Go ogle
This is a digitaJ copy of a book that was preserved for generatioDS on library shelves before it was carefully scanned by Google as part of a project to make the world's books discoverable online.
ll has survived long enough for the copyright to expire and the book to enler Ihe public domain. A public domain book is one that was never subject to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vmy country to country. Public domain books are our gateways lo the past, representing a wealth of history, culture and knowledge that's often difficult to discover.
Marks, notations and other niaiginalia present in the original volume will appeal' in this file - a reminder of this book's long journey from Ihe publisher to a library and finally lo you.
Usage guidelines
Google is proud to partner with librai'ies to digitize public domain materials and make them widely accessible. Public domain books belong to the public and we Lue merely Iheir custodians. Nevertheless, this work is expensive, so in order lo keep providing this resource, we have takeD steps to prevent abuse by commercial parties, including placing technical restrictions on automated querying.
We also ask that you:
+ Make non-commercial use of the files We designed Google Book Search for use by individuals, and we request that you use these files for personal, non-commercial purposes.
+ Refrain fivm aiftomated querying Do not send automated queries of any sort to Google's system; If you are conducting research on machine translation, optical character recognition or other areas where access to a laige amount of text is helpful, please contact us. We encourage Ihe use of public domain materials for these purposes and maybe able to help.
+ Maintain attribution The Google "watermaik" you see on each file is essential for informing people about ihis project and helping them find additional materials through Google Book Search. Please do nol remove it.
+ Keep it legal Whatever your use, remember that you are responsible for ensuring thai what you are doing is legal. Do not assume Ihat just because we believe a book is in the public domain for users in the United States. Ihat the work is also in the public domain for users in other countries. Whelher a book is still in copyright varies from counlry lo counlry. and we can'I offer guidance on whelher any specific use of any specific book is allowed. Please do not assume Ihat a book's appearance in Google Book Search means it can be used in any manner anywhere in the world. Copyright infringement liability can be quite severe.
About Google Book Search
Google's mission is to organize Ihe world's informalion and lo make it universally accessible and useful. Google Book Search helps readers discover Ihe world's books while helping authors and publishers reach new audiences. You can search tlirough the full text of Ihis book on the web
at http: //books . google .com/
iyi^ai[@
Gift Dr. A. V*. fitting
THE DISEASES OF THE NERVOUS SYSTEM
A TEXT-BOOK FOR PHYSICIANS AND STUDENTS
BV
Dr. LUDWIG HIRT
PROFESMIK AT THB fMVEBSlT^ I)f BKBSLAU
TRANSLATED. WITH TERMISSION OF TIIIE AL'TIIOR, BV
AUGUST HOCH, M. D.
tOUIKKLV *ieiST*"T rHYllCUH in rM» JOHNS HOriliH* HtnriTAi. HOW TU TUB HCLBAH HOSPITAL, WAVIRLV, HAS.
ASS15TEU BV
FRANK R. SMITH. A. M. (Cantab.). M. D.
utnucroit IN iisDicKO in n« juhki hofkihs uhivusitv
U'lTH AM INTRODVCT/0!V BY WTLLIAM OSLER, M. D.. F. R. C. P.. F. R. S.
rtO»ltS«olt UP bEPICIhP IN THI JOHN^ HOPKINS ITNIVHStTV, KTC.
WITH ONE HUNDRED AND EIGHTY-ONE ILLUSTRATIONS
NEW YORK
O. APPLETON AND COMPANY
1899
'■.
&^ai!t@
Gift Dr.A.Vi.uitting
r..
INTRODUCTORY NOTE.
^
^
Thr pleasure cf introducing lo the profession of this country a transition uf a standard work is enhanced by the opportu- nity it affords of acknowledging how great is our debt to those — translators and publishers — who have made current in Eng. lish the works of Trousseau. Niemeycr, Virchow, Cohnhcim, and others. All recognize the necessity ol teachers knowing tlie classical works in all languages, but of equal importance is it that the practitioners in all countries should have easy ac- cess by means of translations to the thoughts nnd experience, the ways and methods, of the masters of our art the world over. No belter corrective exists lo the vice of Philistinism — that nar- row conceit of the special prominence of medicine in any one country — than a wide diffusion in all of the best works of each.
Early in 189O ray attention was called by Dr. Weir Mitchell to the first part of Prof. Hirt's Handbuch der Ncrvcnkrank- lieiten, which he chaniclerlzetf as an exceptionally well ar- ranged and thorough work on diseases of the nervous system. The completed work seemed in many respects so admirable a tcxt.book that 1 wrote to Prof. Hirl and asked his permission to have it Translated.
The arrangement of the subjects to which the author re- fers in the ]trelace. though somewhat novel, is justifiable and entirely satisfactory ; and It is a distinct advance in classihca- tidn lo place tabes dorsalis and dementia paralytica among the diseases <if the general nervous system, instead of in the sections on diseases of the cord and diseases of the brain re- spectively.
The fact which makes the work of value to the teacher, the hludeni, and the practitioner is the graphic description of the anatomy and symptomatology of the diScrent diseases. Where all i» so good it is invidious to select, but the chapter on tabes
vu
vili INTRODUCTORY NOTE.
is an illustration of our author's lucid and, at the same time, thorough treatment of his subject The various affections are treated of also from an advanced modern standpoint; conflict- ing theories and passing observations are submitted to a wise criticism through which the author's own large and varied ex- perience is very apparent.
An attractive aspect of the work is the excellent character of the illustrations, which, as they are in great part original, will be a pleasing relief to the hackneyed cuts which have for so long passed from book to book in English works.
Pursuing the via media in the important question of treat- ment, neither displaying the pessimism which too many mala- dies of the nervous system would seem to justify, nor an opti- mism so flagrant as to savor of quackery, Prof. Hirt is a safe guide in the highways and byways of neurolherapeutics.
And, lastly, I think the author has been fairly handled by his translators, who, bearing in mind the admonition of Dryden, " not to lackey by the side of his author, but to mount up be- hind him," have given a clear and interesting rendering of the original.
William Osler.
Baltimore, "January, iSgj.
CONTENTS.
rAO Diseases OF the Brain and its MENiNCis, including those or
THE Cranial Nerves ".,,.. i
PART 1.
Diseases of tmk Meninges of the Bbain 3
Chap. I. — iDilamnialion of the inner surface of the dura mater, pachy meningitis
inlema bE^morrhagica, hxmaloma dune malris .... 4 II. — Inflammations of the soft membranes of the brain, leptomeningitis, puni-
lent meaingilis 8
PART II.
Diseases of the Cranial Nerves 24
Chap. I. — DiseaMS of the olfactory nerve 35
II. — Diseases of the oplic nerve ag
lit. — Diseases of the nerves supplying the ocular muscles .... 4a
TV.— Diseases of the Irigemina] nerve 56
V. — Diseases of the facial nerve 77
VI. — Diseases of the auditory nerve qj
VII. — I)i^cases of the glosso-pharyiigeal nerve 107
VIII. — Disea.ses of the vagus (pneumogastric nerve) IIO
IX. — Diseases of the accessory nerve 136
X. — Diseases of the hypoglossal nerve 140
XI. — Simultaneous affection of several cranial nerves — Multiple paralysis of
the cranial nerves 147
PART III.
IHSE.iSrS OF THE BRAIN PROPER l6l
I. The study of cerebral lesions with reference lo their seat— Topical diagnosis
— Doctrine of localiiation 162
Symptoms referable to cortical legions 164
Symptoms referable to lesions of the white matter of the liemnpheres and
to lesions of the basal ganglia 189
II. The study of cerebral lesions with reference to their pathological nature —
Pathological diagnosis 209
Affections of the brain due 10 disease of the blood-vessels 209
A. Diseases of the cerebral vessels and their consequences . . . 109
ix
X CONTENTS.
rAGB
1. Cerebral bxTnorrhage 213
a. Embolism and thrombosU of the cerebral arteries — Encephalo-
malacia . , , . - - ^ - - , , 244
3. EndartentU (sj^hilitica) aja
4. DiUtacion of the arteries of ihc brain 953
5. The neurosesof the arteriesof the brain (aoaimiaandhyperxniia
of the btain) 254
B. Diseases of the cerebral veins and sinuses 357
Inflammatory processes of the brain substance 360
1. Punilent encephalitis — Brain abscess 360
2. Nonsuppurative encephalitis and its consequences ("athetosis") 366
A. In adults 366
B. In children — Cerebral palsy of children — Hemiplegia infantilis
spastica — Polio-encephalitis 36S
Brain tumors 38}
Appendix — Parasites of Ihc Brain 305
Congenital diseases — Hydrocephalus — Meningocele — Porencephaly —
Absence of certain ports of the brain 30S
Diseases of the Spinal Cord 314
PART I.
Diseases OF THE Spinal Meninges 315
Chap. 1. — Inflammations of Ihc dura mater — PaehymeningilU spinalis . 316 II. — Inflammations of the soft spinal meninges — Leptomeningitis spioalis . 332 III. — Hemorrhage into the spinal membranes — Meoingeai apoplexy — Pachy- meningitis interna hxmorrhagica 326
PART II.
Diseases of the Spinal Nerves 330
A. Diiieases of Ihc motor and sensory nerves 333
I. Diseases of (he cervical nerves 333
Chap. I. — Lesions of the cervical pleius 336
II. — Lesions of the brachial plexus 340
II. Diseases of the dorsal nerves 363
III. Diseases of the lumbar nerves 366
IV. Diseases of the sacral and coccygeal nerves 370
V. Neuritis involving several spinal nerves at the same time — Multiple
neuritis 387
B. Diseases of the Irophio and vaso-molor nerves 397
Appendix — Diseases of the muscles — Primary myopaihies . . . 405
PART III.
Diseases of the Substance of the Spinal Cord 418
I. Consideration of spinal diseases with reference to their seat — Topical diag-
Do!.is 41S
I. Lesions of the gray matler — Poliomyelitis 42;
Chap. I. — Poliomyelitis anterior acuta — infantile spinal paralysis . 426 II. — Atrophia muscularis progressiva spinalis — Progressive
muscular atrophy 434
coy TEXTS.
XI
racK
II. Lcdoat of the while matter of th« tpinal cord— L«<i«onir*lltt* . . 439
A. Prwuuy leuonsi>( ih« white culuMUii 440
D. ScconiUry lc^■onl of ihc whtle calunmt 44S
til. I.aions of the gny iiul white mtlttt of ihc spinal cotd . 446 II. Sflul Ictioni Kgaideil from th«ir iislhdoglcftl akjiccl — Putholuglcil dl^-
kodt 4S0
I. ASeetioiK of lh« hjiinal CArd tluc to diwate* of Ihc blood-vcucU . 458
A. IKieam (d the atlerieK of the t|ilnBl cord oiiil ihcii contcqwcncci 458 1. Spinal fawmonhagc — llrnnorfliapo (01 apoplckin) mcdoUx
tpioalis — HKRiaioinyclia 4S8
1. Embolbm and ihi«mlio«i» of Ihe tpinnl eiterici and mjrclo-
taolacia 460
3. Endancritit (lyphllllica) 461
4. Uilalalion ol th« hplnal aiterlet 4Ca
%. IC«uromorthe tipinal arteiict 46a
O. InSaiiunatorjr proooses in the tubiTniicc of the »pinal conl . . . 46s
I. PunilenI mjrclilia — AbtccM of Ihe tplnal cord . . ■ . 46$
9. The aon-puTulent mreliiU 46$
A. The Kute fiinn . . , ifii
B. The chxiiiic fnnn 4^1
' tn. Spinal lumon ^fi^
Appendii— I'araalioi of the tplnol ootd 470
ir. Cangnillat dbteaw*— llrdroiihachis— Spina bifida . • 47<
U|»SA«BS or TIIK GCKKKAI. NKKVOUS SYSTKU 476
PART I.
UisaAhU or THE GexutAL NEkTotit System wituoit ahv RtcouNiUBUt
Anatomical Baiis—" Functional r»KuiioM:s" .... 479 firit C'vttf. — Senru«*> which are wont to ran iheit tourse niihout anjt eisen-
tlal ira^iltcatioM of the gencnl o«|anitin 481
A. Alfectlont ik which the motorr nerrc* ace chicily impliMiled . 481 Chap. l^C'horea— Choiea Sancti Viii— St. Vitiw" dance— Ball iimti»— Mel.
aaeholia ultaiu — Sydenham's disease . . . ■ . 481
II. — Tdaajr — Teianilla — Tetanui intenniltciu 493
Thoniaen't diteate 496
111.— Paialjrib agltaiu — Shaking paK; — I'arkiniou't disease — Chon«
jimcunlva JOO
n. Alfccilocii 111 which the tiuatirj nerve* arc chicll}' injilicaied . . yaij
Mtniknc— llemlcnnla -SO?
