time,  the  entire  half  of  the  face  becomes 
Invalred  and  a  deep  fissure,  like  a  sabra  cut,  in  the  centre  of  the  forehead 
and  chin  separates  it  from  the  healtliy  Gidc.  Barely  are  both  sides  of  the 
face  involved.  As  a  rule,  there  are  no  disturbances  of  senaibiiity.  Local 
itching  is  fr^uently  present,  and  the  atrophied  ekin  oftentimes  gives  tho 
foiling  as  if  a  rubber  ruaak  was  stretched  across  the  face.  OccsaionaUy 
there  istonicO'Clunic  twitching  of  the  mitaeli'S  supplied  by  the  third  braniih 
of  the  trifacial  nerve.  Neuroparalytic  eymptoma  pointing  to  involvement 
of  the  supf^rior  cervical  ganglion  and  the  carotid  plenuSf  such  as  piD-point 
pupil,  Pushing  of  the  face,  and  hemi-hyperidrosis  have  oecasioaally  been 
noted.  Tbe  course  of  the  disease  is  at  first  rather  rapid ;  then  its  prog- 
ress may  cease  for  a  long  time,  to  be  followed  sooner  or  later  by  a  period 
of  eiacerbation.  The  progriosia  as  regards  recovery  is  unfavorable, 
although  the  dbease  does  not  seeiu  to  ahorteu  life. 


522 


TREiTMKNT  OF  DISEASES  OF  THE  NIRTOUS  STSTEU. 


Tre&tment, — As  the  diaease  is  ineurable>  pi^ventiTe  treatnieiit  if  possi- 
ble, in  the  shape  of  e&rly  discovery  of  the  cmise  and  its  lemovaJ,  is  of  the 
greatest  iiuportance.  Souid  authora  liare  su^fguated  that  the  areA  in  which 
the  atropLy  mauifests  itself  should  be  cut  out  as  bocu  as  pouibl^i  but  I 
atu  at  a  loaa  to  understand  how  eurh  a  proceduro  could  be  of  benefit. 
OthsTB  bare  suggested  earlj  r^eection  of  the  bi-aacbes  of  the  trigeminal 
nervs.  There  are  no  records  Vi  show  that  tbis  plan  has  ever  beea  tried. 
The  113d  of  galranic  electricity  helps  tu  ata/tbe  progrf^ss  of  the  dis«aae  id 
some  iustaace^H  lu  general  the  treatment  is  the  same  as  that  for  bolero- 
derma-  To  overcome  the  cosmetic  defect  whon  the  diaeftfl©  has  come  to  a 
standstill,  the  patient  may  have  a  plate  nia^de  by  a  dentist,  which  con  be 
attached  to  the  teeth  of  the  upper  jaw  on  the  afFected  side  with  a  slightlj 
convex  surracie  against  tlie  miiciius  membrane  of  the  teetb.  This  can  be 
worn  with  comfort  afttir  the  putieDt  auciutomB  himaelf  lo  it,  and  it  do- 
traota  enormously  from  tlje  unsightly  deformity. 

HBuiHVPER'rnoi'fiT  AND  Looix  Htpextropht. 


Hemibypertrophj  of  the  face  and  hypertrophj  of  an  extremity  or 
cne-half  of  the  body  are  extremely  wicommon  conditions  which  are  usually 
considered  under  the  trophoneu  roses,  although  nothing  is  known  of  their 
ciigin  or  pathogenesis.  Unilateral  hypttrtrophy,  limited  to  the  head 
and  face,  occurs  less  frequently  than  hypertrophy  of  one-half  of  the 
body.  It  has  occurred  aasoeiaied  with  inveterate  neuralgia  of  the  fifth 
DGTve,  with  gigantiam,  and  ccugenitaily.  It  inioWes  all  the  Btmcturea  of 
the  hard  and  the  soft  parts,  although  the  hyperostosis  is  more  prominnit 
than  the  hypertrophy  of  the  soft  tiasua  The  course  of  factEd  bemihjpcf- 
trophy  is,  aa  a  role,  a  progressive  one  during  the  years  of  Dorntal  growth, 
but  after  adult  age  is  reached  its  progresii  \n  very  slow.  No  form  of  treat- 
ment haa  lieen  suggested  that  is  of  auy  use,  although  when  its  occnrrenoe 
would  HSem  to  be  associated  with  irritaliion  of  the  fifth  nervet  the  latter 
ahould  be  resected.  Hypertrophy  of  an  extremity  and  general  bemihy- 
pertrophy  is  a  congenital  condition,  save  in  those  instances  in  which  tha 
local  hypertrophy  is  oompenflatory. 


CHAPTER  XLL 

THE  TREiTMEHT  OP  EnYTmtOMELALfllA. 

EfET-rnROHELACGiA  IS  the  name  given  to  a  permlUr  red  oeural^pa  firat 
d08cnbed  by  S.  Weir  Mitchell  iu  1S12,  As  the  nnme  UKliiSte;),  the  dU' 
use  i£  ch&ncterized  by  the  t>ccurreiice  of  pain  and  redness,  which  affecta 
jiriaodpally  the  distal  port  of  the  feet,  much  les3  oftctj  the  haada.  I'aia 
IB  the  fijst  maalfestatioiL,  then  ledneds,  and  ^ally  swelling.  The  pain 
is  of  ncutaJgtc  ?haract«T,  usually  intermittent  in  the  beginning  and  eape- 
mlly  liable  to  DccuireDce  after  coasiderable  use  of  the  feet,  and  toward 
evening.  It  is  increased  by  Hbanding,  walkiugf  hAu^u^  of  the  feet,  &nd 
by  warmth.  The  p^in  may  have  lasted  for  a  coiiBiderable  time  before  the 
rednesa  apficarSf  but  usually  the  latter  ia  well  manifest  vhen  the  patient 
co&9ults  a  physician.  It  ia  associated  with  pulsation  of  the  arteries,  with 
a  dark  reil  dish -purple  color  of  th&  skin,  fr^iiently  with  disteotioii  of  the 
vans,  and  it  is  accompanied  with  lucal  elevation  oF  temperature  and  hj- 
peridroais.  Sensory  dbtorbance  is  usually  absent,  although  teridemeMof 
the  parte,  increased  hy  pendenry  of  the  extremities^  is  the  ixJe,  c^nd  para*' 
thesia  is  not  uncommon-  It  ia  associated  with  rarioua  general  aymptoma 
■Twh  as  gastro-intesiinal  disturbanee^  headache,  vertigo,  cardiac  palpita- 
tion^ attacks  of  uneoDScicuness,  and  general  myasthenic  syiupUinis.  Tho 
diso4se  is  liable  to  prolonged  remisaionSf  and  its  duration  may  be  orer 
a  great  number  of  years.  Unlihe  the  majority  of  vasomotor  neuroeee,  it 
occurs  predominantly  in  males,  especially  during  the  years  ol  young 
<Lnd  middle  adult  life,  A  neuropathic  predisposition  is  traceable  in 
most  casea.  Exposure  to  cold^  hard  manual  labor,  exceaitve  indulgence 
in  &Icohol,  previous  existence  of  an  infectious  disease,  including  ayphilist 
luiTe  been  oonsidered  causal  agencies  in  different  cases.  The  Bjmpton 
iMMDplex  may  occur  with  hysteria,  syringoayeLu,  Baynand's  diieaag, 
hemiplegia,  and  with  Tni:scular  dystrophy.  Itisbighly  probable  that  ^fj- 
iJiriKndalgia  ia  not  an  individual  disesse,  but  &  sympUxn  eomplsx  mmaeor 
ated  with  and  dependent  npon  some  organic  and  foDctional  disease  of  tb« 
oeutr^  or  peripheral  nerroua  systenu  So  far  post-mortem  examinatkne 
and  the  examination  of  excised  tissue  during  life  bare  otA  been  Toy  DVr 
meroos-  Those  that  have  been  made  aeem  to  show  that  in  eases  of  loaf 
dnntian,Bl  least,  then  isma^ed  degeoention  of  the  Mood-Yessfl^  ehsr- 
SiCtetixed  by  tluckiieas  of  the  medi^  and  intefua,  and  i1<i^iiwhImsi  «{ tfce 
peripboTa]  distribution  of  Ht^  ntxrvtu,  sseociftted  with  imrrfsssd 
of  oofUMoCiTe  tisauie. 


5U 


TBK4TMENT  OF  OISKA.SKB  OF  THE  NERVOUS  STSTKtt. 


Tre&tmetit. — The  tTeatmentof  erjthroinelalglawiJl  depend  very  largelj 
upon  tho  codJUiou  with  which  it  oooute.  As  it  ia  most  ftequ^dtly  assocl- 
nt^  with  degecerAtioii  ot  the  blood- veeeeUi  medicioai  and  dietetic  tu«u- 
nregappropriftte  fof  this  condition  muut  b«  adopted,  UofortuDalfily,  it 
vanaJly  reaEsta  all  kiiida  of  treaimeab,  aUhaiifi^li  it  in  generally  ainelioretpd 
by  measures  that  iiicreaae  tLo  patient's  goaeral  health  and  strecgth.  Ele- 
Tftticin  of  tbe  feet  and  the  application  of  oold  uaualty  give  temporary  relief. 
Wbenever  it  la  posaibJej  thd  patient  should  bo  advised  to  take  a  prolonged 
rest,  to  keep  off  the  feet  as  luTir-ti  as  possible,  aud  to  go  through  a  mild 
liydriatiG  restorative  Lreatmeut,  coiabiaed  with  the  use  of  measures  IhAl 
have  been  found  beoeficial  m  aeuralgio  coodltiuDs.  It  haa  beeu  Huggefited 
by  Mitchell  that  the  poaterior  tibial  nerve  ha  excised  aa  a  meana  of  relief, 
and  m  one  or  two  caaoa  this  radical  measure  has  aeemed  to  be  euooeMfiU# 
Dehio  has  also  recorded  a  case  ia  which  extiqialiou  of  the  olnar  Det»e 
oaufled  the  manifeatationB  of  er-ythromelalgia  in  the  l»and  to  diRai^pear. 
Wlieii  the  symptom  complex  is  aaaoriated  with  elicitable  fiioetioDaJ  or 
orgoaio  disease,  measures  should  be  directed  toward  the  oure  or  amelion- 
tion  of  these  oonditiona.  Eadearor  should  be  made  to  allay  the  paiit  by 
tlie  use  of  the  taradie  cutreDt  and  by  adminUtratioa  of  tbe  luodem  aaaU 
gesics. 


CHAPTER  SLH. 

THE  TREATMENT  OF  ACROPARJESTHEBLL 

AoBOi'AUrG.MTiiF^iA  Ib  the  Diime  givOTk  to  the  occurreDoe  of  pEUfestbeeia 
ia  tiie  oitrenuiieaT  uuaasociated  with  organic  or  other  fuiictiooal  nervous 
disease-  The  coDtlition  Yvas  Iwhei  de^trilieil  iii  this  couiil.ry  by  Putaam, 
Dana,  aud  others  as  "the  pwieathetic  neuroais,"  and  in  Europe  hj  Noth- 
uai^]  and  others  as  '^tho  Tasoiaobor  neurofiia  of  th«  eEtiemitka.'^  The 
ohaic&l  picture  is  soniewhat  as  follow^:  The  aulferers  from  this  affection 
&Te  in  faii'l}'  good  health,  e]cc;ept  for  the  par^athesiaj  consiBtlng  of  a  numb 
feeling  in  the  extremities,  especially  of  the  hands,  a  aensatiou  of  pins  and 
needlea  and  formiLiation,  associated  with  iaoi«  or  less  profound  fe^Jing  of 
vreighb,  uniFioIdiuc33,  orjd  ditaiuiahed  destenty>  These  senaatioDS  are  not 
limited  to  the  distribution  of  a  single  nerve,  but  they  are  apt  to  be  most 
severe  in  the  finger  eoda.  There  is  rarely  any  pain.  Objectively,  sensi- 
bilil^  is  intact  or  very  slightly  diminished.  The  skin  is  sometimea  cool 
and  relaxed,  and  Lhe  pulae  lackmg  in  Tigor.  There  ie  no  tcTidemeBS  on 
pressure  over  any  of  the  nerTes  and  no  perceptible  atrophic  or  degeneratiTO 
changes  are  noted.  The  affection  ia  liable  to  ahow  itself  intormittently  in 
paroxyams^  and  the  period  of  the  twenty-four  hours  when  an  attack  is  moat 
likely  to  ooour  is  from  four  to  six  in  the  morning.  The  causes  of  the 
disease  are  not  definitely  knoiru.  It  occurs  in  women  about  five  times  as 
often  as  in  men,  and  especially  those  who  do  washing,  scrubbing,  and 
needk  work-  It  is  seen  more  frequently  during  middle  adolt  life  than 
at  any  other  time^  Occasionally  it  seems  to  stand  in  causal  relationship 
to  the  exhausHon  following  pregnancy,  u>  laotatdon^  the  acute  infectious 
diaeaaea*  and  intestinal  auto- iiito\i cation^  Maijy  of  the  patients  take  tea, 
And  some  of  them  other  atimulanta  and  nateotica  exceasiirelj.  Occasion- 
ally it  complicates  emotional  and  neurasthenic  states.  Barely  is  it  found 
associated  with  marked  arterial  degeneration.  The  parsestheEija  of  rheu- 
matism,  gout,  and  arthritis  are  not  conaidered  under  this  heading. 

Treatment, ^ — Causal  therapy  is  most  important.  An  investi^aticn  of 
Lhe  patient's  mode  of  life  and  occupation  wiU  usLially  reveal  the  factors 
that  are  apparently  the  cxcitanta  of  the  disease;  and  their  removal  or 
avoidance  combined  with  a  toiiio  and  restorative  pkn  of  treatment,  if  it  ia 
peisiflted  in,  will  suffice  to  overcome  this  distressing  ailment.  Prolonged 
raBtisundoubtedly  the  most  important  agency »  but  unfortunately  thiaiatiot 
possible  for  the  majority  of  the  patieLts,      When  it  ia  possible,  it  shonld 


52S 


TREATMENT   07   DTflBABSB   OF  THB 


IVOUB   BYSTI 


be  combined  with  regulatiou  of  tbe  diet,  eapecvally  witb  limitation  of  the 
EiitrogeLoua  foodstuffg,  change  of  occupation  and  habits,  aud  tbe  admm- 
ietfEtticn  of  such  reatoraCirea  as  arseixiCr  phospborua,  strjchiiiiiei  and  iron. 
Ergot  has  b^en  recouLmendedr  but  1  have  aeeu  do  benefit  attend  ita  admin- 
iHtratpiuD.  The  parastliesia  oau  usualljr  be  LeiD{K>rarjIf  relieved  hy  the 
use  of  the  faradic  cuiteiit  and  by  tbe  appJioation  of  Jukewarin  water  U> 
the  extremitiea.  The  faradic  current  may  be  employed  in  the  abapo  of 
the  faradic  li>cal  bath.  Galvani^tioa  of  the  cervical  spin^  and  tlie  iym^ 
pabhotie  plexuseB  also  often  has  a  beneficial  effect.  When  the  attauka 
occur  in  the  early  hours  of  the  momiug  and  awaken  the  patient,  much 
benefit  ia  to  be  derived  from  the  admioiatration  of  ft  mild  hypnotic 
at  bedtime,  auoh  aa  ten  gmina  of  aulfonal  or  trional,  taken  with  a  oon- 
aiderable  (^uaniity  of  warm  milk.  Ooeasionally,  treatment  directed  imme- 
diately to  the  overcoming  of  the  urie^acid  diathesis,  indigestion,  and  mail- 
rial  infetition,  baa  seemed  to  be  very  beoeficiaL  When  auoh  indicationa 
for  opecifio  therapy  exiat,  they  abonld  be  met;  but  &a  a  general  role  the 
treatment  that  is  moat  succosaful  ia  the  general  tonic  treatment  applicable 
to  neurasthenia. 


CHAPTER  XLIIL 


THE  TREATMENT  OP  OCCUPATION   NEniOSE& 
fOocutution  dpafii&«.  Crumps,  l^ns.  hwA  VvaXywit.} 

Tas  n&m€  occnpatioii  aeoroaes  is  applied  U)  %  niimbBr  *>t  iliiturhftDrwii 
of  tucbilitj  a^d  fieusibility  vi  tljH  extrQiuil.iti»r  jiariii^uliu-lj  uf  Uiu  liniulji, 
developing  after  p«riiisteut  uae  of  the  ejtbteiuitjr  at  certain  oooupntioiin 
ot  profeaaioits  which  call  for  the  protracted  uao  of  a  ffrcujk,  or  osoooUlod 
groups  oi  muaclee.  I^euroaet;  resulting  from  the  injuritmsaotiviLy  of  |x>i- 
vms  enoouniered  in  the  oocup&ticit  are  tii>t  o<insidprcid  r»noupAttnn  unin^* 
ses.  The  occupatioD  Deuroaea,  man i felted  il9  pain,  Hpaam,  or  (iriim|k-lika 
oooditioa  in  Individual  uiuacles  or  grouije  of  luuBcles  that  at^l  tj^olliDi  la 
tho  performance  of  certain  oota  of  oo- ordination,  or  as  hil  ina^tivily  of 
these  muscles  amounting  to  paralysis,  occur  in  scrivenersj  teUgraph  opt-r- 
a-tora,  pianista,  milkers,  ta^ilorf^,  golfers,  eigarette  rollom,  smiths,  ballet 
daut.'erBr  drummers,  buglerx,  bowlers,  and  in  hatters  ajid  jireMUTrt  wlio  work 
Titb  A  heavy  iron.  The  uumber  of  theae  oncupation  iivKimmm  would  Hi^Tm  to 
be  on  the  iLCiease  as  human  ingenuity  devisei  new  sport«  or  lubor  miuir- 
ing  for  their  iudulgence  and  performance  complex  oo'ordinatod  miiMCular 
activities^  VVriter's  cramp,  graphospasm,  or  mogigraphia,  a«  it  in  NOKn#- 
times called,  has  be^n  and  is  yet  in  some  conntrit^Hthe  moit  common  ty]>e 
of  occupation  neuroses,  lu  this  country,  however,  where  the  typewriter 
iLas  replaced  to  surh  a  large  Bitent  the  sctivener,  writer's  cramp  iii  very 
uncommon  to-day  in  comparison  with  a  few  yeart»  ago. 

For  a  loug  time  the  occupation  ueuroses  were  oonridttvd  tO  bs  aa  «x* 
pressioD  of  local  fatigue  and  exhaustion^  ruaoUesting  tlietsselvet  lu  periph- 
eral parts,  such  sm  the  mujKles  in  which  the  pain,  spaun^  or  pMicila 
occurs,  TLia  view  haa  beeu  assiduously  promulgated  by  veudonorf  ap- 
paratus to  overcome  the  Bpa«m  or  cramp  which  u  tbo  &KMb  diatrewiag 
symptom  of  writers  or^mp.  Although  there  ia  a  loeftl  or  peripher»l 
fatigue  and  exbanctioci,  this  is  not  aim*  th*  f«*&H  of  th*  hib^  that  tuch 
parts  hav0  perfomad,  bat  h  is  an  eipreasion  of  an  inhflrilMl  or  Mqtti/wl 
cooaLitutknal  aoimu  which  is  i>ow  revealing  itaelf  Mi  MOBoaxA  of  th«  d^ 
prettftioo  aUending  povstent  and  fatigoing  labor.  Bach  ii  iM<m«&i  ha*  no 
indiTidoal  aztatomical  ant  The  oocorrenoe  of  tbM*  OMVpillMl  Mwon* 
in  individuaii  who  ibow  otb«r  oridMoe  of  ftervo  itMkttHf,  mtk  M  tfa^ 
Dx^nine,  nmralgia,  and  not  in  tboM  of  robut  imMllliilliw  lii^  rigonV 
■     ''.      '  '  J    g-        of  ■<  mli  Mil  fcrirr- 


TBEATHKNT   OF   DI8SASBB  OP  THK  NfiBVOUe  eTSTCU, 


i^bondria^  Huoh  aa  lieadiiche,  depteeebu  of  spirite,  iufiODiniaf  and  geoi 
detenoratiou  of  Denromuscular  toae,  testiBes  that  tbe  condition  ia  a  coO' 
atitution&l  oue  with  a.  local  du>plaj  ocourriitg  under  the  auapioea  of  exbaus- 
tioTL.  The  treatment  of  an  oocupatiou  nduroBiB  t^a  be  permanently  suc- 
coaaful  ouly  vhea  this  oonceptioiL  of  its  patbogt'D^ifl  ig  borne  in  caind, 
ujid  llie  plan  of  treatment  ba^  upon  it.  The  Ux^  treatment  of  such  a 
condititm  iiD  writer^s,  t^legraphar's,  piantst^a  craiLip  alone  is  rnrel^  if  ever 
auflinlent  to  effect  &  c»re.  It  may  caiiso  temporAry  alleviattoua,  but  thft 
loanifestaVioDS  of  the  diaeiue  are  eure  to  return.  The  earlier  the  occupa- 
Ljon  ueuroaes  are  dia^ofltinatpd  and  trealM  the  great,er  the  proapeot  of 
alTeiliiig  a  |)eni»atietit  rure.  Before  beginning  the  treatment  of  an  owni- 
patioti  neurodia  all  sourdOB  of  peripheral  cAusation,  auch  as  niyooitds, 
iofiammution  of  a  tendon  orita  eheath,  cioatrioes,  etc,,  shoiJd  be86&rc>bed 
forj  and.  ovemome  if  found. 

Treatment— In  fipeaking  of  the  treatmeut,  writer's  cnuup  may  be 
taken  as  a  type  of  Ibi^  c\u»s  of  dijtorders.  The  luo^t  essential  feature  in 
the  treatuieut  of  tbeat:  affeutiGLs  in  cesaatiou  of  the  ooE;upaLii:/D  whicji  ia  tW 
tnmjediate  CAoae  o£  its  occuiTcncep  Successful  isjauJta  attend  the  cacea  ili 
which  this  ia  iuBisted  upon  from  the  be^uuiug.  Oftentimes  to  relmquish 
one^s  oceupatioa  means  to  give  up  one's  li^^i^bhood,  but  it  ia  far  better  to 
do  thi!4  at  A  time  when  tha  patient  ha,4  the  f'npaeity  to  turn  to  BOTnetblnp 
elae  thiin  to  wait  luitil  nyiaptoma  of  neurastheuiaand  by]>ochondri£,  which 
ore  sure  to  develop,  auffiee  to  unfit  him  for  any  occupatiODr  or  until  Lhe 
m^isclca  that  are  the  sent  of  orainp  begin  to  atrophy.  Valuable  time  i» 
often  loGt  la  the  hcgiuuiug  by  the  trial  ol  aueh  makeshifts  as  apparatus  tot 
wnter'a  eramp,  aiid  learuing  to  write  with  tho  left  hand.  Unless  treat- 
ment to  ijiiprova  the  gt^oeral  health  inHppliwl  siiiiiiUaneciualy  the  beneficial 
results  of  auch  measures  ate  merely  t^ajporaiy-  The  cramp  wdl  be  aure 
to  recur  in  the  hand  that  wears  tlio  appaiatuH  or  in  the  Laud  that  la  htittg 
taught  to  hold  the  pen.  Naturally,  if  the  physioian  is  curisulti-^d  oarly,  he 
may  oouns^l  the  usd  of  large  penholders  or  some  apparatus  tba.t  prevenU 
the  ntust^lcH  from  getting  into  niioh  a  state  of  I'ontraetion  that  cramp  o^^cars, 
and  if  at  the  aaiue  time  active  treatuient  by  hydtotl^etajiy,  eieroise,  local 
and  giinerul  gymuastiprt,  mn^sago,  eletitricity,  and  tonics,  ia  directed  cape- 
cially  toward  the  atrengtheriiug  of  the  muscloB  tliat  be^^ome  cramped,  it 
may  not  be  necegsary  to  give  over  completely  the  ooeupation,  It  will  b« 
an  ecoijomy  of  time  and  mmipy  to  tlo  ho  for-  a  i^Lort  time  in  the  majori^ 
of  cases-  After  the  patient  has  ceai^ed  fiom  the  lalx>r  or  pleasiLre  that  has 
led  up  to  the  epasiu,  he  abou]d  bo  put  through  a  restciative  plau  of  treat- 
ment not  unlike  thiit  employed  for  other  neuroses  such  as  neorasthenia 
and  hysteria,  the  object  being  to  imT>rove  the  nutrition,  iucreaae  tfodily 
weight,  sefure  refreshing  sle^p,  develop  muscular  strength^  and  reatore 
the  equilibrium  between  production  and  expenditure  of  energy. 

Coiucidently  with  the  utiJizatioit  of  means  to  Improve  the   genera] 


THE  TREATKENT  OF  OCCUPATION  SErEOSIS. 


520 


natrition,  meaEui^a  should  be  employai  to  streugiheii  ttt  parte  whJoh 
ftre  or  were  the  seat  of  cramp,  and  of  these  the  most  importai^t  are  local 
g7iQEafiti<?s  and  reaifttaat  exercises  of  llie  individual  mu§cles  of  Uie  fore- 
vm,  hand,  aud  fingers.  Slight  maaaage  of  theae  paita should  be  practiaed 
pcrsifitentlj. 

Tv^tment  directed  toward  the  relief  of  the  apasia  eboald  oODHist  id 
envelopiiig  the  baud  and  foreana  in  a  cold  wst  paok  once  or  tniiw  a  day ; 
tha  iLse  of  the  galvanic  enrrentj  three  milliaiiiperea  dirtied  through  tite 
brachial  plexur^^  the  positive  pole  over  the  latter,  the  negabive  at  the  back 
of  the  neck>  for  from  iifteea  to  twenty  minutes  each  diiy;  en<ltho  aduiin- 
utratioQ  of  such  sedatirca  as  hyoscyanauG,  beUadonna,  btomideS)  ahloral, 
&nd  Talerianate  for  a  brief  time  for  their  fiedative  etTeots.  It  has  been 
StAt^d  in  9ome  cases  in  whii^h  the  tt^tanic  spaBm  resisted  all  tliese 
meaaares  that  the  injection  of  strychniue  iubo  the  contracted  niusGlea  has 
beau  efficftcioua.  It  is  ditficult  to  uuderstand  how  snch  a  subettxnc^  as 
fitrychniue  acts  to  overcome  the  apaeiu,  ijut  there  is  no  objection  to  using 
it  ^hea  the  other  meaeureB  fail  to  bring  abo^it  the  deetred  reaultA* 
OpiUQ]  or  its  alkaloids  are  rarely  indicated  for  the  relief  of  pain. 

The  after- treatment  of  the  woHiiation  n^-nrosea  \n  very  iin|)ortaiit,  a« 
tLe  Urndflncy  to  relapse  alwavs  tMists^  A  return  U>  the  occupation  which 
caccited  the  spaana  should  be  delayed  afl  loug  as  possible,  and  at  the  alight- 
est  indication  of  the  spasm  tlie  occupation  should  again  be  given  up. 
The  treatiueut  of  the  various  other  forma  of  occupation  spasms  differB  in 
nowise  from  that  already  detailed,  eir4:*ept  in  so  far  as  treatment  may  have 
hi  bo  directed  toward  the  part  in  vhicTi  the  spasm  oc^-urs. 

The  treatment  of  occupation  (daisies  calls  for  exactly  the  same  therapy 
as  the  occnpatioa  spasms^  save  that  in  the  fonner  there  are  no  indications 
for  the  temporary  use  of  Gedativee  and  pain -re  lie  vers.  The  exception  to 
this  mle  exists  in  eases  in  which  the  palsy  is  the  result  of  pressure  en- 
ooitDt«red  in  the  occupation.  The  treatment  t^hen  la  the  ume  as  for  ordi- 
nary presAiiie  palsies- 
3-4 


CHAPTER  XLIV. 

THE  TREATMENT  OF  HKADACUE. 

T&c  ieiTo  headache  is  an  extrenit^ly  oamprebenaive  one.  It  may  be 
a|rphe>l  pnrptirly  to  any  form  of  pain  in  the  head.  Tu  du  au,  howererf 
ia  to  cockfoutid  lumecesaorily  mauifestetions  of  diaease  with  individual 
disease,  A  tadic&l  and  extremely  important  ctlaai^ifinatiou  of  headache  u 
aa  follows:  {1)  MigroineL  an  iudividual  disoaec  libe  epile^ioy ;  a  iteuioeu 
of  a  degeuerative  type.  (2)  Neuralgie,:  includiag  tic  douloureux,  supra- 
□rbita],  ocoipita],  aud  nuchal  neuralgia.  {3')  Sympbomatio  lisadach^:  an 
iudioation  of  fuuuLioiial  or  orgauifi  disease,  traniiiatic,  aRrudental,  or  inhet' 
atit.  (4)  Idiopathic  headache ;  a  rare  form  of  cephalalgia  which  has  &o 
determinaUa  auaciciatiou  vith  orgctnio  or  functional  diaeoae.  Here  oaly 
the  third  and  fourth  varieties  are  conaidered,  as  the  lirfit  and  second  an 
properly  ronsidewd  elsewhere  under  separate  captioi;s, 

Headai^hes  have  heen  varioualy  claaailied  by  difTerent  writers.  3Qi^e 
believe  that  they  are  meat  safely  interpreted  when  given  topoi^^phical 
claaaihcation.  Others  oontcnd  that  the  character  of  the  pain  is  tlje  moat 
reliable  distinguiehing  feature,  but  the  majority  lind  it  tacte  aatiBfactory 
to  clasflify  headaches  aooordmg  to  their  causes  and  disease  aasociatiotiA^ 
Almcat  any  form  of  claBsilll^HtioIl  may  be  ma'.le  to  serve  a  useful  purpose. 
In  my  lai^tures  I  often  refer  to:  (1)  Headaches  of  early  life,  embmcins 
the  years  up  to  puberty^  (2)  headaehes  of  adult  lifej  and  i'<t)  headachea 
of  senility,  Surh  a  dLmion  hue  many  advantages.  It  impresaes  paf- 
tiPularly  the  fact  that  the  majority  of  headaches  oceurring  m  obildhood 
are  those  known  aa  reflex  and  the  autotoxio,  that  those  of  adult  life  are  in 
the  main  symptoms  of  the  funotional  neuroaeg  and  intuxicationa,  while 
those  of  late  adult  life  are  usually  eipredsious  of  arterial  de^feuerattons 
and  the  injurioue  aotiona  of  toxio  ageneios. 

The  two  moat  important  facts  to  keep  in  mind  in  endeavoring  to  inter- 
piet  the  significance  of  headache  are^  firsts  that,  it  is  aji  important  symp- 
tom of  a  number  of  funotional  and  organic  diseases ;  and,  seoond,  that  the 
location,  character,  and  duration  of  the  pain  are  oftentimes  the  meana  of 
suggesting  the  condition  or  disease  uix^  which  it  depends. 

Headaohe  may  be;  1.  A  symptoukof  functional  QOrvousdifl«*aaei  neu- 
Pttsthenia,  hysteria,  epilepsy,  and  exophtlmluiic  goitre, 

2-  A  symptom  of  organic  brain  disease;  meningitis,  eocepiialitis, 
brain  tumor,  and  brain  abscess. 


TEtB  TRKATMBNT  OF  HBADACHB. 


531 


3.  An  iDdlc&tion  at  intozic&tioD  aod  Infection.  Tbe  souroes  of  either 
of  tLest!  may  bn  etidogenous  or  exugeuouH^  that  is,  the  laLoiit^atiun  ur 
infection  may  oriiie  from  witlilu  the  tiy&teia,  such  a^  from  dJabctus^  urae- 
mU,  and  intestinal  catarth,  or  it  may  be  introduced  from  without,  as 
by  alcohol,  nicDtine,  tbe  metaliio  poisonsT  the  malarial  plasmodio,  and 
the  acute  infe^^ticua  diseases. 

4.  Due  to  diaturbLLiiQes  aud  diseases  of  the  circulatory  jtyBtem,  such  as 
accompany  the  uuSKUiia  of  aortic  atenosifi  and  regurgitation ,  puhconary 
emphyaema  and  coaaolidaticn,  general  anirmia  and  its  different  forma, 
fLnd  arterial  acleroaia. 

5.  Due  to  OAuaes  that  produce  continued  fatigue  and  exhaufltion  by  in- 
diret^t  or  reflex  action,  such  as  from  iusuEficienniea  of  the  ocular  inuscles, 
ir regular! tiea  in  the  refractivt^  apparatus,  irritation  of  the  periplieml 
olfactory  aud  trigeminal  bi'anchea,  oi  irritation  of  any  of  the  great  plex- 
uses of  nerves.  Headaches  of  this  variety  are  usually  called  reflex. 
When  properly  int«irpreted,  there  ia  no  valid  reason  why  thia  term  should 
not  be  applied  to  them. 

6.  Due  to  trauma:  traumatic  beadac^he.  HeacJai^he  may  be  ths  se- 
queoco  of  an  injury  that  produces  surgical  ooDdibiona,  such  as  wound  of 
tbe  acatp  and  bunos,  and  it  may  follow  truuma  to  the  head  M^hich  doea  not 
pTOducesuch  injury.  The  explanation  of  the  former  kind  duea  not  seem  a 
particularly  difficult  matter,  and  as  for  the  latter^  it  is  probably  a  variety 
0(  traumatic  neurasthenia,  oi?ca*iionally  pachy meniugitig. 

T.  A  local  manifestation  of  rheumatic  involvement  of  th^  epicranial 
and  circumcranial  tissues, 

S.  KiDally.  heaJacbe  may  be  the  expression  of  a  pain  habit,  and  to 
this  the  name  habitual  headache  is  given.  Ln  other  words,  after  the 
ocDurrable  headaches  are  parcelled  out  among  these  varioufi  diseases,  there 
remain  a  small  nimiher  that  canuotlie  allotted  to  any  oae  of  thcm^  Tt  ia 
more  than  probable  that  the  headaches  grouped  under  the  heading  of 
habitual  headache  are  indicative  in  reality  of  e.  congenital  or  degenerative 
form  of  neurasthenia  and  it  is  Tet^  questionable  whether  it  should  receive 
consideration  apnrt  from  this  group. 

With  this  clasaificatiou  in  mind,  it  beconieis  iiecassaiy  to  consider  tl^e 
characteristics  of  headache  ac^companyiug  each  of  these  diseases  and  classes 
of  disease.  tSy  far  the  mout  important  disease  of  which  it  is  a  symptom, 
because  the  moat  eommoQf  is  neurasthenia,  it  is  not  at  all  improbable 
that  nearly  forty  per  cent  of  all  headaches  of  sufficient  intensity  and  dura- 
tion to  demand  treatmeut  are  a  symplom  of  the  neurasthenic  ^tate;  in 
fact,  we  are  justified  in  sayiugtltat  all  he^tdachesof  aa  lutiitctable  nature, 
and  extending  over  a  prolonged  time,  are  Deuraathectc,  with  two  oxcep- 
tioua:  those  due  to  iiraiu  tumor  and  to  meningeal  syphilis.  The  chnrac- 
teriatiGB  of  neurasthenic  headache  are:  (1)  The  lo^^atioo,  on  top  of  the 
head  or  encircling  the  head,      (2)  The  character  of  the  pain^  prdASUra 


532  TREATMEKT  OF  DISEASES  OF  TIlK  NBBV0D9  STSTEV. 

feeling  or  droving  seoflation,  (3)  The  time  of  ite  occnrreiic*,  or,  better 
saiil,  exaeerliation,  for  it  is  asually  present  contiouallj  to  a  certain 
degree.  The  patieut  AwalLona  'witb  headache,  and  it  continues  more  or 
Jesa  during  thd  day,  weaiing  off  toward  eTeningf  being  submerged  by 
tboae  pleLiauroa  or  indulgences  that  inorease  general  neural  tone.  Its 
disappearanoe  coincides  with  the  fpeltng  of  moderate  well-being  which 
moHt  neurasthenics  have  in  the  ereulng,  (4)  The  fact  that  it  in  made 
worse  by  fatigue,  mental  exettioDi  and  eicitemeut.  Sufferers  with  th]& 
form  of  b&adaohe  aie  extremely  voluble  concerning  their  ailments. 
They  harp  on  the  different  maDifestations  of  their  intirmity,  and  have  i 
decided  inclination  to  hypochondri^sia.  Such  pfttiente  ordinarily  preeeat 
the  "suftl  Blight  pUymral  auoompaiainents  of  nministlieiiia :  relaxed  tonus 
of  the  Bkin^  tine  tremor  of  the  extremities,  partieularly  of  the  baud% 
ezcitablo  but  eadily  exhauBted  muscle  and  tendon  rcfiexes  such  aA  the 
hnee  jerks,  and  evideuoeB  of  disordered  digBBtion,  impaired  assixnilatioo, 
and  oonatipation. 

Kysberical  headauhfs  ai'e,  compared  with  tlie  variety  just  considered, 
Tery  uncommou.  Their  diagnosis  rests  6rat  upon  the  nature  and  seat  of 
the  pain,  the  classical  form  being  that  of  a  nail  driven  into  the  head, 
usually  the  aupromo  vertei,  and  its  aasociatiou  with  the  bodijy  and  mental 
stigmata  of  this  ceuroais.  The  more  important  of  these  stignataaie: 
hyper^HtbeHia  or  an#stheHia  in  the  sensory  }<phere  and  apeeial  seoBes; 
hysterical  tremors,  spasius,  or  coatracturps;  hysterical  palsies;  limita- 
tions of  the  intellectual  sphere,  oljspa,sions,  compulsions,  and  defectire 
inhibit  ion. 

Headache  accompany  ing  the  neurosis  known  as  epilepsy  id  an  ex- 
tremely importaut  symptom.  Temporally,  it  may  be  preconvnlsJTe,  post- 
conTulsive^  or  the  <ionviilBi«n  ©ijui^alent.  It  is  rharacteriseil  by  unher- 
alded onoetr  by  extreme  intensky^  and  by  an  abrupt  terminatiou,  followed 
by  a  period  of  great  mental  and  physical  exhaustion.  Pre^wnvidBive 
epileptic  headache  may  be  brief  and  of  tha  nature  of  an  aura.  In  such 
case  it  is  followed  by  a  convuleion,  except  in  instances  in  wbieh  prompt 
and  vigorous  measures  are  taken  to  thwart  the  explosion.  It  ia  particu- 
larly those  cases  in  which  the  headache  is  the  equivalent  of  a  couvulairft 
attack  that  are  followed  by  great  prostration.  The  post-con rula ire  head- 
aches are  characterized  by  a  feeling  of  soreneSB  in  the  he^  undefinL4bi« 
and  unlocalized,  and  by  more  or  less  mental  confusion-  Both  of  tbeae 
diaapppar  as  the  headache  passes  off.  All  cases  of  idiopathic  headachs 
occurring  iu  childhood  and  early  adnlt  life  having  some  or  all  af  ihe  char- 
acteristics just  enumerated^  should  be  iuvesttgated  most  carefully  and 
assidulously  to  determine  whether  or  not  they  belong  in  this  category. 