C AITecllonh lii which the trophic nerve* are chirfljr Impllcateil • Jia
I. AcTonieealy , 51s
9. Oktcoanhiopathjr Jlfr
Appeadii.
t OTai«a'disca»e — l)a»cJav*( ditcatc — Eiaphthalmlc goitre . . J'^
II. Myncrdeina ;>$
Smnd Grvuf. — NcutiMeiin which the entlte organlun U more ee leu Kvereljr
tnpticaied S*9
Cfca|i. 1. — Nearaithenia— NeiToiu prottration jM)
II.— Kyitcria SM
xii CONTENTS.
PAGI
III. — Epilepsy — Fallii^ sickDcss — Morbus sacer — Morbus coTnitialis . 571 IV. — H ystero-epilcpsy — Major hysteria — Hypnotism — Trcalment by
suggestioii 600
PART II.
Diseases op the General Nekvous System with Known Anatomical
Basis 616
Chap. I. — Multiple sclerosis — Disseminated sclerosis — Insular sclerosis — Scl/rme
atplaqMts — Sclerosis cerebro-spinalis dissemioHta sive multiplex . 616 II. — Tabes dorsalis — Locomotor ataxia — Posleiior spinal sclerosis — Leuco-
myelilis posterior chronica. 629
III. — Dementia paralytica progressiva — General paralysis of ibe insane —
General paresis — Softening of the brain 688
IV. — Syphilis of the general nervous system 7CO
LIST OP ILLUSTRATiONS.
I
I
C<iw.
4 39
31
37
37 4"
43
44 45 S7 S8 74 78
84
I. Crau-xctiDD throvgb the cerebral cortex Bn<l iti tnembranei a. DiBgrxm ibming tbe mune ot Ihe optic fibres in the chUim
3. DiAgiam ibowinj; the origin of Ilia uplic rierve {alter Wcrnidic) .
4. Field of litioo of Tbe left and right tyv (aflci Kor^ter) . i. Fteld of vbioo of the Ivfi ami riuht vjr* in iGft-tiiled hrmionopia (aflcr
et»)
6. Crou-teclioa Ibrongb the region of tlie ant. corpora <|uadrigeinina
7. INagnnnMlk longitadtnal icclion tlnvush tho poiu with the nuclei of the
oculu nerra (afiet (^wen) .
9. Cfou-tcclion ttiroui-h Ihe region of (he logmviitum (after Schwatbc) 9. Ctaa-Mttivm ihroogh the poni (after .Schwnlbe) ....
10, Nacleiof the trijccminal riecve Infier Schwnlbe) ....
11. Cnst-ieclion ihtiwifli the mnlitlla oblongata (after Schvalbef II. IHitribvlioit of Ihe teniory cutaneou* nervci on Ihe be.nd I). I>u{;nm ihowinf Ibecourie of the facial Bbm in ihe pom (al^er Schwalbe) ■^ Uiagram ihiiB i ng the dcctutation of ihe fibm going to the exttemitlo. and
lho«e going to tbe face, in the pooi and medulla oblonpu .
IJ. Etb'i dtactan In* facial fiaral^ii B7
lA. Smm of lb«to-cBllc(l "miilor poiTil9''on ihefaceand neck .... 9] ■;. Dli^raniMiiic todion ihtough the medulla oblonpla in Ihe rcpon of the
(lower) oIlvD 96
ll. CreM.wcllun lhit>ilgh itie mcclulla olilongaia (after Schwalbc) iti
t^ BUaieral f^nipi* of the rroirnnl larytigeoL 117
aa. Keciirrcnl Uryni^al jMialyit* 117
II. 1*8101x01 of ibc rMurrciit Inryneeal on the left ^de 117
31. I'araljUb of botk poletior crico.antfnoidi 117
3J. Pualjrux oJ ihe ri|^l |x»l. crlco-aiyicnoid 117
a* I'lnlyik of both talemal IhirTo-aiyMaoida 117
■S. ■'■nl]nb of both inieraal thyroarytenoid* 117
A, Cf«»-MCIian ihnnigh ibe nrrical oord 136
IJ. S«p«rfdal origin of ihc cranial nervrt , 141
M. CMtkalceairet of (he left henUphcTe (after Caweis) t4>
tt, HttnitlroptMlmgmit 14)
to. llvntialropliM lingnic 144
}t. niaryngeal and Urpigol electrode ailh anangtinenl for moliing and break-
iMg ihe mnenl (after Erii) 149
]1. Facial npteuiow in progrculve bulbar pataljiin (l.eyden. EichhonI) . . I!4 1). Croia iWiow Ihroagk ibc upper poiiionof the mc<Ui1lB oblongata. . If6 X- Tha poWerior (dorial) aipect of Ihc incdulla oblongata 157
m
xiv LIST OF ILLUSTRATIONS,
FIS. fACa
35. Right beniisphere (after Exner) 166
36. Left bemi<>phere (aller Exner) 166
37. CoUToIulions and fissures of the lateral aspect of the brain (aflcr Ecker) 167
38. Convolutions and fissures at the base of the bivin (diHgrammatically, after
Kcter) 16S
39- DidgTun illustrating method of determining the location of the fissure of I^o-
londo 169
40. CoDTolulions nnd fissures of the median aspect of the brain .... 170
41. Convolutions of the island of Reil (J. K.) made visible by removing the oper-
culum 170
4a. Topographical relations between the exterior of the skull tuid the surface of
the brain (after Ecker) 171
43. Wernicke's schema for the conical mechanism of speech .... 17J
44, 45. Lichlheim's schema illustrating the seven different forms of aphasia . 179 46. Diagram showing the direct system of fibr« (Plcchsig, Mendel) . 184 47- Course of the libres from the intemal capsule to the eras cerebri (diagram- matic, after Wernicke and Edinger) IS9
4B. View of the ventricles on horizontal sec'.ion (after Edinger) .... 190 49. Horizontal section through the brain, about a finger's brcadlb below that
represented in Fig. 4S (Edinger) igi
50-53. So-called." frontal sections" through the brain (after Edinger) . 19*, 193
54. Points at which Ihe Pitres-Nothnogel sections are made .... 194
55-60. Pities-Nothnagel sections 195-197
6t. Diagrammatic cross-section through the anterior corpora quadrigemina (after
Edinger) aoo
63. Longitudinal section through Ihe region of the corpora quadrigemina of a
human fcetus twenty-eight weeks old (after Edinger) .... 201
63. Uii^rammatic horiionlal section through the decussation of the superior pe-
duncles of the cereoellum (after Edinger) 90l
64. Sagittal section through puns and medulla oblongata (after Mendel) . 3o3
65. Cross-seclion through the region of the ant. corpora quadrigemina ■ 103
66. Diagram showing the decussation of the fibres going to the extremities, and
of those going to the face, in the pons and medulla oblongata . . £04
67. The connections of the cerebellum 307
68. Diigram showing the circle of Willis no
69. The cortical distribution of the middle cerebral artery (after Charcot) . . 211
70. Frontal section through tbe cerebral hemispheres, one centimetre behind the
chiasm 312
71. Cerebral artery from an apoplectic focus (after Comit and Ranvier) . 313
73. Miliary aneurism of a small artery of the lenticular nucleus (after Marchand) 314 73- The latge head electrode (covered with sponge) of Erb 341
74. Porencephaly 367
75. Hemiatrophy of the left side of the body, front 374
76. Hemiatrophy of the left side of the body, back 275
77. Hemiatrophy of the left side of the body from traumatism .... 276
78. Hemiatrophy of the left side of the body from traumatism .... 277
79. Atrophy of (he left upper and lower extremity 278
Bo. The family form of spastic paraplegia (after Newmark) 379
Bl. Atrophy of paralyzed side 38o
83. Atrophy of paralyzed side ; contracture of wrist 2St
83. Atrophy of paralyzed side : contracture of ankle ... . - 3S3
84. Atrophy of paralyzed side ; contracture of ankle 263
LIST OF ILLUSTRATIONS.
sv
rtc
es
S6. tt. 9*
P
IIZ. »"S-
Itfa.
II J.
Ilk
,1.9.
!„,.
m.
in. itj. 111. i»»
M>
CobvuIbvc nuncntenti of lli« cKtrcmUin aS]
Cliotna ltJaDgi«claliciiiD(ancr ZicglcT) , 389
rapUluy tarcinooia in ihc ihird vrnirirlc (after Z)tcl«(> .... Vfi
CTiiiMR-niracemonii (after MarchandJ Joj
Ilyilrecephahu 309
Cfoti-icclioa ibrough ihe vertebral column and the i|Hnal cord (diagrun-
iDitic«IH>^tc( Eichhoni) 316
Crau-MCiioa ihrough Ihe miJdte of Ihe lervicnl mkr^emtnt in pachyiiwn-
inptit ccrvicalit b)-peTlrophici (after Clinrcol) yVJ
INyilioo of (ke band in inchyincningilii cflrvicalin bypetlrupliica (Chikrooll . 319
Uia^rnBinalic oaliino of Iho ccrviml and l>rac]iial I'lriiitei lafler Mlwaltif) 333 CMe uf ri):bl-)i(l«d wriBtus paislytl* In a mftii Ihirlgr-fivc ycais uf ago (after
EichhotHi) MI
TI1D Moc ca>c arith the amn raiwd 3|)
Position of ibe head in tfusm <A iho «pJcniu4 cajiliU on i])e rtghi »id« . . 343
UuKiito^iral jionljrus 3«4
MMOf jiutntt of ibe n>iueulo>»|>lral nerre and ihc initsclM Mtpplied by It , 347 lOOi, Tb« dntrUiutkin of Uie cuianeon* nervci of the um and hand (aflct
Ekhbora) yfi
DlMrlbution of (he teututy ncivet on the tiack of ihc fingcn (Kriuw) . . 3*9
Motor pobiu of tbc tnedfan nerve and ilie mutcin tupplieil by it . 350
Motor poinu of the olaar nenv and the muhclct supplied bj It . . 350
Motor |MMn[» 'if Ihe ulnar nerve Mi
Claw-bandfiftTi Duchenne) ygl
Motor polntt cf the muteukKUtuiooiUi nerve and Ihe maKletnipplicdby It JJt
Motor {Nilntt of Ihe brachial pleim ; Erb*« raiwaclnviculu poiiU . . 3SS 1 1 1. Tbc manner in nlilch a chilil whote ercctorci tplnar ate panlyiod got*
up from tbc ([loniuMaftcr lioii*er%) 31M
DbfraaamMie onliinc of ihe Kimbai and Mcral picuwt .... 367 ■ 14. Arcaaof dittribulion of the caianeous nerve* of the lower extremity
(4fier lletile) 368
MolDt poiMc for the ecrvct and mutelci of the anterior mrface of Ibe leg . 33>
.Moloe poiali for ihc Kiaiic nerve anil The niutvle* suji]ilied by it . . 3B3 C«i« of peri|jlicnil ncunlii »f ihe tcloiic ivcive, with ihorleuini; and atrophy
of llwaiSccird cittemiiy 384
Omk of peripheral neuritis of the fciailc nerve. «ilh thortoninK and atrophy
of the ^ITecird extremity jSj
tao. LiKiinciute in ih« iiuadratai lumborum 386
Atrophy of ihe nuictei of the rij^l upper arm In con>e<|uence of a fracture
of ihe Immcnii levcn yean pieilouily 389
I3J. I^arthriiii wiih leoondity muUii>1e ncurlli* .... 390^ 391
Hemiaitophia facialis 404
S»<all(d JBveaile muKulor atrophy (EA) 407
Jurmile iButcular atrophy iKib) 40C
Jnrenitc muuniUr atrophy (Krbi 409
Jnienilr mmcular airophy (P.rbl , . . . 410
t'iDviciiivc atrophic myopaiby (after Marie el Guinnn) . . ' . 411 ■"Mudo-hypenrophy of the musclei of the legi. with airophy of the muKlet
of (be back laflei Duchcnne) 413
AlMnKT of the finrcarmi 414
Tha nUikini of ihe origin of Ihc nenei to the bodle* of the Tenebnc and
tlie ipinoeit pniccwu (after Uowen) 519
Xvi USr OF ILLUSTRATIONS.
no. rAci
133. Scheme of the conducling paths in the spbi! cord aE the level of fifth dotsal
nerve (after t'lechiig) 430
134. Cr[K&-&ectioii through the spiaal card at difTercnt leve& (after Quain) . . 430
135. Reflex arc 431
136. Transverse section from the cervical portion of the spinal cord (after
Charcot) 436
137. Spinal infantile paralysis 437
138. 139. Progressive muscular atrophy (after Eichhorst) 435
140, 141. Progressive inusculai atrophy 436, 437
141. Friedreich') disease (ifler Chauffard) , . 443
143. Ascendiog and descending degeneration in the spinal cord (after Gowers) . 446
144. Secondary ascending and descending degeneration in a transverse aflection
of the upper dorsal cord (after StrlimpeU) 446
145. 146. Complete interruption of conduction of the spinal cord during life (after
Eichhorit) 4J4
147. Schema of the course of the nerve fibres in the spinal cord (after Brown-
S^uard} 457
14S, 149. Thomsen's disease (after Mills) 4g7, 498
ISO, 151. Specimens of handwriting of patient with paralysis agitans . . 501, iO^
152. Position of hands and fingers in paralysis agilans (after Eichhorst) , , 503
153. Position of the body in paralysis agitans S04
154. Entargemeni of jaw in acromegaly (after Marie) 511
155. Case of acromegaly (after Marie) 513
156. Case of acromegaly (after Buchwald) 514
157. Osteoarthropathy (after Rauzier) S'^
ijS. Osteoarthropathy (after Spillmann and Haushaller) 517
Ijg. Graves' disease 519
l6o. Myxixdema (after Charcot) 526
16[. " Idiotic myioEdemaieuse " 517
163, 163. Hysterical muscular atrophy 546, 547
164. Specimen of handwriting in a case of multiple sclerosis .... 617 l6;. Specimen of handwriting illustrating alcoholic tremor G32
166. Specimen of handwriting illuslraling tremor senilis 633
167. Specimen of handwriting of a patient with mercurial tremor . . . 634
168. Specimen of handwriting illustrating the tremor produced hy the ccmbined
action of alcohol and mercury 63g
169. Cross-section through the cervical enlargement of the spinal cord in a case
of multiple sclerosis (after Bramwell) 636
170. Hemiatrophy of the longoc in an otherwise perfectly healthy child , . 637
171. Specimen of handwriting in a case of tremor m tabes 643
172. Two cases of tabes (after Westphal) 649
173. A case of Charcot's joint in a tabetic 654
174. Erosion of the head of he humerus in tahes dorsalis (after Charcot) . 656
175. Normal humerus (after Charcot) 656
176. Skeleton of a Ubetic foot (after Charcot) 657
177. Plantar fleiion of the toes in the course of tahes 661
17B. Section through the cervical coitl in a case of commencing tabes (after
Strtlmpell) 673
179. Section through the lumbar cord in tabes (after StrUmpell) .... 973 160. Section through the cervical cord in a case of advanced tabes (after Slrilm-
pell) 673
181. Suspension apparatus used in the treatment of tabes 68$
DISEASES OF THK BRAIN AND ITS MENINGES, INCLUDING THE CRANIAL NERVES.
■ Hei
m
■
I
study oi brain diseases, we must confess, has not made the strides that might have been expected alter the numerous and varied researches ihat the last decades have seen. For this our present very imperfect knowledge of the anatomy, and Mill more our doubts as to the pbysioloji^cnl functions of Ihc different parts of the brain must be held largely responsible. The »truc1urc as well as the physintogical functions of the human brain are, up to the present titne, so little understood that we are far from having any sure basis upon which to lay ihc foundations of a cerebral pathology. No small progress h:is been made from an anatomical standpoint through Stil- ling's method of serial sections, a method which Mcyncrt, Henic, Wernicke, and others have not been slow to use. (n r admirable researches, to which important additions have 11 made by the embryological studies of Flrchsig, and by the method of "arresle*! development " used by Gudden and his pupils (atrophy method: Dfgfueralionsmdhoiif. Schwalbe); btit with all this we have only here and there single stones which we have not as yet been able to combine (or the con- struclion of a harmonious whole. Brilliant from a physiologi- cal stand|>nint as was the discovery o( Fritsch and f-Iilzig (1870) of the cicclrical irritability ot the cortex, and of the existence of motor regions therein, unexpected as were the results which the experimental method of Munk brought to light, extraordi- nary and interesting as are the conclusions based upon the clini- cal and post-mortem observations of Charcot and his S4;hi)ol — all these, wide-reaching and admirable as they were, arc far
3 DISEASES OF THE BRAIN.
from having given us a full understanding of the functions of the different parts of the brain, and an explanation of the dis- turbances to which they are subject. Constant and untiring work is still needed, and the best results are promised from the intelligent combination of clinical observation with pathologi- cal research. The pathology of the brain can not be better advanced than by the patient clinical observation of cases dur- ing life and a careful autopsy after death. In institutions where not only the fullest opportunities are afforded for clin- ical observation and for the systematic conduct of post-mortem examinations of the brain, but where also the best men are found to supervise the work, in these will cerebral pathology make the greatest strides.
We shall divide our description of cerebral diseases into three parts. In the first we shall take up the diseases of the me- ninges, in the second those of the cranial nerves, while the third will embrace the diseases of the brain in the stricter sense, i. e., those of the white and gray matter of the hemispheres and of the central ganglia.
PART I.
DISEASES OF THE MENINGES OF THE BRAflT
TllK meninges are relatively more frequcnlly affected by disease than ihe brain subsiaiice itself, and tjuitc a consider- able number al the cases which \vc commonly call disc3M:s of the brain are really to be classed as aReciions ol the meninges. Since these diseases can develop under the most varied con- ditiims, and can be primary as well as secondary, they are of great prnctical importance, and we must try to disiinj^nisii most carefully between the differcnl forms which they assume.
A clear understanding:: of the pathological processes in these diseases will be facilitated by some remarks upon the anatomy of the meninges.
The ouiermoftt, tough, Abru-tcndinons membrane, called the dura tn.iier, fiKmi ai the same time llic inner periosteum of the cranial faoiies. It has an outer, rou^h, aiul art inner, smooth surface. Tor the nerves as they cmcrue from the skull this memhrane supphe^ shcath-hke coverings, among which that of the optic nerve (vagina optia) i« the most conspicuous. The blood-supply of the tlura is de- rived from branches of the mening<.-al arteries. That it possesses its own ncrve» jit doubte<i \>y some (among them I.uschka), affirmed by others (Rticdinicer, Alexander), It in most probable, however, that It is the trigeminus which chielly provideat for the innervation of the durj,
The tccoQd membrane, the arachnoid, is delicate and contains no vcMeU. Its outer surface is smooth and looks toward the subdural »pa<rc. while the inner is rough .ind turned toward the pia mnier. Tlie !>o-catlcd subarachnoid *pacc (I-'ig. i). which in situated between the arachnoid and pia, contains between the meshes of the subarach- ni»id li^Tiue the seroas cerebfo-spinal fluid.
Tlie third menihrane, the innermost, the one which lies directly on the surface of the brain, is called the pia mater. It dips down into the depths of the sulci, forming a continuous lining of thote parts of the hrain-Mem which are covered by the cerebrum and
3
4 D/S£ASES OF THE MKA-liVGF.S OF rffH BKAIN.
cerebellum, and seems to penetrate through th« so-called fiisures into the interior of the brain. These processes, which are called telie choroid etc. present peculiar villous formations, very rich
in capillary vc&s«ls, and therefore of a deep - red color (plexus choroidei). The covering or ependyma of the ventricles is not a part of the pia ma- ter, bul is simply a layer of epithelial celK. The nerves of the pta mater belonic to the sym- pathetic.
The diseases of llic meninges of the brain con- sist mainly of in>
flammatorv processes aflecling cither the pia or the dura mater.
We shall study the diseases of the two nieinbnines separately.
Flo. I.— Ciiom SeiiTiiiH riiKot^uii ritx CtfttmuL Curtcx
ce. Cor<« : /, pin muer : i. a. cuhorachTuild ipocc : >. 4, iul>- dural iTOce ; 4, dun nuiler ; t. p. XiVxA v«bc1i.
CHAPTER I.
INrLAUUATION' OV TIIK INNKK SUBKACK OF THE DHRA MATCH, I'ACIIVMKMKCITIS INTERNA HiCMORKHAUlCA, HEMATOMA Dl'R.K HATRIS.
The origin of the extravasations of blood which at the autopsy arc often found on the inner surface of the dtim, and which can be easily scraped off with the knife, is not alto- gethcr understood. .Some (Virchow, 1856) hold that the pri- mary affection is an inflammation, and the hemorrhage takes place secondarily into the newly formed, highly vascular con- nective tissue, while others look upon the haemorrhage as pri- mary ; and, indeed, recent observations (Sperling) seem to be very much in l.ivor of this latter view. If extensive hxmor- rhugcs occur, after spreading over more or less of the inner surface of the dura (hey become encapsulated, and arc then
tACtlYMBNINCITlS INTERNA H^MORKHAGICA.
s
called kamalomata dura matris. Such a hacmatoroa may con- tain from three humlred to four hundred grammes of extrav^i- sated blood, may attain the size oi a raan*s fist, and so exert a deleterious pressure upon the brain. The walls are some- limes smooth, sometimes rough ; the contents arc not always sanguineous, but may be serous or purulent. They are most commonly situated at the vertex near the (alx cerebri, some- times also in the frontal region, very rarely at the haw;. The arrangement of the hematoma in layers, which is seen on sec- tion, proves that the whole process consists of extravasations which have occurred at different limes. In the least-marked cases only a delicate reddish membrane is found, presenting reddish or brownish specks, and is easily stripped off from the dura. Only gradually the different layers .ire developed, the ODC nearest to the brain, of course, being always the most recent, the one lying on the dura the oldest. Ilctwccn the layers arc the hemorrhages. If it happens that the most re- cent layer is perforated by the haemorrhage there occurs free extravasation of blood between the dura and the arachnoid — that is. an intermeningeal hemorrhage.
Etiology. — In the xtiology, diseases of the heart and kid- neys, but especially chronic diseases of the brain, play by far the most important part. The lesion is seen in almost all aflec< lions which lead to an atrophy of the brain ; further, it may be met with in infectious diseases — for instance, in typhoid fever, scarlet fever, acute rheumatism : also in conditions of what we may call blood-dissolution, as in the gener.il harmorrhagic di- athesis. Frank C. Moyt, of New York, has called attention in this connection to a lowering or complete paralysis of the vaso- motor tone, which according to him is associated with struc- tural changes in the blood-vessels (Medical Record. iRgj. -ji). Among the exciting causes are traumatism of the cranial bones and inHaiiimntion in the neighboring parts— (or instance, in llie petrous portion of the temporal bone. Of predominating wxu portancc, as an {etiological factor, is the abuse of alcohol. Al- most in all autopsies on old drunkards wc find a more or less well developed pachymeningitis interna, which has recently also been experimentally produced in dogs by continued doses ol alcohol ([..eyden). The f.ict that statistics have established that men. and more especially old mm. arc by preference affected by this disease also seems to point to alcohol as the principal cause.
I>/S/iMSes OF THE MES'IUGES OF THE BR A Iff.
i
Symptoms may be cnlircly absent- This is the case when ihe hxmorrhage. or the newly formed membranes are not of sufficient extent; but if symptoms are present, then among the most important we fmd heailnche. which may persist for years, but which of course in itself, even if wc have a history point> ing to this disease, as. for instance, the abuse of alcohol, is never sufficient to justify the diagnosis. With a sudden rise of intra- cranial pressure wc always have agopleclifonn attack^, in which consciousness is lost (or a variable time, and in which ihe patient may die without regaining consciousness. Vomit- inf. slp>r [lulsc. and a very conspicuous narrowing of the pupil are not wont to be absent. F<epealedly peculiar dreamy con- ditions have been observed alter such a coma, during which the patients seem completely dazed and the urine and l;eces are passed involuntarily. I( the ha;matnma lies over the mo- tor area, epileptiform convulsions and hemiplegia may result, serious motor disturbances, limited to one side, which may en- tirely disappear in a short while, or may last (nr months. Uni-J latenil nystagmus and choked disk have been reported by some! {Fucrstncr). The further course depends upon the absorption of the clot or the occurrence of a further ha,'morrbage, as the case may be. The repeated development ol severe cercbrafl symptoms, after striking and rapid improvement, speaks under certain circumstances (or the existence o( h?emaloma of the dura, Ijccause it is just this frequent change in the condition of Ihe patient which is characteristic of the course of the disease. Months and even years may thus pass without a fatal result. and much more rarely than nne would be led to c)ipc*ci is it possible to make a positive diagnosis during life, because all the symptoms which we have mentioned can be found just as well in other cerebral affections, in ha-morrhage, embolism, new growths, etc.. and the only thing we have (o fall back upon is the history, if this be nne of alcoholic excesses. The parox- ysmal appearance of new symptoms is not to be overlooked, inasmuch as it confirms to some extent the diagnosis of pachy. meningitis. However, under all circumstances the task is a difficult one. The cases described by French writers (e. g., Puech, Progr^s mWical, 1S89. 171 under the name apofUxu prth gressivf arc instances of this affection.