Headache  attending  exophthalmic  goitre  is  in  its  nature  of  two  kinds, 
toxic  and  neuraethenic.  The  latter  element  is,  I  believe,  the  more  im- 
portant.    The  entire  symptom  camplex  of  exophthalmic  goitre  is  praoti- 


THE  TREATMENT  OF  HBADACHG. 


I 


collj  tbat  of  &  prafouud  sUte  of  neurasthenia.  AVhetht-r  tliis  itevir^- 
thenic  i^ondition  is  priinarilj  or  secondai-ily  toxiu  dofs  Dot  here  coiicuru 
U6.  The  headache  which  ac(x>i[i^ankH  this  diaonler  is  (rhaTactenzed  b^ 
iU  Tertical  and  frontal  liH^ation,  ]iy  its  throbbhig,  pulsating  charatter, 
and  by  ita  ameaabilitj  to  nieasurea  that  cuDtiibute  to  geuerdl  repose  and 
to  slowaess  of  the  heart's  actioa-  It  ia  aggravated  by  aaytbiug  ihe.i  pio- 
dueea  the  antithesis  of  these,  lU  diagnosis  otfera  but  little  dLflioulty, 
save  in  those  cases  in  vbich  the  headache  is  a  preoursor  of  the  pathogno- 
manio  acconipanimenta  of  this  disorder. 

The  XQO&t  impottaot  organic  disease  of  tUo  brain  and  ita  coverings 
uttended  by  headache  ia  tuiiior,  and  ic  matters  not  very  much  what  the 
nature  of  this  neoplasm  may  be,  although  jte  location  stands  in  some  rela- 
tionship to  the  nature  and  seat  of  the  pain.  The  charaoter  of  the  pain  of 
brain  tnmor  is  a  vary  variable  quantity  In  one  case  it  ia  of  a  boriaq, 
gnawing  c.haractfrj  in  another  of  a  distendiug,  skull -splitting  kind,  while 
ID  a  third  case  it  is  a  dull,  conaciouaQess-benunjbiug  acLcn  In  all  cases 
petaistoaco  is  one  cjf  ita  moat  stiikiiig  characteristiea,  especially  iu  the 
beginning  of  the  disease.  Later  on,  when  the  sensorium  beoomea  so  bs- 
uumbed  from  intraventricular  distention  that  pain  does  not  enter  ss  a 
qiiald  of  i^josi-'ioosneaa  the  patient  ceases  to  complain.  It  is  exacerbated 
by  anything  that  jars  the  beadi  such  as  tapping,  coughing,  sneezing,  and 
bodily  agitatioui  and  by  everything  that  increasea  blood  prHasnre  or  a 
determination  of  blood  to  the  head.  Tho  pain  is  local  or  diffuse,  and 
rarely  does  it  correspond  to  the  seat  of  the  tumor  or  inditrate  ita  location. 
Tumor  of  lbs  cerebellnm^  however,  almoat  invariably  is  aix^ompanted  by 
lieajlacbe^  located  iu  the  n'cipnt  or  the  forehflad.  The  occurrenee  of 
hvadache  of  the  kind  above  deacribcd  can  only  suggest  the  existence  of 
brain  tumor;  its  asJiociation  with  other  symptoms  makes  the  diaguosis- 

The  headache  of  brain  abscess  ia  not  particularly  characteristic.  It 
may  be  said,  however,  thnit  it  ia  petaiatent;  severer  during  the  early  night 
than  the  early  dnyj  increased  by  coughing,  jarring,  and  stooping;  en- 
tirely unaiuenable  to  any  medication,  and  geneiaUy  accompanied  by  cor- 
responding and  inLirenaiug  mental  obacnration.  It  ia  not  infrequently 
locab^ed,  partb-ulariy  when  the  brain  aliscesa  is  of  otitiu  oi-igm,  but  in 
many  eases  the  patient  locates  the  pain  remote  from  the  seat  of  the  dis- 
ease. It  is  diagnostiL^illy  HJgnilir-ant  unly  when  associated  with  the  known 
etiological  '>u\d  fymptoiitalic  fcalun*a  of  the  dii^ease. 

The  headaches  of  acquireil  hydrocephalus,  of  enceplxaiitia,  and  of  dis- 
ease of  the  cranial  sinuses  have  nothing  patho^omon ic  abont  them. 
They  aaaume  importance  only  when  associated  with  oUier  and  more  sig- 
nificant symptoms,  such  na  i-ertigo,  vomiting,  eonvidsion^,  and  paralysis, 
for  hydrocephalus;  tlie  m  ant  fetation  a  of  Inllammatory  phenomena,  for 
encephaJitia ;  aud  tho  accompaniments  of  an  iufeotion  or  uiarEiaTuic  condi' 
tion,  for  sinus  thrambuaia,     tleadaabe  acoompauying  the  latter  diaeaae 


i 


634 


TREATMEm"  OP  DIRHASVS  OP  TOB  JTEBVOtTS  STSTKM. 


Up  however,  almii^rn  invaria-bly  locali/eil  to  an  Kreft  correapODding  to  tphe 
eeat  of  iullammfttiou. 

TLe  headaches  of  meoingitia  cannot  b«  easily  and  aati of aclotily  disposed 
of  in  a  few  words-  Every  practitioner  knows  that  all  the  vanetiee  of 
leptomeningitiij  are  attended  by  severe  headache,  and  that  such  pain  hai  a 
naDnber  of  diatlnguiahing  featursa  and  BHaouiations.  The  pain  in  d  acute 
unttet,  of  a  boring^  unendurable  r^haractar,  whioh  cau»e»  the  sufferui  to 
Bhriokout  iu  liU  sleeping  aa  well  as  in  his  waking  momeflils.  It  embrace 
the  eiitire  head,  shooting  from  one  location  to  another,  and  it  is  accom- 
panied by  BQch  diaguoatie  Gymptomfl  as  nuohfl.1  rigidity,  localized  aitd  geoa- 
era]  Bpaam,  pupillary  m&^ualiticB,  elevated  temperature,  and  finally  par- 
alytic phenomena.  In  tuberoulouH  nieuiiigitis  the  lieadai^he  ia  not  ao 
iiiteoae  as  in  aoaie  of  the  oUier  forms  of  leptomeningitis,  and  it  ia  often 
timea  localised  in  the  occipital  and  cerviral  regions,  while  the  pain  of 
purulecit  mecingitis  ia  more  often  frontal  than  occipital. 

The  comnkon  forma  of  pachymeniugitia  are  those  dne  to  syphilid  and 
to  trauma.  They  are  both,  accompanied  by  inteuBe  headache,  which  is 
dua  to  coiDpresHion  of  the  dural  nerves.  Ifoth  tradition  and  eipenenoe 
have  it  that  th^  headacho  of  Byphilitia  pachymeningitio  is  apt  to  l>e  local- 
lEcd  to  a  very  small  area  or  to  involve  the  entire  occipilai  or  upper  ccm- 
ral  region.  The  pain  is  not  continuous,  is  Bometiines  woraa  at  night,  and 
is  exacerbated  by  intellectual  effort  and  by  ^veTjthing  that  increafies  the 
intraoranial  bluod  supply.  Heatladieof  paehynitiiiingitisraniiot  bediBtin^ 
gui^hedi  from  a  consideration  of  this  syntptom  alone*  from  Cephalic  pain 
caused  by  sunh  a  condition  aa  enlargement  of  the  pituitary  gland  in  acTO- 
megaly. 

The  headachea  of  circulatory  disorders  are  not  so  coTomon  nnmerically 
aa  ane  inigbt  )ia  led  to  Biippoae  from  reading  the  chapters  on  these  dlfi- 
easea  iu  the  text-books.  A  detiade  or  two  ago  cerebral  ansmia  and  hy- 
perferaia  received  a  di3p^op<^^lionate  and  undeserved  amountof  attention, 
b<>th  from  the  neitrologiat  and  the  general  practitioner.  Their  oCQurretJCCp 
It  was  thought,  was  quite  an  every-day  affair,  and  a  fanciful,  intricate 
symptcmatio  HUperHtnirtiire  was  erected  to  eiicompa.=5  their  subjective 
niid  objective  accumpauimenta.  To-day  it  ia  wellnigh  UDiversally  con- 
ceded tliat  Tieitber  of  theiw  conditiona  oocors  as  an  lodividiLal  state  apart 
from  pathological  conditiona  in  other  j^ai'ta  of  the  body.  Undoubted Ij,  a 
condilion  of  cei«bral  artEemia  is  a  common  dependency  of  aortic  stenoffis^ 
and  of  mitral  regurgitatLon  when  the  latter  goes  uncompensated,^  On  the 
other  hand,  pulmonary  empliyseina,  pnlntonai^y  atelectiLsin,  a  prolonged 
paioxyam  of  pcrtunsie  or  aalhma,  disease  of  tlie  right  heart,  tt3ay  and  do 
produoo  difficulty  of  egreaa  of  the  return  circnlation,  and  thus  a  slate  of 
hyperEBmia,  but  no  one  wiU  be  likely  to  <;oiitend  that  the  cerebral  anjxmia 
or  hypoTipmia  thus  induced  ia  an  individual  disorder.  On  the  contrary, 
these  factors  are  parts  of  the  morbid  entity.      It  is  very  possible  that 


THK    TBS  A  THEN  T    OF    HEADACHE^ 


536 


prolonged  and  intense  excitementf  such  as  that  of  acute  majiia,  bhe  taking 
of  \a.r^  quatititiQB  of  cardiac  and  vascular  atiiouJaiitfi,  and  posaiLly  f^at 
phy&Lcal  effort,  may  ddtermine  a  digproportiotiate  aniouut  of  blood  withiu 
the  nraninm,  but  the  facilities  for  adaptation  prGvided  by  the  enormoiiis 
lymph  cisterns  soon  equali^u  tliia,  aiid  prevent  it  from  becoming  suffi" 
ciently  permanent  bo  constitute  the  baais  of  symptoma. 

HeadachQ  Ja  a  common  aocumpaniment  of  ay  niptomatiD  cerebral  hyper- 
ffimia  and  ansmia,  and  of  general  anemia.  Its  IndicativeneHs  is  suggested 
by  association  witli  other  symptoms.  When  the  diagnostio  value  of  the 
locftlitj  of  cepUalin  paiu  is  spoken  of,  it  will  lie  seen  that  bea^Uchee  of 
general  anaemia  are  usually  i^oiillued  to  Ibe  foitihead  aud  eyes,  and  asso- 
ciated with  a  more  or  less  sharply  defined  area  of  occipital  preHsurc.  Such 
li«adac?he  is  in  reality  a  form  of  neuralgia,  in  the  majority  of  instances 
conditioned  by  want  of  noumbing  blood  supply  to  the  trigeminal  aui 
occipital  nervsH,  The  pain  of  anrBtnic  h&adaches  is  a  variable  quautil^, 
but  sometimes  it  is  of  almost  intolerable  severity.  The  patient  Is  rarely 
completely  free  from  it.  Its  character  is  that  of  a  heavy  presfiing  sensa- 
tion, but  at  the  periods  of  its  exacerbatiou  it  is  throbbing,  and  relieved 
by  eztercal  pressui'e.  Thtf  headai?hea  that  accompany  chloroaiEj,  pro^^ea- 
Bive  [^mieiouB  anaemia,  and  leukit'iuia  have  no  striking  cbaiactenstica 
that  difTerentJate  Lh^m  from  general  anaemic  headaches,  Thi»  beadaobea 
attending  leuksemia  are  not  bo  iutolerable,  DOb^itb standing  th«  gravity  of 
this  disease,  aa  those  of  general  anouniia  and  chlorosis. 

Headache  due  to  orgauio  disease  of  the  blood-veaaela,  artorial  scle- 
rosis, is  associated  with  other  v»ry  signiticant  symptouis,  a  cuusideration 
of  vhich  readily  makt^s  the  diagnosis.  These  are  vertigu,  slight  jiyucopal 
attacks,  disorder  of  the  nutritional  equilibrium^  changes  in  the  blijod-ves- 
sels,  detectiblo  to  the  touch  and  to  the  eye,  alight  mental  deterioration, 
and  generaJ  lowered  vitality.  The  headache  is  usually  of  a  throbbing 
character,  oot  infrequently  aaaoeiated  with  so^inds  and  noises  in  the  ear, 
H  BenaatioQ  as  if  the  head  were  being  drawn  forcibly  backward^  and  with 
a  feeling  of  portentous  dread.  It  is  increased  by  everything  that iucreHsea 
blood  pressure  and  by  e^etythiuf;  that  diminishes  vital  force. 

The  headacliea  that  are  grouped  under  the  caption  of  reHez  headaches 
are  a  very  important  clasa,  not  so  mncb  because  of  their  freqaency,  but 
because  of  the  fact  that  they  are  extremely  amenahlp  to  treatment  if 
inteipreted  early;  and  eiLremely  sluggish  to  any  therapeutic  rt'spoiise  if 
they  have  been  allowed  to  go  un  for  a  Long  time.  In  other  words,  if  ihey 
are  attacked  before  a  headache  habit  is  formed,  remedying  t^hc  conditioaa 
on  which  they  are  dependent  Bufiiees  to  core  in  the  vast  majority  of  cases. 
if  they  are  rot,  such  orthopteiHc  measures  only  alleviate  but  do  cot  cure, 
Hy  far  the  commonest  cause  of  reflt:ix  headache  is  improperly  iniplantcl 
or  innervated  musculature  of  the  eyes  and  defei^t  in  the  refractive  media. 
The  headache  whieh  theae  two  oonditions  cause  is  in  reality  an  exhauatioii 


536 


TRttATMCNT  OF  PtS&ASSS  OF  THE  ffSHVOCS  SYSTEM. 


headache.  If  it  (ujoblnuea  for  a  li^ug  time  it  \s  Almost  Empoaaible  to 
ilifTereirttate  it  fraiu  ueuniAtheiiii;  bcadat^be.  If  some  vt  die  tuusclea  of 
the  eyes  are  so  dettcient  congenitally  or  aa  the  rvenh  of  di^eadC)  tbftl  ft 
strain  is  ooiktinii&Ily  put  upon  other  mui^oUa  in  onli^r  to  cuuse  normal  bi- 
HQciuJar  viciion*  or  if  the  comea  and  cryatalliae  leas  ai^  so  ill  prepureLi  for 
their  function  tdiit  tli»»y  do  not  fooua  parallel  rays  of  light  imiuftliately  on 
the  reMiiaaave  hy  the  efTurt  of  iiuLacle^  tu  cliange  their  r^ii  of  i-urvatuiC:, 
ttieu  the  Btraiu  thits  caused  induces  sSteT  a  tiiue  n  state  of  prafounil 
neural  exliauation  which  U  manifest  by  headache,  Thia  headache  has 
ut^ually  the  following  oharactc^FiBtic^ :  It  is  limited  to  the  forehead  or  tu 
a  very  Dtrcuib scribed  spot  in  the  occiput;  it  is  luade  worse  by  use  of  tb^ 
eyes,  aiid  it  is  remedied  by  resting  the  eyes  and  by  anything  that  tem|io' 
rorily  parulyicA  act^jmiitodatioLk.  It  is  never  pceaeut  on  aiisiug  ia  tba 
morning,  and  one  of  its  most  striking  features  is  that  il  is  atrirtty  aab- 
batarian.  Fortutrately  oi-diuary  routine  exatnination  is  often  all  that  is 
Dec«fiGary  to  ahow  the  shortnominga  of  the  peripheral  ociilar  apparatcis 
and  to  indicate  tlie  neeessiiry  nieasnrea  to  overcojiie  it. 

The  next  most  comnioti  voiiely  of  reflex  headache  la  froon  the  pelvic 
organa,  and  this  variety  of  hfadai.^ho  ia  peculiarly  an  exhaustion  h^adacbe^ 
It  ifl  not  met  with  nowadays  one-half  so  often  as  it  was  ia  those  tiinev 
vli«iL  it  was  the  vo^ne  tpO  tinker  with  the  generative  oi-gana  of  tho  fenial^. 
Kellt^x  uterHie  hcnducltci  has  been  expiated  at  the  shrine  of  the  inodem, 
min-meddloftoiiiH  gyui^cologisf.  Headache  assMniat^d  wiUi  j>oaterior dia- 
plarementa  of  the  uteriis  4ind  cervical  lacerations — two  important  causes 
of  utf^rino  bcaduclie—is  usually  neuralgio  in  character,  ita  favorite  loca- 
tion being  in  the  ocHput  Sut'h  cephalalgia  is  often  associated  with  ten- 
derness on  pressure  in  the  cervical  region,  and  with  "weak  back/' 

J(]dging  from  my  <»wn  utperieuce  as  well  as  from  the  statemeDta  of 
rhiuologistSj  headache  associated  with  diaeaae  of  the  n-isal  pa-ssages  with- 
out involvement  of  the  frontal  sinuses  and  cthmoiditis  is  net  very  com- 
nii.111,  althongh  Bome  natial  specialisia  would  bare  us  believe  that  more 
than  thr«e-fcurths  of  all  headaches,  including  migraine,  are  due  to  dis- 
order of  the  nime.  The  LntettL]ier»teneHH  of  such  aelaiui  shows  that  the 
one  who  makes  it  has  his  visual  horizon  limited  to  the  iield  of  the  nasal 
apeculum*  Uasal  hcadacliea  are  usually  duo  to  irritation  of  the  braucbea 
of  the  trigeminal  nerve,  nauso^l  by  awelling  of  the  mucous  membrane  and 
deformity  and  hypertrophy  of  the  nasal  walls.  It  ia  frontal  in  location, 
usually  abfiTe  the  root  of  the  now,  of  a  dull,  boring  eharaotet,  oftentimea 
relieved  by  gentle  frontal  pttrssuru  and  temporarily  lessened  by  sniffing 
pungent  aromatic  eubBlances,  It  is  more  or  less  continuous,  but  v-ery 
liablii  t4>  paroxysmal  e^tacerbations.  It  is  worse  in  the  morning  immedi- 
ately on  arising,  and  usually  Et  diminishaa  materialEy  after  the  patient  has 
hiu\  his  bath,  breakfast^  and  anything  elae  that  improvei  the  general  r'lr- 
culatiou  and  temporarily  invigorates.      If  dependent  upon  ethmoiditis  or 


THE  TBBArMKKT  OF  UEAT>ACBE. 


657 


(lit^ease  of  Xhs  froot&l  einufl  the  accciupajiiment  of  aw^lUog  on  the  orbital 
surfaces  of  the  nose  ard  tha  discharge  a.re  unportant.  H eat] atrliea  that 
are  reflei  from  tlie  eat  are  very  unramzuoii,  aud  when  Uiey  oi^tur  tbey 
have  Qo  difltinguiHhlQg  features,  save  the  location  iu  the  maetotd  and 
temporal  lej^ious. 

Headache  reHex  from  other  sources^  snob  aa  from  the  aexual  organs  of 
the  male,  ate  oft^ntloies  siibjeetive  atates  of  eonsciouBiieflfl  on  the  part  of 
the  diagnosticiaa. 

HeadacheG  of  toAio  origin,  using  the  word  toxio  to  cover  9Qdog«uou9 
and  exogeuoua  sources^  have  little  in  their  localization  or  character  to  dis- 
tinguish them  from  other  headaches.  The  fact  that  they  occur  in  persons 
who  use  tobacco,  alcohol,  tea,  drugs,  e5c.,  aud  in  tliose  who  are  exposed 
to  tha  absorption  of  lead,  carbuu  dioxide,  mercury,  phuaphDrus,  and  other 
metallic  poisons,  leads  one  to  euaitecb  theii  tiue  urigiij,  while  the  presence 
of  othiT  more  characterbtrc  features  of  aui^h  intoxication  atteata  the  diag- 
nods.  Like  the  h^ada^he  of  aiLtotoiJomiQT  particularly  those  atiaoinated 
with  tnteatinal  catarrh,  they  are  oFteneet  hicated  m  the  front  of  the  head, 
and  described  aa  heavy-presau re  feelingv,  though  sometimes  tliey  are  of  a 
thrulihing  nat^ure  mude  worj:^e  by  aaythiDg  that  disturbs  the  vascular  cir- 
culation. The  metallio  poisoiie  arsenic  and  iodine  produce  a  very  charac- 
tenetio  feeling  of  ButTuaion  in  tho  forehead,  \rhile  lead,  on  the  other  hand, 
frequently  causes  a  diffuse  pain  eittending  over  the  entire  cranimo,  but 
occasionally  con fioeil  tooneepoiin  the  distribution  fif  the  trigeminfi.1  nerve. 
More  than  a  few  varieties  of  lieadaclieaare  aoaociatedwith  disorder  of  tha 
digesbiTe  apparatus,  Pour  factors  enter  ordinarily  into  their  production: 
(I)  Th«  abaorption  into  the  ayateni  of  prodn^^ts  of  incomidete  digestion 
and  assimilation,  which,  in  the  process  of  metaboliain,  principolly  in  the 
liver,  result  in  the  formation  of  alkaloidal  Bitbstanoea  having  toiia  prop- 
erties', (2)  diminntiou  of  blood  preasuro  apart  from  that  produced  by 
thv  (ictiou  of  the  resulting  leuconmius  and  ptomaiua;  (5)  gciteral  and 
local  anaemia,  which  la  almost  iuvariably  nn  accouipaniment  of  indiges- 
tion ;  and  (4)  retiexly,  fi^om  distention  of  the  ga^tiio  aud  inteatinal  walls. 
These  hea'Iaehea  are  usually  frontal,  often  located  immediately  above  the 
eyebrows,  and  the  pntifnt  doacrilies  ttte  pain  aa  a  confused,  apathetic  feel- 
ing, with  e^acerLiationa  of  sharp  pain.  )t  ta  almost  iitvariahly  worse  in 
the  morning,  and  ia  fTe<iuently  relieved  by  purgation  or  by  vomiting-  The 
diagnosis  is  to  be  mude  from  the  condition  of  the  patient^s  breath  and 
tongue,  from  the  accompanying  phenomena  of  disordered  etomachie  and 
intestinal   digestion,  and  finally,  if  uecesaary.  by  the  administration  of 

iCMt  meal^  its   removal  and  analysis.      Headache  that   accompanies  an 
k  q£  acute  indigestion  varied  in  its  locaiizatiou,  character,  and  iu- 

naity  with  each  patient.  In  my  experience  the  commonest  location  ia 
the  anterior  half  of  tliohead;  the  pnin  iii  of  a  throbbing  character  ayu- 
ehronouB  with  the  heart  beat,  and  It  is  made  very  much  worse  bj  physical 


538  TREATMENT  OP  DlSKASES  OF  THE  NKKVOUS  SYSTEM. 

Rotivity,  aiiil  HApecLftlly  hy  sudden  chuug^s  in  the  posjtioit  of  tJis  bodj. 
It  ifl  often  H.'asuciatf^d  *ilJm  aeiisaUoci  of  acoUaror  band  boiuid  tigbtljr 
around  ihe  uei^k,  with  fJusbrnguf  the  face  ftiid  alight  uijection  of  tiie  cmi- 
jocativa.  A  form  of  inteatinol  troable  which  «oaietuDea  produoes  h^d- 
arhe  in  ehildren  u  the  pri^sence  of  parasitcB.  The  diagnoBiB  is  to  be  made 
only  wlitin  the  purasittiH  urn  found  In  the  Htools. 

He&dache  is  tho  commonest  foreruuner  of  the  infectioun  diseasea,  but 
with  the  exception  of  a  few,  buch  aa  avphilifi,  malaria,  typhoid  feri^r,  in- 
fiueiiza,  and  epidemio  cerebrospinaJ  ineningitiu,  they  have  no  distlDgiiiHh- 
iag  featured.  Headache  is  an  extremel/  important  accompaniment  of 
Byphilitif!  disease^  and  it  shows  itself  either  during  the  period  of  eruption, 
or  as  a  aymptom  of  ]at«  syphilitic  manifeislatiaiui-  The  headache  of  the 
eruptive  period  may  L^e  distributed  over  the  entire  head,  or  liwited  to  th« 
cooiput  Very  rarely  doea  it  reveal  itnelf  oBht^micrania-  It  is  not  diBtin- 
guiBhed  so  much  by  its  location  aa  it  is  by  the  fact  that  it  occurs  usually 
at  night,  or  in  very  much  worse  at  this  time.  During  the  day  it  dimiiiiahes 
in  severity  or  diaap[>eaifi.  It  ia  not  infrequently  accompanied  by  manifes- 
tations of  froutiil  or  parietal  i>ci-i ostitis,  diacemible  to  Uie  sight  and  to  rJir 
touch.  Headache  aciTjiiLpaitying  the  later  stages  of  syphilis  is  p«rhapB  of 
even  moid  frequent  occur renee.  Although  it  has  a  decided  predileouoa 
to  be  worse  at  night,  it  is  more  readily  recognized  by  its  asBociatiou  with 
vnrtigo,  slight  deineiiLia,  pari'^is,  or  spasm  cif  the  mnsciilatnif  of  the  cranial 
nerves,  and  by  other  irritative  and  paralytic  phenomona  which  pursue  an 
extraordinary  course,  than  by  any  other  feature* 

It  was  formerly  tlionght  thut  headache  of  raalarial  infection  waa 
usually  B  nenralgic-like  patn  over  thi^  eyebrows,  having  as  a  strik.ing  fea- 
ture its  periodical  occurrence,  but  Uie  re«ent  eKperienc^s  of  onr  eiti£en 
acldiers  in  the  tropics  have  ahown  that  at  least  the  he&dacbes  of  aL'ute 
malarial  infection  have  no  diagnostic  features.  It  ia  quitf  impossible  t9 
differentiate  them  from  those  of  typhoid  lever.  It  is  probably  true  that 
the  profound  anemia  which  is  enoh  a  striking  accompaniment  of  chronic 
malarial  poisoning  expreasPB  itself  ciftenest  in  the  nervous  system  by  a 
neuralgia  of  the  supraorbital  uerre-  But  nowadays  one  would  not  be 
likely  to  make  the  diagnosis  of  malaria  without  havini!  discovered  sorne 
form  of  Plasmodium  in  the  blood* 

The  headache  of  epidemic  cerebrospinal  meningitis  is  so  charactemlic, 
both  in  its  Icxialicni  ami  intensity,  that  it  requires  no  detaded  description. 

The  variety  of  headache  knuwn  as  habitual  beadache,  or  idiopatlns 
headache,  haa  very  little  in  its  l^jcation  or  in  the  character  of  the  pain  to 
differentiate  it  from  neuiaathenic  headache,  and,  as  haa  before  been  aaid, 
it  is  not  improbable  that  it  is  in  reality  a  manifeatation  of  this  disorder, 
although  usually  none  of  the  somatic  or  psychical  concomitanta  of  nervous 
exhaustion  are  to  be  found. 

Tranmatic  headache  is  so  obvio^isly  dependent  upon  injury,  and  9^ 


THE  TREATMENT  OF  BKADACEEh 


639 


I 


usually  ftttfinded  witli  iig  objective  BCtotnpanimenta  thatiC  requu'ea  tio 

further  mention.     When  persirtteiit  anJ  rebellious  ki  tn^sitment,  its  asao- 

ciatioii  ^'itili  localized  pach^meuiiigitis,  or  even  graver  diaeo^a  of  tihe 

intracTaiLial  structures,  ohould  be  borao  in  niiad. 

Rbeumatio  epii^ranial  ni3^ositis  la  of  more  Frequent  oceuireiioe  than 

OUQ  would  be  l^d  to  suppose  from  the  aoaat  r«f«reuoe  lo  it  in  the  literA" 

ture^      It  ia  occompH- 

nied  by  beadache,  and 

tba  fianie  features  as 

myojiLtis  ia  B^y  other 

part  of  the  bodj«  and 

by  such  it  ia  to  be 

diagnu8tiiuLt4Ml . 

Much  help  La  the 

proper  interpretation 

of  hcadaoho   may  be 

obtained  from  a  cai-e- 

ful   consideration    of 

ita  location.    Nut  that 

headache  due  to  an 

indiridaal  cause,  anch 

aa  eye  strain  for  ex- 
ample, ia  always  re- 
ferred  to    the    same 

area  in  the  head,  but 

if  mi  average  of  all 

tho  cases  of  headache 

as!Jo<riat^   with  such 

a  condition   is  takeu 

it  will  be  found  that 

the  paia  is  localised 

by  the  sufferer  either 
in  the  frontal  or  the 
occipital  region.     In- 

Btead  of  giv^in^  verbal  deKcriptkm  of  tlie  location  of  headache  as  a  iliag- 
nostiu  indic^ittioii,  use  ia  made  of  the  acoompauyiag  diagraiiks  (Figs.  22, 
1i^)t  which  are  based  on  diaRranis  orijpnally  puldiahed  by  C  L,  Dana,  It 
flbould  be  borne  in  mind  that  thei^e  are  somevrbat  sobematic,  arid  that  the 
headache  of  a  givftn  area  does  utit  necessarily  conBne  itself  tliera,  or 
manlfaat  itself  there  on  eTery  occasion. 

Afti^r  all  that  has  been  said  concerning  the  character,  duration,  seat, 
Intensity,  and  diaguofttic  significance  of  headache,  it  may  Beem  Hopcrflu- 
ous  to  pursue  further  the  aubject  of  diagnosis,  but  aa  the  correct  inter- 
pretatioD  of  headache  ia  of   paramount  iioportanee  ia  determinitjg  the 


Yui.  SL-  l^umibH  \ppTtiX\nMtP  LvrUloiuiol  iNilq  |q  ll<4lv'llc 


nCKATHENT  or  DISKASES  OP  THE  WRVOUB   STSTSM 


54a 


iBCCiOiifill  trfttLftiflut,  it  may  nvt  be  aiuL&a  to  flav  a  few  "wxirdtt  cnor« 
iBpoctwit  pLuv  of  the  subject.     AfMr  the  symptom  hAs  been 
frott  tb6  points  of  new  that  have  been  loentioaed,  the  eTentnal 
sbotU^  ba  roanhrit  bj  process  of  exclusion.     The  fint  tlung  to  do 
«xehidtt  the  f«pbalic  pains  of  Deiiralgia  aad  of  migraite-      The  pain 
«« ipoHk  of  as  oeuralgia  of  tlie  trigemiital  uerve,  and  of  the  cjceipital  u 
Um  uppet  branvlics  of  tbe  o^rrii-Al  n^rres,  ta  to  be  didtiu^LAhe^  6nrti  I 

its   locatjoD   LB   ttei 


tnaf^iufron 


\ 


OK^lai 


'_  y^t 


^ 


Der  vas  and  «loag  Iht 

tL«  character  of  tl 
paiii,  which  is  ofii 
ofaetiarpr  unbcanU 
kind,  reJ&tirelj  p«i 
sUtent — that  i^  will 
out  periods  of  inlet 
mittoncf ,  and 
uouB  for  a  long 
thinlly,  by  a 
tireoess  of  the  epi 
cranial  structures,  hi- 
cludins  ^^e  Ixair,  U\ 
which  theao  uertoi 
are  distributed;  a^ 
fcurtbly,  by  Uio  » 
that  tills  variety  d 
cephalic  pain  is 
ujcst  alvay^  relie 
temporarily  at  t 
by  hot  applications. 

MigrulEie  is  to  ha 
dUtiuguiahed  by  ^M 
location  of  the  piais, 
lOTilly  Pnaflaml  to  one  side  of  the  head;  b j  ita  aaaociatioii  vith  na 
iroaLhtttt^i  lupbtal  depresfiiou;  vasomotor  diBtvirbances  of  the  face^  ei 
fuaUagar  |i&ltor;  hf^miaaopic  obst^uratioa  uf  visioDf  by  flashes  of  ligK 
phaniaaiftf^^' "j  or  sootimiata;  vertigo-  ringing  tiL  the  car9;  and  otrcasiqn^ 
ally  with  paralysia  of  one  of  the  oculomotor  iierren,  all  of  which  aymptoM 
an  OMftla  voT$e  by  the  slightest  physii^al  or  mental  eflWt,  Tliey  are  often 
amtUoratvd,  capei^ially  iu  overworked  mid  iiitoDBely  neurotic  peoplo,  bj 
taking  Baall  quaatitiea  of  predigested  or  easily  asaimilated  food  and 
lUff«^Ua  ^imulauts  iu  ^tuaXl  qunutities, 

j^ftarth^  iLt^aralglc  pain^  uiid  irngraiiie  have  been  excluded,  it  betioi 
a^cl^tTT  to  astabliah  the  fa^t  that  the  cephalidgia  is  not  due  to  dii 


■4 


VMh  fib-  M#iii«ir  JlpffQiJiiiulP  lAailau  *^t  l^ln  U  Ifewliubv. 


Z. 


THS  TnKATVBJrr  or  B%AT>AnfS. 


of  thd  ^picrajiiiini  aud  of  the  cnmial  bones  and  tUeir  oitvitiaa,  tuoh  mm 
rbeumatic  myositis,  periostitis^  caries  and  InHoiikmaLion  of  tho  frontAl 
sinuBes.  Tbe  6rat  ua.ri  bo  excluded  bv  the  local  toBuifeaUtioiiji  juiil  Uy  Llii< 
lASOciatioa  of  other  a^mptoma  of  rbeunnutiam  and  iiHcaci4ljrmi&,  Civioa 
of  the  OTonial  bonea  and  periostitis,  be  they  syphilitic  or  tranmntio,  will 
bA  Accompajued  by  etiological  or  symptomatic  features  that  diatingaiah 
theiD,  while  tha  locatioo  of  haaclache  duo  to  cat&rrh  of  tbe  frontul  sintLiea, 
lis  aasociation  with  disordered  intcuatioii,  and  itfi  accciiLpauMneut  of  uui' 
lateral  tt^al  discharge,  will  prompt  the  di&guoeis.  The  headat:he  of  etli- 
moiditifi,  which,  is  more  commoa  than  generally  BUpposed,  ia  usually  of 
&  neuralgic  naturef  located  in  the  fiootal  sjid  iiitra-orbital  vegtoii'&y  and 
ftceompanied  by  imiZatenl  or  bilateral  aw«Ilmg  which  is  palpable  cm 
«ither  tilde  of  thn  toot  of  the  tiase^ 

Bm:au0O  headache  ia  often  the  iaittul  and  the  moat  c-ouaplcvious  symp- 
tom of  diacaae  of  th&  braiti  and  wenjngea,  painatakiu^  care  shovdd  be 
taken  to  eKcluJe  thetie  diaeaaefl-  Although  headach©  ia  weighty  aboVt* 
everything  eUe  in  auggesting  the  presence  of  Buph  disease,  it  is  only  wjiea 
in  aasodatiou  with  Tomitiiig,  dellTUini,  vertigo,  oonviileimia,  BpajfUdty, 
iiLkchal  rigidity,  paralyais,  and  inflammation  or  atropliy  of  the  optic  nerve, 
determined  ophthalmoacopicallj,  that  ithiu  such  dread  import.  After  the 
pFOce^  of  exelusion  haa  bt?en  brought  thus  far  in  the  estimation  of  tho 
kind  of  headache,  it  behooves  ua  to  give  conaidemtLon  to  the  or^na  of 
apeclfll  sense,  particularly  the  eye  ajid  the  nose,  to  detemiine  wheiber  there 
be  anomalies  of  refrat^tiou,  muscular  iiisufficiency,  or  organic  diat^ane  of 
the  eye,  such  aa  glaucoma  on  the  one  hand^  or  anything  encroachitig  on 
the  nasal  passages  on  the  other. 

Finally,  the  circulatory  apparatiia  and  the  blood  should  be  investi- 
gated, after  which  sourcaa  and  evidences  of  iotoiications  and  infectiona, 
both  within  and  without  the  Irody,  are  paaaed  in  review,  leaving  far  final 
consL deration  the  elimination  of  the  neuroaea,  Deuractbenia,  epilepsy,  aiii) 
hysteria,  it  ia  not  unlikely  that  when  one  ia  done  with  thia  painstaking 
pnx^esB  he  will  tind  that  the  laet  one  conaidered  ia  the  category  to  which 
the  headache  belongs.  Having  his  labor  for  his  pains,  he  may  cociiule 
bimaelf  with  tlie  German  proverb:  *'  Ueibung  macht  den  Meiatei.*' 

Treatment.— In  view  of  all  that  ba^  been  said  coneerning  the  multifan- 
ona  causes  of  headache  and  the  widely  varied  conditions  under  which  it 
occurs,  it  is  not  at  all  surprising  that  no  individual  or  specific  method  of 
treating  it  exists.  There  is  no  aitoeDt  in  the  domain  of  medicioe  that 
requires  more  careful,  searching  investigation  to  elicit  ita  causation  and 
nature  than  headache.  In  order  to  treat  it  successfullyf  the  phyfiiciaii 
moat  determine  the  morbid  indicatiTeneas  of  tlie  symptom,  then  adopt 
meaanrea  which  combat  it.  There  aeerua  to  be  a  aort  of  traditional  belief 
that  certain  dmgs  are  more  or  leas  epecifie  for  headache.  Implicit  credu< 
li^  of  thia  kind  acconnta  in  part  for  many  nncured  headarhea.      At  the 


542 


TRSATHKNT  OF  DISBASB9  0¥  THD  NERVQUB  HTSTEM. 


present  day,  it  hen  it  ia  00  t^yto  relieve  pain  temporarily  I17  giiriug  com- 
mou  on^IgeaiCB,  the  tpeaiptatiun  of  the  pbysiciui  i&  to  prescribe  m  rouCme 
ffiahioii  some  of  these  t^mpovLeing  agencieB,  truBtiiig  that  uatui^  niU  do 
the  rest;  while  the  habit  of  tbe  piitit^Et  Ib  Ijj  go  to  the  dnig-Hbc*^  mid 
buy  a  beaiUrlje  iKtwdei.  Alt.ht^agh  it  i&  a  juat  and  legitiuiatw  ptut&lurc 
bo  qaell  pain  promptly  and  at  a]L  hazards,  it  is  no  h&a  incumbent  upon 
the  phybioinu  to  try  to  prevent  the  rerurrence  of  such  pain.  Trealraentof 
headaches  offers  a  splendid  lit!i  for  the  exercise  of  nuch  etideavor,  and  h« 
who  contents  himself  with  giving  phenaretin,  antipynn,  the  brumidw, 
and  ttifi  liket  without  seBkiiig  the  ulterior  cause  and  attacking  it,  is  pre- 
declined  to  faihuct  and  does  bolh^he  p;(ti<.'nb  and  hiuiself  an  ii;justic«. 
The  Srat  duty  when  ounfronted  by  a  patient  suffering  from  headache  ia 
to  determine  to  whvi^h  of  the  four  categoriea  enumerated  in  tho  beginning 
of  this  article  it  belonga.  Is  it  migrainous,  neuralgic,  symptomatic,  ur 
idiopatbiti  lieadaohe?  Tt  in  extrtimely  uecessary  to  make  ibis  diatincLioii^ 
Ar  altbougb  tbe  treatment  of  one  variety  may  not  be  absolutely  disAimilar 
to  that  for  thf.  othci,  to  recognize  it  ae  belonging  to  one  of  theae  claaaoA 
may  immediately  orient  oue  not  ouly  ajj  regards  treatment,  but  aA  to  pr^- 
nosis  aa  welL  Tbe  nevt  step  is  to  det«rmiue  the  diseaae  of  which  it  ib  a 
aymptoniatjc  accmiipaiiimeut.  Then  ita  treatment  can  b^  legidmateLy 
UUdertakeuK  To  paaa  in  review,  even  though  briefly,  tbe  measures  thit 
have  been  reoommended  for  the  relief  of  this  common  diaordcr  would  bo 
bewildering  and  uuprodtable.  I  Bhall,  therefore,  apeak  only  of  moaAorei 
with  which  1  have  had  personal  e)cpeii?nce. 