Prognosis.— The prognosis for recovery is of course ttbso* lutely bad if thickening has reached any rlegree worth men- tioning : and when wc have to deal with a large hormatoma
PACff y,ve,vmG/r/s interna ha^morkhagica.
I
which cncmachcs considerably upon the intracranial space llic prospect for life is, to say the least, not hopelul. On various anatomical grounds death can occur suddenly and iinexpGCl> ediy.
Treatment can only be of any value in the earlier stages, ttut unfurtunaiely the disease is usually not recognized then. Interdiction, or at least restriction, of the uiic o( alcohol, if this plays a part, energetic antiphlogistic treatment in the form of local bloodletting, the ice-cap to the head, countcr-irrilation by inunctions o( mercurial ointment, and active purgation (calo- mel) would surely give us good results; but, as we have said, these means are, as a rule, used too late, and as a matter of fact the progress of the disease is usually not altered by ^\\y therapeutic measures.
The most common new growths of the dura mater arc sarcomata (endothelioma, fungus durx ntalris) or osteomata. Fibromata and lipomata are but rarely met with. They are only of pathological and not of clinical interest, since they do not give rise to typical symptoms.
LITERATURE.
Eulmtiutg. A, IxhrlHich rfc* Ncncnkrankhdlcn, i. Aufl, Berlin. 1S78. ZirKtrr, Ltlifbuch der allj-emcincn uml ^iprcicllcii tMlholog. Aoiitotnii!. jenii.
1S82. Wrniicli?. l.chrlMich der Oehirnlcnnkhciten. Bd. iii. pp. 483 H ttq. Berlin,
Omrcn. L^tlum on ilie Ui.ifrncMifl of Dlscaaea of the Brain, delivered it Unl*
venity College Hospital, iStij^ Chiirchhitl : iilvi DUki^lon. Phil add plua. UehcnMinicr VoricMingrn ;ibcrdie Kmnkheilen det Ncn-en«y%lenis. P. 306
tt ttq. Leipzig: Vogel. i88fi. Eicbhurtl. Handbuch der tpmicllrn Paitinlogic und Thcrapic. Bd. iii, pp, 439
H u^, 3. Aufl. Wien und l^piiK. I'iH?, SceliKnioltcr, Lchtbuch der Knnkheiien d** Kiickenmirks un<i Gehims. Ahih
II. pp, 401 tt u^. l)riun«chwcii;. 18S7. llnfTrnvin. Zur I'nlhalogic und Thcrajiie der I'achyin, ext. putiil ii.ich Eni-
nindUDgrti des Mitldolircs. Deutsche Zcitschnfi fiir ChiTurgic. May 4.
■ns, vol. xviii. ThlroluiK et du I'utiuier. Oasilkallon de U dure niJre ; inuft pir htmorrtio^e
c<rrt)*ale. Bull, dc U Soc. an.it . Jan. i, 1H91. j t^r„ vii. WtllelL rihrama rA the Dura Mater witlioui Syniptonii. F&lli. Soc Tranuc-
lioiH, 1891. xlitl. p. 6.
CHAPTER II.
INFLAMMATIONS OF THE SOFT MEMBRANES OF THE BRAIN; LEPTO- MENINGITIS; PURULENT MENINGITIS.
A. Pathological Anatomy. jEtiologv.
Inflammations of the soft cerebral meninges occur either at the base or at the convexity of the brain, according as they are primary or secondary — (. c, associated with other diseases- — and one can, indeed, with a few exceptions and bearing in mind the transition forms, put it down as a rule that secondary, metastatic meningitis affects the convexity, while a primary meningitis is usually found at the base.
In contradistinction to what takes place in the dura, where the only purulent inflammations that we find are such as have extended by contiguity from neighboring parts, here we have to deal with purulent inflammations alone. This purulent in- flammation of the soft membranes of the brain, the leptomenin- gitis cerebralis, is an infectious disease, and occurs in epidemics as epidemic cerebro-spinal meningitis, or more rarely sporadi- cally, the two forms, however, being JEtiologically identical. Besides these, we find developing in the course of tuberculosis, sometimes very early, sometimes late, a specific form of menin- gitis, the tubercular meningitis.
Pathological Anatomy. — ^The pathological processes can be traced in the pia as weli as in the substance of the brain. In the meshes of the former we find a purulent exudate, which is in rare cases limited to one hemisphere ; if it is copious, the pia can easily be stripped from the brain ; if it is scanty, this can not be done without loss of substance. The brain substance is oedematous and fills up the skull more than normally, so that the convolutions appear flattened. The ventricles are filled with an unusual amount of fluid (hydrocephalus internus). The hsemorrhages which are recognizable in the brain substance do not exceed in size that of a pin's head, and are either isolated 8
l£P TOMENINGITIS.
or are seen especially near the ventricular walls in greater numbers, the so^alled capillary apuplcxics. Besides these there arc other small punctiform hxniorrhages, or rather spots ol red softening, and minute haimorrhagcs closely grouped to- gether. All these focal changes arc to be looked upon as due to the influence of the specific virus. 1( the process has be- come a chronic one. then the characteristic features are axltma of the pia, wasting of the brain substance, hydrocephalus inter- nus. and thickening of the ventricular ependyma. which gives to the surface a %-elvcty appearance and changes the shape of the ventricles in a characlcristic manner, the normally sharp edges becoming rounded off ^chronic meningitis).
In tubercular meningitis wc find not only signs of an in- Raromatory process, but ulsu the formation of tubercles i both. however, do not pr<^rcss park pauu. There m;iy be a very extensive cntptiun of tubercles and a relatively slight inOamma- tion, or xnct versa, but always, especially in children, the greater [}art of the }elly-like exudate is situated at the base (basilar meningitis), between the pons and the anterior perforated space, and imbedded in it arc the grayish-white tubercles which are seen as nodules, sometimes as large as millet-seeds, and are found in the greatest numbers among the larger vessels of the fissure of Sylvius, on the chiasma. pons, etc- The vessels are fuller than usual, and small ha'inorrhages can occasionally be seen in the pia. The substance of the brain is affecte<l in the manner above mentioned — hydrocephalic effusions into the vcn- triclcs are rarely absent, and there is a decided fullness of Ihe choroid pifsuscs. Foci of softening are noted chiefly about ihe btual ganglia : they are produced sometimes by the occlusion of an artery, M>melimus by the pressure which the exudate exerts on the vessel, or, again, by an arteritis obliterans. Kegcncni- liuii has been known to occur even in tuberculous meningitis. Dilaiatiiin of Ihe ventricles and other signs of .in increased ininicraniul pressure may continue, and collections of flui<l in Ihe pia and in the ventricles m.iy still be present, but tlie fluid may again become clear, the pia moist and nonjidherenl to the cortex, and the tubercles present no infl.immation around them (Wernicke).
A chronic form of Ixisal meningitis, in which the pia is in places either thickened and indurated, or where wc have a formation of brittle crusts, may be of a gummatous nature <W«rnicke). When a purulent process in the dura extends
lO n/SF.ASES OF THE MEAWXGES OF THE BRAIN.
into the sinuses we get what is called a throm bo-phlebitis or a (marantic) sinus thrombosis (see Diseases of the Cerebral Veins).
.^tiologfy. — As has been stated, cerebro-spinal meningitis has to be looked upon as an infectious, sometimes epidemic, disease, the parasitic nature of which was demonstrated by Leyden in 1883, He found in the tissues of the pia and in the turbid cerebro-spinal fluid diplococci, which A. Fraenkel (Deutsche medicinische Wochenschrilt, 1886, 13) and G. Hauser (Miinchener med. Wochenschr., 1888, 36) recognized as identical with the pneumococcus. Whether or not these cocci gain access to the meninges through the nasal cavities and the fo- ramina of the ethmoidal plate, we are unable to say. Children and young people are more easily affected by the disease than adults, and the infection can be carried by them from place to place. In inclosed and crowded localities, e. g., in prisons and barracks, the disease may become endemic.
But even when there is no epidemic, the disease may ap- pear sporadically anywhere, and then also must be regarded as being just as much of a parasitic nature. Whether the direct influence of the sun's rays is capable of producing meningitis, or at least of favoring its development, has not thus far been sufficiently studied.
A tangible cause for meningitis we find in traumatism of the cranial bones, causing injury to the soft parts, so that the pathogenic organisms can penetrate through the open wounds. The (septic ?) Streptococcus pyogenes (Eberth), which is less deli- cate and more resistant than the above-mentioned coccus, has been demonstrated in such cases. If, however, in traumatism, the air remains excluded, as happens in fractures at the base, then the presence of a purulent meningitis is difficult to explain.
The diseases of the bones of the skull, more especially those of the petrous portion of the temporal bone and of the auditory apparatus, play an important part in the aetiology of meningitis. From an otitis media may be developed a caries of the petrous portion of the temporal bone which may perforate the thin roof of the tympanic cavity. The infection extends in such cases along the auditory nerve (Kirchner, Berliner klin. Wo- chenschr., 1893. 33). Another extension of the inflammation mav come from the mastoid cells if an embolus passing from the veins of the bone lodges in one of the venous sinuses, which then becomes the seat of a purulent throm bo-phlebitis. That the tuberculous meningitis has its origin in tubercu-
LEP TOM&NWGITIS.
II
lous processes In other organs is clenr, and tlie xtiology is therefore identical with that o( tuberculosis tn general — i. e., there is invariably an invasion by the tubercle bacillus. It is an interesting (act. however, that though the primary disease in other organs need not necessarily have produced any or at least no marked disturbances, we can still have secondary disease of the pia with the symptoms peculiar to it, which we shall describe. Children especially are not rarely attacked by meningitis the tuberculous nature ol which is only recognized at the autopsy, and we may not have the faintest suspicion of the existence of a previous tuberculous infection. In other cases, however, the meningitis only appears after the pulmonary tuberculosis has made great progress. Caseous bronchial and meiienlenc glands, as well as solitary tubercles in the brain, may be the starling point of the meningeal affection, while it less commonly follows tuberculosis of the joints or bones, or tuber. culous affections of the intestines and genito-urinary apparatus.
The relation of meningitis to other diseases — i. c., its simul* taneous appearance with influemui, pneumonia, scarlet fever, and typhoid lever, ulcerative endocarditis, etc. — has been care- fully studied by Huguenin (Correspondenzblatt fUr Schweizer Aerzle. 1S90, 23. 24). but the question whether in those cases we have to deal with a double infection, or whether we have a single noxious agent which produces both the meningitis and the affection which accompanies it. deserves further study, F. Wolff has recently discussed the possible relation of the occurrence of cerebro-spinal meningitis to meteorological con- dilions — e. g„ to the degree of humidity in the atmosphere. The fact that so many cases occur between February and June is perhaps lo be regarded as a consequence of the greater humidity which commences in September and does not de- crease until April : scarcely any cases occur in July and August, during the period of atmospheric dryness which com- mences in May (Dcutsch. med. Wochenschr,. 1888. 38).
It is well established that children and young people are more frequently and more ,sevcrcly attacked by meningitis than older persons, and it seems as if the disease is never found in old age. Early childhood, the period between two and three years o( age, furnishes relatively the greatest number of vic- tims and gives the most unfavorable outlook (cf. Kohts, Uebcr Paralysen und Pscudoparalysen im Kindesallcr nach Influenza, Thenipcut. Mc.naishefte, i8go).