In  brief,  the  treatment  of  be^ulaehe  preauppases  tha  correct  etiological 
diagnosiSr  which  iu  turn  depends  upuu  a  »earehiug  examinatioa  of  cverj 
system  of  the  body,  and  eajjecially  those  syfliema  that  esperience  has  taught 
ue  stand  iu  frequent  relattotiahip  to  this  symptom,  and  the  use  of  tempo- 
rizing meaaurea.  The  lattt-r  are  of  Tery  groat  value,  and,  fortunately,  few 
in  number.     They  luny  be  pouvenienUy  refenod  to  in  four  groups : 

1.  Drugs  tbali  are  deiived  from  coal-tar  distillation  aud  synthetically, 
possessed  of  arialgeeic  properties;  phenaeetin,  tropheniu,  exalgin,  salol, 
and  liombinations  of  the-ee  with  alkalies,  such  as  antikamnia.  2,  J>rugB 
that  are  plant  derivatives,  aetiiig  pnncipally  upon  tbe  vascular  systfim? 
cafTeinp,  eannnbis  iadii-a,  and  opium,  3.  Mineral  compounds,  auoh  aa  th* 
bromidf  Sf  actiug  principally  upon  nerve  r.ells,  aud  the  salines,  uctiug  upcn 
the  ciroulatoiy  fluids  to  produce  watery  evacuations.  4.  Antiapaacuodirs 
and  paralysers  of  striped  muscular  tiasnc,  Buch  as  ethereal  sabstancee  and 
bella^lonna.  It  is  often  necessary  to  give  one  or  more  of  tbe  coDStituents  of 
theae  four  elassea;  it  matters  nob  what  the  form  or  causation  of  the  head- 
ache may  be.  Speaking  generally,  it  may  be  said  that  tbase  of  the  first 
class  may  be  relied  upon  to  produce  an  amelioration  of  the  pain  in  all  head- 
aches, save  those  due  to  infiamuiatory  disease  aud  to  pressure'  Those 
of  the  second  group  are  particularly  aervicesLble  in  headaches  accompanied 


TBS  TRBATHB!>rr  OF  RBADACBB. 


048 


\i\-  luiirked  deTiatiivu  ^^£  bloud  pressure,  caffemo  being  Ihe  sjmptout  mfi]i> 
ciae  par  excellence  in  Leadachea  ^ssociat^d  with  lower  vascular  Uiutioa, 
aud  canaabia  indica  m  those  asaodatod  with  a  pulse  of  high  C^iiakou. 
The  symptom  medicines  in  the  third  group  have  a  mueh  more  ^^ottBued 
ipplication.  The  class  vepregeated  by  the  bromides  hSTO  their  L^hiof  i»so 
in  epilaptic  headaches  ^id  headache  with  vasomotor  aymptoDjBi  whiln  Lha 
oaltnes  are  Darrowly  coutiued  in  their  \iA&g&  to  tliR  hendaohes  of  auto- 
iatoxicaliojt.  The  dcuga  of  the  fourth  cJoaa  ace  of  use  principally  in 
headaches  asaocia-ted  with  Bpasinodic  aud  fatigued  action  of  peripheral 
tDUSculnr  apprimtus. 

Headaches  of  the  Functional  Heurosea.— UnqiiesUoDably,  the  common 
fonn  of  headache  that  the  general  practioner  ia  called  upon  to  treat  in  this 
couQ  try  to-day  19,  1  think,  that  aaaociated  with  the  exhausted  aud  initabld 
condition  of  the  Ejmpathetie  and  cerebrospinal  systema  known  aa  neurai- 
thenia.  It  is  a  variety  of  headache  that  is  diftlcult  to  curef  especially  the 
forma  that  develop  in  early  life,  aJid  for  which  there  neemH  to  be  no  adi- 
qnate  determinable  cause.  The^e  caata  represent  an  inborn  tendency 
toward  neural  instabilty.  Headaches  sjmptou^atic  (jf  the  ncurastlidiiio 
ptate  ooeurring  in  adult  life  and  from  determinable  causes  are  usually 
quit«  amenable  to  treatment^  while  thosa  occurring  in  later  life^  particularly 
if  th^y  are  the  expreEsion  of  a  second  or  third  attack  cf  lieuraBthenia^  aro 
yery  rebetliouA.  Tlie  treatment  of  □euiaatheuio  beudachea  conaitttfl  in  tho 
removal  of  the  causes  and  the  adoption  of  meaaurea  directed  iinmedialely 
to  the  relief  of  the  neuraathenic  6tat^.  These  measures  comprise  intelli- 
gent restf  exercise,  sport,  change  of  euTironment,  which  maymean  H]m|tly 
change  from  home  to  a  board  in  g-honsej  or  vice  versa,  increase  of  nutrition 
thmiigh  diet,  and  hjdric  applicationa*  and  in  some  rases  the  u?ieiff  rnauag* 
and  electricity.  The  u^e  of  water  in  the  treatment  "i  aeiiraatbenia  w 
adequately  discussed  in  the  chapter  on  neurasthenia  and  need  not  be  con- 
sidered here.  Headaches  osaociated  with  increased  vaacnlar  tension,  flush- 
ing of  the  facpj  and  throbbing  seusaiions  in  the  head,  are  often  reLiev«U 
by  cold  applications  to  the  head,  by  wrapping  the  head  in  linen  wrung  ont 
of  cold  water,  andby  the^uimstrationof  aaitz  liath,  lulf  bath,  ur;idetiT- 
Ative  foot  bath-  Sometimes  they  are  quickly  relieved  by  b^vin^  the  pt' 
tient  bold  each  foot  suoceasivelj  from  thirty  to  for^-fire  seoonds  in  cold 
water  as  it  folia  from  the  tap-  Xeurasthenic  headaches,  araod^tod  with 
sleeplesaness,  are  in  my  experience  more  quickly  and  wholewnnely  tnflu' 
enced  by  a  full  aarm  bath  of  from  9fi^  to  102^  Fj  to  whieb  from  one  to 
two  ounces  of  pine-needle  extract  is  added,  and  given  just  before  retlHng, 
than  by  any  other  meomreA,  By  a  seeming  cotitr^iHion  in  terms,  rest 
for  the  neurasthenic  patient  often  means  coQEiderahle  physical  ezcftiac, 
and  the  advent  of  golf  and  bicycling  a4  faahioDable  indulgmcea  liAve 
marked  the  rocks  and  Uinkeis  oq  which  many  a  nenraatbeDio  bradathe  baa 
been  shstteied.  * 


I 


544  TREATVSKT  OF  DISEASES  OF  THS  NBRVQCfl  BTSTBH. 

The  treatment  of  fmictioaai  symptomatic  headache,  be  it  neunutbenk 
or  hyflterical,  by  KWtrinity  is  not  »  fmitfol  Biibjwl  for  dLsctusaion.  Occa- 
»iGiially  lieoflache  of  this  kind  that  maiutoinA  stuhbomotms  to  every  form 
of  therapy  eiic^umba  to  spaiks  from  the  atatic  mochioc  ftdmiDiEit^retf 
throtigii  a  coronal  olertrodc.  Ocoabionally,  aEuo,  the  admiDiatratton  of 
A  very  mild  galvanic  ourrent  of  from  one-hatf  to  oua  milliampert  and  of 
five  minifies'  duration,  the  poailive  pole  at  the  back  of  tha  rect^  tt* 
neg&live  fioleov^r  the  foreheatl,  has  been  of  service  in  ]ieftdaclji:'»  occurring 
wiUi  tLe  depressed  form  of  tieuraathfiiiia<  The  effect  of  the  electricity  is^ 
I  hfllievef  to  be  attributed  to  Buggeation^  The  medicinaJ  treatment  o1 
neuTQBtheuic,  hystorical,  and  epileptic  headaches  is  not  eo  importaat  as 
the  general  CreatnieTit  save  in  the  lantter  dieease^  In  netirasthenlc  head' 
aches  aosod&ted  with  low  vasi;iilar  tenfliocir  caffeioe,  either  alone  or  in 
combiuatioD,  giyes  exoelleiit  reaulta^  The  foltowiijg  formulae  I  £iid 
ticnlarly  tiaefiil: 

9  riif!i?1n.  cltratLi p.  v- 

Sodii  broiuldl, 

Fiilv.  urti.  tart.. h  AA  gr.  x. 

M,  ri-  pnU.  No,  1-     K-  TtXt  In  «»Lfer  nhlle  elTBrvBWiiig, 


Or: 


Or; 


I)  CftlTeiLi,  MilicyUtiii g 

AQIllJlKlii  tiHlluyliLLlii, 

Plitnol.  Ralk'yIatlK.  .  .  M  gr  v. 

M.  Ft^  Clip,  Na.  1,     S.  OJko  ofifluJe  etery  ibreecr  four  boura^ 


If  Cuffeiu.  poi'.         - er^vn,-ta^ 

M,  U-  c&p.  J^v.  i.     S.  Take  vlib  hot  y»Mai  uid  rcpou  In  one  hour  II 
cjuary. 

As  a  general  piok-mo-up  and  diEfusible  Btimuknt  for  tieurosthenin 

headache,  efl[^cia^Jy  of  women,  the  following  prescription  has  aet-vod 

well: 

It  Ammnnli  carb.. lU}^ 

T&ucu  Hucutiiil,      ........  3vl. 

E^ptfl.  tavaactulu:,  ...,.,.  ^  1. 

Kill   fimmonU  vAlerliLD-,     ,         -  ,         -  id   J  Vil j> 

M,     B,  Two  toiuppoonfuls  over?  three  havM  lu  iralcr. 

Naturally  these  remedies  are  symptoin  medicinea  and  they  auffire  only 
for  amelioration  and  temporary  cure.  The  admijiiatration  of  geaeral  ton- 
ics and  n^rvinpq  nhould  not  be  Tieglected.  One  of  the  most  satiifaotory 
mixtures  that  I  use  in  the  depressed  forma  of  ueurastheiiia,  aapecially 
ueuiaethenic  aud  aua^mio  headache}  is  aa  follows: 

^  Zlxm^  pbospbatli, ■  Ei"  i 

Ferr^  reducL,      .        , -  gr,  u^ 

E?i[ra4:[,  uaols  voinleic,         .         ,         ,  .         .  £■*'  U' 

M'   It-  pll,  >o^  vjM.     S,  One  pLll  two  <r*  tkPt9  tinvfi  a  di^. 


THE  TREATMENT  OF  HEADACBB, 


£46 


In  headaohea  of  a  similar  nature  ai^c^nnpaiiied  by  L<onaider»b1e  diatiirb- 
an»  of  the  emotional  life,  that  iB,  hpariachea  having  the  character  of  neu- 
leuic  Leadachbb  occurring  io  hy3t«^i(^al  people,  tte  followiDg  fonnala 
be  Tccommendoil  after  a  number  cf  years'  esperiBDOe: 


Kei,  rhei. 


Asafcetiilffi U  3!, 

M.  ft.  pil.  No.  iz.    One  pill  three  times  b  d&y- 

Before  taking  leave  of  thia  part  of  the  subject  I  wiah  to  aa/  one  word 
f^oncerning  the  use  of  bromides  iu  the  headaohes  of  ueurasthenia  and  hys- 
leriu.  It  will  ha  Tcmark^d,  no  doubt,  that  very  little  mention  has  so  far 
been  made  of  the  fialta  of  bromine.  And  thiB  for  the  reason  that  It  is  my 
belief,  aa  it  is  the  belief  of  many  TieuixjlogiBts,  that  bramidea  have  been 
done  to  death  in  these  diuurderfi.  I  \iAv&  do  iuteutioii  to  deny  the  utility 
of  the  broinidea  in  certain  forms  of  neursAthenic  and  hysterical  headache, 
fori  am  appreciative  of  their  utility ;  but  nothing  has  been  more  im- 
prcAsed  u|ion  me  from  my  i[itercourse  with  physjciana  of  experience  than 
the  fact  that  thts  abiirie  of  hrouudfH^  PSEiecJally  in  fuin-tioiial  nervous  dls- 
aases.  Is  one  of  the  evils  of  the  time.  There  is  no  diaeaae,  with  one  and 
possibly  tvo  exceptions,  these  being  epilepsy  and  migraine,  in  -which  itia 
justifiable  to  administer  bromide  for  any  <-onsiderablo  leugth  of  time. 
'NeverthelesSf  it  cannot  be  denied  that  many  practitioners  are  either  un- 
willing to  subscribe  to  this  view  or  they  are  heedless  oE  sLioh  advioe, 
Tliere  ate  c^rtatn  cases  of  neitrasthenic  headache,  especially  those  associ- 
ated with  geueral  erethism  and  anorexia  nervosum,  iu  which  the  adminis- 
tration of  bromides  for  a  feir  days  is  extremely  sernocable,  and  one  of  the 
niofit  popular  prescriptions  at  my  olinic  ib  tha  following,  known  as  mis- 
tuni  nigra : 

B  Sodiuia  bromidfr, .         ^         .....         .  ^n. 

pepitn  m-Bles,        .         .         - 3IJ. 

Pi»!t.  VHg.  chfljcoal.      -,.,,..  3ilBB. 

Qljceriii J  i j. 

Spesrm  I  at  wnter,  .         .         .         ,         .         ,         .   oil  ^  U  j- 

Hh     S.  TcospooaEol  two  or  threa  times  &  day  after  uieab. 

The  headaches  associated  with  the  neuroses  that  are  now  being  cocaid- 
cr^  almost  always  uiiLUir  iu  people  whose  digestive  and  aaaimilatlTe 
functions  are  disordered  and  whose  avenues  of  excretion  are  more  or  less 
sluggish.  These  disorders  of  function  demand  attention,  bat  it  is  ud- 
neceasaiy,  I  believe^  to  make  speciSc  mentien  of  the  substances  employed 
to  gain  such  ends.  What  has  been  eaid  for  the  treatmentof  neurasthenic 
headaches  applies  also  to  those  occurring  as  a  manifestation  of  the  hys- 
terical state;  but  the  treatme[it  of  headache  which  accompanies  the  other 
two  grand  neuroses  enumerated  in  the  classiBcatiou,  viz.,  epilepsy  and 
35 


546 


TBEATTSIEKT  OF  PiaEA8B3  OF  THE  NKRVOCfl  flYflTEM. 


exophthalmic  goitre^  requires  very  different  drug  adzniiiistratLOn,  aJcliougU 
the  general  dietetit,  mei^lianicHl,  and  diaoiplir&iy  nieA^HureH  aje  the  sam^J 

The  EiioM   iiuporlaut  fact  in  the  treatment  of  e[iUeptic  heaJacbes  id 
that  tlioss  whicli  arc  the  equivaleuta  of  an  attack  should  receive  the  aami 
careful,  methodiealt  perGiHtent  biotinde  treatment  as  the  iion^^lsive  forfq 
of  epilepsy.     The  mdicaticns  for  tuedicinul  li'eatmeiit  in   Ihe   preconyuj 
^Hiva  fonu  of  epileptic  headache  are  tu  giro  difTufiible  stiiDLil cults,  iiifh 
as  the  aitrit?&  and  if  the  oepheJalgiu  preoedert  the  cumul^iTe  attacki 
for  any  length  of  lime  a  large  doee  of  one  of  the  bromide  rialta.      Port- 
courulflive  epileptic  heudaolie  ie  beat  oom^ted  by  Bouie  awvh  diffusible 
Btiinulaat  UB  ooffeo  given  in  the  sltftpe  of  &  hot,  black  infusioit. 

The  hcadi^hesdf  exophthaliDtt'.  goitre — whieh,  in  reality,  are  not  tob« 
difTerentiated  in  their  origin  or  io  their  maiiifeBtatioEkB  from  tht-  headaflbca 
of  neurodtheniat  but  which  are  alwfi^'?  of  a  tbrobbirtg  rhaiactcT — are  best 
relieved  by  absolute  bodily  and  mental  rest,  and  by  the  admini  strati  on  of 
aconitia  in  ^  j^-grain  dogesT  repeated  every  three  or  four  hours  if  the  vftS' 
cular  tension  is  high,  or  by  the  admin latratirm  of  digitalis  or  ita  alkaloid 
in  full  physiological  doaen  if  the  pulse  is  of  low  tension. 

The  treatmenbcf  beadacbea  accompanying  orj^anic  disease  may  be  din- 
miased  after  very  brief  consideration,  fur,  as  a  rule,  it  may  be  oaid  that 
Oi^erative  interference  is  the  only  form  of  treatment  id  all  varieties  of 
organic  headacbea  save  those  due  to  syphilis  aud  non-pyogenic  iofectlCiQ. 
The  latter  reipiiri*  trnatrnt^iit  directed  immediately  against  the  f^auAM. 

HeadacheB  of  Infectioas,  Intoxioationi,  and  Auto-intouoatioiu. — The 
headaobea  of  intoxtcattone  and  infections  may  Likewise  be  briefly  diA- 
misaed.  Those  accompanying  tho  iafectious  diseases  do  not  call  for 
any  particular  treatment  aside  fr«m  tht  meaaurea  taken  to  combat  tb« 
infpctions  proneaaes,  while  tha  treatment  of  hefiilai^he  due  to  the  inges- 
tiou  of  vi^getable  vi-  mieeral  poisons  rusohea  itself  lutu  the  very  aimplp 
matter  of  preventing  the  further  ingestion  of  the  poison,  be  it  IM, 
aloohol|  toba^'co,  or  poisonous  substances  administered  therapeutically  of 
eTkcoufitered  io  occupations,  and  the  elimination  of  any  of  the  poieoita 
remaining  in  tlie  system  froiri  the  body.  After  that,  the  faeadaelie  disa^i- 
pears  ou  the  restoration  of  general,  including  neural,  nutrition.  To  thoa 
restore  nutrition,  general  tonic  treatment,  very  similar  to  that  describcii 
under  neurasthenia,  is  required-  And  mean^vhile  the  headache  may  be 
relieved  temporarily  hy  the  admin  ifltrati on  of  some  of  the  preaoriplioos 
possessing  analgesic  propcTties  already  mentioned.  A  fonnula  thai  1 
often  uae  a«  a  general  tonic  aud  stimulant  in  hesidachea  following  the 
infections  and  exogcnotis  intoKioations  is  the  following; 

B  Opll  pnlv  . 

ZLn<!i  phuspFilil.,   .        .        .  H        .  U  gr.  M. 

M.   ft,  pIL,  Nu-  XX.     6.  Ut\a  pill  thr^  limen  a  day- 
It  is  to  me  nothing  less  than  remarkable  the  tODic  effect  which  coe 


THE  TRELATUENT  OF"  HEADACH2. 


Sir 


1^  ftom  this  stnaJJ  quantitj  of  opiujn.  Ail  the  infectioaa  and  iatniica- 
CioQfl.  without  ojiceptioQ,  produce  a  more  or  less  profouDd  conditTon  of 
gener&l  ana?mij^  tmd  this  aDcemia  must  be  reckon^  with  m  «stiiiiatttig  thft 
mture  ftnd  detet-nuniag  the  traatment  of  the  beadachfi.  Early  In  the 
Ir^atineitt  of  such  headaches  oome  such  seardiiiig  tocuo  ad  the  foUtnrlng 
ohouEd  he  adminLBtered ; 

Q  Fern  etUDCnonil  oitr&tif^     - ^^  il' 

Llq- poumli  ar»iutii«  .         ,         ....         Izl. 

$;r.  zinglberia.     --..-...         5«. 

Inl  calutobv.  .         ,  ad  S  It. 

M-     >S.  Tvto  tuqwonfute  afier  edhUa, 

I  ajn  espwiallj  apt  to  tn^e  thu  mixture  to  children  ^ho  compluD  of 
h«adache£  following  the  infectious  diseaaesi  while  for  adultB  the  tnistura 
fern  et  ammouii  acetatia  is  subatitut^  for  the  citrate  aaJt. 

In  tha  treatment  of  headach€B  regulting  from  the  absorptioD  into  tha 
tijatefi]  of  *onie  endogflnous  poison,  such  aa  that  of  diabetea,  iin«mia,  and 
the  auto-intoxic^tioua  and  iafectionfi,  the  general  measores  to  l>e  adopted 
do  not  differ  tnaterially  from  those  already  spoken  of>  The  headaohe  is 
<^rnhated  when  the  formation  of  the  poison  and  its  abaorpticn  into  the 
system  are  interfered  with.  In  this  way  dialtetic  headaches  are  treated 
by  diet  and  bj  the  u»e  of  remedies  againab  the  anemia  and  oligocjthEBmia, 
vhile  urteniic  headache  i3  combated  by  moaauros  that  prevent  the  forma- 
tion of  nren,  and  by  those  that  facilitate  ita  excretion.  In  urcemio  head- 
aches aocompaaying  chronic  interstitial  nephritia  of  alow  progreesioa,  I 
nee  the  following  prescription  as  a  diluent  and  dinretio  with  good  effect; 


Tlnpt.  hyoscyaini, 

Spt  otherla  niuoain        .        .        .        .        . 

Inf.  flcopArii.  r         .         .         .         ,         , 

M.     S.  TabYt«poonful  in  water  tbrea  tiriiBA  a  duy. 


If  it  IB  pefipssary  to  inoreaao  vaacular  tension,  infnaion  of  digitalis  may 
be  added  to  thia  mixture. 

Headaches  arising  froni  auch  intoaication  as  that  of  ainiQDniemia  re- 
quire lonai  treatmeut  of  the  cyatittSi  and  the  institution  of  measures  to 
combat  the  coeKtsting  anemia. 

Headaches  arising  from  atito-iDtoxication^  the  original  soaroe  of  the 
diseaao  beiiiig  stomachic  and  intestinal  catarrh,  functional  perveraion  of 
the  glands  supplying  the  digestive  juicea  and  of  the  liver,  or  through  the 
aotiTity  of  noa- pathogenic  bacteria,  taken  in  from  outaide,  form  an  un- 
pOTtant  class,  and  one  that  is  happily  rather  amenable  to  treatment*  It 
must  suffice  for  me  to  say  that  after  the  general  measures  for  regulating 
the  alimentary  tract,  and  its  assoriated  functloual  (ie[)t'ndencie-s  (suoh  as 
oTcrcoming  constipation,  administrationof  auitabiecholagagueaandaperi' 
ente,  stimulating  the  liver  to  produce  a  suitable  kind  and  amonnt  of  bile, 


548  TREATMENT  OV  D19HASKS  OF  THB  HBRVOUS   BYSTEU. 

the  gWios  of  Buliatancea  that  aid  m  restoring  the  fiinrtioas  of  th^  p&n- 
cre&B  and  epleen),  tho  treatment  coEGtsta  in  the  admin Utrati (in  of  sub' 
Btancea  that  correct  ttie  apparent  trouble  of  digeetion,  and  of  thoae  thftt 
<|i.i@|]  the  headache,  A  favDritA  prescription  for  headache  utaociated  vith 
flatmlency  and  pyrosis  is  thi)  following: 

It  SodU  bicarb., 
I  B^BUJutEii  «ubgBllaL» 

L Puiv,  acfcTi^h,  .       ,       .       .  .  aa  i  i- 

^^^  Aqnic  d»9t.,  .....,,.    ad  2  viij. 

S.  Two  toocpoohfulii  bfllore  nieihU,  repeated  In  three  boon  If  necoBAfj. 

Id  headaches  agflociated  with  atonic  dyapepflia, but  v^itbout  ajiy  oonaid- 
^rable  flatulency,  I  make  use  of  the  foUuving  pillH^  and  especially  Id  the 
LeadaclLKB  ocourring  tu  women: 

U  FhitL  kiilpbatlri. 
I  Qnlninic  aiiliihuUfl,  .-'...,   aa  gr.  iv. 

I  Sotlii  nrfleciiU,    -  -         ^         ^        .         .         .         .         gr- es- 

I  Pulv-  rhoi, 

I  I'lih,  «hi}7il«r1itH  .  >  .  iA  gr- X. 

I  M.   fl.  pll.  No,  srU-     S.  Ou«  pill  Uiree  llmea  a  dnf  Afur  DMalti. 

Headachefl  of  Diiorder  of  the  Cironlation. — ThetroaCmentof  headache* 
due  IpO  di^«atte  of  the  circalatory  syaboiii  requires  considerable  diacuaaiofif 
not  so  much  because  of  their  froquencv  &e  bec&uae  of  the  fa<:t  that  if  they 
arc  properly  interpreted  they  yield  readily  to  treatmetit.  He&dachea  that 
acnompany  organic  digoases  of  the  heart,  whether  tliey  be  associated  with 
excegs  or  deJidenry  of  propulsive  power,  naturally  require  treatment 
directed  to  that  orgaUr  as  does  any  pulmonary  condition  which  interfera 
with  the  return  cerebral  circulation.  Headaches  occurring  with  functional 
diaturbanoQB  of  the  heart  are  oftentimes  very  ameuablo  to  therapeutic 
meofliires,  not  drugs.  For  inslaucef  a  heart  that  is  working  violently  oa 
the  result  of  great  phyaiPal  effort  or  excitation  of  miad  or  bo<iy  may  be 
so  quietM  by  the  appHiiatioii  of  a  simple  culd-water  compress  to  the 
cardiac  region  that  the  accompanying  frontal  throbbing  headache  dtaap- 
peara  promptly;  and  the  eJlicaci  onsneas  of  stimulating  foot  hatha  and  hot 
sits  bntbs  in  combatinf^a  headache  of  increased  vascular  tension  within  the 
sknll  '3  very  well  known.  It  is  rarely  necessary  to  administpOr  the  more 
powerful  card io vascular  depressants  in  cases  of  this  kind,  the  require 
equalizing  cf  the  circulation  being  obtained  by  hydric  procedures  and  the 
administration  of  a  few  doses  of  the  bromides.  When  headaohii  is  an 
accompaniment  of  a  slug^bb  circulation,  there  being  no  deficieney  in 
the  amount  of  the  blooti  and  no  changes  of  its  constitution,  the  diffuaible 
etimulanta,  caffeine,  and  stryGhnino  may  be  relied  uix>ii  to  bring  about  its 
prompt  relief.  CannabiH  itulica  is  a  drug  that  I  frequently  use  with 
good  oGTect  in  this  form  of  headache.  The  method  of  presonbing  it  is 
in  the  following  pills; 


THK  TBEATUENT  OF  HEADACHE. 


610 


Ext.  getxtiaue,     . 
H.  ft  pit  So.  i. 


UeacUches  that  are  dependent  upoa  a  general  aneemia  aro  oftonttmes 
eitramelj  resUtanb  to  treatmeDt^  find  although  temporar}-  improvemeDt 
Lisuallj  follows  tonic  ajid  stimuLating  treatment,  the  anemia  must  be 
fuuglit  nuswerviiigly  far  a  tntig  time  to  etfe(;t  a  complete  cure  and  to  stay 
the  recurrence  of  Lhe  headache.  The^e  headaches  are  u^iually  accotu- 
panied  by  a  very  Eluggiah  condition  of  the  dilative  tracts  to  combat 
vhi«h  I  have  used  with  very  good  resuita  the  following  combination  of 
tonics  and  laxatives  in  the  shape  of  a  dinner  pill : 


EiL  aloes  oq. ,    , 

Ihilv.  cHpsicl. 
Pulr.  Ipecu..    . 
GlycarlD,  . 
M.  ft  pil.  Nth  xii. 


.  .la  gr.  tL 


S.  Ono  plU  At  middAy- 


Or,  if  afifiociated  with  cooaiderabld  vital  depreasion,  I  uae  the  following 
pill  iostead,  giving  at  the  seme  time  some  absorbable  form  cf  iron : 

4  Ext  imciK  vDinii^ie,    ,  .         .         ^         .         .  gr.  tK. 

Pil.  rhci  DOEiip..  .,,-.,,,  gr.  iij. 

Pulv,  capeici gr.  i 

H.  ft  pil  Ku.  L    S.  Oua  pi  LI  it  midday. 

Naturally  it  ia  very  often  neoosury  to  give  at  the  same  time,  for  ita 
jmnediate  efTect,  soroe  analgesic  or  a  combination  of  these  with  a  stimu- 
lant, such  &e  calfeine,  and  Buch  a  prescription  as  one  given  above,  contain- 
iag  caiTeiDe,  pheaacetin,  and  salol,  usually  meets  the  requirements. 

Hes^dai^he  associated  wiLhorj^anic  dEseaaea  of  the  blood- vpssels,  sncb 
as  arterial  Hulenraia,  aitfriot^apillary  filinjsis,  as  it  is  oftentimes  called, 
requires  very  naethoiiical  treatment  in  addition  to  the  maintenance  of  the 
highest  possible  degree  of  nutrition.  Fortunately  the  number  of  iDedi- 
oinea  which  ore  serviceable  is  very  email,  being  covered  practically  by 
iron,  nitrite  of  sodivim^  one  of  the  iodine  salts,  and  occasionally  one  of  the 
cardiao  nervines,  sui-h  3H  fitroi>haijUiuJi.  For  the  acnter  manifestations 
ot  6Uoh  disease,  suob  as  violent  throbbing  in  the  head,  buzzing  (n  the 
ears,  and  a  feeling  as  if  the  head  were  being  dragged  foroibly  backward 
the  bromides  are  of  aerviceT  eepeeially  when  exhibited  in  connection  with 
the  Foot  hath,  fiit/  bath,  or  full  bath  to  which  pine-needle  extract  haa 
been  ailded^  When  these  nica^^urca  do  not  sufBt^e  I  have  frequently  seen 
brilliant  results  follow  the  Eulmiiiistration  of  a  capsule  containing  cocaine, 
camphor,  and  powdered  opium,  the  latter  in  very  small  quaiitity.  The 
value  of  nitrite  of  sodium  as  aiL  agent  to  dilate  the  arteries  does  not  seem 
CO  mo  to  be  fiufflciently  recognized.  It  has  the  great  advantage  over  the 
other  nitrites  thatit  maintairL!^  the  dilatation  nf  the  ve^sf^la  for  about  four 


TREATMEPrr  OF  I>T8KA8S9  OF  THE  NBHroue  gYBTESI, 


hours,  whereas  the  action  of  jtitroglyceriu  and  nitrite  of  amyl  i»  ever  in 
less  tb&D  bulf  ao  Iiour.  The  ueceewity  of  recoguUuig  tho  fact  Uiat  wide- 
spread  fikttj  degtsneration  la  the  natural  sequence  of  vasculur  sclerDsia  ia 
verj  great,  partioularly  la  direoting  the  dietary  and  phjek^al  hygiene 
of  fluch  a  patient.  Any  considerable  amount  of  fatty  degeneration  is 
inimical  to  an  activo  degree  of  uxidatioD,  and  as  this  process  is  at  the  liasb 
of  tisauQ  metamorphoflia  aud  fi»d  E^ombuatioHf  one  lauat  be  on  the  alert  Dot 
to  give  Food  in  suoh  quantitiea  aa  bo  clog  up  the  system  ^ith  effete  mat- 
ters and  therefore  add  another  burden  to  the  eoonoray. 

Headaohei  of  Reflex  Origin. — A  brief  review  of  the  treatment  of  eo- 
ralled  refli^ic  headaches  niunt  now  he  made.  Although  volumeti  have 
been  wriLten  cu  the  Hubject,  it  does  not  seem  to  me  difficnlt  to  make 
judicious  disposal  of  tlie  subject  in  a  few  words*  Leat  it  may  Ije  teth- 
ered that  I  luidereatimate  the  importance  of  dieorder  and  diseat^t  of  the 
sense  organs  in  oausmg  headache^  £  may  say  that  it  is  my  belief,  baaed 
upon  experience,  that  from  one-third  to  one-half  of  all  heAilaeliea  ar^ 
caused  or  influenced  in  tlieir  occurrence  and  maintenanue  by  snch  con- 
ditions. This,  however,  does  not  prevent  ute  from  aaying  tbut  the 
treatment  eummarizei  in  a  few  wards  is,  to  remove  the  (?auBe,  eithei 
by  operation  or  by  the  applioatioii  of  the  indicated  orthopicdic  appli- 
ance such  aa  gksa<?s,  and  then  treat  the  exliauated  state  of  tlie  ner< 
vous  Hyhtem  whic^h  has  liteu  mJuced  through  the  strain  of  iin[>erfect 
organs  doiii|^  the  work  for  whieh  normal  phystological  apparatuB«^u  were 
intended.  Further  than  this,  one  or  two  facts  should  be  kept  in  naind. 
The  first  is,  if  the  headache  dependent  upon  defective  eenee  organs 
haa  existed  for  a  long  time,  no  amount  of  orthopiEdia  appliance  will 
raniiuish  th^  headache  in  a  consiiierabte  propordoii  of  the  eases,  and 
ftirlliermore,  m;tny  car^^^  oi  h«*ad!tche  due  Lc  defect  in  the  seixse  organs 
reiiuire  as  well  general  treatment  that  the  peTUiaueut  cure  may  be  fnlly 
t<niompassed-  After  having  said  thie,  it  does  seem  necegaaty  to  say  in 
detail  that  patients  who  have  aHtigmatismf  hyperopia,  and  insufiidency 
should  be  glassed.  No  more  does  it  seem  necessary  to  say  that  ehronic 
lurgeztcenr'e  of  Lbc  njisA  mucous  membrane,  de<-.ayed  teeth,  and  catarrh 
(if  the  middle  ear  Ahuuld  be  trcat.e<]  when  toimd  aaaociated  with  a  bead- 
au he  whose  duration  and  character  seem  to  point  to  these  abnormalitiea 
as  its  fiouree.  Such  ti-uisms  go  withcut  saying.  In  latter  years  w«  have 
heard  miiah  of  the  lack  of  musrular  balance  of  ihe  eyes  as  a  eaviee  of  he^- 
aohc,  and  a  cousiderabla  literature  has  sprung  up  burdened  with  the  no- 
menelature  of  eaophoria.  exophoria,  aJid  hyperphoria.  These  oonditions 
a  few  men  who  claim  special  skill  m  overcoming  them  would  hare  iis 
believe  are  responsible  for  a  large  proportion  of  all  headaches,  aa  well  as 
cauaative  of  sufth  profound  neuroeea  as  migraine,  epilepsy,  and  H>inting- 
lon's  chorea,  Bui  tlie  coaseiiHUSof  opinion  of  those  who  have  carefully 
studied  the  question  aud  who,  from  their  training  and  eiiierieiice  as  well 


TUB  TBEATM&»r  OP  HBADACBK. 


6di 


as  from  t^eir  inherent  mentaJ  qualities,  sre  entitled  to  belief,  is  that 
auch  loss  of  muscular  balance,  whether  due  to  improper  ini plantation » 
UUkfsrvatioD,  or  fatigue  of  certain  eje  nikiscle^  haa  be«a  euormously  over- 
cstiiiuit«d  as  a  cause  of  heatlache.  It  is  dilHcult  far  one  who  has  investi- 
gated this  mattop  iu  aa  uubiaesed  and  critical  state  of  mind  to  dtvopoe 
himself  from  the  thought  that  those  who  cluini  to  nure  so  many  scores  of 
hendat^jiea  by  almu»t  imperceptible  tenotomies  of  the  eye  uiUHoles  do  it 
for  Aurdid  and  even  less  oonimendablQ  motivea. 

Space  precludea  further  consideration  of  the  treatment  of  other  reflex 
headachea  and  even  though  it  did  net,  some  of  them,  aiich  a±i  uteruie 
headache,  might  be  disposed  of  in  a  word,  vh.,  put  the  pelvic  organs  in 
3s  nearly  a  normal  state  as  possible,  then  forget  the  existence  of  tha  pel- 
vic organd  aud  ceittre  your  attentiou  on  tho  individual. 

Habitual  Headache.— I  ha^e  ]irev'iously  spoken  of  a  form  of  cephalal- 
gia to  which  the  name  habitual  headache  is  given,  and  a  few  words  were 
devoted  to  a  theory  of  its  pathogenesis.  It  is  diagnosticated  by  prooeas 
of  exclusion.  Its  treatment  ia  oftentimes  an  altogether  unaatisfactory 
experience'.  It  is  nsually  aaflO<iatad  with  evidences  of  gpiieml  lowered 
viWity  and  disordered  fuuctioua  in  other  parts  of  the  body^  These,  of 
course,  must  be  vigorously  combated-  i^uch  headache  ia  often  aocom- 
panied  by  leuoorrh^sa,  ;iud  under  auch  circumstancea  1  not  infrequeutly 
I       employ  the  following  prescription: 


Tl  Amuxonli  chloridi, 

Kl.  ext.  hydrMtid  (non-aJcnbolh^). 

Kl.  B£t.  vibuTh,  upul 

Rliiit  aiuiUi  .... 

M.     S.  T^aflpfionhd  Uiree  ilnitfl  uriay. 


gr.  fali- 


■d    liJJ. 


If  the  headache  is  accompanied  by  more  or  less  ovarian  pain,  I  aome- 
timea  substitute  tlie  bromide  of  ammouLumfor  the  chloride  salt.  Taking  it 
all  in  all,  headaches  of  this  nature  are  to  he  combated  by  m&int^ning  the 
highest  possible  degree  of  nutrition,  by  the  occasional  use  of  eymptum 
medioines  that  are  not  opiates  to  relieve  the  pain,  and  by  mental  augges- 
non,  particidarly  in  those  who  tend  to  develop  some  degree  of  hypoohon- 
driaais- 

After  thus  passing  in  review  the  important  caiiaes  of  headache  aud  tbe 
necessity  for  the  most  aearehiug  examimttien  of  eery  system  of  the  body 
ith  order  to  determine  its  pathological  relationship^  it  seems  to  me  incum- 
bent on  him  who  writes  of  headache  to  say  that  despite  the  greatest  diog- 
oostio  skill  and  the  most  herculean  therapeutic  efforts,  the  patient  often 
remains  iu  a  frame  of  mind  to  say,  paraphrasing  Shakespeare: 


How  weajy,  stale,  flftl,  v>A  unprnfiUble 
S*em  10  me  all  th«  phyvia  of  the  worlrl. 