I>
1>/S£AS£S Of TUB ME/ftA'GBS OF THE BRAt.W
B. SVMPTOMS, DiAGKOSIS, AND TREATMENT.
Symptoms. — The idiopathic, purulent meningitis of thcl aduk usually begins alter tnsigni^cant prodromal symptoms, such as digestive disturbances, hebetude, etc., with headache, which soon attracts by its severity and it5 duration the atten-J tion o( the physician. Exceptionally the patient has hours of' comparative ease; usually the headache is so intense that he becomes almost frantic. lie tosses about in bed with sighs and groans, and, even when the mind has become dulled, in- voluntarily again and again puts his hand to his bead. Some- times delirium develops early, to cease again and sooner or later give way tu a dull and somnolent cundilion, which in its turn passes into a deep coma, the immediate forerunner of death.
In some cas<rs the diagnosis is facilitated by characteristic symptoms, such as rigidity of the neck and marked hyper- ar^thesia of the skin and muscles. The former is especially well recognizable when the patient is asked to sit up in bed, which he can not do without intense pain : the latter is often detected in the examination of the patellar reflexes, which themselves present no particular abnormalities. If we then find besides these symptoms in the beginning of the disease occasional (cerebral) vomiting, a strikingly stow pulse, which Is in remarkable contrast with the elevation of temperature (io3* and more), and if we carefully examine the pupils, we can not easily make a mistake in the diagnosis. The pupils are usually very much contracted, but may show alternate contraction and dilatation when illuminated (or any length of time (Ocstreichcr, Paradoxc Fupillenreaction, Berl. klin. Wochenschr.. 1890, 6), Only exceptionally, however, do we meet with a combination so favorable for the task of the diagnostician. More frequently, as we shall explain at length, he has to encounter considerable difficulties. There is no doubt but that the *-omiting is of cerebral origin : but where ihc center for thu: is to be sought, whether in the medulla oblongata or, as HIasko claims (Dor- pat, Inaugural Dissertation, 1887), in the corpora quadrigemina. still remains undecided, as also does the question whether or not we arc dealing with a functional stimulation of this center. Choked disk and transient paralysis of the ocular muscles are occasionally observed. The former is not easily recognized when the patient quickly passes into sopor: the latter, how- ever, is recognized without difficulty by the strabismus which
iJiP TOM EN I SGI Tin.
13
it causes and the nystagmus-)ike movements ol the eyeballs. Symptoms of irritation, partly referable to the cortex, in the form of general or unilatcnil convulsions, muscular unrest, or carphology, partly to individual cranial nerves {grinding of the teeth, trismu!>, facial spasm), have been repeatedly noted. Tliey seem, however, not always to occur, and for diagnosis must be considered as of minor importance.
The course of purulent meningitis in the adult is different in different cases. As a general rule, however, certain symp- toms. es|>ecially headache and the rigidity of the neck, some- times hyperesthesia of targe areas of the skin, persist from the onset and incre,ise. while others, as. for instance, the vomiting and the cranial nerve symptoms, arc only transient.
The duration of the disease can be two, three, four, to eight, more rarely ten to fourteen days, and the younger the patient the more dangerous is usually the disease. The patients die, as a rule, without regaining consciousness, but the coma may last for days.
The symploms of the epidemic contagious (Kahlmann, Berliner klin. Wochenschr., 188 j, 17) cerebro-spinal meningitis arc on the whole quite similar to those of the idiopathic form. In l>uih the headache is the preduniinating symptom, and the rigidity of the neck is rarely absent, but in the epidemic more frequently than in the idiopathic form the disease begins with a chill. The course of the fever presents nothing character, istic. It is sometimes of a remittent, sometimes uf an inter, mittcnt ty|>e. the temperature sometimes reaching a height of 104*" lo 107* F. More or less severe disturbances of con. sciousncss may occur c%-cn without a marked elevation of tem- perature. Atnong the cranial nerve symptoms, the disturb- ance fn hearing caused by the auditory nerve taking part in Ihe inflammniory process has to be mentioned (Schwabach. Zcilschr. i. klin. .Med., 1891. xviii. 3. 4). Visual disturlwnccs ■re more uncommon, but opiic neuritis has been repeatedly noted. II other cerebral symptoms— convulsions, hemiplegia, aphasia — occur, they have to be considered as C4)mplicaii(ins due to an extension of the inflammation lo certain parts of the brain substance.
The spinal symptoms, which arc superadded, may consist ol a distinct lenderness along the whole vertebral column, of a hypent^thcsia of the legs (which is of diagnostic importance), and of twitchings of the extremities. X peculiar, but. as it
>4
/y/S/iAS/CS OF THE MEKI.VCES OF THE BRAIX.
appears, extremely uncommon symptom is the so-called flexor contracture of Kcrnig: tlie patient when in a silting posture is unable to extend his knees, because a contracture in the flexors is developed, which disappears as soon as the thigh is no longer flexed at the hip-joint. Bull (cf. lit.) has made some communications on this point. The mechanism of micturition is only influenced when the patient becomes unconscious; then the urine is passed involuniarily. Besides this there are no important bladder syinptunis. The urine sometimes contains albumin or sugar, also some tube-casts. Sometimes the quan- tity voided is greatly increased, a polyuria, which we have to consider as a cerebral symptom.
Ol her organs rarely take part in the disease. The circula- tory, respiratory, and digestive apparatus usually remain nor- mal, and serious stomach alTcctions, endocarditis, and pneu- monia, of which we have already made mention above, are seen only rarely as complications. Moderate splenic enlarge ment often occurs. Among the skin eruptions which some- times accompany cerebro-spinal meningitis, besides urticaria and (much more rarely) roseola, we have a herpes labia lis, which, without being of any prognostic value, possesses a ccr- tain diagnostic significunce.
The course of epidemic meningitis is still more uncertain and variable than that of the idiopathic form. It may be rapid, and end fatally within a day or a day and a half, in which case convulsions arc followed by deep and persistent coma. It may, however, also be protracted, and with remissions, during which the patient is in fairly good condition, may List (or weeks. In the beginning of the epidemic usually grave cases are more common, while the longer it lasts the milder they be- come. It seems as if an attenuation in the virulence of the mi- croorganism had taken place. There occur, besides, abortive cases, in which, while they undoubtedly must be classed with llie epidemic disease, only a small, someiimes quite insignifi- cant, part of the symptoms arc developed. The period of in- cubution is from ihrtx m tivc days. Frequently an attack of cerebro-spinal meningitis is followed by certain scquclx. among the most common of which are headache, pain in the neck, or neuralgias, which may persist for a long time after cotivales* oenoe.
The sytnploms of tuberculous meningitis diScr somewhat in children and in adults.
LEr TOMB/flNCI T/S.
15
{a) In children the disease runs either a very acute or a more chronic course. In the lirst case only a few days may elapse between the onset and the fatal issue : in the Ltttcr, weeks and months may pass before amt^Huratiun and recovery, ur in these cases also death takes place.
The acute form usually begins suddenly with epileptiform convulsions. Apparently healthy, robust children fall into con- vulsions and then complain of severe headache and nausea, which is often followed by vomiting ; the pulse becomes irrcg- ular, and its variations in frequency are more striking than in any other disease. On examination, we find the temperature only moderately elevated, but the patient is very restless, throwing himself about in bed and complaining of pain in the abdomen, chest, etc. Strabismus, trismus, grinding ol the teeth, are often noted, and on mechanical stimulation of the skin striking circumscrihed red spots. Trousseau's tathti cfn'- braUs. appear. The patients sigh deeply when examined, or give an unexpected loud, sharp cry, the cri kydTdte^pkalique. a very unfavorable symptom which is of far greater importance than the spots, from the appearance of which we are not justi- fied in drawing either favorable or unfavorable conclusions. The approach of death is announced by an enormous increase j io the frequency of the pulse, by renewed convulsions, and) deep coma.
The chronic form begins insidiously and gradually, the first thing to attract our attention being the change in the disposi- tion ol the child. Previously gay, friendly, playful, and com- panionable, he becomes peevish, irritable, unmanageable, and willlul. On the least provocation he begins to cry and lo be naughty, so that the parents find it necessary to punish him. It is not until the sleep begins to be disturbed and the child losses about all nii^ht and groans In its sleep, wakes up in the morning without being rested, and complains of headache, that the parents become apprehensive, and the loss o( appetite, the occasional vomiting, the obstinate constipation, and the pale, lickly appearance confirm the fear that a serious malady is on the point of showing itself. The symptoms may for weeks remain obscure ; hit;h temperature may alternate with low, a frequent with a slow pulse, without it being possible to say anything definite about the case. Only when one day an epi- leptiform attack occurs, the headache increases in intensity, the child becomes somnolent, cries out during sleep, shrinks on
l6 DISEASES OF THE MENINGES OP THE BKAIN.
being touched (hypcrscsthcsia of the skin), only then is the condition clearer, and finally cnn not be mistaken when such a focal symptom as paralysis of the eye muscles appears. Even then remissions may occur, and decided improvement or even complete recovery is not impossible. The outlook is always doubtful, and can, even when the prospects appear most favor- able, be very serious.
(A) In adults the difference between the chronic and acute form is less marked llian in children. Patients who have by no means presented dehiiite si|;n$of tuberculosis begin to com> plain of vague headache, general prostration and malaia: their sleep becomes disturbed and restless: especially in the morn- ing they fee! tired and unstrung: they complain of loss of ap- petite, and may have occasional vomiting spells. In some cases the psychical symptoms are the most prominent, and i( may happen that the disease begins with the symptoms of a deliri- um tremens, especially if the patient be a drinker. In all cases the scnsorium becomes sooner or later dull ; the patient appeans dazed, gives confused answers, and conveys in general the im- pression of a man whose mind is afTected, Not rarely delirium comes on : in it the excitement and exaltation are the moM prominent features. But with all these symptoms the influence of a severe, agonizing headache still makes itself known, and even during unconsciousness the patients often raise the hand toward the head, throw themselves about in bed restlessly with gro:ins, and seem sensitive to the slightest touch or tap on the head. lipilcptiform seizures have repeatedly been observed (Meloir, fitude sur la forme 6pilepiique de la m^ningitetubcrc, Thisc dc I'aris. rS88). The participation of certain cranial nerves, especially the ocuhj-molor and the abducens, is evident from the transient ptosis, the inequality of the pupils, and the strabismus : the ophthalmoscopic examination not uncommonly reveals choked disk. II in looking for the latter wc are able to find tubercles in the choroid, this is of course of the highest importance for the diagnosis. The facial nerve, which often becomes affected, may be the seat of spasm or o( paresis. If wc remember that the base of the brain is the chief seat of the inflammation we can easily understand why these cranial nerves sliould be implicated. If motor disturbances, consisting of gen- eral or unilateral convulsions, or of hemiplegia or paresis, as well as speech disturbances, make their appearance, wc may assume that an eruption of tubercles has occurred in the brain
LEP TOMENINGI TIS.
i;
cortex, an assumption which is to a certain extent supported by the occasional appearance of trismus. The more pronounced the*c disturbances, which are to be regarded as focal symptoms, the more likely is it that circumtvcribcd tuberculous sollctiings exist in the cortex. Sometimes also a peculiar tonic rigidity devcto[w in all (our cxtrcmilics which seems to be of reflex origin. The reflexes, at first increased, but presenting nothing chamctcristic, usually lose in intensity as Ihc disease goes on, and finally dis:ippear altogether. With regard to the sensory changes, it should he remarked that hyperncsthesia of the skin is Dot so regular a symptom in this as in the 6rst described form of meningitis. The temperature, as a rule, is somewhat above the normal, yet it varies, and occasional remissions may be followed by elevations, or it may remain constantly between toi" and tos*" F.. or thereabouts. Nothing certain, however, can be said about it. Strlimpelt reports a temperature of SK" during Ihc agony. Equally variable is the pulse, which as a rule is slowed. Wc may count 40 to 50 beats a minute, while in a few hours it may rise to too or 120.
Other organs take but a small share in the disease, and even the lungs show signs only when simultaneously affected with miliary tuberculosis. II the respiration assumes a Cheync> Stokes type (alter a series of shallow respiralions. which be- come deeper and deeper, a complete pause), this is usually a bad omen.
To say anything positive about the course of tuberculous incningitis in the adult is impossible. It is not constant, but sometimes acute, sometimes chronic, sometimes presenting long tntermissions, and sometimes steadily progressive. A subdi- vision into different stages may look very well on paper, but to demonstrate them at the bedside is only rarely possible. A period o( cerebral irritation has been distinguished from one of increased intracranial pressure, and this again from a period of paralysis. The first has been thought to be characterized by headache, vomiting, and delirium; the second, by slowing of the pulse and paralyses; the third, finally, by increase in the frequency ol the pulse, elevation of temperature, and deep cocna. But such a division entails no practical benefit, as the 8<M:&lleil "stages" arc often not distinguishable from each otber. but pass directly one into the other. From the instruct* ive treatise of Hirschbcrg {c(. lit.) we learn that evi-n the ni.in- ner of onset may vary much, and that it may be dilTtcult even
I8 £>/SEASES OF THE MENINGES OF THE BSAIN.
in the stage of focal symptoms to make a diagnosis. If a con- sumptive suddenly develops symptoms of motor or sensory paralysis or irritation, this should always make us suspect the existence of a tuberculous process in the brain.