CHAPTER  XLV. 

THE  TREATMENT  OF  DELnUCM. 

Drlirium  U  a  goneral  dUturbance  or  perTenidn  of  conaciouanMS  char- 
acterised by  aa  apparent  exaltatioa  of  mentai  proceaaca-  Close  exaiDma- 
tion,  however,  ahows  this  to  be  in  reality  a  diinination  or  tcfitrictiou  of 
apperoepbion,  althciLgh  association  may  be  quicliened  and  in  ooTis«quetie« 
neflmingly  enrkhi^d.  In  detail  it  manifestiS  ilselt  by  suiue  degree  of  men- 
tat  irritation  and  coDfuaion,  by  mote  cr  lesa  passing  deluaione  and  6eetiii^ 
lialluclnationa,  by  dlttorderod,  acn^elcea  speech,  aud  by  motor  UDreat.  It 
varies  in  intensity  from  the  slightest  bo-oalled  "flightioeaB,"  up  to  a  moat 
intense  maniaoal  condition.  The  term  delirium  is  not  used  fiynonymoiuly 
with  iiiHBniiy,  although  the  former,  of  rtniise,  prraupposea  an  iinsnund 
mind  while  it  lasts,  I  refer  principally  to  the  temporary  mental  disturb- 
ance occurring  vith  bodily  diseaaee,  and  not  at  all  bo  the  more  or  lean 
highly  organized,  tiAi^d,  or  changeable  deliria  of  paranoia,  of  chronic 
mania,  inetauchoUa,  general  pareeia,  and  the  like.  In  other  words,  h&re 
the  tdrm  delirium  is  not  given  the  wide  applination  whioh  the  modern 
French  writer  accords  it. 

To  facilitate  diflcuoaion,  and  in  no  waiy  to  be  considered  ^bsolnlely 
comprehensive,  delinum  may  be  classified  into:  primary  uid  aecondarj 
delirium. 

Primary  deliriiuii,  delirium  acutum,  delirium  grave,  is  not  a  disease 
Sill  tftni^r'is.  That  is,  it  la  not  an  individual  afTection,  hut  a  coudittoo  of 
varying  mental  dislurbauce,  which  oocaaionally  atbenda  different  states  of 
bodily  disorderr  such  as  oollapse,  intosicationi  katatonia,  etc.  However, 
il  ia  often,  if  not  always,  dependent  npon,  or  at  least  associated  with, 
demonstrable  ehangas  in  the  cortex  of  tlie  brain. 

Secondary  delirium  is  by  far  the  mure  vomnioii  and  the  le-ua  under- 
Htood.  It  may  be  subdivided  into  the  delirium  of  (1 1  infection,  (2) 
intoxication,  (.I)  eibauatiou,  (4)  irritation  (peripheral  and  central),  and 
(5)  senility. 

Etlelogy. — The  deliria  of  infection  ai'e  more  common  in  tbe  young  and 
in  the  alile-bodied-  Timy  occur  particularly  with  the  diseaaea  that  are 
depeudeut  u|)on  apecihc  organisms,  auch  aa  typhoid  fever,  pLcumouia* 
scarlet  fever,  yellow  fever,  puenjcral  fever,  and  pysmia,  although  de' 
lirium  occurs  with  analogous  diseaaea  which  have  not  yet  been  proven  bo 
be  dependent  upon  specitio  organieras. 

Deliria  of  intoxication  roay  be  subdivided  into  endogenous  aud  exoge- 


THK   TBEATJIKXT    OF    DKLDCrUH. 


£53 


tioua.  The  endogenous  compriae  Uioad  depeudent  upon  aeptic  intOEi- 
cjuttOf  and  :Lre  included  under  the  head  of  Bapnen).ta>f  urcenua,  oholoemio, 
di^betcfi,  auio-intaxitratiou,  aJid  insolatioTi,  whila  the  eTOgenous  Includd 
tlkoae  due  to  aloohol,  the  drugs  which  belong  to  the  grcup  of  mirdriatios^ 
morphine,  cocainej  mineral  poLaonSf  iodoform,  and  the  like. 

The  dtdiiia  of  exhnuation  may  be  subdivided  into  those  duo  to  inani- 
tion,  to  acute  anaemia,  Buoh  ae  refluite  from  hemorrhage,  ot  from  the  pies- 
ence  in  the  blood  of  some  powerful  h^eniolytie,  euch  as  eialgin,  the  Plas- 
modium of  maliguBnt  forms  of  malaria,  wasting  diseases,  eio«saivi> 
lactation,  and  the  like. 

The  deliria  of  ceutral  or  peripheral  irritation  maj  be  subdivided  into 
those  due  to  local  injurj  of  the  brain,  such  as  blood  clot  from  accidental 
tiauma  or  surgieal  operation,  to  meningitis,  acute  encephalitis,  or  to  other 
central  diseases.  The  peripheral  irritation  or  eicitation  which  may  bd 
associate  winh  delirium  is  pain,  a  condition  that  could  not  be  mani- 
fested without  central  in terp relation,  Delirinm  may  also  be  due  to,  or 
uasocialed  with,  Atatea  of  central  depreaaion,  such  as  epilepsy  and  hja- 
teria. 

The  delirium  of  senilitir  requites  no  subdirision,  for  although  it 
occurs  apparflutly  uuder  the  anspicea  of  different  exciting  factors,  it  in 
tealitf  is  caused  by  the  morbid  state  of  the  vascular  sjatem  incident  to 
old  age. 

It  maj  bo  remarked  that  no  particulai:  mention  has  been  made  of  the 
delirium  followiug  sai^ieal  operations.  This  has  been  done  adTiaedly 
becaose,  although  such  delirium  is  nut  iafreiiii4<nt,  it  is  due  to  one  of  three 
things,  viz.,  to  infection,  intoxication,  oi'  exhauadon,  aud  thus  it  falU 
under  one  of  the  captious  mentioned  above- 

The  diagnosis  of  delirium  is  very  ea9j,  and  observation  only  is  needed 
to  determini>  its  intensity  or  degree  of  severit}'-  But  neither  its  diagnosis 
nor  the  knowledge  of  its  severity  is  of  much  service  in  siiggeatlng  suitable 
therapy^  This  cau  be  decided  only  when  the  causation  and  the  patho- 
logical aasociatiuus  of  the  dellnum  have  been  discovered- 
Primary  Deliritun. — ^The  delirium  of  the  symptom  complex  which  li 
now  uoiTarsaily  known  as  acute  delirium,  or  delirium  grave,  resembles 
very  much  that  which  is  associated  with  febrile  diseases.  It  is  usually 
aocompanied  by  considerable  rise  of  teiufieratiite  which  has  nii  deiiTLit« 
course,  g^^at  prostration^  and  by  rapid  development  of  an  asthenic  or 
typhoid  state.  The  treatment  ordioorily  resolves  itself  into  fulfilling 
two  indications,  vi^.,  securing  steep  and  mamtainmgthe  patient's  vitahtV' 
All  further  treatment  should  be  with  a  view  to  these  two  ends.  Of  the 
various  sleep^producing  measures,  the  cold  pack  and  th^  administration 
of  aulfonal  or  trioual  in  small  doses,  gr.  x.  to  si.,  repeated  every  three 
hours  are  the  most  successful,  Wlien  aulfonal  and  trional  combined 
with  these  measures  fail  to  give  the  desired  eleep,  chloral  hydrate  may 


TftEATMEKT  OF  DISKAfiKfl   OF  THH  NKRVOCfl  8T9TEM. 


be  g;iven  iu  full  doses,  but  I  uever  use  it  afi  thd  first  by^ijuotic  in  tliis  eon- 
dibion  uoleaa  there  are  bdeip3  spcciaJ  indications.  In  c&afs  Atteod^  oorlj 
with  great  reBtlesBUGBs  und  «xdUmentf  the  oold  pook  is  of  aignaJ  service, 
both  iu  eouaervtug  the  patisnt^s  atreogtlt  and  in  aoutbing  bim  to  a^  condi- 
tion that  will  invita  sleep.  Drngs  that  produce  hjfiDosis  mid  roinoident 
or  aubasquent  depreasion,  8ucb  ha  tbe  bromidea,  opium,  chloradaiiiidei,  and 
byoscyaiuine  (althongh  the  latter  ia  not  usually  rated  as  n  b^pnotfc,  but 
as  a  generLil  motor  oed^tive),  are  to  be  aroided  if  possible.  Quite  aa  im- 
portant In  the  early  Blages,  and  much  note  ao  in  the  later,  is  the  careful, 
judicious  ndmiTii.qtratirin  iif  partially  or  readily  digested  food  in  small 
quautJties,  and  of  the  sauie  temperature  aa  Uie  body-  SuJTtcient  empha- 
sis cannot  be  laid  upou  tbd  fact  that  in  reality  the  chances  of  recovery 
from  an  atttit-k  of  acuta  deliTium  atQud  in  definite  rektiouebip  to  the 
patient's  ability  to  retain  and  absorb  food,  iHtentiiueB  fori'cd  feedini^'  is 
neceaaavy,  and  no  time  ahoidd  Iw  lost  in  resorting  to  the  stomach  tube^  If 
the  atomacih  will  rt^tain  ttiiLall  q^iautitles  of  nutriment,  this  method  haa 
advautagi^H  over  rectal  feediugt  no  rjiatter  how  carefully  the  latter  is  done. 
As  in  all  acute  anthenie  oonditioiia^  atimulanta  must  be  given  eajly,  and 
this  is  one  of  the  diaeaaea  in  which  alcohol  is  luore  etbc-aciona  than  uther 
forms  of  fttimulfttioa.  There  shoidd  be  no  heaitflney  in  giving  it  early, 
A  little  ex  jienenca  noon  tea I'hef*  that  more  alcohtjl  i-aii  lie  giuen  with  bene* 
fit  ill  thia  diiti-aae  than  in  any  othi^r  form  of  iiitiacrauial  mischief.  Thia 
]H  the  exception  to  the  rule  which  applies  to  tlie  adminiatratiou  of  aJcoholic 
alimulanta  En  diseases  of  the  bmn,  ^^atiiraHy,  the  det^iiU  of  treatment 
vary  with  the  eauaation  of  the  acute  delirium. 

ThoBd  cases  of  acute  delirium  whit^here  complicated  with  or  foUov  other 
diseases  reiiuiie  a  more  varied  iheiiipy  diierted  toward  ihe  latter.  For- 
mrtly  it  wiirt  oo&flidureJ  of  prime  importimce  to  ur»e  what  inay  be  called 
revulsive  treatment,  such  as  the  administration  of  Bslines,  the  opplicatioD 
of  leocht-a  to  the  Bcalp,  and  blii^LerFi  iMfhlnd  the  earSr  hut  at  the  ^''^sent 
day  aneh  meaHureii  are  <toriiiidered  barlianniH.  The  treatment  of  acute 
delirium  may  be  summed  up  in  a  few  words:  induce  sleep,  mainlaiu  nu- 
trition, fight  the  progressive  astheuiawith  stimulnoU^  counteract  the  pro- 
found unrest  and  fever  with  th<?  <*old  pn*'h,  and  rarefidJy  guaril  the  period 
of  conualescvuce,  A  good  nurse  is  far  more  useful  than  au  indilTenint 
physician.  The  most  importiml  wuining  is^  never  give  motor  depres- 
santfl,  even  though  they  may  seem  momentarily  to  le  indicated.  They 
are  in  reality  therapeutic  boomerangs,  Jf  it  is  borne  in  mind  that  la 
every  case  of  delirium  acutum,  or  delirium  grave,  we  are  dealiug  with 
acute  parenchyraatouB  encephalitis,  we  will  rarely  jualie  the  mistake  of 
adminiaT.ering  motor  depTeasants  to  overcome  motorial  unrest. 

Deliriuia  of  Infections.— ^ The  treatment  of  the  del iria  which  I  have 
called  secoudajy  ja  a  very  much  more  important  aubjer^t  to  the  general 
practitioner,  for  they  are  common  attendants  of  the  diseases  which  he 


«Dco<aiit«r3,  As  has  already  been  sfuil,  ilelirium  frequently  occTirs  with 
tlie  infectious  dtaeatiea^  in  many  of  the  minor  forma  of  vbit^h  it  is  sn  alight 
«ad  transitory  that  it  requires  no  treatmeat  Such  are  the  deliria  occur- 
ring  in  young  children  with  meaales,  anterior  poliomyelitis,  infectioo  of  the 
gastro-iuteatinal  tracts  aiid  broaohopneumonia.  Jn  other  dtBeoseE^  aud 
particularly  in  ^phoid  fever,  pneumonia,  and  starlet  fever,  ita  early  oc- 
eitrreaoe  Is  a  danger  signal  wbich  abould  proiiipt  immediattf  action.  Initial 
delirium  is  not  very  coinmou  in  typhoid  fercr,  nor  in  pneumonia.  When 
it  occur?  in  the  fi^rmer,  it  inanifestd  Itself  either  in  a  mild  form,  preceded 
or  accompanied  b3'  a  degree  ol  anxiety  which  ia  soon  foOowed  by  deprea- 
sion,  and  what  la  f?olJoquia1]y  termed  ''  flightinesB."  Such  a  mental  state 
has  absolutely  no  relationship  to  the  temperature^  and  may  even  precede 
the  rise  of  the  latter.  In  olhrr  cases,  the  delirium  \&  so  severe  an  to  coii' 
atitute  actual  mania.  Theae  caaea  are  Ukowiae  iDfrcquently  attended  Ij^ 
high  temperatures.  They  differ  very  raaterially  both  in  their  clinical 
(lEUiLfefitfltiora  and  Ln  their  indications  f^jr  treatment  from  the  delirium 
ithfch  ocoiira  during  the  third  and  fourth  weeks  of  the  disease,  Th«^ 
fumier  variety  stands  in  direct  relationship  to  the  amount  and  intensity' 
of  infection,  while  the  laiter  is  often,  but  not  always,  an  exhaustion  de- 
liriutn.  The  treatmcat  of  initial  delirium  of  typhoid  fever  ehould  hu 
directed  particularly  to  counteracting  the  effects  of  the  infection  on  the 
nervous  system.  No  farm  of  therapy  ineeta  the  re'juirements  so  thor* 
oughly  zs  the  admiuiatration  of  one  or  two  large  doses  of  calomel,  fol- 
lowed by  th^  injection  of  a  large  amount  of  ealine  solution  into  tlie  int«s- 
tinee,  or  subcutaneouely  bcueath  the  mammary  gland.  Jn  three  recent 
oueaof  typhoid  fever  with  initial  delirium,  both  of  the  acute  maniacal 
form,  aubcutaneouB  injections  of  normal  salt  solution  into  the  loose  eelJu- 
lar  tissua  beueath  ttre  mammary  glaud  were  foHowed  by  moBt  gratifying 
results.  Ita  ptesence  iu  the  blood  seems  to  baye  a  aalatary  inBoence  in 
neutralizing  or  conntcractiug  the  injvuious  action  of  the  poisonous  mat- 
tere  on  the  vital  eeutres.  >~T^m  four  ounces  to  a  ha^f-pint  or  more  may 
be  uaeid  at  one  sitting.  The  treatment  of  delirium  occurring  in  the  later 
stages  of  typhoid  fever  does  not  differ  materially  from  that  of  delirium 
due  to  other  exhausting  conditions. 

In  this  connection  a  few  words  must  be  said  concerning  the  relation- 
ahip  of  fever  to  the  occurrence  of  deliriumf  not  alone  in  typhoid  fever, 
but  in  other  febrile  diseases.  There  is  a  well-deJined  conviction  iu  the 
minds  of  many  physicians  that  the  oecnrrenee  of  delirium  stands  in  def- 
inite relationship  to  the  degree  of  febrility.  This  riew  is  not  held  tiy 
tlie  writer.  Fever  j'rr  ">-  playa  little  part  in  the  genesis  of  dclinuiOt  and 
consequently  treatment  directed  immediately  to  the  fever  is  of  no  avail 
in  counteraj^tiug  the  delirium,  except  in  bo  far  as  sueh  treatment  opevmtea 
against  the  factars  upon  which  tbb  delirium  depends. 

If  fayperthermia  in  itself  can  .ause  delirium,  thia  symptom  abenld 


556 


TREATMENT  OF   DISEASBS  OF  TBK  NERVOUS  &Y9TSU, 


^□(iDmpaijy  liyperLhermia  artiRctallj'  produced,  &ad  be  a  coniinun  sjiuptoEn 
of  diseaseB  attended  by  Etigli  teLDperature.  A  little  eiperieocd  will,  I 
believe,  £iiow  tliia  to  be  not  a  fact.  For  inataDoe,  uote  tbe  coloBstJ  rise 
of  temperature  whit^b  soTnetimes  occtiis  in  uaJarial  infection,  in  rheocift- 
tism,  kud  ai?i?aaioDally  erenin  inFiolaticn,  while  the  mental  fai?u]tieB  remain 
UTiimpainsl-  Oj»  the  eontrar^v,  the  mental  sUte  in  quite  as  often  thfi 
opposite  of  delirium  in  euch  caaea-  It  cannot  be  ilghtfulljr  eajd  that 
because  cold  water,  applied  according  to  tbe  most  approved  plan,  in  the 
acute  febrile  diaca^ea  tt'uda  to  prevent  deliriiuu  and  to  control  it  when  it 
does  oocut,  that  the  hydrie  procedure  prevents  or  overcomes  the  delirium 
by  lowering  th()  temperature.  On  the  c^nti-aryj  tlie  cold  water  Iiaatenft 
the  elimination  of  the  poisons  in  the  blood  which  ate  acting  harmfully 
upon  the  anterior  poles  of  the  cerebral  hemiapherc;  itaasista  the  blood  to 
oxidize  and  oonsume  these  injurious  productet  lutd  it  stimulatee  tte  vital 
centres  to  renewed  elfurt  in  their  combut  with  tbe  overwheluting  agencies 
which  are  working  uiiBchief  by  euahrouding  the  Benaorinm.  Trtie  it  is 
Uiat  tlie  hydrjc  meaaurbs  at  the  aame  time  reduce  the  temperature,  aud 
their  beneficial  effects  on  theae  two  symptoms  may  be  coincident,  but  thid 
in  no  way  should  fosti^r  the  belief  that  tht  two  are  interdependent-  On 
tbe  contrary,  it  spt^ma  to  mt*  that  fever  is  conditioned  by  a  mechanism 
quite  apart  from  that  wbich  ccinaes  delirium,  and  that  to  speak  of  febrile 
delirium  to  cover  tbe  deliria  of  infectious  diaeases  is  an  nnwarran talkie 
assumption  of  the  iuteTdepeDdeni.-e  of  these  two  aymptoms. 

loilial  delirium  in  the  pneumonia  of  the  adult  always  meona  one  of 
two  things  ■  that  the  aubject  ia  alcohulic  or  that  the  infectiou  ie  extremely 
severe.  Occurring  in  the  infanl  ic  suggests  that  we  have  to  do  not  only 
witJi  a  severe  lufectiou,  but  with  an  apical  involvement  aa  well.  If  aloo' 
holism,  or,  better  aaid.  the  alcoholic  habit,  can  be  left  out,  the  ohancei 
are  that  tlio  patient  haa  a  streptococcus  pneumonia,  and  not  a  djploooo«ii.i 
or  tuber('ulouB  pneumonia,  as  intCial  delirium  ia  of  much  more  common 
occurrence  in  the  fnrmer  variety.  As  an  indication  for  the  election  of 
therapy,  it  nmttera  not  very  much  upon  what  the  deliriuiu  ia  dependent 
The  treatment  in  every  instance  may  be  auinmcd  up  in  one  word;  otimu- 
lation,  unless^  indeed,  the  administration  of  a  apeci^o  antitoxin  bocon^ 
aidered.  The  election  of  the  stimulant,  or  combination  of  fittmolants, 
will  depend  upon  cir  cum  stanches.  If  the  patient  l>e  alcoholic,  it  will  be 
necessary  to  ccjutinuo  giving  to  him  the  prop  that  aerved  him  ao  ill  in 
times  when  be  could  make  his  own  selection,  and  to  combine  it  with 
strychnine}  while  in  non-alcoholic  cases  the  more  di^uaible  Bttmulants 
and  digitalis  may  be  indicated.  Here  again  it  is  nec^sary  to  Bi>ealc  of 
the  cliciice  of  a  hypnotic.  In  ebildi-en,  and  in  non-alcoholic  adnlta,  chlo- 
ral ill  small  dosea  ia  tbe  best  bypuotic,  especially  ia  the  beginning  of  tbe 
disease;  at  least  this  has  been  my  own  oiporicnce.  For  the  insomnia 
and  delirium  occurring  later  in  the  course  of  tlie  affeutioDi  atid  in  alco' 


m  noATic&yT  or  DKUBirv. 


liolir*.  FuIioDAl  has  served  !□«  wen  aoiriioloriljr,  poitiUy  Inmia*  it  U 
ttJw»j-s  giT«!fi  m  iMit  milk,  vhieli  ol  iti^  is  not  mnoDMgnttttkl  tat  a 
ntipialinv  and  sedalzre. 

The  delim  xvundiiiE;  sculpt  fcr«r,  uad,  va  ffhrt,  a^ll  of  fhm  •npltt^ 
daseaaefi,  are  best  oountem^n^  m  tho  e^jly  sta^a  by  ap^^l^iag  tbt  io«  «(p 
and  the  oold  pack.  On  ftocouiit  of  th«  fT^uenoy  of  raniil  oomfvlioAtkot, 
and  the  wideepread  belief  od  the  part  of  the  laity  i-hnt  <H^1d  wai^r  rt)4k*« 
like  eruption  "strike  in,"  there  is  often  gitni  objeeiion  liy  pu^itA  wlwn 
the  cold  pack  ia  sogg^sted  -,  hut  I  un  sure  tliAt  i^o  ctlier  nicajiMro  or  (com- 
bination of  ToeaeuMS  eoiaparea  in  eiHeaeiou^ut^sa  with  it  in  th«  tmaUnftiit « 
of  this  Bvmptom,  ereo  though  th«r«  b«  no  by[)ertheniiiiL  I 

The  deliriuni  attPiKling  the  severe  infocrioDB,  sMch  ns  jHlfirp«ml  f«vw 
Uui  pjeecoia,  requires  practically  the  smug  treaiuieiit  aa  that  MOOnpuiy* 
iitg  aeptic  pneumonia.  In  all  of  these,  as  in  delirium  kciiIaliii.  eleep  m^isi 
bo  obtained  fit  all  hnzarda,  and  the  patient's  vitality,  vi;.,  his  nuUitioni 
mtist  be  continual  1 J  aided.  Here  the  mistake  of  giving  motor  dctfrcMJUitflb 
Boch  as  the  bromides,  ehloral,  and  hjoscyamine,  should  nerer  ha  Tnaill^ 
Moreover,  it  matters  not  hovr  mauiacal  Uie  patirut  tmiy  beo^me,  riii^ohiTii- 
cal  restraint  shouJd  not  be  employed  e^eept  aa  a  laat  resort.  All  Die- 
ehanical  restraint,  except  that  vhioh  makea  eaptive  the  leipi  alone,  isa^ 
pedes  freedom  of  respiration,  aud  thits  becomes  a  very  pjwerful  iiiAuem*a 
in  contribudng  Ur  ajHtlieniu  uonsolidalion  of  the  lunga.  The  reHtrainkn^ 
influence  of  one  or  more  nurses,  added  to  the  aleep-prodiicing  jKittmny  of 
twenty  graius  of  fiulfonal  or  trional,  giyea  in  liot  iikillc  itr  in  nouw  form 
cf  alcohol,  is  far  better. 

Deliria  of  IntoaicatiojiH — As  to  the  endogmiouA  varietioM  of  this  oIan 
very  little  need  l>e  aatd.  The  treatment  eonsinta  of  efTortH  to  cwerei}iri« 
the  source  of  the  nKift'nes  jporbi,  to  couEiteract  its  efTetrt  uihitl  llin  rtinlrul 
oerrous  syalem,  and  to  secure  iU  eliiiiiiiatiou  from  tlje  njatejii.  Tlieitt 
ftrd  tvo  important  faets  which  if  ke]jt  in  mirkd  will  giitntly  ximplify  the 
treatmeut  of  tOKio  and  autotuxio  detiria:  fjrut  help  nature  tu  get  rid  of 
at  least  Bome  of  the  poisoQ  tn  the  system,  then  strike  at  the  souri-e  uf  tho 
intoxication.  If  the  latr^r  be  a  wouud  that  in  litled  with  ifidoform,  the 
removal  cf  the  latter  is  a  rery  evideat  duty  -,  but  if  tita  aliHjHjrnt  surf^v 
be  the  entire  gastro- intestinal  tra<;t,  and  the  injurious  snbnUuM-e  thn  ui 
yet  unknown  luxin  whic-h  producea  the  chuieal  plienuinena  of  insolation, 
the  task  is  much  more  diflieult  But  th«  important  msitter  lirst  of  all  In 
to  determine  with  what  the  delirium  is  puhologieally  ■asooiate'lr 

Of  the  deliria  having  their  origin  in  touc  sulMtanc«a  eoriiirig  from 
withmit,  delirium  tremens  is  the  most  Ituportant,  beoauM  it  is  so  com- 
moo,  land  because  it  ia  ao  uniformly  fatal  after  the  first  <rr  BVCOnd  BXbttilLti 
All  toxie  deliria  are  associated  with  more  i^^r  \^**%  profound  WtbaaUi  iU 
the  first  aim  of  treatment  ahonld  bd  to  eoiantermrt  this  nath^nla  while  tl 
the  same  time  fiilfillijig  a  more  pointed  indication.      In  aloohuliA  mlpjMtfl 


5B8 


TREATMENT  OP  DlflEASEH  CF  Tfl 


'EH, 


tiicre  bad  almost  iiiTariably  been  a  proloofied  ^nd  outr«g«oua  indulgence 
in  HLibetEUicea  which  deatroy  the  metabolic  functioDS  of  the  econoiuyT  ajid 
b«fore  measures  can  be  Cakeo  to  coimteract  the  influence  of  the  j>oUoa  it- 
self iipnn  the  nervoua  ajsteni^  the  j*nni/x  vIhj  aud  the  aveuuea  leading  up 
to  it,  laiiat  be  carefully  atLenJed  to.  Tberefure  iLo  firhl  *od  moat  im- 
portant Uierapeutic  measure  la  tiiD  mtroduotion  of  email  quantities  of 
partially  digested  or  predi^ested  nourishment  into  the  paticnt^e  aiimeO' 
tary  tract.  There  should  be  no  heuitatiou  in  r^^ortiug  to  nuQommoD 
aveuuea  of  introducing  nourishment  if  the  patient,  bacauee  of  snoruia 
or  under  the  iuflueiipe  of  a.  delusion  or  hallucmatioo,  refuses  food,  1 
am  HO  Qonviuc-ed  that  at  least  OLC-half  of  tlie  pabienLa  in  the  early  sLaijBa 
of  di^lirium  trcinens  vould  weatlier  aa  Aatiufactorilj  the  danger  incident 
to  their  rice  by  this  plan  of  treatment  alone  that  I  not  infrequently  em- 
ploy it  to  the  eiclusiou  of  all  other  treatuect  aave  that  of  aonie  of  the 
rapidly  acting  tiypuotics  ^hich  are  not  depressanta. 

It  is  extremely  common  fur  pbyHtoiaus,  when  they  meet,  for  the  firxt 
tiiaei  a  patient  eiiSeiiug  from  delirium  tremenSt  to  write  a  preacriptioa 
containing  abuut  lifti^en  graiua  of  cUoral,  thirty  of  hromide,  and  from 
three  to  six  drops  of  tincture  of  digitalis,  aud  instruct  that  Ibis  be  ad' 
nnnistered  ev^ry  four  hours,  and  at  the  same  time  give  more  or  leas  per- 
fimetory  insti-uctioiis  r^^ardiog  tlje  diet  At  a  fiubsequent  viait,  if  the 
patient  is  very  delirious  and  diMcult  to  reatraiUf  they  give  a  hypodermic 
iiijectiou  of  morphine,  and  possibly  leave  oiilera  that  it  be  repeated,  if 
neoi^Bsary,  8uch  a  combination  very  frequently  does  more  harm  thaa 
good  by  adding  to  the  paCleut'a  asthenia  and  to  the  depravity  of  the  blood, 
f  confess  that  1  ahould  have  tn  be  puj^hpd  very  hard  before  indulging  in 
the  admin  ist  ratio  a  of  a  mixture  reoumnieiided  in  one  of  the  most  recent 
treatiseEi  ou  therapeutics.  The  writer  of  the  article  to  which  I  allude 
says  that  it  ia  hia  ouatnm  to  give  drachm  dosce  of  the  bromide  of  ikmrno- 
niunt,  Hfteen  gndpH  of  t-hhiral,  aud  one-quarter  of  a  gram  of  morphine,  in 
order  t.c»  indure  sleep.  8iudi  a  mixture,  it  seems  to  nii^,  has  entirely  too 
liigh  a  poteutiaJity  of  dangerousiiesa  to  give  to  any  person,  but  particu- 
larly to  one  whottc  vitality  ia  at  a  lifw  ebK  Aa  «  matter  of  fact,  1  naver 
use  the  bromide  aud  chloral  mixture,  nor  hyoacyamua,  until  four  otfiet 
hypnotics,  aulfonal,  trioual,  paraldehyde,  and  chlorolaniidd  have  failed 
Tiie,  and  a  thorough  trifll  of  prolonged  wai-m  hatha  or  a  brief  very  hot 
bath,  If  the  stimulaiita  atrychiiiue  aud  digitalis  are  properly  used,  and 
if  the  indications  for  maintaining  the  patient'a  streugth  as  mentioned 
abofo  arg  fultilled,  the  depressant  drugs  will  rarely  be  found  necessary. 

I  am  not  ludined  to  use  alcoholic  etimulnnts  in  the  treatment  of  deli' 
rinm  tremens  nnless  this  condition  ia  asaociated  with  pneumonia,  aa, 
Unfortunately,  it  not  infrfujuently  is.  When  this  complication  is  indi- 
catedi  whiskey  and  brandy  freely  given  will  sometimes  save  the  patient's 
tife. 


^ 


DeliriQin  of  Sxha^aBtion.— The  deUrium  of  exhaustiou  is  tbo  our* 
whiL-h  is  tLe  least  understood  of  siEl  tbe  d«Uria-  It  ifiAUis  ditflciilt  t^r 
some  to  admit  that  it  really  ocuurs,  but  although  it  ttt  oiio  uf  %}m  tnva 
forraa^  there  can  bo  uo  doiiht  of  itg  existenue.  Its  aaflouiatioii  au^gesta 
(he  iudicatiou3  for  tieatment,  auU  there  ^ould  be  do  difficult  in  follow- 
ing out  the  proper  therapeatio  plan  were  it  not  that  Lt  muflt  ba  r«oo^i£Ad 
by  a  proeess  of  exclusion^  The  treatment  is  symptom  a  tie,  uiid  «hould  lis 
directed  partimilarly  to  overccnuing  exhaustion. 

Delirium  of  Senility. — Senile  deliriiiui  is  in  reality  a  delirium  of  oa- 
hauation,  remotely  conditioned  by  pathological  chungua  iu  tlio  blood*?«- 
eelsj  and  imipodmtely  by  disordered  iotraoranial  blood  aupply.  An  ohUf 
clinical  charade ristioa  are  that  it  ia  of  the  so-tialled  "  husy/'  aptiv«  kind, 
and  it  almost  iuvartaljly  oceurs  at  night.  During  the  day  the  [mttinit  may 
have  customary  mental  luridity.  In  addition  to  the  ordmary  mojuuroi 
to  maintain  tho  patient's  nutrition,  special  prei^arvlons  ahculd  l>e  takfjo  to 
prevent  harmful  lowering  of  vitality  in  the  early  niomiug  hourfl.  If  iuqIi 
ft  patient  is  taking  one  of  the  iodine  salta  and  uitroglyceriii,  it  it  v^ry  ad* 
visable  to  give  him  a  full  doso  on  retiring^  and  also  %  liberal  amomit  of 
nriu  p«t't<)ni£ed  milk,  and  to  repeat  this  oiioo  or  tivic«  during  the  (li^hl, 
«Ton  though  it  be  necesaaiy  to  awakeu  him.  Alcoholic  Btimulants  aro 
likewiM  of  signal  aerviee  in  preventing  deliriom  of  thid  nature,  Tbetr 
efGeaciousne^s  seems  to  be  increased  if  given  in  hot  water  or  in  hot  mOk. 
Tbe  value  of  dry  beat  to  the  eEtTeniities  aUoidd  not  be  overh>ok«d- 

Scliriuiti  of  Irritation.— The  deliria  of  oenLral  or  peripheral  iiritatiou 
is  a  very  large  subject,  and  one  that  I  cannot  attempt  to  banllo  iu  a  brM 
consideration  of  this  kind.  From  the  slight  experience  which  I  baro  bad 
with  cerebral  injuries,  either  aeridectal  or  eorgfu^  I  am  iuellMd  to  tht 
opinion  that  surgeons  are  more  apt  to  aefk  the  eanae  of  tbe  deliritm  In 
infeGtioa  than  they  are  in  local  itTilation.  Thera  may  be  ample  rewuae 
for  thia,  bat  neTcxtheless  delinum  la  so  freqoeatly  B  sympti'Ttt  of  mokln* 
geal  and  cerebral  irritation,  unattended  by  any  Mitsideraljle  infection  or 
iatoxieatioa,  thatita  occrurene^  sb^d  ea^ufl  do  aatonishDMoL  Wbcft 
the  britetiaa  iaof  mpQ>t-tt<waiatiPorigi«,ttdtb»  Jetinaa  k«o«tlMioi^ 
tiua  ahoold  ht  anBriffnt  ta>  waitapt  opentjra  latarf^rmfm. 

Tbe  deliria  asaoriated  with  atatea  of  eeotral  drprfinn,  aaek  aa  epl' 
Icpayattdhj  Iter  la,  demand  ftggteateitctTCttaaapectiomiBthw 
andiDttrpvecatiOQ.     Psjchseal  epOepvy,  Hat  ia  cpOspij  is  vUA  iIm  to*' 
tocury  notor  erpbwo,  kC  1M  nr,  k  wpiattd  bf  pifchM  fkmommm^ 
IfaUe  Batst^  i^  In  pfoportni  %m  tts  flvdlnafj    1 1    j  i  j , 
mbei  —maiiMii  sad  tibia  pcHh^a  vemnto  br  IIm  £Mtcbtkii» 
iwwgntifd  vbea  ii  doei  ocnn.     The  ^mjchim  enoivileBt  aaj  aa 
tte  f aim  «f  detinvB,  erca  tea  tbf  vcty  lf^M«M|_  ii  ^tfiigyay 
I  aa  «nKMffy  Botar  •pOil^  a^  ^HnaM  is  ic« 
'^  bnag  ntHnMSsi  by  m  um  i  iileioa,  mmAtv  %j  a 


660 


TREATUBKT  OP  mSBASBS  OF  THR  NBRVOUS    BYBTBH. 


I 


state.     The  same  is  true  of  hysteria,  althoi^h  hysteric  delirium  is  reU 
lively  more  common  tb&u  epileptic  delirium. 

Occasionally  there  ia  superadded  to  the  typical  symptoms  of  a  seToi 
Sydenham's  chorea  a  profound  state  of  un^stematized  delirium.  It  ha: 
been  suggested  by  some  writers  that  the  delirioni  ia  the  expressioD  of  ai 
extensive  encephalitis,  it  beiug  kuown  that  in  some  cases  of  chorea  whid 
have  proved  fatal  vascular  ehangea  have  beeu  found  vrtuch  point  to  i 
mild  degree  of  parenchymatous  inflammation.  Personally,  I  am  notiu' 
dined  to  this  view.  I  believe  that  the  delirium  from  which  chorei 
insaniens  takes  its  descriptive  adjective  is  analogous  and  comparable  b 
the  delirium  which  is  occasionally  an  accompaniTaent  of  rheumatism,  and 
that  its  causation  is  to  be  sought  for  in  the  profound  dissociation  of  the 
component  parts  of  the  blood  which  occurs  in  both  of  these  diseases. 
The  treatment  of  chorea  insaniens  would  be  very  simple  were  it  not 
for  the  profound  vascular  depravity  behind  the  chorea.  This  militates 
against  the  administration  of  a  drug,  exa^in,  whioh,  if  ^tcu  in  three-  to 
five-grain  doses  and  repeated  every  two  or  three  hours^  ivould  soon  atop 
the  delirium,  at  least  temporarily  j  but  as  exalgin  tends  to  liberate  the 
hfemoglobin  and  thua  act  aa  a  severe  hfemolytic,  it  should  never  be  used 
The  general  treatment  of  asthenic  delirium  (enforced  rest  in  bed  and  the 
administration  of  small  doses  of  bromide)  suffices  to  control  the  attacks  in 
most  cases.  This  is  one  of  the  forms  of  deliria  in  which  hyoscyamns 
should  never  be  given » 

The  treatment  of  epileptic  delirium  is  practically  the  treatment  of 
status  epilepticus,  save  that  the  necessity  for  giving  stimulants^  which  is 
so  patent  in  the  latter  condition,  is  not  so  urgent.  In  reality  the  treat- 
ment is  small  doses  of  one  of  the  bromine  salts — let  us  say  ten  grains 
every  hour  or  two,  ^rhich,  with  mechanical  restraint,  usually  suffices  to 
end  an  attack.  The  treatment  of  hysterical  delirium  often  baffles  every 
resource  of  the  physician,  aud  then  after  resisting  them  alt  disappears 
spontaneously.  The  most  powerful  element  in  its  treatment  is  complete 
isolation  aud  the  application  of  cold  packs,  although  in  many  of  these 
cases  the  salts  of  hyoscyaminegivenin  doses  up  to  theirfull  physiological 
limit  are  of  the  greatest  benefit. 

General  Remarks  on  the  Treatment  of  Delirium. — Although  therapeu- 
sis  must  vary  in  every  case  of  delirium,  and  the  indications  in  one  kind 
may  not  suffice  in  another,  nevertheless  there  are  a  few  underlying  prin- 
ciples in  the  treatment  of  all  deliria.  In  the  first  place  it  is  the  opinion 
of  the  writer  that  sedatives  are  used  too  often  aud  too  indiscriminately. 
Bromides  especially  ate  frequently  given  offhand  in  large  doses  and 
over  an  extended  period,  apparently  forgetful  of  the  fact  that  they  may, 
by  adding  to  the  vascular  depravity  which  is  so  often  at  the  bottom  of 
the  delirium  accompanying  asthenic  states,  intensify  and  prolong  the 
duration  of  the  symptoms  for  which  they  are  given. 


THE  TRKATMK>T  OF  DEURIUkt. 


m. 


t 


The  gener&l  indicadons  in  the  tr^atiu^nt  of  delirmui  am  fttal  to  ssonn 
sleep;  s&candf  to  overcome  motor  itnivst^  third,  to  Gupjnrt  %xv\  luaint^n 
die  patieut^a  TiUUty  bj  raQtributing  to  bui  nutrition;  nod  toitrth.  U^  dis- 
oo76r  &nd  reniov«  the  cause  tipou  nbkli  tho  delirium  ia  d«p«udeut. 

To  laeet  the  tirat  indication  hypaotics  ftre  jUmoat  ftlvnya  requi»d« 
although  it  should  n^ver  for  a  moment  be  forgotten  thnt  &u  hour's  »1eep 
induced  by  uieasiireH  taken  to  fulfil  the  third  condilion  is  far  niore  »aIu- 
tar^  th^n  LlLie^-houTB'  sleep  obtained  by  the  uao  of  a  hypnotic.  More* 
over,  that  in  many  forma  of  asthenic  delirium,  whether  the  aatheuia  be 
induced  by  infeetion,  intoxication,  exbaufftioTi,  senility^  or  whnt  uot, 
sleep  ifl  more  readily  induoed  and  maintained  by  meaaurea  directed  iin- 
inediatflly  agaiuMt  the  asthenia  than  against  the  inflotnnia^  Tn  the  seleo* 
tion  of  a  hypnotic  the  one  least  depreasant  to  tlie  phtient*a  vitality  tunl 
leaat  apt  to  be  followed  by  depreaaion  should  ;Uwaja  be  gi\eu  proferenei*. 
The  motor  depToaaants  ebould  never  be  used  in  the  delirium  aooompauy- 
ing  the  aathenio  state,  except  as  the  very  kst  reeort.  In  certain  fonrm 
of  asthenic  delirium,  and  especially  those  in  which  a  sedative  effect  ean- 
not  be  produced  by  the  external  apptioatiou  of  water^  drugs  whioh  Are 
motor  depreaaonta  and  at  the  same  time  hypnotics  may  be  used  with  tho 
greate-st  benefit-  Of  these,  the  alkaloids  of  hyosoyojiius  are  the  ujOHt 
available. 

The  second  principle  is  that  great  rare  ahould  be  had  in  the  appllea- 
tion  of  met^hanical  reatraiut  ici  all  forma  of  asthenic  deliriunt,  lest  thn 
cncroachmeui  on  leapiratory  capacity  load  to  pulmonary  complications 
which  jeopardize  the  life  of  the  pafciedt.  Whenever  poaeible,  mamial 
and  moral  reatroint  are  very  much  less  daagerous,  I'Oncemitig  the  third 
principle,  that  of  maintaining  the  patient's  vitality,  sufficient  baa  already 
been  said.  The  meeting  of  the  fourth  indication,  \h.,  the  discovery  and 
removal  of  the  cause  of  the  delirium,  is  after  all  the  most  essential  pro* 
redure  in  the  treatment  of  this  symptom.  To  do  this  the  pathological 
asQOCiatioti  muat  be  determined^  and  then  our  ammunition  levelled  directly 
against  itf  while  aimultaneoualy  the  three  first  enumerated  principles  are 
guiding  uf;  in  symptomatic  therapy. 

3b 


CHAPTER  XLVL 

THE   TltEATMENT   OP   VXBTTOO. 

VRKTjfin  IS  tlte  term  applied  to  a  diaburbjuire  of  the  semse  of  eqiii- 
librium  and  of  pooition  in  apace  relative  to  objects  of  the  enTiroji- 

ment.  The  Dommoa  Bynouyms  are  giddinGoa  anil  dizainsas,  the  latter 
teriu  being  less  appropriate  thaa  Ihe  foriuer.  Vertigo  ia  often  referred 
to  RB  Bubj«wtlve  and  objective,  accordiog  to  whether  the  surrtkuuding 
objects  neeiik  to  move  and  to  be  unstabte^  or  the  (latient  himself  seems  to 
be  tha  aeat  of  tlie  movemeot-  In  ita  leaa  a«vere  miJiifestatioiiB  rertjgo 
ia  a  common  diaorder,  yet  compared  with  headache  it  15  relatively  ua- 
eonimoB.  Like  headocbo  it  ie  always  a  eymptoni,  although  one  form  of 
vertigo,  Thi(?h  is  now  uuivcTaally  known  by  the  name  of  the  physidazi 
who  firnt  described  it,  M<^iif>re*i  di^eaMe,  ii  iiHually  rdn^idered  a  disea>« 
uti  i/enrriM.  But  even  bora  vertigo  iB  only  one  of  the  aymptoms  aseoci' 
atcd  with  the  leaion  in  and  around  the  semicirciiljir  i^anaU.  It  luatten 
not  the  condition  vith  which  vertigo  is  associated,  if  Iha  sympt/^ma  are 
8uffi4.^iently  eevere,  it  ia  usually  preceded  or  aoeompanied  by  nakisea,  7om< 
iting,  vasomotor  pbenomerta,  and  a  aen^e  of  depreasion  or  il^beisg, 

Vertigo  19  really  a  aubjeotive  diBtiirbauoe  of  consciouaness,  a  payehioal 
oceurrenuH  in  vbioli  a  feeling  or  seusjition  of  iastability  ia  the  must  prom- 
inent feature.  Formerly  it  was  tauglit  that  vertigo  vaa  conditioned  by 
disturbance  ot  the  iutr&cranLal  cirGidatioUf  and  in  thia  way  trord  inter- 
preted the  aural  vertigoa,  ocular  vertigOB,  toxie  vertigoa,  and  tli«  like. 
This  explanation  being  ptirely  hypothetical  was  unable  to  withstajid  the 
ttrata  of  eii>eriniental  physiology.  TIjc  latter  has  shown  that  irritation 
of  the  cerebellum  or  its  peduncles,  of  the  eemiciroular  canala,  and  of 
^hut  appeare  to  he  the  auditory  nerve — but  whieh  ia  in  reality  a  nerre 
tiaveUing  with  the  acoustic  nerve  and  destined  especially  for  the  eenii- 
circular  canals,  known  aa  the  nerve  of  Cyon. — pnxlur.ea  a  variable  but 
always  intense  degree  of  vertigo,  even  though  no  changea  in  the  TBSCular 
supply  accompany  them.  Receutlyf  Mendel  haa  contended  that  the 
proximate  cause  of  alt  vertigo,  apart  from  that  ariamg  as  a  disturbaoco 
of  the  organiam  of  equilibrium,  ia  a  functional  disturbance  of  the  gan- 
glion cells  that  form  the  nuclei  which  preside  over  the  movements  of  the 
ocjilar  muflcle9t  and. is  conditioned  through  the  circulation.  The  fact 
that  the  fine  terminal  branches  of  the  iioaterior  cerebral  artery  which 
euppliea  the  nuclei  cf  the  ocular  muaolea  do  not  anaatomose  ha^  led  Ueo' 


THE  TEKATMENT   OF   VRRTIGO, 


663 


1  to  the  belief  that  cociparatireljr  alight  diaturb&iiQG  of  vaacuUr  Uma^ 
IB  these  veasela  may  eauae  vertigo. 

For  purposes  of  coDvenience  vertigo  may  be  clafisified  a^: 

1.  A  Bymptom  of  disease  or  disturbacce  of  the  Bemicircular  canals, 
ths  nervea  of  CyaHj  ^^t  of  the  cerebellum;  in  shorty  digturbsnce,  vhether 
organic  or  non-organ i^%  of  the  apparatus  of  equilibrium. 

2.  Pfleudo-SI^niera'adisea^ei  disease  of  the  external  and  middle  eaxr 
auial  polypi  i  disease  of  the  Eustaohian  tube. 

3.  A  symptom  of  organic  brain  disease;  brain  tumor  j  brain  syphilis; 
multiple  sclerosis. 

4.^  A  symptom  of  inco-ordination  of  seuaory  impressiona  hy  the  Virain, 
receUed  particularly  through  the  sense  of  sight. 

5.  A  symptom  of  disordered  blood  supply  to  the  braiu,  be  it  depen- 
dent upon  functional  perversion  or  orgaoio  disease  of  the  vessels. 

6.  An  act'ompaoiment  and  symptom  of  one  of  the  neuroHea,  such  as 
epilepsy,  neurasthenia,  aud  hysteria. 

7.  A  symptom  of  the  drscrasiic  or  of  the  inboxicationa  and  infections 
leadicg  to  them^     Gerlier's  disease,  anjemia^  etc 

8'  Vertigo  ^hir^h  may  be  described  as  redez,  in  order  to  explain  the 
Ci3rrelatioQ  between  the  ocurrence  of  vertigo  and  disorder  of  aome  dis- 
tant organ.      Stomachio  vertigo,  laryngeal  vertigo,  etc. 

Hiniere'fl  Diseasc.^I^y  far  the  iLost  important  of  all  the  vertigos  is 
that  known  aa  ML^ni^rc'a  disease,  or  aural  vertigo-  This  diae&sevraa  hrst 
described  in  1S61  by  M^i^rc,  nho  reported  the  ea£e  of  a  young  gitl  who 
was  suddenly  taken  with  viol^-nt  vertigo^  vomiting,  aod  deafness,  She 
died  vkthin  a  short  time,  and  pust-moit^m  examination  showed  that  the 
semicircular  canals  were  partially  filled  with  a  red,  plaetio  exudate.  It 
•voA  inferred  from  this  experience  that  lesion  of  the  semicircular  canals 
had  caused  the  disease,  but  it  baa  since  then  been  abundantly  proven 
that  fiimilar  manifestations  may  occur  without  such  pathological  process. 
There  seems  to  be  iiioontrovertible  evidence  that  the  symptom  cnmpler 
of  Meniere's  disease  m.ay  be  cauaed  by  difTereut  chronic  pathological 
proceeses  of  the  middle  and  intenul  ear;  and  it  is  unquestionable  that 
encroachment  upon  the  nerves  of  Cyon  in  its  coiirse  outside  of  the  semi- 
circular canals  can  prodace  like  symptoms.  These  varieties  of  vertigo  are 
u^aally  known  as  pseudo-M^oi^re^a  disease,  and  although  it  u  oftentimes 
difliculL  to  distinguiah  them,  it  is  unnecessary  to  do  sii.  Tt  ha^  been 
shown,  moreover,  that  aural  vertigo  doee  not  always  come  on  in  the  sud- 
den, unheralded  way  first  described  by  M^ni^re,  although  it  docs  in  per- 
haps more  than  one-half  of  oil  the  ccflce.  When  the  attack  comes  on  in 
apoplectic  fashion,  the  patient  is  taken  suddenly  with  subjective  noises 
and  rumbling,  and  bozzingg  in  the  head  and  ears.  These  are  imm^ 
diately  followed  by  a  sensation  as  if  tlie  surrounding  objecE?  or  the 
patient  himaeLf  were  turomg  aroond  on  a  vertical  or  a  horizontal  axis. 


564  TABATHKEfT  OF  DI8BABS8  OF  TB&  NKBVODfi   fiTSTKH. 

This  is  Aooompanied  bj^  disturbaDoe  of  eo-ordmation,  vhioh  maj  b 

gnaX  tliat  the  patient  falls  violently  to  the  ground,  aod  bj  a  fselin 
mental  and  physical  distress,  nausea,  and  vomitiiig.  At  the  heigh 
the  attack  there  is  some  encroachment  npon  or  limitatioa  of  cooxi 
ness.  Nearly  always,  however,  this  is  only  paaaiii^.  These  phenoni 
may  last  for  only  a  few  minutes,  or  they  may  oontmne  for  several  ho 
and  then  gradually  grow  milder  and  disappear,  leaving  a  sensatioc 
weakness  and  exhaustion  and  a  diminution  of  hearing*  in  one  or  both  e 
which  is  persiatent- 

The  attacks  occur  with  no  regularity.  In  some  cases  a  few  dj 
while  in  others  a  number  of  months  intervene.  In  the  interval  the 
tient  feels  pretty  well  ordinarily,  but  there  is  alwayn  a  tendency  to  i 
zinesSf  especially  on  coughing,  sneezing,  and  making  qnick  movemei 
such  as  getting  up,  and  turning  around  suddenly.  After  the  £rst  itb 
examination  of  the  hearing  shows  lessened  aerial  conduction  and  tn 
or  less  lose  of  bone  conduction.  Eventually  hearing  is  entirely  li 
and  then  the  attacks  usnally  cease,  for  this  is  an  indication  of  oompl 
destruction  of  the  semicircular  canals.  The  outcome  of  M^nidre's  disc 
is  not  usually  very  satisfactory.  In  the  apoplectic  cases  the  prc^uosi 
rather  grave-  In  the  milder  cases,  those  that  come  on  more  gradual 
life  does  not  seem  to  be  shortened  by  the  occurrence  of  the  vertiga 

Treatment  of  KiniAre^s  Disease.— Aa  in  every  other  aymptom  cc 
pleXf  the  treatment  of  M^niSre's  disease  consists  first  in  searching 
and  removing  the  cause,  and  then  adopting  treatment  directed  towj 
relief  of  the  symptoms  and  prevention  of  their  repetiticm.  AH  that 
known  of  the  causation  of  the  disease  is  that  it  occurs  with  leukKm 
neurasthenia,  and  occasionally  with  tabes  and  in  those  who  give  hiati 
of  syphilitic  infection.  The  medicinal  treatment  of  M^niire'e  disease 
of  greatest  importance.     During  the  immediate  attack^  the  patient  ahoi 

!.  be  kept  in  bed.     Some  relief  is  often  obtained  by  the  application  of  h 

ter^s  coil,  or  cold  apphcation  to  the  head  when  the  former  is  not  to 
had.     Counter-irritatious  to  the  back  of  the  neck  and  over  the  mastol 
as  well  as  blood-letting,  do  not  seem  to  give  any  benefit.     The  admi 
istration  of  a  rapidly  acting  cathartic  ameliorates  the  symptoms  if  tb 
continue  for  any  length  of  time.     The  drug  which  is  superior  to  j 

I  H  others  is  quialne.     It  was  originally  su^ested  in  this  condition  by  Chi 

cot,  who  was  led  to  use  it  by  a  consideration  of  the  intracranial  su 
jective  phenomena  which  it  produces  when  taken  in  physiological  dose 
It  should  be  given  in  three-grain  doses  four  times  daily,  and  kept  i 

i|l  for  a  period  of  from  six  to  ten  days.     Then  it  should  be  stopped  f 

about  a  week,  when  it  is  renewed  ^ain,  and  kept  up  an  equal  numb 
of  days.  This  plan  of  giving  it  in  alternate  intervals  should  be  conti: 
ued  for  a  number  of  weeks-  When  it  is  first  given  it  almost  invariab 
causes  some  exacerbation  of  the  symptoms,  but  after  being  kept  up  f 


f 


i.! 


IKB  TmxATmE^T  or  vmBTliMX. 


(fae  patimt  or  »  e™>4t  ^  BBttiovit  Ml  kAnu^  ^Mt  U  b»r>»wi  b«tt* 
able,  KerettMeo^  «  aimhrg  «f  tman  pcvr«  wfc<Uw—  to  this  pUm 
tn*t&€fit.  Tbo  tntk  of  tbk  u  ■iifciartly  indMted  Iqt  Um  hM4  that 
otk«r  drags  haruv  m  ph^vnlogial  aMioft  sinuUr  t»  qnum  i&  lu&ny 
raipeeta  kave  ben  weow— drf.  Of  thaet^  nM  tn^l  s^lUc^Ui*  a(| 
■^*'""  an  Ibe  most  imporluitt  tbe  fomir  givea  in  from  li\v~  tu  IM* 
gmn  doeca,  three  timce  »  d&y.  «n4  th«  Utttc  la  douU^  ittftl  ^ua&lil^. 
Thej  «re  irarmET  rsooiUMnded  bj  eowe  vriton,  but  im  Uigr  «xi*«nci)(^ 
Lhej  vre  not  su  sAtufaotofj  &>  quioine.  In  eeace  ib  vhieh  the  thr\«Ltbu^ 
and  soueiBg  Doiaea  in  the  cam  ar«  «tr«imljr  Mv«n%  Ui«  aiimiuiBMUuu  of 
orgot  and  nitrite  of  am/l  is  soin^Udies  ftillovt^l  by  rst'<-lWt  twiiilia,  ihk 
tike  other  L^ad^  when  the  peripheral  rin^itlaUou  ia  iwWc  niul  thvro  tkn 
eridencea  of  piofou&d  sjuapathetic  nerve  ilrprceaitjii,  tiiic^tura  vf  bUl 
TOiaica  given  in  five-drop  doe^  every  hour  vill  be  fo^iod  ^r^vj  aemOMbi^ 
The  bromine  salta  lto  given  v«ry  «xtensn^«]j  in  thii  and  otb«r  Vtllstisi' 
of  vertigo,  but!  have  had  no  benefit  from  tJiein  th^t  warnuiu  lua  lu 
Tecommeuding  their  admin  is  tratiou  iu  M^i^re's  dist^aac^ 

The  general  treatment  of  M^ni^re^a  disease  is  priKticftlly  Ulv  k^^^^S^ 
treatment  of  neuraetheuia.  Patieata  vbo  c4(q  nffonl  a  chauife  of  aur* 
roandings  should  be  advised  to  sojourn  for  a  few  weplcs  m  nn  nltitudt  uf 
fiorae  two  t)  thred  thouaaud  feet^  and  the  bodily  tone  iihould  bt>  iiikiih^ivfid 
by  meaos  of  suitable  appetiserj^,  food,  and  medicinal  UNnue  bujldefii,  and 
Alao  by  tho  uae  of  tonic  bydriatic  measures  and  exMrcise  lu  tho  ui>nii  uir. 
The  necessity  for  giving  up  etimulauta  ami  nurcotii'i  aucl  urnidittg  my- 
thing  that  causes  disturbance  of  intracranial  droulalioti,  iiud  Ibe  adoption 
of  a  quiet  lif*^,  f<)r  fl  time  at  leaat,  is  very  evidL*ut. 

pBeudo-M^ni^re'B  Disease. -^Tlie  faitt  that  a  similar  symjiLnin  rotiipUv 
sometimes  developa  with  acute  otitis,  sclerotic  iufljunmaticin  of  the  inld* 
die  ear,  relaxation  of  the  membraui  tytiipani.  and  divaaao  of  the  omiolaa 
has  aJready  been  mentioned.  Thisia  properly  known  asapsuudo-MdniliFt' 
symptom  complex.  Ca^es  h^ve  b^&ii  recorded  in  ^vUirh  the  rMUoval  of' 
oerumen  and  foreign  bodies  from  the  external  auditory  oanal  ]ia«  rnlievad 
auditory  veitigo.  The  treatment  of  vertigo  associated  with  niliMJi^-ear 
diaeaae  depends  entirely  upon  the  nature  of  the  IcNioik  If  it  ia  du«  tO 
retaliation  of  the  membrani  tym|>aiii,  desiralile  results  ofti*ii  follnw  jierfora* 
tioaof  the  drum  by  meaoa  of  the  elai>tric  cautery.  Tlie  pi^iUraction  which 
ac^(roT]jpanie8  soar  formation  is  sufHc^i^fnt  to  Lake  up  tire  rnlaiiition.  'I'm' 
otoniy  of  the  tensor  l^mpaui  hds  also  been  suicgeslcd  for  tlie  rflliff  of  Uiia 
coDditioQ,  but  it  b  not  looked  upou  witli  much  favor  by  auriat*,  Wh^n 
the  symptoms  oE  aural  vertigo  occur  io  a  jxttiimt  who  tioii  evideii/^i  of 
Groachment  upon  the  Eustachian  tube,  it  i»  nefinMary  to  explortt  the  DJ 
pharyoz  and  remove  any  vegetations  from  the  poaterior  nasal  fossa  or 


666 


TRKATMENT   OF    DTSEABBS    OF   *fFK   VKRVOV^  BTSTBlf. 


counteract  any  disease  that  may  eiist.  Many  oaaea  of  ralddle-^ar  diseAse 
with  ttcoompaijyiDg  Mt^aiire  Byinptom  complex  ate  relieved  by  oatheter 
lEation  and  the  Qarefu]  uae  of  Folit^ter^fl  air  douche.  It  ia  of  gr«at  im^ 
portaiice  that  Eof>  great  aerial  tomppeBsion  sliould  bsnvoidt^rl  ,in  Politicri- 
ztttion,  otherwise  the  trauma  which  it  |irodmres  will  rflmilt  injtirioiisly. 
PuruloDt  proceaseH  in  the  middle  ear  must  b«  evacuated  by  puuoture  of 
tba  drum  membone.  AdbeaiotiB,  BcleroaiSr  and  induratioti  of  the  tym- 
panic  cavity  require  medical  treatment  directed  agalaat  the  conditLoas 
which  uaLise  theee  lesionSf  ba  they  syphiUdo,  gouty,  rheumatic,  or  pcMt- 
iiifiammatary-  A  great  niiriib«r  of  meaaurea  have  tieoii  proposed  to  over- 
come the  sol  erosia  and  thickeuiugof  the  tympanic  cavity,  surh  as  maa- 
aage  of  the  tympanum,  the  use  of  the  galv-oiiio  current,  the  application  of 
amiill  blisters  or  j/oint^  d«feM  over  the  mastoid  prooeaa.  It  is  possible 
that  in  cai^es  lu  which  these  m^aaurea  ara  immediately  indicated  b«iefit 
sometimes  follows  their  careful  xpplicatiuu.  It  would  be  extretnely  haz- 
ardous to  apply  them,  bowever,  save  uuder  the  imiuediate  directdoQ  of  u 
esperienred  auriat.  If  oae  may  liaae  an  opinion  on  the  writings  of  the 
latter,  it  ia  safe  to  ttay  thut  au  a  nde  theso  measures  are  not  look^  upon 
with  much  favor  by  otologists. 

In  vertigo  dependant  Yn>on  Bclerosifl  of  th*  middle  ear  and  post-in- 
flaiujiiatiOiy  thic^beniug  of  thti  tympanum  ivith  adhesion  of  the  oHBLclea, 
I  have  fltien  the  Qdniiuintration  of  bromiile  and  iodide  of  potnaeium  to- 
gether cause  very  considerable  improvement,  Mauy  writers  reoominead 
the  iiHc  of  the  galvanie  current,  the  ]>ositive  pole  on  the  tragus  and  the 
negative  pole  on  the  rhest  or  back,  letting  as  sirr^iig  a  curreut  How  as  the 
patiert  can  stand,  then  gradually  dlmiuiahing  it.  This  prooednre^  as 
well  aa  galvanization  of  the  aympalihetic,  is  mentiotied  uuly  to  be  txm- 
dtmned,  The  appliuation  of  electricity  often  adds  nialctially  to  the  in- 
tensitrf  of  the  vertigo,  and  never,  I  believe,  has  any  inHuenoe  in  shaping 
it.3  reoovery.  The  measure  that  is  of  most  serv^ice  in  the  treatmetit  of 
labyrinthine  vertigo^  ^vln^tUer  it  be  due  tr>  hemurrhagi^  inflammatory  ex- 
udate, or  encroachment  upon  the  nerve  of  Cyon,  is  the  subcutaneous 
injeotion  of  hydroohlorjito  of  pilocarpine;  from  two  to  ten  drops  of  a 
two-pei'-eent  solution  Bluudd  be  given  three  or  four  times  a  day,  or  uatil 
it  pruduoea  sweating  and  Halivation.  The  medicament  should  not  be 
uaed  for  more  than  a  few  daya,  iinleBB  evident  benelit  follows  the  first  ten 
cr  fifteen  iiij(^tiona 

Vertigo  of  Organic  Brain  Disease, — Vertigo  ia  one  of  the  most  con- 
stant symptoms  of  organic  braiu  disease,  particularly  of  the  slowly  do- 
velopiiig  varieties  such  aa  tumor,  disseminated  scleroBis,  arrd  brain  syphi- 
lis, meniageal,  vaacular,  orof  the  braiu  aubstanee.  It  is  a  very  important 
symptom  of  braiu  tumor-  7t  occura  in  frojjj  one-tbird  to  one-half  of  all 
the  casoa  of  tumor  of  tbe  frontal  region,  while  it  almost  always  accom- 
panies cerebellar  tumor,  particularly  if  the  worm  in  its  basal  segments  ia 


J 


THK    TREATMENT    OF    VKKTlOO. 


fiffr 


mrolveJ.  TVtieo  ita  occurrence  ia  aesocJated  with  irritative  or  parfilytid 
motor  phonomena  thd  ceatnl  couvolutiona  are  probably  the  seat  or  the 
ii8op1adin.  The  odIj  tberap^ntic  fODdueioTi  to  be  dracvn  itoaa  thU  is  thac 
Its  oLfurrence  and  as^ociAtion  may  be  of  Home  Jocaliiing  value  and  thus 
puiut  for  ot  ai^aiust  operatiuu. 

Vertigo,  a  sympbouiatic  accompaniiLent  of  brain  syphilid,  is  Dot  an 
eaay  matter  to  interpret  EatiafactoHly.  Jt  is  oitsn  one  of  the  earliest 
symptoms.  It  is  usually  associsled  with  other  £j'mptoms  ^vhose  ejttsit- 
ence  l>^speaks  the  implication  of  the  blood-vessels,  surh  as  fleptiiig  attacks 
of  syiiL'Ope,  transient  obsciirslion  of  \iBioi»,  noises  in  tlie  head  aud  ears^ 
feelings  of  ezhauetiouj  depression  of  spirits,  and  emotionality,  Karelj 
ia  it  associated  with  conTulsive  or  paralytift  phenomena.  Its  diagnosis  is 
to  be  made  from  its  histoiy  and  associated  symptoms.  Its  existence  calls 
for  the  moat  vigorous  autisyphlHtic  treatment,  rest,  and  mild  vascular 
stimulation. 

The  vertigo  that  accompanies  cerebral  dbseminated  sclerosis  does 
not  call  for  particular  consideration.  It  occurs  in  nbont  forty  per  eent 
of  the  eiises.  \'ertigo  of  hydi'ocephalus  may  be  leliered  by  the  use  of 
lumbar  puncture,  or  other  surgical  procedcm-  nppUiMLIe  to  this  t'ondition, 

Verti(^  Hccomp&iiieh  both  aiixiuia  and  hyperiemia  of  the  brain, 
whether  these  conditions  ]«  dependent  upon  functional  disorder  or  organic 
diaea^eof  the  veasel^  For  instance,  it  may  ocuur  with  idiopathic  anarnia, 
with  secondary  aniemia,  and  with  insnflicJeni^y  of  the  aortic  valve.  On  the 
other  hand,  it  ia  in  many  cases  an  extr^mdy  early  and  important  symp- 
tom of  arterial  degeneration,  especially  of  the  snferotic  variety.  It  is 
particuIflTly  liable  to  occur  when  tTie  arterial  aclerosia  develops  rapidly,  aa, 
for  instance,  afltir  infcclion  and  from  the  activity  of  continual  intOKica- 
tion.  In  the  begimihig  it  may  bo  tJio  expression  of  increased  arterial 
prvsfiuro  without  material  cbange  in  the  braio.  Very  soon,  howeviT,  it 
ifi  immediately  conditioned  by  deficient  blocd  supply ,  and  is  associated 
with  beginning  chnnges  in  the  parent^hymaof  tlie  htajji,  Tliese  are  indi- 
cated hy  the  fart  that  in  advanced  cases  vertigo  uf  arteriosclerosis  is  ac- 
oompanied  by  general  mental  weakness*  inability  to  concentrate  thought, 
forgetfuliiess,  irritability,  and  in  the  grax'er  forms  by  epileptiform  and 
syni'opal  attacks.  Vertigo  in  arteriosderosia  is  oftentimi'a  the  harbinger 
of  api:>p1exy,  rupture^  embolic  process,  and  softening.  Vertigo  that  ru- 
tults  from  congetitjon  of  the  cerebral  blood -vessels,  lie  it  from  excessive 
cardial  atimulatiorif  aJi  attack  of  astlmia,  or  frrjm  prctlougcd  menial  workt 
is  combated  by  cerebral  and  cardiac  ecrlativee,  eu<'h  as  bromide  of 
sodium,  given  alone  or  in  connection  with  fluid  eitract  of  ergot;  by  rest, 
by  the  sppltcaHon  of  sinapTsma  to  the  extremities,  and  by  stimulaiing 
foot  baths.  On  the  other  band,  if  the  anaemia  is  an  exfiression  of  aortic 
insufficiency,  the  Itidicfttionsare:  the  adoption  of  meaaures  which  will  fEuril- 
itate  ventricular  compensation;  the  utilization  of  cold  applications  over 


5fiS 


TRKATME^ar  OF  DlSBASRa   OF  THE   NERVOC8  STSTBU, 


tho  uardiaa  regioui  ftbaolute  refit  ^  minute  doa^  of  di^t&lisj  and  thd  par- 
Bislent  aJciiuiatTation  of  an  at^aorbahle  jireparation  of  iron,  which  is  v^iy 
eHdeDt.  It  is  uDueceBsary  likewUe  to  Bpeok  of  giviog  Iron^  arseiiii*, 
and  the  vegetable  bittern  to  combat  the  Tcrtigo  of  aoy  form  of  general 
auremia,  as  auoh  trcatnioot  19  plainly  indjcated  to  orercom©  the  condition 
on  which  the  vertigo  ia  ddp«ndeat.  Aa  a  temporizing  iDeasure  m  evch  & 
coofJitioiJ,  a  pill  composed  of  gr.  ^^  of  eitrart  of  opium  and  phosphide 
of  zinc  will  be  found  of  great  eervice.  The  imirortant  measiirtB  in  com- 
bating arterial  Boli^rosis  are:  suitable  dietary^  methodioal,  unCTe^ntfal 
regime;  plentiful  supply  of  fTCch  air;  the  prolon^^ed  admiiiiatration  of 
email  dosea  of  (six  to  tea  grains)  of  iodide  of  pt^tassiuin  or  of  aodium. 
combined  with  rDinute  dosea  of  digitalis  (gr.  J  to  j) ;  small  doses  of  iron 
to  reaiat  tendency  to  fatty  degeneration;  and  the  yt&a  of  temporary  meaa- 
Lirea  to  dilate  the  smaller  blood -Tenselfi,  aijd  thus  dimmish  raaeular  tension 
and  promote  Lymph  circulation.  For  this  purpose  one  of  the  nitrite  prop- 
aratLous  is  used,  preferably  the  nitrite  of  GodiuiuT  given  in  one-gr&in  doses 
every  four  hours.  Its  administration  ia  kept  up  for  a  few  days  only  and 
tlien  st^jppft],  to  be  resumed  whencYer  aymptomatif,  mdicahons  arise. 
If  a  cardiac  stimulant  ia  indicated  Ln  connection  ifith  the  nitroglycerin 
or  nitrite  of  sodium,  camphor,  given  in  a  capsule,  with  minute  doses  of 
opium  or  valerianate  of  menthol,  will  be  found  more  tntstworthy  thAo 
any  other  meastiT^a. 

1  ^  Meiidiol-  ^-n1rTiUlat, , 

I                     I*ulv.  oph.     ..-.,..,,         gr  I 
I  01,  olivA, iL 

I  M>  fu  capB>  Ko.  dl.    B.  One  ctpiule  twice  adaj. 

The  writer's  e3|)erionce  with  alcoholic  stimulants  in  arterial  aoleroau 
doee  not  tally  with  that  of  many  fellow-praotitionera  who  have  written 
on  the  subjects  The  absolute  interdiction  of  mild  etliuulantSt  suoh  as 
amall  qaantitiea  of  whiskey  and  hot  water,  and  a  very  light  wine  with 
meals,  \&t  1  believe,  a  mistake  in  treating  itatients  with  artenoeapillfiij 
fibrosis,  at  least  in  the  elderly.  The  pern ioiousuess  of  niuotine  ia  im- 
meaaurably  greater  in  these  caaea  than  that  of  alcohoL 

It  la  well  known  that  gout  is  one  of  the  moEt  potent  factors  in  causing 
arterial  degeneration,  and  it  ia  not  surprising,  therefore,  that  vertigo 
aooompanying  thin  diatlie^is  ahunld  be  looked  upon  as  a  manifestation  of 
the  graver  disorder.  Neverthelewa,  in  a  large  pro[>ortion  of  the  caaes  of 
vertigo  attending  sn  acute  attack  of  gout,  and  in  a  fair  proportion  of 
those  accompanying  gouty  manifestations,  vertigo  i^  dependent  rather 
upon  the  change  in  the  blood  than  upon  changes  in  the  veaaeJs.  Thi« 
variety  of  vertigo  is  to  be  interpreted  by  other  more  certain  manifesta- 
tinns  of  the  gouty  state  and  by  the  absence  of  degeikeration  that  can  be 


THE  TBEATUEVT   OF  VERTIGO. 


669 


Tocogiiiied  in  the  veasela.  Its  iTeatment  rarely  requires  anj  other  medi- 
cation than  thai;  diracted  tovard  ths  cunditum  of  whirh  it  in  a  sjmptonu 
Regulation  of  the  diet,  the  odmiitiatraLicn  oC  alkalies,  the  adoptdoa  of 
sutRiuent  exercise  to  fncilitate  metaboliam,  audthoeshibitiouof  colchicuia 
in  some  fotm  u^uaUj  sutiicf  s  t<^  keep  the  gouty  monifestatioiis  in  check, 
Uiough  they  may  not  cure  the  diathesis.  If  there  are  evidences  of  arte- 
rial s^lerosU  in  a  patipiit  who  hns  gouty  vertigo,  it  ia  necesflary  to  adopt 
tho  form  of  treatment  already  H[X)kea  of  to  cokinteract  this  disease.  Ver- 
tigo ia  relatively  an  eiitremely  uucouimOD  rheumatic  mauifeatation, 
Although  Bometimes  itoocura  vhen.  there  aro  exidencea  of  accunmlation 
of  urio  aeid  in  the  blood.  8ome  writers  have  endeavored  to  show  that 
uric  acid  is  one  of  the  commoneRt  eausea  of  vertigo,  hut  they  hring  for- 
wanl  very  uu>4&tEb factory  proof  iu  Hubfitautiation. 

Vertigo  of  the  Xeurosea. — Vertiyo  somctimea  occurs  ^a  an  aura  of  epi- 
lepsy, and  it  often  occurs  after  aii  epileptic  convdaion,  with  the  fatigue, 
mental  oonfusion,  and  prostratiou  of  this  period.  It  is  an  open  question 
whether  or  not  vertigo  [nay  talce  tlit*  plaice  of  an  epileptic  attack,  that  is, 
be  the  epileptics  equivalent.  There  ia  a  form  of  vertigo  which  comes  on 
«uJdenlj,  independently  of  any  apparent  source  of  eicitatioti,  and  of 
more  or  less  irregular  occurrence,  apparently  conditioned  aomewLat  hy 
fatigue  and  exhaustion,  to  which  the  name  epileptoid  vertigo  ia  given. 
It  ia  more  respoaaive  to  an ti -epileptic  treatment  than  to  any  other  meas- 
ufe.  This  treatment  cijuaista  in  the  administration  of  bromides,  eaie  of 
the  digeabivQ  tract  and  the  emunctotiea,  and  the  general  condition  of 
health.  Although  apparently  it  doea  not  tend  to  develop  into  the  motor 
form  of  epilepsy,  it  may  nerertheteaa  he  legitimately  looked  ujion  aa  of 
similar  pathogenesis.  The  trealmentofpre-epilepiic  vertigo  is  in  reality 
the  treatment  of  epilepsy.  Vary  rarply  can  any  medicjition  he  uiuier- 
taken  between  tho  time  of  the  vertiginous  nmuifeatations  ami  the  convul- 
sive state-  In  all  such  i;aaes  it  ia  well  to  give,  alung  witii  the  hromidea, 
a  mixture  of  Jinid  extract  of  belLodoutLa  and  flmd  extract  of  adonia  ver- 
nalie.  Post-epileptio  vertigo  shoidd  be  made  more  bearable  and  less 
severe  by  insi^Jting  upon  absohiie  quiet,  and  by  giving  a  rapidly  diffusible 
stimulant,  such  as  a  cup  of  strong  coffee,  caffeine,  or  valeriftuate  of  am- 
monia. 

The  most  essential  factor  in  the  treatment  of  vertigo  oeeompanjing 
neurasthenia,  hysteria,  exophthalmia  goitre,  and  enteroptosis,  is  the 
recognition  of  the  condition  on  which  it  is  dependent.  The  measures 
that  must  he  adopted  for  its  relif*f  may  jierhaps  include  all  of  Uu*sb  rec- 
ommended in  the  treatment  of  any  of  these  conditions.  Vertigo  ia  one  of 
the  commonest  complaints  of  neurasthenic  patienbs,  yet  very  rarely  is  it 
neoeesary  to  use  remedies  directed  immediately  to  ita  relief.  Tho  genera! 
tonic,  restorative,  educational  treatment  of  neurasthenia  encompasaea  its 
disappearance.     The  same  may.be  aaid  of  the  treatment  of  vertigo  accom- 


670 


TBEATHBNT  OF  DISEASES  OF  THE   NERVOUS  BYSTEU. 


panying  Grftvea'  disease.  NevertlkeleAflj  it  should  be  kept  in  mind  I 
oc^^asion^lj  the  Tertiginous  H^mptoms  of  ezophtbaliuic  ^itre  vo  coi 
tioned  immediately'  hy  insufficiency  of  one  or  more  of  the  eye  muec 
Vertigo  accompanying  Glcnard'a  disease  requires  no  other  treatment  tl 
that  directed  for  the  relief  of  the  enteroptoaia.  Such  measures  may  b( 
simple  as  the  wearing  of  an  abdominal  bandage,  or  bo  radical  as  the  oj 
ation  of  nephrorrhaphy. 