Diagnosis. — None of these different forms of meningitis that we have described is easy to diagnosticate, with the exception, perhaps, of the epidemic cerebro-spinal. When several cases have occurred in a community the recognition of new ones pre- sents no difficulty, especially if we keep in mind the frequency with which herpes labialis is met with in the disease.
A serous meningitis may be not infrequently confounded with the purulent form, a fact to which Quincke has lately called attention in his excellent paper (Sammlung klin. Vortr., N. F., Leipzig, 1893, No. 67). The absence, or the slight de- gree, of fever, often also its irregular appearance, together with the relative mildness of the manifestations pointing to cortical involvement, such as headache, stiffness of the neck, and clouding of consciousness, and on the other hand the relative frequency of choked disk, are the features which are more characteristic of the serous form.
Of other diseases, typhoid fever is perhaps the most likely to be mistaken for meningitis. There is no doubt, and it has been shown by reliable observers (Curschmann), that there are cases in which meningitic symptoms are very well marked, but in which typhoid bacilli are found in the cord at the autopsy to be the infective agent. We might be led to believe that at least the characteristic temperature curve, the splenic enlarge- ment, the condition of the stools, and the rose spots would be sufficient to make a mistake impossible, but this is by no means ii-miri ihe case: there are instances in which typhoid fever ca^ ^A. ■with certainty be excluded, and then the differential &-^;^zi'jhi^ ii dimply impossible.
i: •j.-Kr=:ai *nters into the question of diagnosis, the exami- natiyii v. tbt urine Cfor tube-casts, etc.), suppression of the urine, a it sho'jid i>t present, and the appearance of the convulsions will Jaciiilate lie recognition of the true condition.
Whether we have to do with a case of croupous pneumonia or with meningitis is. in the majority of cases, easy enough to decide. Both afieciions may, however, occur together, and then it is imporumt to remember that marked hypersesthesia of the skin, staggering gait, and rigidity of the neck may all be present with pneumonia alone, if this be complicated by
LEP TOUH^'tAFCl T/S.
•9
of the gloitig, so that respiration is difficult, the patient will fix his head in order to bring into play the auxiliary mus- cles o( respiration, and thus in the rtcumbcnt position loo the rigidity of the neck is simulated (Wernicke). The existence of meningitis is only, then, to be assumed if pronounced basal symptoms arc present, and especially if paralysis of the eye muMrtet! has existed (or a certain period o( lime.
More fretpiently delirium tremens is associated with men- ingitis, and we are not always able to decide whether the delirium, (he tremor, and the epilepliform convulsions are referable to the latter or to the former.
It is well to remember that there are cases in which, al- though the symptoms of tuberculous meningitis seem pro- nounced. in a few weeks the patient completely recovers, in which instances the assumption that there is a pseudo-men- ingitis of hysterical origin seems necessary (Carrier, Lyon m^., October, 1892. Ixxi). Of course, the previous history of the patient, the family history, etc.. have to be taken into con- sideration before such a diagnosis, which wc think is always very risky, can be even thought of. Of interest are the ob- servations of Carl n and Iscovcsco (La France mid.. 136. 1888) upon a diagnosis of meningitis in cases of iodolorm poisoning. The occurrence of meningitic symptoms as a consequence
I ol worm», which l>cvaux (cf. lit.) has upheld, is certainly ex> ceptional, and can hardly, for any length of time, give rise to
[an error in diagnosis.
With sufficient care we can easily avoid confounding men- ingitis with eclampsia infantum.
Prognosis. — The prognosis in every case of meningitis is very serious; we are never in a position to predict with any
I certainly the outcome, not even when everything seems to be going on very favorably, and grave symptoms have not de> clared themselves. These may suddenly develop in one night, and a patient whom we have left in fairly good condition in the evening may the following morning be hopelessly ill. On the other hand, we should not give up our patient too soon : the gravest symptoms may f.idc away, and improvement is still posjtiblc even where the case seems desperate. Undoubtedly, however, meningitis is one of the most serious diseases, and one in which recovery is rare, the epidemic cerebro-spinal meningitis being the only form which sometimes runs a more rorablc course.
20
DISEASES OP THP. MENINGES OF THE BRAIN, t
Partial recoyeries are much more often seen than absolute ones. II, for example, in the course o( meningitis, a hxmor< rhaf^tc inflammarion of Ihe inner car develops, tins gives riSrC lo pormuncnt dcaincss. which in younger children, as a rule, leads to dcaf-tiiurism (Schulzc, Taiibstummhcit und Meningitis, Virch, Arch., 1890, cxix. p. 1). or if purulent inflammation of the eyeball, a panophthalmitis or a choroiditis coexist with the meningitis, this may entail a grave disturbance of sight, even phthisis buibi, and complete amaurosis. In cither ol these cases the meningitis may get well, but leave in one deafness, ia the other impairment or loss ol sight, and in Ihe most unfavor- able cases both remain behind without the development ol any mental delects. Blindness may also be a consequence of an optic neuritis, which does not get well, but causes shrinking of the opiic nerve and atrophy of the disk. Cases of meningitis confined to the convexity sometimes recover, leaving a more or less marked leeble-niindedness.
Treatment. — The treatment is first to be directed against the inflanmiation, and later endeavors should be made to aid absorption of exudates if such be present. For this purpose we make use of stvcalled surgical revulsives {Erlcnmeyer, Deutsche mcd. Ztg-. 1893, p. Gi): for example, local bleeding and the application of cold inunctions of mercurial Dintmcnt, (our to eight grammes ( 3 j t<i 3ij) a day to the shaved head, or blisters (Mr)sler, Deutsche med. Wochenschrift, 18*8, No. 30. p. 621). In some cases we shall succeed with such me.is- urcs in lessening the severity ol the symptoms, but often little or nothing is achieved by them. Painting the shaved head with tincture of iodine is objectiDnable, owing to the disagree- able and painful tension which it produces, and which is but little alleviated by ice. That free purgation with large doses of calomel .ictunliy produces an antiphlogistic effect can not be proved, but there is no reason why it should not be tried, the drug being given until the characteristic stools appear. The absorption of exudates is attempted by large doses of polas. slum iodide, four to six grammes (3j to 3jss.) a day in hot milk, a medication which is especially indicated in the gumma- tous form of meningitis.
During com:i the patient may be put into a tepid bath {90" to 93" F.) and cold water (66' to 60° F.) be poured over bis head. These cold-water allusions may be continued (or eight or ten minutes, with the frequent result of actually ruus-
LEP TOMBNlNGtTlS.
21
ing the patient out of his unconsciousness, an improvement, however, which generally does not last very long. The repc. tition of this procedure several times a day is therefore neces- sary, notwithstanding the considerable difficulties with which it is (at least in private practice) attended.
Symptomatica I ly the agonizing headache and ihc jactita* tions may lie met with morphine. The same drug is used against the obstinate vomiting, which is hard to treat, and in- deed may resist all efforts. It may happen thni all intcrnnl medicines, cracked ice, champagne, opium, aromatic tinctures, etc., as well as .ill applications of spiritus sinapis, etc.. remain without eflcct ; then wc arc forced to resort to morphine, the subcutaneous ad miitist nation of which generally accomplishes more than all remedies previously used. The regulation of the bowels should of course ne%*er be overlooked.
We can only. then, with reason hope for success from our (hcrapcutic eflorts if we pay careful attention to the nutrition of the patient. As soon as this is left out of sighr the battle is practically lost in spite ol all medicines and inunctions. More than in any other disease it is here the chief task of the physician to see that the strength of his patient is kept up. so that he be 6t, if necessary, to stand an iltncss of weeks: and more than in aity other disease is here the prolonged use of wine indicated, and is much more important than all drugs. Besides wine, a Inblespoonlul of beef-tea is to be given every hour. This is prepared by gradually heating lean beef cut into small cubes, afier the addition of a little sail, in a lightly closed glass bottle over the water-bath, and cooking it until the pieces arc completely disintegrated. Two pounds of meat furnish about a cupful of beef-tea.
In very cvccplional cases operative measures are indicated, tiAmely, where we have sufficient reason to suspect the exist- ence ol an exudate in (he ventricles, which would manifest itaclf by an aggravatitm of the symptoms of increased intra- cranial pressure. Trephining and lapping of the ventricles (Keen. Philadelphia) may then be resorted to if the circum- stances arc in other respects favorable. In cases ol otitis media the tympanic membrane should be punctured and the cavity syringed out with antiseptic solutions. It is scarcely lo be expected that the treatment of tubercular meningitis by ]>;ira> centests of the spinal canal, a procedure practiced in four cases
22 DISEASES OF. THE MENINGES OF THE BRAIN.
by W. Essex Wynter (Lancet, May 2, 1891), will meet with general acceptance.
The treatment of tuberculous meningitis in children has to be conducted according to the* plans just laid down, with this difference, that the inunctions of the head with mercurial oint- ment are to be replaced by the administration of calomel, three to five centigrammes (grs. ss. to j) every two hours. Besides, the inunctions of the head with iodoform ointment, lately so warmlj' recommended, should be tried ; but here, too, the preservation of the strength must be our chief aim. Milk, with the addition of a little Hungarian wine or a few drops of cognac, should always be kept ready.
LITERATURE.
Bull. Uebcr die Kemig'sche Flexionscontractur der Kniegelenke bei Gehim-
krankhdten. Bert. klin. Wachenschr., 47, [885. Lcyden. Bermerkungen iiber Cerebrospinal me ningilis und iiber das Erbrechen
in fieberharien Krankheilen. Zeitschr. f. klin. Med., iX\, 4. 1887. Devaux. Oxyures et symptdmes pseud o-mfningitiques. Progr. m£d.. No. 46,
1887. J. Simon. Diagnostic diBErentiel de la miningile tuberculeuse. Gai. des H<)p.,
No. 13a. Nov.. 1887. Woltr, Felix. Bemerkungen iiber das Verhallen der Cerebraspin at meningitis zu
den Infections krankhdten. Deutsche med. Wochenschr., 50, p. 1080,
1887. Weichsclbaura. Ueber die Aeiiologie der acuten Mening. cercbro-spin. Fort-
sclir. d. Med., i8, ig, 1877. (■' Diplococcus inlercellularis meningitidis.") Hormann v. Ueber die acute Meningitis in angeblich ursachlichem Zusammen-
hange mil Misshandlungen oder leichten Verleliungen. Wiener med.
Woctienschr.. 6. 1888. Pio Foa und Guido Bordoni-UfTreduizi. Ueber die Aetiologie der Meningitis
cerebrospinal is epidemica. Zeilsclir. f. Hygiene, 1888, iv, No. 1, pp. 67
et seq. Baaz. Die Cerebrospinalmeningitis, ihr Wesen und ihre Behandlung. Berlin-
Neuwied, Heuser, 1888. Freyhan. Zur Kenntniss der Typtiusmcningitis. Deutsetie med. Woctienschr.,
1888. No. 31. p. 630. Wolff. Felix. Ueber meningiiische Erscheinungen beim Typhus abdominalis.
Ziemssen's und Zenker's Archiv, 1888, xliii. Heft 2 u. 3, p. 250. Stephan. Des Paralysies pneumoniques. Revue de mid., 1889, ix. No. I.
(" Meningitis as a Complication of Pneumonia.") Adenot. Des meningites mikroliiennes. Paris, Bailliire, 1890. Fox. Amer. Journ. of the Med. Sciences, June 6, 1890, xcix. Oebeke. Ueber Meningitis eerebrospinalis. Berliner klin. Wochenschr., 1891,
No. 41- Hilt>ert. Berliner klin. Wochenschr., 1891, No. 31,
LEP TOMENINGITIS.
23
Matthcs. LinksBcitige Hypoglossusiahmung bd tuberculiiser Meningitis.
MiinchencT med. Wochenschr, 1892, No. 49. Trevelyan. Cerebro-spinal Meningitis. Brain, Spring Number, 1892. Schwabach. Ueber Ciehiirstorungen bei Meningfitis cerebrospinalis und ihre
anatomischc Begriindung. Zeitschr. f. klin. Med., 1892, xviii. No. 3 u. 4, pp.