Ocular  Tertiga^The  commonest  cause  of  vertigo  is  some  distorba 
of  the  mechanism  of  visioD.  The  pathogenesis  of  this  symptom  baa  b 
already  referred  to.  Whether  or  not  it  be  immediately  conditioned  b 
perrersioQ  of  circulation  in  the  nuclei  of  the  ocular  moBcles  does  not  h 
concern  us.  It  may  be  contended,  however,  without  fear  of  contradicti 
that  the  immediate  factor  in  its  occurrence  is  the  reception  by  the  hr 
of  disparate  and  unaccustomed  sensory  impressions  coming  in  through  I 
eyes.  It  does  not  by  any  means  follow  that  such  impressioDB  ue  i 
normal.  For  instance,  severe  attacka  of  vertigo  have  been  known  to  f 
low  the  operation  of  tenotomy  for  strahismus.  In  such  a  case  the  pan 
has  become  so  accustomed  to  interpreting  monocular  images  that  ^e  i 
ception  of  double  images  puzzles  his  visual  seDSorium,  and  the  result 
vertigo.  Vertigo  is  the  commonest  accompaniment  of  palsy  of  any  of  t 
ocular  muscleSf  in  which  case  it  is  due  to  a  similar  faulty  projectioQ  of  t 
visual  field-  Such  vertigo  is  exactly  similar  to  that  which  may  be  pi 
duoed  in  a  normal  individual  by  looking  through  a  prism,  base  upwar 
for  a  tew  minutes.  Ocular  vertigo  is  frequently  aasociated  with  dipl 
pia,  and  if  this  symptom  is  mentioned  by  the  patient  it  promptly  leai 
to  the  correct  Interpretation.  Pareaia  of  the  superior  rectus,  perhaps  tJ 
commonest  palsy  of  the  eye  muscles,  often  induces  vertigo  without  dipli 
pia.  This  variety  of  vertigo  is  frequently  extremely  puzzling,  and  oftei 
times  receives  much  misdirected  treatment.  The  treatment  of  ocuh 
vertigo  may  be  summed  up  in  a  liue:  it  consists  in  remedying  the  shor 
comings  of  the  ocular  muscles  iu  so  far  as  it  is  possible,  either  by  tl 
use  of  glasses  or  by  tenotomy  of  the  eye  muscles.  As  the  ocular  palsy  i 
often  an  expression  of  severe  bodily  disease,  such  as  syphilis,  it  is  necei 
sary  to  inquire  carefully  into  the  existence  of  such  conditions,  and  t 
combat  them  vigorously  when  found. 

Toxic  Vertigos. — The  occurrence  of  vertigo  from  poisoning  by  tobacoc 
alcohol,  lead,  quinine,  and  salicylic  acid,  and  after  the  infectious  dii 
eases,  is  not  an  easy  matter  to  interpret.  In  addition  to  the  enervatiu 
etfect  which  these  substances  have  upon  the  peripheral  neuromuscular  af 
paratus  of  the  body,  and  their  iujuriousnesa  to  the  nerve  cells,  they  ac 
destructively  upon  the  blood,  to  impair  its  constitution  and  composition 
and  upon  the  mechanism  of  its  circulation-  All  these  factors  are  ctti 
cemed  probably  in  the  causation  of  vertigo.  This  is  seen  by  the  accom 
panying  phenomena  such  as  a  feeling  of  uncertainty,  sinking  sensatico 


THE  TREATMENT  OF  VKETIGO. 


571 


li&i]3«^  and  Taaomotor  auU  secretory  manifCfitatiODa.  Therefore  Ihetraat- 
meut  of  vertigo  ariaing  from  the  use,  abuse,  or  occiirreDce  of  these  in- 
tpOxicatioDS  antl  diseases  cgiifiisLa  uot  alone  in  iuterdictiug  or  combating^ 
them,  but  io  a-dopting  meaauree  to  couuteract  the  iieuromuscii.Uir  impair- 
mdDt  aad  U>  recover  the  loaa  froja  hiriiioljtic  destrucbion.  The  occuirenoe 
of  vertigo  after  the  infectious  diaeaflee,  exich  aa  measles,  scarlet  fever, 
and  tjpboid  fever,  should  always  prompt;  us  to  search  most  diligently  for 
pnralent  infection  of  the  middle  e&i,  and  of  the  uasojiharyiigeal  carities, 
and  whea  found,  to  adopt  uieaaurea  looking  to  their  iuimediate  relief. 

Qerlier'i  Disease. — Gerlier^s  diaeaee^  yertigo  with  plOGia,  or  paralj'^ing 
vertigo^  la  Xho  uamo  given  to  a  rare  diaeaae  characterized  by  vertigo, 
peciUiar  paralytic  phenomena,  and  pain  which  occurs  in  men  and  in 
Bomo  i}f  the  lower  animals  ^t-he  itat).  It  is  caused  by  living  ixj  close 
contact  with  stabled  cows,  eBpeciiiUy  hi  hot  vreath(;r,  in  the  region  around 
Lake  Geneva.  Cases  of  the  diaeaae  (for  in  all  probability  it  is  a  general 
infcotion  arising  from  the  actirtty  of  a  poison  generatei:!  in  staliles)  hare 
recently  been  reported  from  Japan.  The  discasf'  is  probably  a  cerebral 
motor  neurosis  due  to  a  fungus.  Althuugh  rertigo  is  a  prominent  symp- 
tom, there  are  hi  reality  more  important  ones.  These  are  more  or  less 
tfaoaient  ocular  palsies  which  cause  diplopia;  ptoaia;  transient  paresis 
of  the  muscles  of  the  back  of  the  neck  associated  with  great  pain  in  this 
region  ajid  in  the  lumbar  region;  and  a  peculiar  inability  to  open  the 
mouth  and  to  close  the  bauds,  described  as  paeudo-n-ismua.  The  gait  ii 
weak  and  staggering^  and  during  an  attat^k  of  verldgo  the  patient  may 
fall  hearily.  The  vertigo  '\s  uaJoubtedly  of  the  oeular  variety.  Gerlier 
distingtiishea  three  t>'pes;  (1)  The  sleeper's  type  in  which  ptosis  is  the 
pronunent  syriipCom^  (li)  The  devout  type  in  which  in  addition  to  the 
ptosis  the  head  drops  nn  the  chest;  and  <3)  The  drunk  and  blind  type 
in  whioh  In  addition  Id  the  above  symptom  there  is  paresis  of  the  lower 
eJitremities  and  consequent  ^'ttaggeting,  vraddling  giiit-  The  symptoms 
occur  in  attacks,  each  lasting  oue  or  two  minutes,  and  foilownd  hy  an 
interval  of  variable  duration  during  which  time  the  patiait  feels  used  up, 
tremulous,  and  emotional,  A.u  esaoerbation  can  be  provoked  with  cer- 
tainty by  using  the  eyes.  The  r**Hl  treatment  is  prophylaxis.  The  dis- 
ease lasta  from  one  to  a  few  months,  and  is  not  fatal.  Its  disappearance 
is  baatoncd  by  giWug  mcdiciiiea  that  facilitate  elimination,  and  at  the 
same  time  tonic,  restorative,  physical  or  medicinal  treatment. 

Keflex  VertigOB. — Formerly  the  rel^ex  origin  of  functional  nervoua 
disease  ptaynl  a  much  more  important  rfile  than  it  does  nowadays.  Ver- 
tigo was  one  of  the  conditions  or  symptoms  that  wiw  thought  to  be  very 
frequently  of  refles  origin,  that  is.  caused  by  factors  operating  from  somo 
distant  or^an  connected  only  very  indirectly  with  the  parts  or  tiaauea  in 
which  the  symptoms  were  manifest.  Vertigo  of  a  mild  and  transitory 
character  is  sometimes  associated  with  gastric  distuFbatice,  sueh  as  chronic 


672 


TBEATHBNT  07  DISBA6ES  OT  THE  NVSVOUS   STSTKH- 


gastrio  oatatrhf  and  injastheiii&  g&strica;  with  constipation;  with 
sluggish  state  of  the  d^etive  system  oommonl^  known  as  biJioiuiiess ; 
with  disorder  of  the  pelvic  organs  in  women.  Such  vertigo  is  much 
common,  however,  than  ia  usually  supposed.  It  ia  entirelj  posaible  U 
plain  its  occurrence  on  the  ground  of  the  absorption  into  the  Bjfftem  of 
eterious  matter  from  the  alimentary  canal  on  the  one  h^od,  or  the  e 
rating  influence  of  long  disturbed  nutrition  on  the  nenromuaoalar  appar 
on  the  other.  And  in  the  use  of  the  word  reflex  we  should  bare  no  oA 
formula  of  pathogenesis  in  mind.  The  elements  that  condition  its  oo 
rence  are  those  that  cause  neurasthenic  and  hypoohondriaoal  symptom 
often  associated.  The  treatment  of  such  vert^  ia  in  a  word  the  tn 
ment  of  any  morbid  condition  with  which  it  is  associated,  whether  it 
dilatation  of  the  stomach,  achylia  gastrica,  constipation,  cholelithiasis 
intestinal  parasites-  Some  rhinologists  claim  that  many  oases  of  rert 
are  relieved  by  the  removal  of  nasal  polypoids,  the  deatrnotion  of  the  1 
pertrophio  mucous  membrane  that  results  from  chronio  nasal  catarrh,  B 
by  the  treatment  of  turgeaoent  turbinates.  The  general  practation 
passing  in  review  all  the  deviations  from  normal  which  the  patient  p; 
sents,  will  not  fail  to  detect  these  if  present,  and  institute  meaanres  1 
their  relief, 

A  remarkable  symptom  complex  described  by  Charcot  as  laryngi 
vertigo  must  be  mentioned,  although  it  ia  very  unlikely  that  it  can 
considered  reflex  vertiga  Its  occurrence  is  preceded  by  a  sensation 
dryness  and  irritation  in  the  throat  accompanied  by  an  irritating  coog 
and  soon  followed  by  abrupt  loss  of  conBciousoeas,  with  or  without  efule 
tiform  twitchings.  The  attacks  may  occur  as  often  as  twenty  in  a  da 
In  reality  this  symptom  complex  is  a  symptom  o£  cortical  or  spinal  irrit 
tiou  or  explosion,  and  haa  very  little  relationship  to  vertigo  aa  it  is  gene 
ally  understood. 


CHAPTER  XLVn. 

THE  TREATilENT   OF  COfSVFLSlON9. 

A  CONVULSION  is  alwjiys  a  ffymptom.  Therefore,  oa  casual  oousider- 
fttioQ  it  may  seem  unneeess^rj  to  refer  to  the  siibj<.'Ct  apart  from  the  con- 
ditions of  wbioh  lI  ts  a  symptom.  But  the  Game  iti.ty  b^  BOid  of  hejidaohoi 
of  delirium^  neiir^gia,  hemiplegia,  £ud  other  symptoms  which  it  has  been 
thought  advisable  to  consider  individiuiJly,  Oftaa  the  physician  ia  Bum- 
EQODed  to  treab  what  are  apparently  coumlaious,  and  it  is  well,  iherefure, 
to  have  iu  miad  not  ouly  the  conditions  which  they  indicate^  hut  the 
meaaurea  that  are  of  use  in  combating  them,  whatever  be  their  cause^ 

ConvuleicDS  are  an  expression  of  irritation  of  tlte  motor  areas  of  the 
cortex,  or  of  the  convnlsive  areas  in  the  brain,  ganglia,  pong^  and  oblcn^ 
gata.  This  irritation  may  be  direct  and  mei?hanical  due  to  a  clot  of  blood, 
or  a  apkulum  of  bone;  direct  aod  chemical  as  from  the  oirealation  uf 
peccant  matter  in  the  bloody  it  may  be  indirect  as  from  tho  transmiGsion 
of  sensory  Irritattoa  from  an  adjitcent  or  distant  part  of  the  body,  the 
atvmenC^ry  tract,  the  nasal  mucous  membrane^  the  seiLLtat  organs;  or  it 
may  be  a  manifestation  of  idiopathic  epilepsy-  Under  ttie  fint  iimy  be 
included  new  growths  of  ^very  kind,  either  of  the  brain  tiubstan<:e  <»r  of 
the  aurrounding  tissue  which  causes  encroach  men  t  upon  the  brain,  ami 
inflammatory,  hemorrhagic,  and  traumatic  ptoditet*.  Under  the  second 
are  Included  febrile  states  of  the  blood,  au^h  as  pneumonia,  er?arlatiua, 
and  measles^  irritant  matters  circulating  in  the  blood,  endogenous  or  ei- 
Dgenoua,  which  include  tlie  dl^erent  poiaoas  arising  within  the  system 
fro-n  perverted  glandular  action  and  incompetency  of  the  emnnctories, 
such  ae  urcemia  aud  auto -intoxication  in  diabetes;  and  those  coiumg  from 
viihout,  such  aa  the  iofeetioos  and  intoxicatione-  Under  the  third  head- 
ing are  included  all  the  so-t^atled  refle:^  convulsions  which  are  not  uncom- 
mon in  childreur  although  eKtremt^ly  so  in  adults-  The  starting-point  of 
the  reflex  irritation  is  eonunonly  some  part  of  the  alimentary  canal. 

It  will  be  readily  seen  that  a  detailed  discussion  of  ttic  causes  of  con- 
TTilaion  would  require  oonsideraliou  of  many  diseases,  1  shall  thera- 
fore  limit  myself  chiefly  to  a  discussion  cf  oonvulsiona  in  children^ 
The  name  eclampsia  is  used  to  indicate  ronvulsi^'e  attacks  which  occur 
during  the  first  year  of  life,  and  are  not  dependent  upon  organic  disease  of 
the  nCTTous  system.  Convulsions  are  much  more  apt  to  occur  from  slight 
causes  in  young  children  than  in  adnlis.     It  should  nirt  be  forgott«D 


674  TRBATHBNT  OF  BISEASBS  OP  THB  ZfaBTOUS   STBTEll. 

that  they  are  frequently  manifestatioDB  of  genuine  epilepsy,  and  thai  erco 
though  parents  m&ke  light  of  them,  they  deserve  the  most  carefcd  consid- 
eration. Close  inquiry  into  the  history  of  epileptic  patients  abows  thit 
about  twelve  per  cent  give  a  history  of  spaams  or  convulsions  in  infancy, 
which  were  attributed  to  teething,  indigestion,  worms,  and  the  UkA,  while 
in  reality  they  are  the  original  manif estations  of  the  epiJeptio  nenroeia. 

The  liabUity  to  convulsions,  of  whatever  origin,  is  greater  during  tha 
£rst  year.     After  this  time  it  diminishea  rapidly,  and  eclainpeia  in  chil- 
dren is  rare  after  the  £rBt  dentition-     The  most  po'vrerful  predispofliiig 
cause  of  infantile  eclampsia  la  the  perversion  of  nutrition  known  as  ra- 
chitis, and  the  improper  feeding  which  contributes  to  it.     The  influence 
of  deutition  in  causing  convulsions  in  children  has  been  Tarionalj  esti- 
mated, the  trend  of  opinion  at  the  present  time  being  to  attach  JittJe  im- 
portance to  this  physiological  act.     Nevertheless,  it  would  seem  to  be 
beyond  question  that  in  some  instances  it  is  the  exciting  cause-     Tbe 
convulsions  that  occur  with  gastro-intestinal  disorders  are  either  reflex  or 
autotoxic,  probably  more  the  former  than  the  latter.     Inteatimd  parasitea 
constitute  the  most  uncommon  cause  of  infantile  eclampsia. 

The  same  general  principles  apply  to  the  treatment  of  convulsions  as 
to  that  of  all  other  symptoms  which  are  so  profound  as  to  require  treat- 
ment directed  to  their  relief  individually.  In  other  words,  it  is  not  suffi- 
cient to  treat  the  symptom  itself^  the  cause  must  be  sought  for  and 
removed,  or  its  activity  combated-  When  a  physician  is  called  to  a  child 
with  convulsions,  the  urgency  of  the  symptoms  often  does  not  permit  of 
search  for  the  cause-  Both  on  account  of  tbe  parents'  peace  of  mind 
and  the  patieut^s  welfare  the  convulsion  should  be  terminated  at  onc«^ 
Although  there  are  many  domestic  measures  which  are  of  some  service 
in  lessening  the  intensity  of  the  convulsions  and  shortening  them,  as  a  rule 
these  will  have  been  used  before  the  arrival  of  the  physician.  If  they 
have  not  been,  and  the  convulsive  seizure  is  a  severe  ouCt  it  is  a  loss  of 
valuable  time  to  put  the  patient  in  warm  water,  to  apply  stimulating  ped- 
iluvia,  etc.,  although  these  measures,  together  with  the  removal  of  the 
cause  of  the  convulsions,  may  be  all  that  is  necessary  in  mild  attacks. 
The  fact  that  the  mortality  of  infantile  eclampsia  is  upward  of  ten  per 
cent  shows  how  necessary  it  is  to  adopt  adequate  measures  to  check  the 
convulsions.  Por  this  purpose  no  hesitancy  should  be  had  in  using  in- 
halations of  chloroform  or  of  nitrite  of  amyl,  or  a  mixture  of  equal  parts 
of  these  drugs,  naturally  with  great  precaution,  until  the  tonic  or  tonico- 
clonic  spasm  begins  to  subside.  There  is  some  slight  danger  in  this  pro' 
cedure,  and  if  the  patient  should  die  while  inhaling  the  chloroform,  it  is 
almost  certain  that  blame  would  be  attached  to  tbe  physician ,  but  in  view 
of  the  mortality  rate  already  spoken  of,  and  the  reasons  against  giving 
the  most  potent  anti-convulsantr  morphine,  to  young  children,  this  pro- 
cedure is  unconditionally  recommended  for  the  severer  cases-     Indications 


THE  TRKATMENT  OF  CORVrUMOM, 


575 


of  tiie  recuTT^n^e  of  th«  spasm  should  be  met  hy  n[ieMing  thit  iahala- 
tioTis^  It  is  !i&rfllj  «Ter  Q^icessArj  to  carrj*  th«  pativitt  iuto  even  n  Hligbl 
state  of  tiarcoaia,  except  in  those  ui3l«.uce3  in  which  tl^e  coTiviilsioQ  ia  ati 
cspreefliou of  actire organic  process,  suob  as  heiuorrhftgii^  ciKM^phAlitia.  If 
tbd  patient  is  put  Itl  a  waim  net  pack,  vith  ioe  to  th«  iKstid  after  the 
first  oooTulsion^  this  will  very  often  pr«Tt*nt  a  seoond  attack,  nui  bo  will 
immersion  for  a  long  time  lei  a  lukewarm  bAth, 

After  the  severity  of  the  coiivulaiona  h&»  be«ii  comUat«d,  or  tifter  tbo 
attack  has  ceaaed,  at  lout  temporariljT  then  ts  the  time  to  find  oiit  what 
the  coiix'uUion  sigoifiea,  and  to  apply  measures  looking  directly  to  the  rs' 
movai  of  the  cause.  At  this  time  a  number  of  anlioouvulsiveB  which  nr* 
not  sufficient  to  cope  with  the  fpasm  itself  may  l>e  iLse[l.  The  beut  of 
these  are  the  hroiuide^  and  chloral,  both  of  which  may  l>e  given  by  enema. 
In  adult^i  opium  atlmirably  and  adequately  fulfils  the  ii»dicatii>uB.  The 
patient  should  be  kept  absolutely  quiet  in  bed,  and  given  the  simpleet 
diet,  while  cold  by  means  of  on  ice-bag  ia  applied  to  the  head,  Drngs 
that  have  repute  &s  antispasmodics  or  anticonvrilsivefl,  such  aA  valerian, 
asafoftido,  and  beliadouna  may  he  given,  but  it  ia  diiRcult  to  eatimaLr)  tlieir 
real  service,  except  in  hysterical  caaes. 

When  the  convulQidt^  ia  the  forerunner  ot  an  aceompauiment  of  scarlet 
fever,  measles,  pneumonia,  malaria,  or  other  iufectious  diaaaae,  the  meas- 
ures that  have  already  l>een  mentioned  for  comhatiog  the  attack  shoulii  be 
utilia^ed;  and  afterward  an  attempt  made  to  mitigate  the  severity  of  the 
diaea^se*  Iii  such  oases  it  ia  generally  the  high  temperature  that  pio' 
voices  the  convuleioui  and  it  should  be  borne  in  mind  tlint  h^pertheratlflp 
it  matters  not  the  disease  vitb  which  it  occurs,  is  most  aafely  and  quiokly 
combated  by  the  use  of  cold  water. 

Treatment  of  the  Causes— In  many  cases  it  will  be  possible  to  remove 
or  combat  the  cause  at  uoee,  as,  for  inebance,  when  the  attack  is  duo  to 
mdigcstibJe  or  irritating  products  in  the  stomach  and  bowels,  to  cholera 
infantum,  dysentery,  swollen  gums  associated  with  eruption  of  the  teeth, 
uid  organic  poisons  in.  thd  blood,  eucli  as  urea  and  gluoose>  But  in  other 
instances  in  which  the  cause  is  of  an  organic  nature,  and  the  eoDvulsiona 
are  an  expres»i(ju  of  ^oiue  mechanical  irritation,  such  as  meningeal  hemor- 
rhage, products  of  inflammation,  new  growths  of  the  centrnl  nervous  sys- 
tem or  ltd  coverings,  and  traumatic  conditions,  itwdl  be  impossible  to 
remove  the  cause,  at  least  at  the  tmie,  alLhotigh  measnrvs  may  l>e  at  once 
taken  to  alleviate  it.  The  appropriate  causal  treatment  vanes  with  the 
different  diseases  or  conditions  upon  which  the  convulsions  are  deiH*]jdent- 
If  they  are  an  expres±iion  of  intracranial  iuflammatiou,  the  trEiatment 
should  be  ice  bags  to  the  head,  and  the  application  or  administration 
of  derivativee,  such  as  diuretiest,  diaphoretics,  and  cathartics,  stimulatiog 
pedilnvia,  and  the  abstraction  of  blood.  If  the  convulsions  are  due  Ui  ttie 
eircniation  of  injurioiu  suhstancea  in  the  blood,  measures  must  be  taken 


f 


576 


TRBATUBNT  OF  DIBRA&BS  OF  THE  NKBVOUS    8TSTKM. 


to  aecure  their  eliminatioii  b;  the  different  emunctories,  while  drags  it 
oombat  the  activity  of  the  poisons  are  ^ven.  The  cauaal  therapj  for  oc 
TulsiiHia  which  arise  from  irritation  of  the  motot-ial  areas  bj  the  prodiu 
of  acoideata  or  new  growths  needs  oqIj  oaere  mention.  It  is  chiefly  si 
gical-  The  treatment  of  hysterical  and  epileptdo  convnlsioiu  is  the  m 
&3  that  indicated  for  these  neuroses,  plus  the  treatment  of  an  atta 
which  has  already  been  considered*  * 

ConyuUioas  are  often  brought  about  or  c<mtribnted  to^  eqveoiaUj 
children,  by  hydrcemia  and  other  impoverished  conditions  of  the  bloo 
such  as  occur  with  rachitis  and  after  acute  infectious  diseases.  They  mi 
occur  without  any  other  cause  than  loss  of  blood.  When  any  of  the 
conditions  can  be  found  it  should  receive  particular  treatmenL  In  r 
chitic  children  phosphorus,  cod-Uver  oil,  arsenic,  and  quinine  znaj  I 
given  for  their  constitutional  effects,  and  at  the  same  time  small  doses  i 
bromides  or  valerian  for  their  transient  symptomatic  effect-  Cases  i 
which  there  is  profound  hydremia  should  be  treated  by  subcutaneous  ii 
jectiou  of  normal  saline  solution,  or  by  intravenous  transfnsioD. 

The  condition  of  the  buccal  cavity  and  the  gastro-inteatinal  cam 
should  be  investigated  with  great  care  in  every  case  of  eclan^psia  infan 
turn-  Swollen,  inflamed  gums  should  not  h&  treated  by  cutting,  nor  b; 
giving  the  patient  something  to  bite  on;  such  measures  add  to  periphera 
irritation  which  is  already  excessive  to  a  pathological  degree.  Tbe^ 
should  be  treated  by  antiphlogistic  application,  such  as  cold  to  the  outsidi 
of  the  face  and  diiute  solution  of  aconite  and  iodine  locally.  If  there  ii 
resson  to  suspect  the  presence  of  indigestible  substances  in  the  stomach 
a  brisk  emetic  as  ipecacuanha  should  be  given  and  then  a  cathartic,  oj 
thorough  intestinal  irrigation  should  be  made.  The  latter  is  sufficien' 
when  constipation  alone  seems  to  be  the  cause  of  the  attack-  A  auapicioi 
of  intestinal  worms  justifies  the  administration  of  any  of  the  reliabh 
anthelmintics,  such  as  santonin  and  the  salineSf  after  which  the  stool: 
should  be  scrutinized  for  small  worms  and  sections  of  tape-worms,  and  iJ 
these  are  found,  remedies  adapted  to  their  expulsion  given.  Garefu! 
examination  of  the  urine  and  of  the  blood  is  of  the  f^eatest  servicCi  anii 
any  deviations  from  normal  which  such  examinations  reveal  should  b« 
rigorously  combated. 

When  convulsions  are  apparently  excited  by  hyperthermia,  the  mosi 
gratifying  results  follow  putting  the  patient  in  a  bath  of  from  B6°  to  7d^ 
P.,  and  letting  him  remain  there  from  fifteen  to  thirty  minutes.  If  this 
is  not  feasible,  the  same  object  can  be  gained  by  cold-water  ablutions,  or 
by  the  application  of  the  cold  pack  and  an  ice-bag  to  the  head.  If  an  ad- 
herent prepuce  or  any  other  source  of  peripheral  irritation  can  be  discov- 
ered, it  should  be  corrected  as  soon  as  possible- 


TU  TEKAT3IK5T  OF  CUNVLLs^ONS,  577 


LaiTDgiamna  abidulos,  or  cerebnl  croup.  »»  it  is  aomi^tiukeii  e&llml, 
11  %  local  form  of  coavuUion  vhich  occora  »luiOAt  ^xclusivtily  ih  ohil- 
dzen  who  aro  profotrndlj  nctutic  mtid  who  ptv^ct  au^-h  iiiftiiirt^UliniiH 
of  that  DutntiODal  disturbance  aa  oranioiaibtf^  epiphyst^al  eular^ttiitiuilH, 
lad  rachitic  rosar;.  The  spaam  comes  on  abruptly,  autl  the  HyiiipLumii 
Kwn  become  bo  alaiming  that  often  it  is  neoe«S;iry  to  use  heroio  iui^um- 
nres,  such  aa  tracheotomy,  to  spare  the  child'^  lifv.  In  tlto  ortliuury 
esse  it  ia  sufficiettt  to  lift  the  child  from  bed«  throw  the  head  kim^k  ho 
that  air  may  enter  the  respiratory  passages  witti  facility  a^  siHtu  na  tlits 
Mfmva  relaxes,  pull  the  tongue  forward,  throw  oold  water  iigtiiTiHl  thu 
body,  or  aubject  the  skin  to  smart  dagellatious  in  order  to  HtiTiLiilulu 
tiw  iospiratory  centre  to  activity.  When  this  oceurs  the  prolon|{rd  hi- 
■piration  is  accompanied  by  a  whoop  and  the  spasm  retakes,  if  it  ia 
posaible  to  make  the  patient  inhale  at  all,  a  tw  drops  of  cbtoroforiu 
or  of  nitrite  of  amyl  will  quickly  end  the  spasm,  and  whenever  they  are 
at  band  and  can  be  used  this  is  the  treatment  to  follow.  lu  aome  in- 
atancoa  wrapping  a  compress  wrung  out  of  hot  water  around  Uie  thruat, 
and  then  throwing  oold  water  against  the  surface  of  the  body,  is  quickly 
afficacious- 

If  the  spasm  ia  persisteot,  and  the  child^s  life  ia  despaired  of,  there 
shoald  be  no  heaitation  in  opening  the  trachea  to  permit  the  iJigrcBii  of 
ail.  In  caaea  in  which  the  ordinary  measures  do  not  suffice  to  relieve  the 
■paam  promptly,  it  is  advisable  to  give  a  small  dose  of  morphine  hypo- 
dermioally.     This  ia  usually  aoon  followed  by  relaxation  of  the  spasm. 

Attacks  of  laryngismus  stridulus  are  usually  over  before  the  physician 
naohea  the  patient.  It  theu  devolves  upon  bim  to  prevent  recurremre  of 
the  symptoms.  This  can  be  done  by  giving  bromides,  valerian^  asaftttida, 
etc,  for  their  symptomatic  effects,  and  substances  that  4;ombat  the  de- 
pravity d  nutrition  which  allows  the  aymptomy  to  occur.  The  condir 
tion  of  the  uvola  should  be  investigated,  for  in  some  instances  hypertro- 
phic or  inflammatory  enlargement  of  it  is  the  cause  of  the  spasm.  When 
■ooh  is  tike  case,  the  uvula  should  be  shortened  by  operation,  if  treatment 
of  the  causes  ia  not  sufficient  to  overcome  the  enlargmeut. 

SPAflMUS   NllTAXS. 

H«ad  nodding  and  rotatory  movements  of  the  head  are  not  very 
tmcommon  in  rachitic  infants,  especially  those  who  have  recti-.tfd  V'to^ 
uijnry,  such  aa  a  blow  or  fall  on  the  head.  The  condition  la  ^Ji^*:1J 
aasociated  with  nystagmus  and  occasionally  there  is  a  history  of  cou^ul- 
aiona.     By  some  the  disease  is  looked  upon  as  a  form  of  traumatic 


678  TBEATHRNT  OF  DISKASEB  OF  THE  NKBTOUB  SYSTEM. 

neurosis,  but  persoQully  this  riew  U  extremely  antipathic,  aa  1  am  of 
the  opinion  that  psychical  trauma  la  a  tine  qua  rum  of  every  Tarie^  of 
traumatic  neuroflis.  CJfiildren  irith  head  nodding  and  rotatory  spasm  in- 
variably recover  when  they  are  given  treatment  suitable  for  theii  impaired 
nntrition,  which  has  been  found  in  every  case  that  has  come  under  the 
writer's  cbservaticn.  This  treatment  does  not  differ  fr<uu  that  indicated 
for  rachitis.  Rarely  is  it  necessary  to  give  a  sedative,  such  oa  the  bro- 
mides. I  have  seen  marked  benefit  result  in  a  number  of  oases  from  ^ 
plying  some  support  to  £he  bead  and  neokr  as  each  as  very  li^t  plaster 
c<^]ar,  and  in  one  protracted  case  recovery  was  quickened  by  applying  s 
jnry  mast  for  a  few  weeks. 


CHAPTER  XLVin. 

TlIB  TItBATMENT  OP  HEMIPLEGIA. 

ALTHoroe  hemiplegia  U  a  aymptoiQ,  not  a  diseftsp,  it  ia  a  coi^dition 
wliioh  often  vfi.uaes  the  patient  to  oonsult  the  physician,  and  one  that  the 
tatter  ia  not  infrequenlJy  called  upou  to  nutigate  or  OTeioome.  tJofor- 
tunately,  in  the  majority  of  instanoea  hemiplegia  is  attendant  upon  oi^anic 
disease  which  haa  neither  inclination  to  Gpontoneous  cure  nor  reaponsive- 
nesB  to  medical  treatment.  In  &  t&vf  infitanees  only  is  the  lesion  of  such 
ft  nature  and  neat  that  it  can  be  removed  by  the  sargeon.  Hemiplegia 
which  is  not  the  Hymptoui  of  eitenaive  vasuular  difieaae  or  prugressive 
l^wthfl  within  the  brain  is  oftantdmos  of  prolonged  duration,  and  the  pa- 
tient demands  that  something  be  done  to  mitigate  hia  intirmity  so  that  hia 
luefnlnesB  and  comfort  may  be  added  to.  Many  of  the  cases  that  are  de- 
pendent upon  vascular  lesion,  especiaUy  those  occurring  in  early  and  mid- 
dle advilt  lifn,  are  amenable  to  Lreatmeut  in  a  measure,  particularly  if  the 
latter  be  properly  selected  and  applied.  When  undertaking  the  care  of  a 
hemiplegic  it  is  essential  to  discover  the  eocdition  upon  which  the  symp- 
tom is  dependent  in  order  that  causal  and  restorative  tcatment  may  ho 
employed  Bimultaneoualy, 

The  organic  diseases  upon  which  hemiplegia  ia  dependent  are  inflam- 
matory and  hemorrhagic  Atatea  of  the  meningeal  intracranial  tumor  and 
abecem,  encephalitis,  multiple  aclcrosiat  general  paresia,  and  more  fre- 
quently than  any  or  all  of  tbeae,  hemorrhages^  thrombosia,  and  embo- 
lisin-  The  fnnetional  conditions  with  vhioh  it  occurs  are  prmoipally 
byateria  and  transitory  spasms  of  the  blood-vessels.  Occasionally^  it  is  an 
epiphenomenoii  of  uriBmia  and  a  symptom  of  certain  pathological  stAtea 
of  the  brain  having  an  inherent  tendency  to  Tocovery,  such  aa  localized 
cedema  and  cerebral  hypercenua* 

Treatment.-  -The  causal  treatment  of  hemiplegia  aa  well  aa  the  treat- 
ment directed  immediatply  to  the  morbid  condition  uiwn  whi<?h  it  is  de- 
pendent, be  it  functional  or  organic,  haa  been  considered  in  the  respective 
chapters  dealing  with  these  states.  Here  I  shall  conaider  onl}'  those  meas- 
ures that  are  available  to  improve  the  patient' s  most  eonapiouous  inlirmi^ 
oraymptom,  the  hemiplegia.  The  meaaures  that  are  of  service  in  combat- 
ing the  paralysis  are  massage,  foTiied  movementa  attended  or  not  with  effort 
of  the  patient  toward  fon^ble  movement,  hydriatic  procedures^  general 
hygiene,  and  nursing.  Electricity  and  medication  pLay  no  considerable 
r51e-      Pasaive  movementa  are  by  far  the  most  important  measure  in  com- 


560 


TBEATHBNT  OF  DISEASES  OF  THE  NEBYOUB   SYSTEM. 


bating  the  immobility  of  the  jointa  of  the  paralyzed  aide,  tbe  atrq 
with  which  thia  is  associated  and  cau»atire  of,  and  the  contraetim  wh 
develops  in  the  muaoles  of  the  paralyzed  side  in  the  majority  of  caaei 
hemiplegia.  They  should  be  instituted  early,  if  poaaible,  before  an] 
thefle  phenomena  hav^  made  their  appearance.  It  is  particularly 
joints  of  the  upper  extremity  upon  which  greatest  effort  should  be 
peuded,  for  the  lower  eitremi^  and  the  face  are  apt  to  be  much  ! 
involved.  As  soon  as  the  patient  fully  recovers  from  the  comatoae  sb 
the  limbs  of  the  paralyzed  side  should  be  subjected  to  pasaire  movemc 
for  a  brief  period,  at  least  twice  a  day-  Some  member  of  the  fau 
can  be  readily  taught  to  do  this.  Beginning  with  the  joints  of  the  fingi 
each  one  should  be  forcibly  put  through  whatever  movementa  the  const] 
tion  of  the  joint  allows;  then  the  wrist^  elbow,  and  ahoolder  joints  taJ 
in  succession.  The  same  procedure  should  be  adopted  for  the  lower 
tremity.  The  stance  may  be  terminated  by  light  massage,  stroking  J 
kneading  movements,  which  are  of  service  in  improving  the  circulat 
and  general  nutrition  of  the  part.  Massage  must,  however,  be  emploj 
with  circumspection,  as  it  is  capable  of  putting  stress  npoD  the  intrac 
Dial  blood-vessels  and  of  fatiguing  the  patient  to  an  injurious  exte 
Although  the  patient  is  quite  incapable  of  making  any  voluntary  mo 
ment  whatsoever,  he  should  be  encouraged  to  make  the  mental  effort 
voluntary  movement  simultaneously  with  the  movement  executed  p 
slvely.  This  treatment  should  be  kept  up  patiently  and  persistently  J 
a  number  of  months.  In  many  instances  it  will  be  rewarded  by  t 
development  of  sufficient  mobility  and  dexterity  to  allow  the  patient 
make  considerable  use  of  the  extremity.  A  special  procedure  for  t 
re-education  of  the  hemiplegic,  particularly  in  walking,  has  been  reeoj 
mended  by  Erbeu.  It  is  well  known  that  the  fiexors  of  the  thigh,  t 
extensors  of  the  knee,  aud  the  plantar  flexors  of  the  tibiotaraal  articul 
tion  are  much  less  completely  paralyzed  in  ordinary  hemiplegia  than  t 
dorsal  flexors  of  the  knee  and  foot-  The  greatest  obstacle  to  the  patieni 
locomotion  after  he  has  recovered  sufficiently  to  attempt  walking  is  t 
difficulty  of  flexing  the  paralyzed  leg  when  it  is  lifted  from  the  ground 
be  advanced.  In  order  to  make  up  for  this  want  of  fiexion  of  the  kn 
and  the  foot,  the  patient  finds  it  necessary  forcibly  to  flex  the  thigh 
the  paralyzed  extremity  on  the  pelvis,  which  allows  the  leg  to  be  raift 
and  propelled  forward.  In  order  to  obviate  this  and  thus  to  facilita 
locomotion,  Erben  has  recommended  that  the  foot  of  the  healthy  aii 
shall  not  be  advanced  beyond  the  line  of  the  paralyzed  foot.  This  necc 
sitates  that  the  patient  take  very  short  steps  aud  walk  very  slowly  •  h 
gradually  it  will  transpire  that  the  foot  of  the  bemiplegic  side  can  be  p 
further  forward  until  a  comparatively  useful  stride  is  acquired.  Th 
method  of  education  naturaHy  can  be  adopted  only  after  the  patient  h 
made  sufficient  recovery  to  begin  walking. 


THE  TREATMENT  OF  HEMIPLEGIA. 


6S1 


Hydriatic  measures,  if  employed  with  sufficient  skill  and  discretion, 
can  be  relied  itpoi)  U)  itui'itive  ihs  g&wstaX  uutritioii.  Tbej  must,  how- 
evQT,  be  used  with  great  i^iri^uiuHpectiicu,  an  mouy  of  them  are  capable  of 
puttiug  such  streae  upoa  the  iutracrauial  blood-re sselsi  if  they  are  du- 
eased,  that  di&astrQufl  conaequeDcee  may  follow.  Proloiif^ed  lukewarm 
batli3»  followed  by  passive  movemGDis  and  light  massage,  ofteTi  [eud  aome 
aid  to  the  laCtaf  measure.  The  tonic  effenla  of  the  cool  aplsBh  bath  maj 
also  t>B  tiometiiiies  iaroked.  If  bher?  la  advanced  diHoase  of  the  blood- 
r&^sels  eitreuiea  of  temperaturo  ate  bo  be  avoided, 

Electricity  in  all  ita  foi'ma  has  l>een  extensively  ti'ied  in  the  troatmenb 
of  hemiplegia,  and  ia  Btdl  probably  extensively  used.  Patients  readily  be- 
come eouviuced  tba-t  it  ia  au  agent  of  great  serWceability  to  overcome  their 
intirmity,  and  Gfteutimes  make  great  saeriftt^e  tliat  tliey  riiay  avail  them- 
selves of  it.  The  unJy  kiuda  of  hemiplegia  in  which  it  ia  of  any  service 
TPhatBoever  ard  the  daccid  variety  in  which  there  ia  uo  exa^^ratiou  o£ 
the  tendoD  jerks,  hemiplegia  with  h^'mianictithcBia  aud  without  n^arked 
contracture,  and  possibly  also  hemiplegia  attended  with  oonsiderable 
muscular  atrophy.  In  hysteric^al  hemiplegia  it  is  naturally  oftentimda  of. 
signal  benefiL  It  may  lie  statt^d  tlmt,  an  a  I'ule,  the  faradir  current 
should  uot  be  employed  except  in  the  fuuclional  variety.  If  used  early 
it  is  very  liable  to  add  to  the  contracture  or  to  provoke  it.  Lf  it  is 
thought  advisable  to  use  the  galv;hnic  current  for  the  benelicial  effect 
which  it  may  have  upon  the  circulation  and  cutritioa  of  tlie  paralysed 
part,  the  positive  electrode  of  large  size  should  be  placed  over  the  back, 
and  the  negative  electrode  applied  lu  labile  fashion  Lo  the  mus<;le3  of  Ibe 
paralyzed  extremity,  ^o  effort  should  be  made  to  cauae  tbem  to  contract 
by  interrupting  the  current,  eacept  as  stated  above  in  the  flaccid  variety. 
The  average  liomiplegic  individual  thinks  that  it  maki^s  him  feel  better 
to  have  the  paralyzed  exti-emiiy  treatwl  with  aparka  from  the  atatio  ma- 
cbioe  every  dny,  and  it  ia  unijuestioLiable  that  mauy  of  them  walk  more 
flprigbtly  for  a  short  time  after  such  treatment.  If  there  is  no  consider:- 
able  contracture,  and  if  the  patient  receives  passive  exorcises  as  described 
aJ>opeT  this  form  of  eleotnaity  may  be  employed  advantageously*  In 
hysterica)  hemiplegia  it  is  of  the  greatest  service,  tbe  paralysis  aome- 
times  diaapjiearing  after  the  first  application. 

The  hygiene  of  the  hemiplegia  patient  ia  a  matter  tliab  ca]l>«  fur  scru- 
pulous attention  on  the  part  of  the  paticEit  and  family,  and  explicit 
directiouB  on  the  part  of  the  physician.  Cleanliness  of  the  skin  is  of 
the  greatest  necessity.  The  peripheral  cireidation  ia  generally  much  de- 
praved and  trophic  legions  readily  develupi  especially  if  the  patient  is 
taking  considerable  qnantltiea  of  iodide  cf  potasfiium.  After  the  cleans- 
ing bath  the  skin  abould  be  covered  witli  Bome  bland,  slightly  antiseptic 
powder,  such  as  oxide  of  sine  or  subnitrate  of  bismuth,  and  parta  that  are 
particiUarly  liable  to  pressure  or  irritation  should  be  dusted  repeatedly. 


562  TREATMENT  OP  DTBBASBB  OF  THE  NERVOUS  SYSTEV. 

The  bladder  should  be  carefully  watched,  aud  if  there  is  need  for  cathe- 
terization, thifl  should  be  done  regularly.  The  dietary  and  the  state  of 
the  alimeutary  tract  should  rdceire  th«  personal  attention  of  the  physi- 
oian.  Kothing  is  to  be  gained  by  the  use  of  counter-irritants  to  the 
head  or  to  the  apioe  with  the  view  of  limiting  secondary  d^eneration. 
No  mention  will  be  made  of  internal  medication,  for  that  depends  entirely 
upon  the  oondition  which  causes  the  hemiplegia,  save  to  say  that  strych- 
nine should  not  be  administered,  Even  in  cases  in  which  the  oondition  of 
the  Tasoulai  system  would  seem  to  call  for  the  tonic  effects  of  this  dru^ 
the  danger  that  it  will  add  to  the  ooottacture  is  so  real  that  it  cannot  be 
legitimately  employed. 


CHAPTER  XLIX- 

THE  TREATMENT  OF  INSOMNIA- 

IxHo>i»iA  ift  a  oooditioii  5uac«ptible  of  detiiiition  bj  negation  only, 
▼iz.,  the  abaeni:a  or  want  of  sleep.  Although  the  detiaitioD  of  txiaomDia 
is  thua  uegatiue  with  tefereaoe  to  a  condition  whii^h  is  accepted  and  well 
known  as  a  uormal  phyaiologioa)  one,  ateep  till  remains  beyond  the  limits 
of  aBcert&ined  knowledge  of  cause  and  effect^  while  the  couditiou  of  sleep- 
lensiio^a  liaa  beeu  aubjeoted  to  careful  examiiiatiou.  AitLough  the  causa- 
tiou  of  sleep  is  not  bs  yet  aacertained,  the  phenomena  themselves  are  ddi- 
nite  enough.  The  human  beatg  in  sleep  as  coDtraatcd  with  the  same 
person  awake  is  in  a  state  of  total  unconsciousness.  All  aenae  of  persoc' 
alil^  is  gone,  and  for  the  most  part  emotions,  sensatiODs,  and  ideas  cease 
to  exist-  It  ia  not  pusBJble  to  defiida  to  what  extent  this  unnihilation  of 
the  conscious  life,  these  twiuklings  of  oblivionf  ia  merely  a  seeming  and  a 
forgettia^.  The  chance  recall  of  dreams,  oftentimes  suggested  by  some 
object  or  idea  of  the  environment,  wanit^  us  of  the  possible  esiisteaoe  of 
mental  phenomena  during  the  sleeping  state  which  utider  theordinarycir- 
cumataiieea  of  Vita  du  not  L^oimect  themselvta  with  the  oonsoioua  memory, 
perhaps  because  they  have  Dot  made  a  sufEicieut  tuipreasion  or  because  the}'' 
have  not  established  the  requisite  associations-  With  respect  to  the  men- 
tal life>  sleep  may  be  of  different  degreea  of  depth^  Tarying  from  a  aemi- 
QonsciouB  state  in  which  fleeting  ideas  and  sensations  may  be  subsequently 
recalled,  either  U\  whole  or  in  part,  to  an  absolutely  dreamless  stata 
This  temporary  aljeyauce  of  consriousness,  whether  complete  or  partial^  is 
without  di:)ubt  associated  n'itb  the  ceasatiou  of  the  functious  of  the  cere- 
bral hemiapheres-  It  is  perhaps  safe  to  eay  that  the  progression  from 
light  to  deep  steep  marks  a  successive  diminution  of  the  functiona  of  the 
frontal  lobes,  sensorimotor  areas,  and  finally  of  the  ipeeial  sense  areas. 
One  cannot  hay  that  there  is  aliaoluta  cessation  of  function  of  the  brain, 
although  there  seems  to  be.  Increasing  depth  of  sleep  is  marked  by  a 
similar  progrossire  diminution  of  many  cr  all  of  the  functions  of  the  body. 
The  closer  the  functions  are  associated  with  the  consciousness^  and  espe- 
cially the  volition  of  the  individual,  the  more  completely  are  the  functions 
auppressed.  Thus  the  striped  muscles  are  almost  always  in  a  state  of 
quiescence  and  flii'rt'idity  -  the  mistriped  muaculature,  on  the  other  hand, 
frequently  retains  its  capacity  for  funftiouing,  even  though  these  functions 
are  leas  pronounced.     Digestion,  breathing,  the  cardiae  cycle,  the  circn- 


584  TKBATUBNT  OF  DiaBABK8  OF  THK   KBBVOUB  SYSTEM. 

latioDf  all  contiDae  \  but  oil  of  them  show  m&rked  depreciatiOQ  of  Bitnu% 
and  activity.  Depth  of  sleep  is,  therefore,  oot  only  proportional  to  t 
abeyance  of  consciousueas,  but  also  to  this  depreciation  of  all  bodily  foi 
tious-  An  approximation  toward  the  state  of  sleeplessness  or  insooti 
maj  therefore  be  indicated  aa  an  approach  to  the  normal  waking  phj 
cal  and  mental  coudition-  As  a  aymptom,  however,  which  the  phjsicL 
is  most  frequently  called  upon  to  treat,  the  persistent  continuance 
mental  activity  in  some  form  is  usually  the  sisnal  feature. 

Insomnia  is  therefore  a  relative  term.  The  amount  of  sleep  tli 
suffices  for  one  individual  would  be  productive  in  another  of  snob  depia 
ity  of  nutritioD  that  might  lead  to  disease.  In  discussing  its  causation  ai 
treatment,  we  must  therefore  bear  in  mind  that  the  individual  equati 
must  be  determined  in  every  inatauce-  Sleep  is  measnrod  by  its  dep 
as  well  as  by  its  duration.  Difficult  as  it  may  be  to  express  in  abeolu 
figures  the  requisite  quantity  of  sleep  for  the  normal  human  being  in  p< 
feet  health,  it  is  still  more  difficult  to  describe  at  all  adequately  the  reJ 
tive  degrees  of  depth  of  sleep,  but  experience  teaches  that  the  deep 
the  state  of  sleep  may  be,  that  is,  the  more  profound  the  cessation  of  no 
mal  physiological  and  mental  functions)  the  less  protracted  need  th 
sleep  be  in  order  that  the  individual  may  receive  adequate  physiologic 
restoration  and  refreshment. 

I  have  hitherto  considered  sleep  only  aa  it  ctrntrasted  with  tl 
normal  waking  state.  Sleep  is  one  of  the  many  periodic  phenomec 
of  the  human  organism  of  which  menstruation  is  the  moet  remarkabl 
and  typical.  It  may  be  eaid  that  the  normal  human  being,  uncontam: 
nated  hy  the  requirements  of  a  civilized  environment^  will  fall  int 
the  state  of  sleep  after  the  taking  of  food,  and  at  the  onset  of  darb 
ness;  that  he  will  continue  in  this  state  until  the  light  of  day  agai 
revives  his  depreciated  functions,  or  until  hunger  or  some  other  signi 
stimulus  acts  with  sufhcient  intensity  to  arouse  the  functions  of  the  cere 
brum,  with  which  will  reawaken  all  the  activities  of  the  body,  Th 
sleeping  organism  ought,  therefore,  to  be  undisturbed  by  internal  or  eztei 
nal  stimuli.  In  the  proportion  that  these  tend  to  awaken  consciousness 
in  that  proportion  will  they  diminish  the  depth  of  sleep  and  its  cousequen 
restoration.  The  period  from  nightfall  till  early  morning  is  both  th 
time  indicated  by  the  very  nature  of  man's  organism^  for  the  "blessei 
barrier  between  day  and  day  "  and  also  the  time  when  he  is  least  likel; 

^to  ba  disturbed  by  these  external  and  other  stimuli.  Were  it  not  for  th 
associated  factors  of  noise  and  light,  it  is  not  at  all  unlikely  that  sleep  oh 
tained  during  the  day  would  be  as  refreshing  and  beneficial  as  sleep  oh 
tained  at  night.  That  many  of  those  who  are  perforce  compelled  t 
work  during  the  night,  or  those  who  voluntarily  elect  to  do  so,  suffer  eve: 
ir(  though  they  obtain  the  full  complement  of  sleep  measured  by  hours,  im 

pairment  of  nutrition  and  strength  is  not  so  much  due  to  inadequara  slee] 


THE   THEATMKKT  OF  rNaOMNlA, 


aa  to  the  etfeeta  of  sititiciai  light  and  vitiated  air,  assixiiixted  us  they  oftetk 
are  with  iodu^gence  m  stimulanta,  aod  with  other  hygienic  infractiouB, 

CUtiifloBtion  and  Canuition  of  Inioinnia, — Tnaoinnia  is  a^  coQDamitant 
of  many  functional  and  organic  diHeaaea,  aud  It  often  oixiura  Jipait  fiom 
eithdr.  It  will  facilitate  our  diacnasion  of  the  treatment  of  iuaomnia  to 
diacuaa  brieHy  the  cauei'S  of  iuBomziia,  and  attempt  a  clnaavtication, 
Sleepleaaness  might  be  classified  according  to  the  time  of  ita  oceurience, 
as  the  tnsomrtia  of  different  times  has  been  obovn  to  atand  la  definite 
relationship  to  different  etiological  factors.  For  luRlance,  one  cUsh  of 
aviJferera  hare  great  difficulty  in  getting  to  sleep.  If  they  are  allowed  to 
prolong  their  alumbeis  into  the  Jay,  there  are  usually  no  ulterior  con- 
aequencee^  but  as  duties  compel  thejn  to  arifie  at  a  stated  time^  they  ^uf- 
for  from  the  efiects  of  curtailed  sleep.  Moreover,  the  misery  attending 
impotent  effurts  to  Bei'iire  eleep  asHiats  to  exhaust  the  sufferer^a  strength 
and  uerre  energy.  This  vai'iety  of  Bleepleeaiiesa  has  rather  uniform  cau- 
aation^  and  ia  commonly  dopeDdeut  upon  mental  c^uditionfl.  It  not  in- 
frequently has  ita  begicnhig  in  purposeful  curtailment  of  sleepj  that  the 
time  deToted  to  work  may  be  greater.      So  many  forget  that — 

*'Ko(j  (luppy^  oor  maiidrm^iira 
Xur  all  tba  drowty  Kjrupii  of  the  world. 
Shall  ever  uiadtciDa  tLce  to  ttiat  Bweetdaep 
WT)ich  than  owdost  yeatcrdaj/' 

Another  variety  of  sleepieBsneas  consiata  of  profound  drowainesB, 
often  terminating  in  u1eep  ev(*n  though  the  patient  makes  great  effort 
to  avoid  it,  which  cornea  on  in  the  early  evening,  followed  after  an 
antefreahing  slumber  of  varied  duration  either  by  repeated  and  appar- 
ently causelesa  awakenings  or  by  complete  awakening  and  meutal  alert- 
ness- rnsomnia  of  this  kind  is  moat  commonly  associated  with  infectiona 
and  intoxications,  parLicalaily  auto-intoxications.  It  is,  of  course*  itmre 
liable  to  occur  in  neurotic  iniJividuala.  A  third  variety  of  insomnia  ia 
that  which  oonsiats  of  persistent  repeated  early  awakening,  such  as  at  four 
o'clock,  before  tho  requisite  jiiunber  of  hours  of  aleep  have  been  obtaiued. 
Insomnia  of  this  kiud  is  commonly  associated  with  organic  diae.aae  of  the 
blood-vessels,  such  as  arteriocapillary  tibpoala  and  kidney  disease  j  with  in- 
testinal iudigeation,  and  occasionally  with  the  excessive  use  of  alcoholics, 
such  as  champagne,  and  oai'cotics,  such  as  morphine.  Finally  may  lie 
mentioned  a  Tai-iety  of  slot'pleaflneflain  which  the  adequate  number  of  houra 
la  apparently  obtained,  but  it  is  not  followed  by  the  refreshed  feeling  of 
invigoration  as  nopmal  sleep  should  be. 

It  will  beat  serve  my  purpose,  however,  in  discusaing  the  treatment 
of  insomnia  to  olassify  this  ayniptoui  ac^Mrdiug  to  its  causiitionT  and  not  on 
a  temporal  basis  as  indicated  above,  Sleepleasneas  may  thus  be  claaaified 
as  due  to; 

1.   BiaTted  states  of  the  sensory  sphere,      Hyperjesthesic  conditiona. 


586  TBSATUENT  OF  DISSA8BB  OF  THS  KERVOUS   ST8TB1C. 

of  which  pain  is  the  beat  example.  Thia  gronp  includes  panevthes 
every  kind,  fonnio&tion,  buzzing  and  ringing  in  tl^  eare,  miffocatioii, 
choking  feelings.  It  may  also  include  B0'<^6d  reflex  insonmia  anc 
from  adhesions  of  the  prepnoe  and  clitoris  and  irritation  from  iiit«ol 
worms. 

2.  Psychical  causes:  anxiety,  grief,  fear,  worryr  overwork,  inab 
to  dismiss  recurring  thoughts  or  trains  of  thought,  mental  exaltation 
depreasioD.  There  might  alao  be  included  under  thia  bead  such  co 
tiona  as  change  in  the  mode  of  life  and  environment,  which  migh 
looked  upon  aa  both  paychical  and  physical. 

3.  Toxic  causes,  of  which  there  are  three  distinct  subdiTisioDB: 
the  infections,  such  as  from  acute  diseases,  as  pneumonia,  typhoid  fe 
scarlet  fever,   etc.  \   {b)  exogenous   intoxication  a,    alcohol,     tobacco, 
coffee,  drugs,  etc. ;  (c)  auto-intoxications,  from  disorders  of  digeation, 
acid,  gout,  rheumatism,  diabetes,  urwmia,  and  excessive  bodily  fatigi 

4.  Insomnia  of  organic  disease,  principally  vascular,  such  aa  dis< 
of  the  heart  and  arterlocapillaiy  fibrosis. 

5.  Habitual  insomnia.     This   is  an  uncommon  form  of  insomnu 
which  there  seems  to  be  no  dependency  upon  bodily  or  mental   disort 
Under  certain  circumstances  it  may  exist  for  a  long  time  without  prod 
ing  either  of  these.     When  they  develop,  as  they  eventually  do,  it 
comes  difficult  to  differentiate  cause  from  effect- 
Treatment — The  first  and  most  essential  factor  in  the  treatment  of 

somnia  is  to  discover  its  cause  and,  if  possible,  remove  it.  When  it  ia 
such  a  nature  that  it  is  impossible  to  remove  it,  then  measures  looking  tc 
ard  its  mitigation  must  be  adopted.  The  routine  treatment  of  insomn 
particularly  by  the  administration  of  hypnotics,  all  of  which  are  injurioi 
ia  always  dangerous  as  well  as  most  unscientific.  Insomnia  is  a  sympt 
of  so  many  entirely  dissimilar  diseases  that  it  is  most  unjustifiable 
treat  every  case  in  the  same  way.  There  are,  however,  certain  measm 
which  can  be  applied  in  the  treatment  of  insomnia  in  something  like  n 
tine  fashion  to  great  advantage,  but  these  measures  do  not  include  drui 
I  shall  discuss  these  briery  before  giving  special  consideration  to  t 
different  forma  of  insomnia.  Another  important  feature  to  bear  in  mi 
in  treating  insomnia,  that  causal  therapy  may  not  be  disappointing, 
that  after  sleeplessness  has  continued  for  any  considerable  time,  it  ia  l 
only  necessary  to  determine  the  nature  of  the  insomnia  and  to  overcoi 
the  conditions  upon  which  it  is  dependent,  but  to  break  up  the  habit 
sleeplessness  as  well-  To  accomplish  this  the  hypnotics  are  of  the  gret 
est  value. 

The  general  treatment  of  insomnia  must  consider  the  individual  ai 
hia  environment.     Kot  only  should  the  bedroom  be  selected  with  refc 
ence  to  the  exclusion  of  noises  and  other  distractions,  but  it  should 
large,  well  ventilated,  devoid  of  unnecessary  furniture,  eapecially  tl 


THE  TBMATMKST  OF  XXSOMNtA.  567 

kind  thit  nuikM  &  nxaa  siafSj,  and  one  in  which  Um  piAMni  teb  eou- 
fortftble.  Th«  bed,  its  <?ovennK  «itd  pillows,  tbooid  contaribote  to  npoM 
and  oomfofft^  Thu  individual  muA  be  considered  in  rftfeittieM  to  hia  htb^ 
its  and  castcms,  regsiding  picpazfttioD  for  sleep,  Tbether  it  be  in  walk- 
ing, bftthing,  reading,  ealin^  drinking  or  erai  aiwAing  Some  penoas 
find  it  quite  necessarj  to  partake  of  some  easily  digested  food  tr  mild^f 
stimulating  drinks  before  ntinn^  while  for  others  reading  or  being  read 
to  is  eondodTe  to  sleep.  Altboogh  much  has  been  written  of  the  efficacy 
of  directing  the  thoughts  toward  some  monotooous  task,  snch  as  Tecitii^ 
ooontiiig,  or  calling  np  soporific  meutal  pictoreA  in  inducii^  ftl^^Pi  it  i> 
really  &  reiy  unimportant  measure.  Few,  nnfortanatelj,  am  so  well  pio- 
Tided  for,  that  ther  like  the  poet  have  banks  that  are  furnished  with 
bees  whose  mnrmnr  inrites  one  to  sleep.  Not  a  few  find  it  advantageous 
to  expose  the  naked  body  to  the  cool  air,  to  make  cold  ablutkma,  to  take 
warm  foot  baths,  or  to  hold  the  fretfor  a  few  seconds  under  running  cold 
water.  All  qf  these  may  at  tdmes  be  iodulged  in  adrsntageously,  espe- 
cially if  the  insomnia  is  dependent  upon  psychical  causes  or  habit  In- 
somnijL  associated  with  or  dependent  upon  organic  disease  of  the  blood- 
TCBsels  is  often  succeasfully  combated  by  instructing  the  patioDt  to  take 
»  small  amount  of  Htimulsnt,  such  as  whiskey  and  hot  water  or  milk,  tm. 
retiring,  and  repeat  this  in  tho  early  morning.  The  danger  that  the 
patient  may  contract  the  alcohol  habit  should  make  one  eaiefol  in  pre- 
scribing snch  treatment  Ivr  insomnia  due  to  psychical  causes,  especially 
in  women. 

Of  the  general  measures  in  the  treatment  of  insonmia,  the  applicatioQ 
of  water  is  perhape  the  most  important,  A  prtdraiged  warro  bath,  to 
which  may  be  added  volatile  substances  that  irritate  tfae  skin  and  cause  a 
determinatioo  of  blood  thereto,  such  as  pine-^needle  extract,  is  frequently 
efficacious  in  insomnia  due  to  psychiosl  causes,  mental  and  physical 
exhaustion,  and  a  mild  d^ree  of  pain  or  paresthesia.  Occasionally  a 
bath  of  this  kind  is  more  efficacious  if  it  is  followed  by  massage.  A 
moderately  prolcmged  bath  of  from  102°  to  UW  F.,  after  which  the 
patient  ia  wrapped  in  a  flannel  blaubet  for  a  few  minutes  until  it  absorbs 
the  moisture,  and  is  then  eichaoged  for  the  night  drees,  followed  by  the 
Application  of  cold  compresses  to  the  head^  ia  often  serviceable  in  the 
same  conditionH.  In  neurasthenia  and  hysteria  the  dripping  aheet  (see 
chapter  on  Hydrotherapy)  and  the  Keptune  girdle  are  sometimee  serrice- 
able. 

Massage  ia  another  available  general  agent  iu  the  treatment  of  insom- 
nia, particularly  iuaomnia  dependeot  upon  psychical  causes.  The  most 
advantageous  form  in  which  to  administer  it  is  general  massage,  which 
can  be  given  very  vigorously  up  to  the  point  of  fatiguing  the  patient, 
providing  there  bo  no  physical  infirmities  contraindioating  its  use.  Throat 
Stroking  and  masss^  of  the  feet  are  also  sometimea  of  great  servioe. 


58B  TBSATUBNT  OF  DIBKASBB  OF  THB  NBBVOUS   BT3TEM. 

Some  eases  of  sleepleaaneas,  pafticularlj  those  associated  with  contiuiul 
recurreDce  of  the  same  thought  or  trams  of  thoughts,  are  amenahleto 
light  percussion  of  the  head,  and  an  apparatus  has  been  devised  to  applj 
this  bj  means  of  the  electrical  current. 

Sleeplessness  due  to  paia  constitutes  comparativelj  a  small  proportioQ 
of  all  cases*     It  ia  combated  by  the  use  of  measures  that  relieve  the  pain. 
Morphine  does  this  with  more  certainty  than  anything  else-      Considering 
the  danger  that  attends  its  use,  of  which  every  one  knowe,  it  is  neoessaiy 
to  interpret  the  dependency  of  the  pain.     If  it  is  due  to  some  intractaUa 
or  incurable  disease,  its  administration  is  not  justifiable  so  long  as  a  degree 
of  relief  from  the  pain  and  insomnia  can  be  obtained  from  the  use  of  other 
pain  relieveie,  whose  administration  does  not  entail  habituation-     If  it  is 
not,  morphine  should  be  given  to  the  complete  relief  of  the  pain.     If 
this  does  not  sufQce  to  overcome  the  sleeplessness,  one  of  the  least  in- 
nocuous hypnotics   should  be  used  simultaneously.      Sulfonal  and  trio- 
nal  in  from  twenty-five-   to   thirty-grain   doses   meet   the    indications. 
Trional  acta  more  expeditiously  than  sulfonal,  and  its  effects  are  not 
often  manifest  the  next  day  as  are  those  of  the  former.      Their  action  is 
often  expedited  if  given  with  a  small  quantity  of  some  alcoholic,  such  as 
sherry  or  whiskey,  or  hot  milk.     Some  oases  of  insomnia  associated  with 
pain  dependent  upon  chronic  organic  or  functional  disease,  each  as  tabes 
or  neuralgia,  respond  with  greater  certain^  to  chloral  than  to  any  other 
hypnotic.     The  immediate  and  remote  effects  of  this  drug  should  make 
us  chary  o£  its  repeated  use. 

Sleeplessness  dependent  upon  paresthesia  is  overcome  by  the  utiliza- 
tion of  measures  that  immediately  combat  these  conditions.  It  is  difBcult 
oftentimes  to  determine  the  dependency  of  the  par^esthesia.  For  in- 
stance,  the  complex  of  symptoms  known  in  this  country  as  the  parses- 
thetic  neurosis  and  abroad  as  acroparfestbesia,  is  due  to  different  causes, 
many  of  which  are  unknown.  Studious  consideration  of  the  patient's 
history  and  careful  investigation  of  the  different  systems  of  the  body  will 
usually  reveal  the  cause.  Then  measures  may  be  taken  to  remove  it  and 
to  combat  its  effects.  These  may  include  a  change  in  the  patient's  mode 
of  life  and  dietary  to  overcome  autointoxication  and  a  beginning  diathe- 
siSf  such  as  the  uric  acid,  or  the  administration  of  vascular  stimulants 
such  as  strychnine  to  aid  a  jaded  heart.  After  these  indications  have 
been  fulfilled  the  insomnia  may  still  persist,  but  this  can  usually  be  over- 
come without  resorting  to  hypnotics  by  the  use  of  hydriatics  and  mas- 
sage. 

Insomnia  associated  with  sensations  of  suffocation  and  strangulation 
usually  succumb  to  measures  directed  immediately  to  the  hysterical  con- 
ditions of  which  they  are  a  part. 

Sleeplessness  dependent  upon  psychical  conditions,  such  as  anxiety, 
grief,  worry,  fear^  overwork,  obsession,  excitement,  or  depression,  wheth^ 


THE  TREATUEXT  OP  IXSDUNIA. 


569 


er  or  uot  tber«  be  ancillary  pheijDnieii&  of  dtae&sd  like  neuraatheiuA,  hy^ 
teria,  hypochondriasisi  manias  or  melaacholia,  is  the  commooc^t  variety 
of  msoBUiia  ejj^.'ountered  by  the  nourclogist  and  probably  al3t>  by  Uie  gen* 
era]  practitioi]«T,  It  is  usually  tb£  most  difficult  to  treat  beoause  the 
state  iipOD  which  it  U  deppDd«nl,  although  discoveTabler  is  not  «&sily 
overcome.  Mauy  of  these  cciDditious  do  iivi  leapoad  re&dily  to  treal- 
meQt,  while  the  lueaaoi^s  adequate  to  cope  wilh  others  &re  ofteu  unfortu- 
nately beyond  the  patient^s  reach.  Stiff«T«rs  with  inaonmia  of  this  kind 
becM>ma  viutims  uf  drug  habits  more  oftea  than  any  others  becanae  of  the 
refractoriness  of  the  couditiuns  of  which  it  is  a  symptum.  These  morbid 
itateEi  TH^uire  tu  be  vi^rously  assailed  and  overcome  if  possible.  In 
eadeavori&g  to  do  tltia,  one  will  make  use  of  hypugtitrs,  ma^a^  reatv  and 
exerc'iAe,  aport*  occupation,  dietary^  eleotncity,  dru^,  or  anything  elsA 
available  which  Deems  to  be  indicated.  The  specihc  applir^ation  of  these 
aro  considered  in  Fort  I.^  and  in  the  respective  (.'haptera  cievoteil  to  the 
considerntjon  of  the^e  diseases.  Here  it  ia  uecesfiu-y  to  say  something  of 
the  rarious  hypnotics,  oue  or  all  of  which  may  have  to  be  given.  Despite 
tho  manj  new  and  excellent  sleep-producers,  the  moct  reliable  hypnotio 
at  the  preseut  da^  ia  chloral  hydrate,  A  knowledge  of  the  immediate 
and  remote  dangers  attemiing  its  administration  should  counsel  its  use  as 
rarely  as  possible.  The  only  absolute  contrainJieation  to  its  use  is  degen- 
eration of  the  cardiovaAcuIar  apparatus.  There  are  many  asthenic  condi- 
tions in  which  the  admin  iat rati un  of  chloral  is  iiiim.ica],  but  if  it  is  ahoo- 
Intely  neoesBary  to  give  it,  the  system  can  be  fortitied  and  protected  by 
the  aitnultajieous  administration  of  other  dniga  or  measures  so  that  ita 
USB  will  be  attended  with  no  considerable  risk.  For  instancy  chloral 
hydrate  is  a  very  serviceable  drug  In  the  treatment  of  the  insomnia  fol- 
lowing ahatineuce  from  alcoholic  stimulants  and  morphiee.  When  it  is 
gireu  for  such  conditions  the  simultaneone  adtniaiatration  of  some  cardiac 
stimulant  as  strycbJiineT  strophantus,  or  sparteine  is  rearly  always  indi- 
cated. Of  the  modem  chloral  derivatives,  crhloralamide  and  ehloralose 
are  the  most  serviceable.  The  former  is  in  reality  a  very  servic^eable 
hypnotic.  Its  use  is  free  from  risk  that  the  patient  will  form  a  haUt, 
and  it  is  neither  a  solvent  of  the  red  blood  corposclea  ncr  a  profound 
depreciator  of  cardiovascular  pressure,  like  chloral.  It  may  be  given  in 
twenty-  to  forCy-grain  doses.  UHUsally  no  disagreeiihle  aftPr-eSe^^ts  at- 
tend Its  use.  Chloralose  in  from  five-  to  ten-grain  duses  is  a  fairly  reliable 
hypnotic,  and  may  be  given  under  the  same  circumstances  as  chloral- 
aiaide.  1 1  is  useful,  particularly,  in  the  &lecple6»uess  of  mental  irritability 
and  exhaustion.  Amylene  hydrate  ia  a  less  powerful  sleep- producer  bhau 
ch^3Talamide,  but  it  is  not  ilisagreeabla  to  take  and  it  has  no  unpleasant 
after-effcctji.  The  average  beginning  doEc  is  adrachiti.  Sulfuiial^  trional, 
hypnal.  and  hypnone^  e^tpecially  the  first  two,  are  among  the  moat  service* 
able  drugs  in  the  treatment  of  inaomnia;  not  only  because  of  their  eflSca* 


5^0 


TREATMENT  OF  DlSEAdES  OF"  THE  NERVOUS  BYSTEM. 


oy,  but  becfiuso  of  tUeir  coiupiiriitiTe  innooaousuMs.  The  average  doae  Qt 
each  of  them  is  from  lifte^n  to  twenty  giains,  aiid  there  are  pr&cticolly 
no  nontraiadi^^tioua  to  their  us**  sav6  profoimd  &Htbema.  They  Btid 
their  Avidest  field  of  usefiUneu  iu  tlie  iuaomuia  depoudeut  u|nn  pay cLical 
canues  and  f«briUtj  unatbcDded  with  pain. 

fs'oxt  in  certainty  of  action  to  chloral  hydrate  in  the  OTercoming  of 
ioHomuiiL  due  to  psychical  cauKaa  is  paraldekjrda.  Were  it  not  for  itM 
diaagti^eable,  [it^rsistent  odor  and  its  naustioua  taste,  it  would  ftpproxi- 
mate  the  idoal  hj^pnotic.  Its  use  in  drachm  dosea  is  uiuittended  with 
dijiger,  Gni  in  many  c.-vaea  tvo  ct  three  timea  this  anioout  can  bo  gi^ea 
with  perfect  safety.  It  haa  but  slight  depresaiug  effeot  upoa  the  bcarl, 
and  trilling  deprecLatiDg  effect  upon  tlie  tisvues.  It  haa,  honeTori  a  teb- 
rJpiK'y  to  disiirder  digestion^  and  must  ba  used  carefutly  for  patients  wich 
senaitive  stuuiarhs^ 

The  aalta  of  bromine  are  used  very  Jai^ly  in  the  treatment  of  iunom- 
nia,  with  the  mistaken  idea  that  they  ari^  hypDctica.  Although  tbcy 
often  induoe  sleep,  they  are  no  more  bypaotics  th&n  is  luorphine-  They 
contribute  to  aleep  by  relieving  the  peripberal  or  central  irritation  upon 
which  tlte  wakerLiliiesa  is  dependent.  For  instance,  ill  HtateH  of  (erethism 
aofiociabed  wich  ceiel^ial  hy|^r£bmiar  tl^e  rurtult  of  soum  puisou  aitling 
through  the  heart  or  directly  upon  tho  blood-vesseU  of  the  brEUD>  or  a  oon- 
coinitant  of  mental  excitement,  a  full  doae  of  one  of  the  bromides  will  go 
far  toward  oorttributing  to  the  tranquillity  which  preoedea  aleep.  They 
are  often  combined  with  chloral  to  bring  about  such  a  state  in  the  treat* 
meut  of  tnsGtiiiua  of  asllienic  delirium  and  auto^mtoxicatioua.  Iu  aome 
ca6ea  of  ^teepleasneaa  dependent  upun  mental  iiritabLlity  it  ia  better  to 
give  15  graiuB  of  bromide  of  eodixuu  one  hour  after  each  tueal  instead  of 
giving  a  large  doae  at  bedtime^  but  it  should  not  be  turgotten  tha.t  the 
bromides  should  nei'er  he  given  repeatedly  nor  continuously  in  order  to 
induce  steep. 

The  indioationa  for  the  treatment  of  insomnia  dependent  upon  Uiiie 
matGriaLs  in  the  syatam,  whether  they  be  taken  iu  from  without  or  manu- 
factured and  elaborated  within,  are  coin pu rati vely  aimpICj  even  though 
tbe  aleepleaanesa  dues  not  always  yield  readily.  The  Grat  and  most  im- 
portant thing  to  do  ia  to  determine  tbe  causer  ^^^  ^  remove  it  or  com- 
bat it>  It  ia  sometimes  as  difficult  to  do  the  one  aa  the  other.  Sleep- 
lesancss  accompanyiug  the  iufcctious  diseases  is  often  ameliorated  by 
appropriate  treatment  directed  ajj^ainst  the  fever,  but  it  is  frequently  nee- 
ctLKary  to  aiiminiater  soma  hypnotic  aa  well.  The  election  of  the  hypnotic 
will  depend  largely  upon  the  state  of  the  patient^s  vitality,  ospeejally  the 
condition  of  the  heart,  Tlie  faot  that  sulfonal  and  trional  have  only 
slight  depressing  effect  upon  the  vascular  system  makes  theui  the  safest 
for  this  purpose.  Tnaonmia  of  the  exogenous  intoxications  is  often  very 
rebelJious  to  treatment,  even  after  tbe  source  of  tbe  intoxication  baa  been 


THE   TREATMENT  OF  INSOMNIA. 


591 


shut  off-  Co^ea  of  tbU  scrt  famUh  opportunity,  and  with  a  fair  prospect 
of  suoceas,  for  the  utilizatiOTi  of  the  phyaic^ai  mea&uree  that  liave  been 
mentioned.  Remedies  that  are  capable  of  combatiug  the  general  de- 
|jreciatioii  of  vitality,  mauifeGt  by  diiwrder  of  circulation^  digeatioD,  and 
aa3aDilalio[i,  must  be  giren  simultaneously-  Of  the  hjpuoiica  to  he  uaed 
in  insocDnia  of  this  class,  paraldehyde  is  by  far  the  mcst  reliable.  Chlo- 
ral, its  derivatives  and  compounds,  ore  to  b«  avoided,  principally  because 
of  their  effect  upon  the  blood.  The  same  may  be  said  of  the  broiaidefi, 
AVhen  ifymptoma  of  ^eueral  eretbiarn  indicate  the  administration  of  ihese 
salts  fior  their  calmiug  effects,  they  should  be  given  only  for  a  brief  period. 
In  treating  the  insomnta  of  aut^- intoxication  from  diaorders  of  digeation, 
urio  acid^  gout,  diabetes,  etc,,  the  admiuiatration  of  hypiLotics  ahould  be 
delayed  us  loug  as  possible,  and  th«n  used  very  sparingly  because  of  their 
capacity  to  impair  digestion  and  assimilatioTi  and  to  retard  metabolism, 
Begulatiou  of  diet,  attention  to  the  avenuea  of  elimination,  appropriate 
eserciflp,  the  use  of  hydriatics  and  massage,  and  the  administration  of 
remedies  thai  operate  directly  upon  the  auto-intoiioation,  ate  the  measuroB 
to  bo  rdied  upon.      Hypnotics  shouM  \te  u^ed  as  sparingly  as  possible. 

Great  1^1^e  and  skill  are  necessary  (ii  the  tieatmeiit  of  insomnia  due  to 
organic  diaerise  of  the  viaeera  in  whieh  the  sleeplessueas  is  nut  due  directly 
to  paia^  Disturbed  and  unrefreahing  sleep,  dyssomnin,  is  one  of  the  most 
ciouatant  symptoms  of  arterioeapillary  libiosia.  The  proper  administration 
of  iodide  of  sodtnm  or  potassium  and  oiie  of  the  nitritea  and  carefu]  ali- 
mentation do  more  to  relieve  this  symptom,  except  it  be  temporarily,  than 
does  anything  else.  Naturally,  it  is  often  necessary  to  administer  sleep- 
producers^  The  selection  of  the  most  serTiceabie  cne  irill  be  aided  by  a 
t:on3ideratiou  of  the  causes  and  extent  of  the  vascular  disease,  Suifonal 
or  tnoaal  administered  with  a  small  quantity  of  alcoholic  stimulant, 
takeD  vhen  the  patient  awakens  after  a  more  or  less  brief  sleep  in  the 
earlier  i>art  of  the  night,  is  often  very  useful.  Cliloralamide  and  ehlora- 
lose,  given  in  moderate  doses  until  the  tolerance  of  the  iodividuaJ  baa  beeu 
determined*  can  be  alternated  vith  them. 