273-297. Mcrtz. Deutsche med. Wochenschr., 1891, xix, Na 2. AUya. Three Fatal Cases or Cerebro-spinal Meningitis, with Autopsies. Med.
News, May 14, 1892. Maulwurf. Wiener med. Wochenschr, 1892, xlii. No. 47. Mensie Carbone. Riroima med.. 1893. ix. No. 2. Zmkcndbrfer. Zur Bacteriotogie der Meningitis suppurativa. Prager med.
Wochenschr., 1893, No. iS. Boix. Revue de m^i., 1893, p. 413. Randolph. Bull, of the Johns Hopkins Hospital, July 4. 1893 (forty cases of
meningitis, examined clinically). Klemperer. Ueber die Bedeutung des Herpies labialis bei der Cerebrospinal*
meningitis. Berliner klin. Wochenschr, 1893, No. 29. Friis. Ugeskr. f. Laegenidensk, 1893, xxvi, No. 27-29. ("On Meningitis
cerebrospinalis epidemica.")
PART II. DISEASES OF THE CRANIAL NERVES.
If we once have a clear idea that in the cranial nerves we have to distinguish the origin, which in aU probability is found in the cortex and the nuclear region o( the medulla oblongata, from the partly central (intracerebral), partly peripheral (ex- tracerebral) course, it is self-evident that the diseases of the cranial nerves are divisible into those which aflect the nerve at its origin, the center, and those which aflect it in its course. As we shall come to deal in the next part of our book with the affections of the brain substance proper, it necessarily results that in the following chapters we must either touch upon things which properly belong to Part III, or that in the latter we shall not be able to avoid some repetition- Neither of thSse courses is without objections ; still, from a practical point of view, we have deemed it best to treat of the diseases of the cranial nerves here in toto.
The central lesions of the cranial nerves olten form merely a part of a more general disease of the nervous system. Those of peripheral origin occur also independently — for instance, as the result of exposure to cold, traumatism, etc. In very many cases we are not able to determine definitely whether the dis- ease has a central or a peripheral origin. For a clear under- standing of the following chapters, a knowledge of the anatomy of the parts naturally can not be dispensed with. Some remarks bearing on this, which, of course, are not meant to take the place of a detailed study, have therefore been inserted at the head of each chapter to recall to the reader's mind in outline the necessary anatomical relations. a4
VISKASES OF TIIK OLfACTORY NERVE.
25
^
I
p
I
CHAPTER r.
DISKASRS nv THE OLPACTOHV NERVR.
olfactory nerve begins in a small pyramidal [obule, the tu- ber ulfaclotium (caruncula mamillaris), the base of wbich la situated in front of the anterior perforated space. Al its beginning, the nerve is broa<l, but narrows into a band ^omcwliat prismuidal on Metiun, which is called the olfactory tract, and which in its turn ends in an oval gray swelling, the olfactory bull). From the tower as]7ecl of thi» bulb, which lies on the cribriform plate of the ethmoid bone, two groups of fibers [»ass through the Itlile openinKs of the bone into the nasal cavity, and it is only the sum of these filaments (the fila olfac- toria) which can be looked upon as the nerve of smell in the strict seiiKc of the term. The olfactory tract and bulb arc parts of a cere- bral lobe, the so-called olfactory lobe.
The origin and the course of the roots of the olfactory nerve (ttie X Dlfaciorii, Schwalbc) are not known. It is, howi-ver, Kocrally :rced ihat there are three roots, The outermost, the siningest, i» said to be traceable into the island of Keil. Schwalbe supposed the eaistencc of a lateral root (radix lateralis, sen longa, sen externa) originating in the hippocampal convolution, and of a median (radix mcdialiK mu interna, scu brcvis), coming from the gyrus fornicatus. Other* have looked utK>n the anterior commissure and the corpus striatum as the starting points of the olfactory nerve, but nothinff positive is known. An olfactory center has been assumed in the gyrus hippocampi and in the gyrus uncinatus. Lately Zuckcrkandl (cf. lit.) has claimed Ihat the cornu Ammonis is a part of the olfactory center (cf. also (he extensive paper by Troland, l>c I'appareil ncrveux central de Tolfaction, Arch, de Neurol., 1891, Ix, p. 335 ; Uii, p. 183: Ixiv, p. 69; l»v, p. 103).
Notwithstanding the fact that the affections ol this nerve are not of very great practical importance, ihcy afford a great deal of interest, because they may under certain circumstances (i. c., il a careful clinical description is followed by an exact and accurate post-mortem account] ^ive us some information about the anatomical and physiological questions concerning the course and ori^^in of the nerve, and again beciiuse they may attain a considerable importance and value in the diagnosU of certain cerebral diseases.
The olfactory nerve may be diseased in its central or in its peripheral portion. In the former case it may be the olfactory
26
D/SKASJiS Of THE CKANIAL NERVS.S.
center which is afTected, or ihe conduction may be inlerfered with somewhere in the course of the intracerebral paths.
Since, as we have stated, the situation of the olfactory cen- ter is not definitely known, wc can not be expected to know much about its diseases. It would appear, however, that it may be affected by dcstriiclivc as well as by irritative lesions; the latter manifest themselves by hallucinations, the former by lo!.s of smell (anosmia). Among the diseases in which hallucina- tions of smell occur are various psychoses, also mjj^raine. tic douloureux, epitcpKy, and tabes. Usually the smell which such patients describe is bad, disgusting — of licces, sometimes of poisonous plants, putrid substances, etc. (kakosmia) — and it is rare for them to imagine that they smell pleasant substances. One ol my cases, who. owing to an ocular paralysis, was treated with the galvanic current passed through his head from one side to the other, declared that he smellcd oil of lavender from the moment the current was closed until it w.is again broken. This seems to point to the possibility that by the galvanic cur- rent the olfactory center may be stimulated. Central anosmia is sometimes observed in cerebral lesions following fracture o( the skull, which cause hemiplegia and aphasia, the disturbance being confined to the nostril on the same side as the lesion. Anosmia is also known to occur in hysteria and in old age ; in the latter case it is probably to be attributed to atrophy (senile anosmia). Cases have been repeatedly noted in which tumors of the anterior fossa of the skull, exostoses, meningitis at the base of the frontal lobe, have given rise to anosmia. The fact that several odors acting on the olfactory nerve at the same time suspend each other is probably to be explained on physio- logical grounds, as is also the fact that the acutencss of olfac- tory perception is diminished if at the same time another cranial nerve— e. g., the optic or the auditory — is strongly stimulated.
Interference with conduction in the olfactory nerve may be assumed In cases where there is a history of traumatism — a fait u|»(>n the head, more especially upon the occipuL Accord, ing to Carbonieri, complete loss of smell suggests strongly dis- ease of the olfactory tract or bulb.
The treatment in the central affections of the olfactory nerve must of course be directed against the underlying disease.
Of greater practical interest are the peripheral affections of
D/SSASSS Of TUB OLf ACTOR Y NKRV^B.
%1
the oUactory. which chiefly consist in a decrease of the power of smell. Leaving out of cunsidcration the common cases in which an acute or chronic nasal catarrh causes partial or, tem- porarily, even complete anosmia, the sense uf smell may be aflected as the result of abnormal dryness of the nasal cavity (diminution in the secretion of tears in trigeminal anasslhesia, diminished How of tears into the nasal cavities in facial paral- ysis). Not rarely certain occupations give rise to anosmia, which is sometimes associated with a tolerance of disagreeable odors which at first were highly obnoxious to the workers. Such anosmias are to be found in soap-boilers, catgut spinners, tanners, skinners, and butchers, whose sense of smell is often eonMclcrably dulled ; again it may be due to disturbances in nutrition, to the action of caustic substances, or injury to the peripheral nerve endings — effects which are due to the chemi- cal composition of the inhaled substances. Thus we have ob- $er\-ed loss of the sense of smell in those working in chlorinated lime, while it was found to be diminished in laborers occupied with the pulvcrizaticm of chrome-ironstone. Strieker has also known it to occur in an entomologist in consequence of the protracted inhalation of ether.
■I have observed hyperesthesia of the olfactory nerve, in hysterical women especially during pregnancy, and also during galvanization of the brain (v. s.).
The treatment consists in turadiitation (Beard and Rockwell) and galvanization (Fieber) of the nasal cavity, or painting with a one-pcr-ccnt solution of strychnine (in olive oil). The use of irritative snuff powders has repeatedly been recommended for ani]«mia of peripheral origin, but has frequently been used without benefit. Spontaneous recovery is not rare. Finally, we may say a word or two about the method of testing the sense of smelt. All those substances which irritate the trigem- inus should be avoided, as. for instance, acetic acid, smelling salts, snuff, tobacco; the patient would feel what he can not smell, and wc might be thus led astray in our conclusions. Cologne water, oil of rosemary, musk, catnphor, anise, oil of turpentine, asaf<£lid.l, and sulphurctcd hydrogen, arc sufficient for most tests. That each nasal cavity must be tested se]>a- ratcly goes without saying- A special olfactometer has been devised by Zwaardemakcr i Birl. klin. Wochcnschr., 1888, No. 47; Fortschriltc dcr Med., 18S9, No. 19), and another more recently by Savelicff (Neurol. Cenlralblatt. 1893. No. 10).
2i DISEASES OF THE CRANIAL NEKVES.
LITERATURE.
Notta. Rccherches sur la perte de I'odorai. Arch, g^nfr. de xt\kA., April, i %^a. Ogle. Anosmia, or Cases illustrating the Physiology and Pathology of the Sense
of Smell. Med.-chir. Transact., 1870, liii. Molliire. Note pour servir il'histoiredu nerf olfactif. Lyon mid., 1871, No. 30. Carbonieri. Zur Localisation des Centrum olfactorium. Riv. clin., xniv, 9. p,
657. September, 1885. Erben. Wien. meil. Blatter, 1886, No. 43, 44 (kakosmia in tabes). Moldenhauer. Die Krankheiten der Nasenhohlen u. s. w. Leipzig, Vogel, 18S6. Cowers. Lectures on the Diagnosis of the Diseases of the Brain, delivered at
University College Hospital, London. Churchill, 1885. Also Blakiston,
Philadelphia. 1885. Thudichum. On ihe Nature and Treatment of Hypertrophies and Tumors of
the Nasal and Pharyngeal Cavities. The Lancet, August 27, 1887, p. 401, Zuckerkandl. Ueber das Riechcentrum. Stullgarl. Enke, 1887. Roth. Die Erkrankungen der Nasenschleimhaut. ihre Beziehungen zum tibrigen
Organismus und Behandlung derselben. Centralbl. fiir d. ges. Thcrapie, v.
Heft X, October, 1887. Zwaardemaker. Berliner Klinik, Reviewed in Wiener med. Presse, 1890,
No. 39. Zwaardemaker. Zur Methodik der klin. Olfactometrie, Neurol. Centralblatt,
1893, No. 21,
CHAPTER II.
DISKA6R» OP TIIK OfTtC HIXVK.
The optic nerves derive their fibers from the occipital lobes, the oplic thalami, lltc outer and inner geniculate bodies, the anterior corpora quadrigcmina, and the cerebellum (through the superior |K«liincle of the cerebellum).
What arc known as the oi>ti<: Irarls bernn- the chiasm is reached, afcer thisi point become the optic ncrvo.. These arc niund hard cords, about (our millimetres in diameter, which, passing in a iliverging direction through the optic foramina, enter the orbits and reach the eyeballs after iheir pa&^gc through the orbital fdl. Here they pass the sclerotic and choroid and spread themselves over the fibrous
layer of the retina. The outer ■" covering of the nerve, which is
a proccu of the dura mater, is called the diiral sheath; the process of the pia, the inner or pial sheath. The two arc Bcparated by a space which be- longs to the lymphatic system, thn so-c.illed iniervaginal or siibvaginal space. The aiteria centralis retina, a branch of the internal carotid, enters the optic nerve atmiit fifteen or gp twenty iniHimctre» from the eyeball and runs together with the vein of the same name in the substance of the nerve to the retina.
The chiasm, which is formed by the union of the optic traclBi is a fl«nen«d four-sided body, in which the croxMng of the optic fibers lakcft place. This crosxing, as we now know with a fair amount of certainty, is. however, only parttat, a semidecussation. The fibers from (he outer half of the retina (represented by an interrupted line) pa«s to the center without decussating, while those of the inner half
«9
•. DtMMUM SMOWDfO THE OuRn Tilt Umc FIBMICS IM lilt: CuM^iM.