No  special  rules  can  be  given  for  the  treatment  of  the  form  of  insom- 
nia, knovn  as  habitual,  as  the  indications  vary  with  the  individual,  and 
what  will  prove  of  benefit  toontr  will  be  quite  iiaeleasfoT  another.  Many 
of  those  ccastitnting  this  class  of  patients  secure  in  reality  sufficient  eleep 
to  maintain  a  fair  degree  of  health*  Thus  many  xho  aver  that  they 
obtain  scarcely  any  sleep  get  sufficent  "to  knit  up  the  tavell'd  aleeve  of 
care"  for  they  do  not  lose  weight  cor  suffer  diminution  of  hemoglobin, 
although  they  may  lack  strength  and  energy.  Change  of  snrToundings 
and  mode  of  life  sometimes  benefit  those  who  can  avail  tbemaelres  of 
Lhem.  But  for  the  majoritii'  aiich  luxiaries  are  impossible.  Jlany  drug 
habitues  are  recruited  from  this  class-  Hypnotics  should,  therefor^  be 
given  with  the  greatest  circumspection. 


INDEX. 


ABLOTION0.  description  of«  76 

Abficeae  of  bi&in,  137 

AccidenlAl  cauBee  of  nervous  dlwuo,  7 

epilepsy,  4fll 
Aconite  08  pain  leLkever,  57 
Aconitift,  dangers  of,  67 
Acquired  c&uaes  of  nervous  dlseaaei  7 
Acromegaly  f  514 
Acroparfeathefiia.  525 
Acupuncture  in  sciatica,  3S9 
Acute  bulbar  myelitis,  288 
AlfusLoDB,  description  of,  76 
Alcoholic  neurits,  32e 
Alcohol  I  em  and  epiJepsy,  444 

acute,  treatment  of,  658 
Alexia,  210 

AEoaorosis,  hysterical,  424 
Amblyopia,  hysterical.  424 
Amimia,  2\9 

Amflena  hydrate,  doae  of,  68 
Ampere,  definition  of,  00 
Amperemeter,  9fi 
An^ctropbic  lateral  scleroBls,  300 
Antemia  and   hypcriemia  of  the  brain, 
vertigo  In,  667 

of  the  brain,  534 
Aneemic  headachee.  535 
Ansatheeia,  byeterical,  424 
Analgesics,  niodenx,  67 
Aneurlem  of  brain,  192 

treatment  of »  202 
Angioaeuroilc  (edema,  614 
Anorexia,  hyBtericaL,  treatment  of,  437 
Anoeniiat  424 

Anterior  poliomyelitis,  STO 
AntisyphiUtica,  mode  of  administering, 
31 

time  of  admlnlsEerlng,  31 

^  treatment,  influence  of.  30 

Aphasia,  clasalfication  of,  215 

compound,  216 

congenital,  218 

definition  of.  214 

etlolCffy  of,  216 

88 


Apbaflia,  medtcioftl  treatiueDt,  sao 
motor,  215 

pedagogical  treatment  of,  223 
sensory,  215 

surgical  treatment  of,  221 
symptoms  of,  219 
treatment  of,  214,  220 
true,  215 
Aphaslc  patient,  education  of,  225 
Aphemia,  215 
Aphonia,  hysterical,  439 
Apoplexy,  cerebral,  203 

from  cerebral  coDgestion,  212 
from  cerebraf  (edema,  212 
without  known  anatomical   teelon, 
213 
Aran-I>uchenne  type  of  progressive  mu^ 

cular  atrophy,  294 
ArgyU-RobertAon  pop! I,  217 
Arseoio,  use  of,  59 
Art«Hal  fibroals,  headaches  of,  £35 
Arterlocaplllary   fibrosis,  treatment  of, 

204 
Arteriosclerosis,  vertigo  of,  667 
Arthritic  diathesis,  relation  to  nervoua 

disease,  37 
Arthrodesie   in   ireatment  of  poHomy^ 

litis,  2S7 
Arthropathies  of  Ubes,  237 
Arthropathy,  hypertrophic,  516 
AfltBBia-Abaaia,  433 
Asthenic  bulbar  paralysis,  302 
symptoms  of,  303 
treatment  of,  304 
Ataxia^  hereditary  cerebellar.  264 
Friedreich's,  252 
locomotor.  (^.  tabes  dorsalia,  227 
paraplegic.  255 
Ataxic  paralysis,  subacute,  276 

paraplegia,  hereditary  form.  S6B 
Auditory  vertigo,  665 
Aura,  epileptic,  459 

AatO'lntoxication   as  cause   of   nerfons 
disease,  18 


G94, 


INDEX. 


Ba]»  iiAHiTH,  eradication  of,  4^ 
Balneotherapy  of   exopbthalmlo  goitre, 

efficacy  of>  in  chronic  acialLoa,  388 
Bfuedow'i  dlAeofte,  600 
Batter leSf  electric,  »ii 
Bell's  parslyalB,  S87 
Bcr[-beTl  or  kakb«,  327 
Bicycling  for  nervouH  patieata,  110 
11  i  nil  pa1ai«,  180 
Blind ne«R,  irordn  T^iO 
Brachial  iieiirnlgia,  :UVi 
Brain  abaceM,  107 

character  of  headache  in,  633 
etiology  of,  lOU 
meUatatic  variety,  171 
of  otitic  origin.  170 
of  rhiai tic  origin.  I7t 
relation  to  traama,  170 
Beat  of,  in  relaiLon  to  cauflft,  172 
■ymptom»  of,  176 
traaiment  of,  lltt 
tuborouloaB,  172 
nrletiea  of,  168 
aneuriuD,  treatment  of,  202 
gumma,  treatment  of,  202 
tumora,  190 

character  of  headache  In,  53.^ 

etiology  of,  191 

exploratory  and  pall  litlve  opera- 

tlotii  in,  108 
general  treatment  of,  201 
operabiilty  of,  180 
reiationahip  of  trauma  to.  lOS 
symptomaiic  treatment  of,  200 
iiyinptome  of.  1^ 
the  dangen  of  operation  in,  lint 
treatment  of,  lli6 
Bromide  cacheiia.  454 

intoxication,  phenomeim  of.  464 
aalta  in  epilepay,  comparative  vahi^- 
of.  461 
Broniidea.  abiiae  of,  66 
dose  of,  5(1 

in  Uie  treatment  of  migraine.  478 
medicinal  adjuvantj  of,  456 
modi- of  adminlflterinf;,  in  epilepay, 

4r>a 

toxic  effcctfl  of,  treatment,  466 
Broniism,  manifeetatlomi  of.  464 
Rniw  ague.  63tt 
firuclne,  uaeof,  6& 
Bnlbar  paralysiA,  2^7 


Balbar    paraiyeia,    chronic,   cnuKa    of 
death  in,  208 
chronic,  duration  of,  208 
chroniC}  etiolc^  of,  207 
chronio,  exciting  caueea  of.  398 
chronic,  family  form  of.  302 
chronio,  treatment  of.  290 
poliomyelitis,  286 

CuEaoN  diaeaae,  263 

Causes  of  nervous  diaeaaea.  1 

Central  gray  matter,   inflammation   of, 

278 
Cephalalgia,  f;f.  he«dacbe,  630 
Cerebellar  tnmora,  operabill^  of,  197 
Cerebellum,  tomora  of,  106 
Cerebral  annmia  and  hyperemia,  G84 
apoplexy.  203 

prediapoaing  cauaee.  204 
preventive  treatment  of,  204 
treatment  after  an  attack,  307 
treatment  of  attack,  206 
emboli  em,  etiology  oft  208 

treatment  of,  ^^10 
hemorrhage,  etiology  of,  20S 
paliles  of  infancy,  180 
thrombcflla,  etiology  of,  200 
treatment  of,  210 
Cerebrospinal  fever,  etiology  of,  149 

Bymptoma  of,  153 
Cervlco-bracblal  neuralgia.  306,  367 
Charcot  douche,  BO 
Chloral  hydrate,  abuaeof,  58 
Chorea  (Sydenham  *a),  481 
electric.  481 
habit,  481 
Huntington 'a,  481 
iiiHaniene,  600 
of  pregnancy,  485 
Ben  lie,  482 
treatment  of.  486 
Choreiform  diaeaaes,  claaaitlcation  of,  481 
Cbronlc  encepLalltia,  107 
myelitis,  274 

dependent  upon   lethal  anemia 

and  iox«mia,  273 
treatment  of,  275 
progreesive  bulbar  paralyeia.  297 
ophthalmoplegia,  304 
ChvoHtok'a  symptom  of  tetany,  322 
CKmatotberapy  of  nennothenla,  417 
Coccygodynla,  398 
CoitUB  reeervatua,  redulta  of,  42 


INDEX, 


595 


Combined  sclerosis,  27tt 
ComprossiOD  myeUtiB,  2GM 

due  to  Potts*  diiwase,  treatnuint 

of,  271 
symptoiiiB  of,  270 
CoDgenital  aphasian  SI8 

iafluenc^fl   in  ctUftLng  iiervoiia  (IEb- 

eaA«,  2 
nerroua  diBtiAtfeB.  causeA  of,  ii 
arphilis.  Iti 
CoaLum,  uses  of,  <H) 
ConatitutioDal    diflorders    and     nerrous 

dlAeaH-a,  30 
CoDTulsEona  (eclampsia),  673 
epileptic,  45B 
hystei-lcil,  423 
treatment  of^  674 

of  the  cauees  of,  6T;> 
Coprolalia,  paycho^nea&B  of,  4l1I) 
Cortical  motor  aphasia,  sf  mptoota  of,  211> 
Coulomb,  definition  of.  OO 
Counter-iTTltation  in  sciatica.  dSi* 
Crampflf  occupation,  627 
Cieiinism,  results  of  treatment  iu,  6 

treatment  of,  10 
Current,  faradic,  100 
galvaoiCf  92 
BtatLc,  96 
Currents,  electrical,  87 

Dbafhesb,  word,  22U 

DefOrmitiefl.   occurring   wLUi  polioiuje- 

litis,  treatment  of,  286 
Degeneracy,  functional  stigmal*  uf,  0 

somatic  atlgmata  of,  6 

Btlgmata  of,  5 
Delirium,  652 

acutum,  563 

c1a«si  tication  of,  562 

etiology  of,  562 

of  eihaustion,  660 

oF  tn(ectioua,  664 

of  IntoxicationB,  667 

of  irriution,  550 

tremena,  658 
DlabfltWf  relation  to  neirous  diieaae,  ^7 
Dlatheals,  neuropathic,  3 
Diet,  120 

adequate  one  fornervoaapaiients,lHO 

and  r^ffime  in  tabes,  240 
DleUTf  of  eplleptica,  460 
Dialocation  of  cervical  verlebne,  treat- 
ment of,  272 


DiHMmlnated  Insular  acleroaU,  1S6 

niver's  disease,  2ti3 
Douche,  action  of.  78 

directions  for  giving,  TO 
iJi-eamy  Btatea  of  consciouaiiMB,  460 
1  )i  ugs,  abuse  and  use  of,  64 

advisability  of  giving,  empirically, 
64,01 

contrasted  witli  otlivi-  remedial  meafl- 
ures,  4U 

doeed  of,  in  comuion  uae,  02,  it3,  M 

efflcieucy  of,  49 

most  commonly  abused,  5G 

moat  commonly  luvd  in  neurological 
practice.  50 

purpoae  of,  4ti,  49 

remedial  action  of,  ^i 
Uuboisine,  u^e  of,  (lO 
Ductless  glands,  relation  of,  to  certain 

djasasea,  51  ~ 
Dystropbies,  310 

poBHible  relationship  to  thymus  £ime< 
tion,  61 

primary  typee  of,  310,  311,  312 

treatment  of,  31^ 
Dystrophy,  juvenile  form  of,  311 

Landouzy-DejerLne  type,  311 

Leyden-MObiuH  type,  311 

EcLAiiFSiA  of  children,  6T3 

Kducation,   moral,  of  neuropathic  chil- 
dren, 44 
of  neuropathic  child,  42 
Electric  bath,  lOti 
Electrical  reaistance,  SB 
Electricity,  an  estimate  of  ita  therapeu- 
tic value,  86 
forms  of,  87 
In  the  treatment  of  chronic  Hclatlca, 

380 
In  the  treatment   of    eiophtbalmic 

goitre,  fi06 
in  the  treatment  of  byateria,  432  ^ 
in  the  treatmentot  neurasthenia,  414 
in  the  treatment  of  pollomyelltlB, 

286 
In  the  treatment  of  tabes,  240 
modes  of  applying,  106 
therapeutic  application  of,  lO^i 

action  of,  SQ 
use  of,  hi  neuralgia,  'A\9 
use  of  Btreet  current,  102 
Electrodes,  varieties  of.  07 


596 


INDEX, 


Electrolysis,  103 

Blectroiaoiive  force,  daflnltioD  of,  M7 
ElectroemofllB,  103 
Electrothenpy,  S5 
Kl«cuotonuB»  lOa 
Ellilrof  life,  52 

Embollem  of  cerebTHi  TeaselB,  etiolog}' of, 
208 
ireatment  of,  210 
Encephalitis,  irt4 

acute  hemorrba^c,  non'pumlsDt,  MM 
etlolr^y  of,  143 
sytnptoins  of,  16fi 
treatmenc  of,  1M 
chronic,  167 
'         purulent,  107 
EncepbaloniAlaclH,  :J0& 
Envirotiment,    unpropltlous,  the   avoiil- 

aace  of,  U8 
Epicru)la]  myosULs,  539 
Epidemic  cerebrouplnftl  meningitis,  l-ll> 

treatment  of,  1GB 
Epilepsia  procttraiva,  treatment  of,  4iH) 
tarda,  442 

treatment  of,  460 
Epllepfly,  441 

andberedily,  444 
clissiflcatlon  of,  44] 
congenital,  varletlefl  of.  44:i 
diet  In  (reatmetit  of,  4fi0 
etiology  of,  443 
medicinal  treatment  of,  4&I 
moral  and  hygienic  treatmetil  of,  447 
of  reflei  oHgIn,  44't 
relfitlonshLp  to  syphilln,  446 
surgical      treatment     of     accLileiiTjt] 
variety,  4f[:j 
Epileptic  atlacke,  treatment  of,  4t,H 
delirium,  G60 
headaches,  532 
EpIleptLcK,  colonization  of,  44R 
Kpoch,  the,  relationship  to  [lervouH  ^tls- 

eaae,  21 
Krb's  juTenlle  dy atrophy,  811 

oymptom  of  tetany.  822 
Frythro melalgia,  523 
Essential  palsy  of  children,  271' 
Etjnlogy  of  nervous  dlaeaw,  1 
Exercise  in  the  development  of  chiMivn. 
44 
in  the  treatment  of  nervoua  dls^Mses, 
117 
Eiophihalmic  Roiire,  TiOO 


Eiophihalmlo  goitre,  etiology  of,  600 
surgical  treatment  of,  606 
treatment  of,  602 

Exothyropexy,  £06 

Facial  hemiatrophy,  521 
paralysis,  387 

Hymploms  of,  338 
ireatmetit  of  ^  339 
Yarietlee  and  causes  of,  337 
FacioHKapulO'hunjeral  type  of  musculsr 

dy atrophy,  311 
Family  diiieasee,  prevetitlon  of,  21 

form  of  amyotrophic  lateral  acleru- 
sis,  307 
of  bulbar  paralysis,  302 
Faradic  emrent,  100 
Femoral  neuralgia,  376 
)-'leury  douche,  80 
Focal  epilepsy,  442 
Food,  time  of  uklng.  133 
Foot  baths,  73 
Foth«n^Iira  painful  affection  of  the  face, 

362 
Fracture  of  vertebra,  treatment  of,  273 
Fraenkers  method  of   treating  ataxia, 
242 
treatment,  contraindication*  to,  243 
fornkula  of,  243 
Frankllnlc    electricity,    application    of. 

107 
Friedreich 'e  dlecaae.  2i)2 
Full  bath,  cold,  TJ 

Galvanic  current,  02 

series,  W 
Gasserian  gatrslion.  extirpation   of,   for 

tic  douloureux,  3'13 
Getsemjiuii.  uu  of,  TiH 
General  fai-adtzatioii,  105 

galvatilzatlorj,  106 
Oerller'e  disease,  GTI 
Giddiness,  602 
Goitre,  exophthalmic,  500 
Golf,  For  nervouH  patients,  120 
Gotity  vertigo,  b^m 
Graves'  disease,  -500 
Gravity  cell,  1)2 

Gumma  of  the  brain,  treatment  of,  2U2 
Oymnasrica,  114,  121 

llAhiTs,  necesRJty  of  breaking  up,   42 
Habitual  headache,  538 

treatment  of,  551 


INDEX. 


697 


HEemBtemeeiSt  bysterical,  irestmeDt  of, 

437 
Half-bath,  prolonged,  72 
Head  Qodding,  677 
Headache,  530 

claBaltlcation  of,  £30 

of  drugs  used  In  the  Lreatment 
of,  642 
diagrama  of  locatLons  ot  pain,  &39 
locatLoiL  of,  !□  reference  tocauw,  580 
of  cin^latory  dlBordera^  treatinetit 

of,  MB 
of  infectEona,  intoxloatlona,  and  au- 
U>-lntox[catLona^  treattueot  of,  54tl 
of  InfectEouB  dlaeaae,  53B 
of    the    functional   neurow^i    treat- 
ment of,  543 
of  toil c  origin,  531 
Bjmptomatlc,  530 
tr&atment  ol.  Ml 
BemlcraaiHi  473 
Hemi hypertrophy,  522 
Hemiplegia,  treatment  of ,  579 
Hereditary  aiaiio  paraplegia,  2u5 
cerebellar  ataila,  2&4 
diseaseo,  prevention  of,  S7 
iafluenceA  in  causing  nervous  dis- 

eafle,  2 
spinal  ataxia,  W"! 

cLiuLcaL  features  of,  25H 
etiology  of,  252 
treatment  of,  '2^i 
fiyphlUs,  ao-called.  IH 
Hoffmon'a  aymptom  of  tetany,  3^t 
Hotr^ir  boi.  70 

HydriatLo  treatment,  time  of  Ita  applica- 
tion, 82 
HydriatLcB  Iti  neoraathenEa,  412 

in  treatment  of  subacute  and  chronic 
Bclatica.  3B1 
Hydriatisia.  intemperatt;  claluis  of,  (ME 
Hydrocephalus,  101 
Hydrops  genu  int«rmiltena,  Hl't 
Hydrotherapy,  Sj 

an  estimiLie  of  its  value.  V,~t 
Indications  and    contraimUcatiomi, 

02 
in  hysteria,  4211 
of  exophthalmic  go Itre,  'jO'* 
of  insomnia,  587 
Hyoscyamlne,  use  of,  00 
Uyperihermia,  relatloiwhip  of,  to  delir- 
ium, 5J>6 


Hypertrophy,  local,  G22 

Hypnol,  UM  of,  66 

HypnoUca,  accession  to  the  list  of,  58 
abuse  of,  68 

Hypnotism^  deSnitloQ  of,  143 

Id  the  treatment  of  hystarla,  144, 

434 
uses  of,  143 

HysrorLa,  4S2 

etiology  of,  422 
general  treatment  of,  428 
medicinal  treatment  of,  434 
prophylactic  Ireatinent  of.  426 
surgical  Dneuures  in  the  treatment 

of,  434 
symptonu  of,  423 

treatment  of  the  psychopathic  state 
in,  427 

Hysterical  attacks,  treatment  of,  4S5 
contracture,  treatment  of,  4,19 
headaches,  characteristics  of,  6S2 
paraLysia,  ireatment  of,  437 
sensory  symptoms,  treatment  of,  439 
stigmata,  treatment  of,  430 

Irico-uDTOH  action,  13S 

Tdiopathio  headache,  53S 

Imaginary  pain,  137 

Incontinence  of  urine  In  tabes,  treatment 

of,  236 
Infantile  cerebral  palsiea,  180 

CBUflea  and  varieties  of,  180 
treatment  of,  182 
paralysis,  279 
Infections,  cause  ot  nervous  diBease,  T 
explanation  of  remote  developments 

after,  8 
relation  of,  to  acute  myelitis,  201 
InfectiouadiBeases,  necesBlty  of  treating, 
30 
relation    of,   to  syphililic  dia- 
easee,  10 
meningitis,  causes  of,  152 
treatment  of,  155 
Inferior  degenerates,  0 

polioencephalitis,  291 
Inaomnia,  583 

clarification  and  causation  of,  5B5 
the  use  of  hypnotics  in,  580 
treatment  of,  580 
Intermittont  swelling  of  the  knee,  515 
Iniereostal  neuralgia,  309 
Intoxication  and  nervous  disease,  16 


698 


INDBX. 


lodothyrEn  in  myrasdeiDK*  610 
iloae  and  u>e  of,  52 

jACKK)NiA?r  epilepsy,  442 

Jendnsslk'a  medicxl  of  reinforciog  th« 

knw  jwk,  230 
Jumpen,  46ti 
Juvttiiile  vu-iflty  of  dyxlropLy,  '^1 1 

Kernig'H  filgn,  IM 

LABEO-aLOSAO-LARYNUEAI.   pOTAlytllll,    2l>7 

Laryngeal  crisw  !□  tabeK,  231 

Laryngeal  vertigo,  572 

LaryngiHiDUH  fltrfdnliifl,  &T7 

I^taJi,  4(W 

LateropulBloji  in  paralyalH  agltans,  4U0 

Leclanchd  ceJt,  93 

I^  pftlna  wkh  varicoae  ve^nH,  :t70 

Idpro«y  almulatlng  syringomyelia,  :j5& 

leptomeningitis,  eCloloi^  nf,  14fi 

varieties  of,  145 
LiUle'adlaeaM,  182 

J^ocal  aspbyxiaor  Raynanil'H  disetwe,  61 1 
Local  cold  baiba.  mode  of  giving,  lA 
lx>ci>iDOlor  ataxia,  214 
Lumbar  pnncture,  technlcin«  of,  IGO 
Lnmbo-abrlominii.1  nein'algia,  -iTA 

Mavuary  nenralgia,  :ETI 
Marriage  for  epElepticfl,  44i) 
Maasage,  108 

estimation  of  its  wi^rih,  lOH 

in  iieuraathenla,  417 

in  the  Ireatment  oT  insomnia,  0^ 

in   tbe  treatinent  itf  pollomyellEUH 
285 

mo*le  of  applying,  111* 

the  £^rtncc,  112 

nses  of,  10!» 
Maaaey  controlk'r.  \it\ 
Maatodynia,  371 
Masturbation,  22 

treatment  of,  4-1 
Medical  (j^umasiii^e.  114 
M^niAre'd  diaeOBe,  ^30:! 
Meningitis,  character  of  headache  in, 534 

infectious,  causes  of,  HG 
varieties  of,  146 

aaroBa,  definition  of,  146 

treatment  of,  146 
Menopause  and  nervous  ditiease,  24 


Menatraation,  eBtablishment  of-  and  the 

neuroses,  24 
Meralgia  parsaUietkca,  >£76 
Mercury,  uae  of,  61 
Metabolism,  defective,  and  nervoua  dl>- 

eaMs,  19 
HetaUrsalgia,  causes  of,  3W 

treatment  of,  B95 
Metbyloce  blue,  use  of.  67 
Migraine,  473 

autotoTiemlc  theory  of,  480 
phenomena  of,  473 
treatment  of,  476 
an  attack  of,  471} 
Milk  as  food  for  nervous  patienUt.  1-tO 
Milllameter,  07 
Mind,  Influence  of,  in  causing?  Tkercout 

disease,  2 
Mode  of  life  for  neuropath,  38 
Mogigraphia,  527 
Moral  educatloiiof  neuropaihic  children, 

44 
Morphine,  abuse  of,  ft5 
Morton's  neuralgia,  3tK 
Morvao^s  disease,  identical  with  Kyringo- 
,    myella,  258 

Multiple  nenritin.  causal    ireatinent  of. 
330 
cHnical  form}*  of,  32)4 
exciting  causes  of,  A2'i 
general  reatoralive  (reatment  of, 

■.m 

pretiJapoain^  tanseaof,  ^25 
prophylaxis  of.  3SM> 
i-eiiiedial  treatment  of,  3:M> 
jtymptoms  of.  327 
HCleroniB,  IBO 

etiology  of,  im 
symptoms  of,  18^ 
treatment  of,  I  Pi" 
M  Macular  dystrophy,  the  treatment  of,  810 
Myasthenia  gravis  pseudoparalytica.  30v' 
Myelitis,  acute,    canaal   relationship  lo 
poisons,  202 
etiology  of,  2ft  1 
Kymptoms  of,  2t^i 
treatment  of,  200,  2<M 
chronic,  274 

symptonjs  of,  276 
nf  compression  T  200 
secondary,  203 
Myelomalacia  and  blood  diseasw,  9QS 
jVfyotonia  congenita,  316 


INDEX. 


59» 


U>7acbit>  466 

Myzcedema.  608 
treatment  of,  &t 

Nabcotics*  injurioaaneaa  of,  37 

Xerve    atretchine    and    coaipreHaioii    \n 

sciatica,  391 
NerrouB  diseftaes  and  trauuia,  10 

caiues  of,  1 

due  to  GonatUuiiooal  dlBorders, 

praventLOti  of,  26 
relatlonghip  to  work,  21 
Neural  progresaive  moocuJiu-  atrophy,  ^fta 
Neuralgia,  343 

cer7ico-bracbi»U  367 

electricity  la  treBtznent  of,  3&0 

fsmoral,  376 

general  etiology  of,  343 

BymplomMology  of »  346 
treatment  of.  34b 

lnterco«Ul,  300 

mammary,  371 

Morton's,  394 

objective  accauLpaniokeiittt  of,  347 

obturator.  37fl 

occipital,  366 

of  tbe  cervical  pleiua,  ^j 

of  the  crural  nerve,  37S 

of  the  fett.  394 

of  the  lumbar  plexus,  373 

of  the  puiiic  nerre.  3W 

of  the  sciatic  pleins,  377 

of  the  small  sciatic  plexus,  3l'3 

testicular,  374 

topographical  division  of,  343 
Neurasthenia.  391^ 

dleUry  in,  40B 

drugs  in  (he  treatmem  of,  410 

etiology  of.  3W) 

general  hygiene  of.  4<J6 

iDierdiclion   (if   stimnlanu    in    the 
treatment  of.  4l'£ 

isolation  and  dlKlpline  in  ihe  treat- 
ment of.  404 

local  trtatujent  in.  419 

plan  of  treatment  In.  420 

prophylaciic  treatment  of.  404 

reat.  exen:iAe.  and  lyrrupation  in,  415 

stigmata  of.  403 

tbe  climatic  trtatmcm  of.  417 

tbe  bydriatic  tKumeui  oL  412 

ibe  aecnr^inent  of  sleep  jd,  44T 


Xeuraslheuia.  treaUnent  of  an  attack, 465 
of,  by  electricity,  414 

NeurasUienlo    headache,    cbancteriatlca 
of,  631 

Neuritis,  multiple,  mn 

Neuropathic    cblldn-n,  engroruLng  worh 
for,  46 
diathesis,  deflniUnn  of,  '-l 
gangrenous  trophoneuroals,  61 1 

Neuroee<  of  degeneration,  derinltJon  of,  5 

Neurotabtw,  328 

Nodding  headi  ri77 

Nuclear  ophthahnoplegla  ovutv,  2t*\i 
chronic,  3*H 

Nux  vomica,  uhu  of,  Mi 

OuTuiAToa  neuralgian  376 

Occipital  neuralgia,  m\ 

Occupation  as  a  theratieutlc  afceiivy,  127 

cramps,  b27 

for  epileptics,  449 

neuroaes,  Ga7 

palalBS,  G27 

spasms,  G2T 
Ocular  vertigo,  670 
Ohm,  deflnitlon  of,  BH 
Ohm's  law,  90 
<JphthaliiLOpleglA,    chronic    tiroKri'SHl ra* 

304 
Opium  treatnieni  of  epilepsy,  4M 

PAt'Ki,  technique  of  a])plylriK,  77 

varieties  of,  76 
Fain, '«imagiiiai7,"i:n 
ParteHtlietic  Tieurwjs,  'r:£'t 
Paralyslt  a«itauj4,  4U) 

alleged  causen  nl,  41f2 
course  of,  iufj 
etioliigy  of,  4m 
HymptJiins  of.  4W 
treatment  of,  4ti7 
fseiaU  337 
Paraaypbilkie  epilepsy,  treatmef Jt of , 4iH 
nervous  disKwiM.  11 

relation     of,   to    aiJEiv^rihiiiti'; 
Ireaitmeni.  14 
I*arkins'')j's  dlseaK,  ii't 
Pc^laf^lfy  and  neurofAthi':  cbiirir^fi*.  t^ 
niatpbomii,  unK  of.  fJh 
Pltuilaiy  extract-  ^jH 

in  ibe  treauueut  of  teffUt^K^^y.  ^aI^ 
F'jdalg^a.  3f>4 

of  pea  plauvi.  3U6 


600 


INDBXp 


Folloenc«pb&lLtifl  Inferior,  291 
AuperlOT,  S80 

aod  itiferloj«  278 

caiuea  ol,  280 
luorbfd  pTix«w  In,  280 
prophylH^tia  treatment  of,  2S2 
eymptoma  »nd  coorva  of  the  dlnftw, 

3B1 
treatiuent  at  time  of  attack.  262 
of  early  cotuequflDOea  of,  283 
of  remote  ellecta  of,  28& 
UM  of  electricity  In,  284 
PoUvlum  Iodide,  modeof  admlnletering, 
61 
use  ol,  61 
Polt^B  dlMftse,  myelltifl  In,  £6(1 
Prepared  foodv,  134 
Primary  dellrluui,  5fi3 
Frogreulve  facial  hemiatrophy,  £21 

muecalar    atrophy,    Charcot-Harle- 
Tooth  type,  30B 
etiology  of,  295 
neural  form,  308 
eplnal  origin,  294 
treatment  of,  29fi 
muscular  atrophiee  of  central  ^irlgln, 
Tariet[e8  0f,  2^2 
Proeopalgfa,  362 

PseudCKhypertrophLc  paralyaiB,  311 
Paeuclo-M«ni«re'8  disease,  Cti5 
PBeudo-tabes,  3^8 

Paychlcal  irauma  and  nerveua  disease,  20 
avoidance  of,  by  the  neuropath. 
38 
I'syclietherapy,  136 
]*«ycbrophore.  31 
Pudendal  neuralgia,  397 
Purulent  encephal Ufa,  167 

RjtCHlAM.TA,   371 

Raynaud's  dlBeaae.  511 

Rectal  irrigator.  81 

Re-education   of  ataxic    extreuiltieu   in 

tab^e,  242 
Reflex  epiiepey,  446 

headacliesH  535 

treatntent  of.  550 

vertigo,  571 
Relaxation,  the  art  of ,  12(f 
Remedial  action  of  drugs,  53 

uieaaures.  general  application  of,  40 
Rest  cure,  adjuvants  to,  1:^4 


Rett  cure,  schedole  for,  125 

in   treatment  of   nervous  diseases, 

117,  19« 
treatmeDt,  123 
HesistUlty.  Sfi 
RheosUt,  95 

Rbeumatlim,  relatlonahip  of,  to  chorsa. 
4B4 

Sanatoria,  adTlsablUty  of  rwomniend- 

iiig.  39 
Sciatic  pain,  causes  of,  378 
Sciatica,  377 

chronic,  electi-lclty  in,  886 

treatment  of,  385 
medlcinfll  treatment  of ,  392 
objective  accompaniments  of,  380 
SurglCiil  treatment  of,  301 
symptoms  of,  379 
treatment  of  recent  cases,  381 

of  subacute  and  chronic  varis- 
ties,  364 
Scleroderma,  619 
Scottish  douche.  80 
Senile  delirium,  569 
paraplegia,  274 
Sensory  aphakia,  symptoms  of,  219 
Seroua  meningitis,  etiology  of,  152 
symptoms  of,  154 
treatment  of,  160 
Serum  ttierapy  in  tabes,  2% 
Sexual  Indulgence,  relationship  to  nsi- 

vous  disease,  21 
Silver-chloride  cell,  9:1 
Sitz  batliH,  75 

Sleep, amoant  neceasary .584. </.  Insomnia 
amount  needed.  41 
the  secnremeiit  of.  41 
Knninal,  use  of,  58 
Spasmus  nutans,  577 
Gpeclflc  medication,  60 
Spinal    progressive    muscular    atrophy, 
family  form.  293,  206 
tumors,  myelills  due  to,  2»2 
Sports  and  gymnastics,  116 
Sutic  electricity,  96 
Stigmata  of  degeneracy,  5 
Stimulants  and  narcotica  in   cauaatloo 
of  nervous  disease.  17 
excessi  ve  use  of ,  In  relation  to  syphi- 
litic diseases,  15 
necessity  of  Interdicting,  37 
Subacute  ataxic  paralysis,  276 


INDEX. 


601 


Subcortical  motor  aplu^ai  ByniptomB  of, 

ai9 

word  bllndnfln,  2^ 

word-doafowfl,  220 
fiuggestioD,  dflflnltioQ  <tU  139 

therapeutic  qicb  of^  14Q 
Sulfonal,  effects  of,  68 
Superior  degeneimtes,  ti 

poUoeQcephalitiSt  acute»  280 
Slrychnlue,  UK  of,  &9  ^ 

SuiRpecflioQ  la  treatment  of  Ube«t  ^-il 
SwediBb  mOTfltaenUi,  IIG 
SydenhaiD^a  chorea^  481 
Symujetrlcal  gangrene,  511 
SypbilU  and  nervoua  diaeaaee,  0 

of  nervooH  flyateaif  0 

general  treatioeut  of,  ^5 
predlHpOBingG&aB«B  of,  1^ 

treatment  of,  in  preventing  nervoua 
diBeasea,  14 
ByphlJilic  diseases,  prevention  of,  20 

epilepBj,  treatment  of,  463 

nervous  diseaaes,  cauaea  of,  13 
Tarieties  of,  11 

spinal  paralysis,  274 
Syringomyelia^  26d 

etiology  of,  267 

leeion  of,  and  its  location,  266 

symptom*  of,  257 

treatment  of,  258 

Tabes,  214 

advLsabllity  of  aniisypbllitk  treat- 

jnent  in,  233 
affection  of  special  senses  in,  231 
Rud  flyphills,  215 
causes  and  lesions  of,  !^14 
couTBfl  of  dlsesfie,  232 
dletandr^meiu,  240 
drug  treatment  of,  260 
general  treatment  of,  23B 
moior  symptoms  of,  217 
plan  of  treatment  in,  248 
rest  in  the  treatment  of,  260 
summary   of  the  treatment  of,  250 
symptomatic  treatment.  235 
eympwms  ou  sensory  side,  231 

on  sympathetic  side,  231 
tieatmeniof,  232 

of»  by  suspension,  241 

of  crisis  in,  236 

of  morbid  process,  234 
use  of  electricity  in,  230 


Tabetic  amaorosls,  Lreatment  of,  237 
Tendon  grafting  in  treaiuient  of  polio- 

inyelLtiB,  287 
Testicular  eitractfl,  52 

neuralgia,  374 
Tetanus  uititoiin,  use  of,  50 

varieties  and  use  of,  320 
bacilli   of,  method  of  propagation, 

3tS 
symptoms  of,  318 
treatment  of,  317,  310 
Ta^etiesof,  317 
Tetany,  322 

constitutional  treatment  of,  322 
treatment  of  the  spssm,  324 
Telrona1(  oontracted  with  sulfonal,  68 
Thomsen's  disease,  316 
Thrombosis  of  cerebral  TeBsels,  etiology 
of,  200 
treatment  of,  210 
Thyroacetio,  use  and  dose  of,  67 
Thymus  extract,  52 
Thyroid,  mode  of  idministering,  52 
secretion,  composition  of,  61 

results  of  lack  of,  61 
therapy,  61 

treatment  of  myxcedema,  510 
Tic  and  degeneracy,  467 
douloureux,  352 

surgical  treatment  of,  362 
the  treatment  of,  by  strychnine, 
300 
neurosis,  465 

etiology  of,  466 
treatment  of,  476 
Tics,  clasHiflcation  of,  466 
Total  aphasia,  220 
Toilc  headaclHS,  537 

vertigo,  570 
Training  of  neuropathic  child,  42 
Trauma,  avoidance  of,  by  the  neuropath, 
38 
cause  of  acute  myelitis,  262 

of  nervouB  disease,  ID 
relation  of,  to  syphilitic  nervous  dla- 
ease,  15 
Traumatic  epilepsy,  461 

headache,  538 
Transverse  myelitis,  274 
Treatment  of  delirium,  general  remarks 
on,  560 
of  nervous  diseases,  advances  in  the 
art  of,  1 


602 


INDBX. 


Trifacial  neural^lft,  352 

etiology  of,  3M 

BEirgLCAl  treatment  of^  3tfZ 

Hymplom*  of,  3M 

trealment  of,  3fiC 
of  an  attack,  .%4 
Trlona],  use  of,  58 
Trophic  leflloEiB  of  tabea,  tmcmeut  of, 

•JS7 
Trouneau'fl  flympUnn  of  teLuiy,  S^ 
Taberoulomaof  br&tn,  treatDMOt  of,  302 
TabArculoiu  m«DingitlA,  etlolc^  of.  150 

aymptouis  of,  154 

ireatment  of,  IW 
Tamora  of  the  brain,  varletlea  of,  Jul 

of  «plna]  cord,  treatnientot  272 

Vallielx'b  points  In  neuralgia,  iA~ 
VarlcoAfl  velruf.  leg  palms  with,  -170 
Vertigo,  liflld 

claaal float Loti  of,  6fLS 

of  arterloHCleroflin,  067 


Vertigo  of  orgaiiio  brain  diiieuie,  5tHt 

of  the  neuroaes,  56H 
Vott,  dellnltlonof,  eo 

Wabh  batliB,  general  use  of,  74 

manner  of  giving,  14 
Water,  a  drink  for  nerrous  pMient«,  I'M 
art  of  applying  remediatly,  W1 
eSectJ  of  application  of,  68 
mode*  of  Implying  in  nfirroDa  di»- 

eaae,  71 
ubject  of  applying,  t^7 
Withdrawal,  pernlcioiunen  of,  42 
Word  blindttesB,  aubcortlGal  dependency, 
220 
fleafneHH,     aubcurtlcal     dependency, 
^0 
Work  and  cailing,    relation    tu  nerroua 
dlflease.  Hi* 
and  nenouB  dlaease*,  21 

ZAFcoKit  eierciBef^  115 


LANE  MEI3ICAL  LIRKAKY 


To  avoid  line,  this  book  shf*ultl  be  n-turncJ  on 
<)r  ln'fi>fc  tbc  dale  last  !4taniiH*d  IjcIow. 


1341      OolXlns,    J, 

071  Treatment  of  nervous 

laoa.  -dlpeaaeB.  5:5958 


fUNB 


DAT1  1MB