30
J>/S£AS£S OF THE CRANIAL NERVRS.
cross over and pass to the centre of the opposite side (cf. Fig. s). Each occipiul lobe, therefore, receives fibres coming (rom the lein- poral as well a& (rum the iia&al half of the retina. Thus, for in- Htance, the left receives fibres from the outer temporal half of the left and from the inner nasal half of titc right retina. In dine.itcs of this lobe, therefore, images falling upon the left half of the retina, or, in other words thoM which tie in the right half of the field of vision, arc no longer perceived — right-sided hemianopia.
The optic tract, the superficial fibres of which can be traced into the white covering of the pulvinar (the bo-called stratum zonalc ihal- ami), originates by two rootii — an outer, much stouter, the end ganglia of which are the anterior corpus (juadngcminum, the outer genicu- late body, and the pulvinar, and by an inner root which can be easily followed lo ihc inner geniculate body (Wernicke). These end ganglia of the optic tracts form at ihc same time the terminal pointx of certain fibres of the corona r.-idiala, which run in a sajtittal direc- tion forward from the «(r<:t])ital lobe, and arc connected with the pulvinar, the brachium anterius of the (juadrigeminal body, and the outer geniculate body. This bundle of fibres ih the sagittal medul- lary tract of the occipital lobe, or what is called the optic radiation, and is designated in the diagram by i {vide Fig. 3).
The exact localixalion of the cortical centre of vision has not as yet been established. According lo Ferrier, it is in the angular gyru«; according to Munk, it iit in the convex surface of the occip- ital lobe.
It would be beyond the scope of the present work lo treat in exUnio of those diseases of the optic nerve which belong^ strictly to the domain of ophtbalmoloffy ; they can be con- sidered here only so far as ihey are connected with the nervous system. To these belong, first of all, certain infl;nnmatory con- ditions which act upon the intraocular end of the nerve, the papilla (diski, and {five rise to what we therefore term papU litis (choked disk). The name optic neuritis, which is (re-1 quently used as a synonym for papillitis, is inexact, because it may imply an affection of the whole nerve trunk.
The papillitis, choked disk {SinHuugspapUU. as the Germans call it, after von Graefe, (859). is frequently, although not al- ways, met with in cases of intracranial tumors, and is (accords ing to von Grade) to be attributed to a high grade of venous engorgement, produced by an impediment to the reflux of the venous blood into the skull cavity. Later, when Schwalbe hadj discovered that there was a communication between the fluid
DISEASES OF TUB OPTIC NF.RVS.
3<
contents of the skull and the intervaginul space of the optic nerve, it was shown that the subdural space was distended with a serous iiitlammaloiy tluid, and that the uptic nerve at its |)assage through the lamina crit>ro!>a o( the sclerntic becomes compressed (iichmidl-RimpIer). Finally, Deulschmann (cf, lit.)
FIC- ]■— Dmokam HHowiiro the Okmim ov THt Orric Setivc (Arur WcKHictu^> /, cnatB o( 1)m ens certtiri^ m. nibMantui nicn: •'/•. inim, tgt. nuur c'i'culm bnlr : r/. bnch. paM. CDfp. qnadr. ; f«, fancll. UU. <aq>. qukd, ; ^. pulvinar \ i, uptle mtUioo.
ha^ put fonh the view that papillitis is not caused by mechan- ical influences, but that it is due to the action of pathogenic organisms which euler from outside. How (ar this view is correct further experience will show. Besides the pure papil- litis there is also found a papillo-rettnitis. the nphthatmoscopic picture of which diflcrs from that of the lormcr affection, and which is to be referred to a meningitis, which has advanced ftiong the sheath of the optic nerve.
A pure papillitis, as we have said, is chiefly found in intra- cranial tumors. Patients in whom a brain tumor is suspected ought to be examined for choked disk even if they do not complain of any subjecrive symptoms pointing to it, because tight may, even if the disk \?- markedly swollen, remain nor- mal for a long time. Only when the nerve or the chiasm is 5tronglv compressed does amblyopia or amaurosis occur in the early stages.
32
DtSEASRS OP THF. CRANIAL h'ERVES.
The scat of the tumor has nothing to do with the occur- rence of papillitis. Basal neoplasms can, iTirough direct press- ure upon the optic nervt. cause a simple atrophy of the same. Nor does the nature ot the tumor play any part here. Gum- mata, tubercles, cntozoa (cyslicerci. cchinococci), carcinomata. gliomala — any one of these may produce a papillitis, which is usually bilateral (in ninety-three per ccut of the cases, Annuslcc and Reich), although the processes need not necessarily be equally developed in both eyes.
Of practical importance arc the sudden spells of blindness which occur sometimes in the course of a papillitis, termed by H. Jackson epileptiform amaurosis. They are probably due to a temporary swelling ol certain tumors and ihe consequent compression of certain areas of the brain or the vessels (Leb«r) distributed to ihem. These attacks may last for hours or days, and either disappear completely or leave a permanent increase in the amblyopia The ophthalmoscopic examination docs not teach us anything about this periodical blindness.
A papillitis rarely ever gets well; in by far the greater number of cases a papillitic atrophy and totnl amaurosis take place, first in one and then in the other eye. Cases in which one eye is seriously damaged while the other remains per- fectly well arc extremely rare. I have, however, bad occasion to observe an instance of this with Magnus. More Irequenlly both eyes become diseased, one soon after the other. Dropsy of the ventricles may give rise to a simultaneous amaurosis of both eyes.
Fapillo-rctinitts is not very rare in tubercular basilar men- ingitis; in epidemic cerebro-spinal meningitis it is exceptional. Chronic cerebral affections of children often lead to it, the amaurosis in these instances usually developing quickly, while the general symptoms become intensified.
Inflammations of the optic-nerve trunk occurring alone may be caused by cold, febrile diseases, syphilis, disturbances in menstruation, and hereditary influences. On ophthalmoscopic examinatiua either nothing remarkable or only a slight blurring ol Ihe disk is recognizable, because the in flam mat ion ailccis more espt-cially that part of the nerve which is bchiinl the eye- bull (retrobulbar neuritis ot von Grade). The disturbance of vision usually liegins gradually, and is confined either to the periphery of the field of vision or it consists of a central am- blyopia or a circumscribed central amaurosis. It dues not ter-.
D/S/-ASES OF THR OPTIC KERVE.
M
minale in complete blindness ; frequently only marked disturb- ance of color vi<iion remain;*.
To the neurologist the cases o( optic neuritis in patients with a neuropathic lamily history arc of extreme inierest. Such perS'His usually suffer even in eiirly youth from migraine, nervous palpitation of the heart, vertigo, somclimes also from epileptiform attacks. lietween the ages of twenty and thirty they begin to complain of trouble with their sifjhi, either of subjective light or color sensations or else that objects appear lo them enveloped in a dense mist; within from four tu six weeks they may become completely blind, but their blindness as a rule docs not persist, but gives place to a central ambly- opia with normal sight at the periphery of the field Of vision. The prognosis differs markedly in different families. It is ol interest to note that as a rule only the male members ol the lamily arc wont to be afTecIed by the disease.
In Ihe second place we will consider atrophy of the optic nerve. It consists in a wasting of the nerve elements, and may be cither primary (genuine) or inflammatory, the consequence of a previous neuritis. It may also affect the trunk of Ihe nerve as well as the intraocular end of it. If the nerve, besides the wasting of its pulp, also undergoes a diminution in its volume, so that it appears like a gelatinous grayish-yellow cord, the atrophy is known .is gray dcgcrncration.
Tumors and inflariunatory exudales, as well as splinters of bone, may by pressure, by shutting ofl the blood supply (as, tor tnsluncr, in embolism of the arteria centralis retinee), and through ititerlercnce with the nutrition lead to atrophy.
The progressive atrophy, or, as it ts better termed, progress. Ive gray degeneration, which may be of cerebral or spinal origin, is characterized clinically by a diininulion in the acute- ness of the central vision, a contraction of the whole visual field, and disturbance of the color sense. In the ophthalmo- scopic examinaiion the bluish-white discoloration o( the disk and the atrophic escavation of the nerve {due to wasting of the sutrstance ol the disk) are very apparent. The acuteness of vision, grows gradually bui progressively less, and months and years may pass before complete amaurosis is developed. Oa the other hand, the whole process may run its course in two or three weeks. The contraction of the field of vision is rarely concentric ; usually the delects are in one direction only, and are often sectorial (Leber). Enormous contraction of both fields ol J
34
iiiSEAS£S OF THE CRASIAL ^'BHVES.
vision, with at tlic same time normal acuteness of sight in the center, which was eventually (ollowcd by btinclncss. has been obscr\'c<l by Schwciggcr. The (listtirbaiicc in color vision is at first limited to the perct-ptjon u( green, which is confused with white or gray, the perception of blue and yellow being rcla- lively longest retained. The atrophy develops bilaterally, al- though one eye alone may at first be affected, and the other eye remain intact for years.
Foci of softening in the brain, progressive paralysis of the insane, sometimes also epilepsy, are the cerebnil diseases in which the affection is not rarely observed. It is besides alM> noted in multiple sclerosis, although in this disease ft never leads tototal amaurosis, a fact which Charcot was in the habit of emphasizing in his lectures.
More important is the fact that in locomotor ataxia optic atrophy is comparatively frequent. Wharton Jones (British Medical Journal, July 24, 1869) makes the sympathetic re.spot)> sible lor this, assuming that the paralysis of the vasomotor nerves, producing first hypcrarmia, leads finally to atrophy of the optic nerve. This explanation, however, is at once over- thrown by the tact that in the optic atrophy of tabes there are at no time any traces of hypcnemia.
Congenital optic atrophy can sometimes be traced to hered- itary influences, or lo consanguinity of the parents; several cases have been known lo occur in the same family without apparent cause (Nicolai, Ncderl, Weekbl.. 1890, i. 5): some- times it is due to hydrocephalus. Injury to the skull in conse- quence of instrumental interference at birth very i^rely has anything to do with it.
The diseases of the chiasm and optic tract may be consid- ered together, since they possess one symptom in common which is of special interest to the neurologist, vix., hemianopia. It is the only form of visual disturbance where one can with certainty diagnosticate a central affection of the optic nerve. It is likely lo be of cortical origin if the hemianopia occurs sud- denly as the only symptom, there being no change to be found on ophthalmoscopic examination ; whereas if other symptoms accompany it — aphasia, hemiplegia, etc, — this idea of a cortical lesion must be given up. By hemianopia in general we mean a loss of one half (the right or the left) of the field o( vision, so that patients affected with right-sided hemianopia see the objects which are in the left half of their visual field, whereas
4
J>/SEAS/iS Of THE OPTIV XKRVE.
35
Ihosc to the right arc not perceived. l( ihe disturbance affects the halves on the same side of both eyes — that is. the nasal on the one, the temporal on the other — we cnll it a homonymous hemianopia. If in both fields the temporal halves arc lost, this constitutes what is known as temporal hemianopia. which is of rarer occurrence ; the absence of both nasal halves of the field of vision docs not sccra to occur, and the superior and inferior hemianopia. where the line of division is not vertical but hori- zontal, seems to be extremely rare.
The explanation of the hemianopia in lesions of the cortical center for sight is quite evident if we accept, as is now gener- ally done, the existence of the above-described semidecussation of the fibres in the chiasm. The path from the optic tract to the cortex of the occipital lobe may be divided into the follow- ing segments (Wernicke): The first includes the optic radia- tion in the occipital lobe, the lesions of which give rise to homonymous hemianopia without any other focal symptoms, lesions of the right occipital lobe causing left-sided, ihose of the left right-sided, hemianopia : the second will include the place where the fibres of the optic radiation enter the internal capsule-. aii<I the ganglia of origin of the oplic tract, the pul- vinar, and the outer geniculate body — hemianopia and hcmian- aathesia ; the third will include the optic tract in its course at the base of the brain — hemianopia with hcmiplrgi.-j. If in ihe region of the visual center or the optic radiation a bilateral focat lesion occurs, then we may have complete blindness set- ling In with an apoplectiform attack. This is in reality a bilat- eral hemianopia, and is dcsign.ited cortical blindness. The (uDclion in the two halves of both eyes need not be totally lost ; atrophy of the optic nerve does not take place- Weir Mitchell has shown ihat a lesion of the chiasm may produce bilateral hemianopia: his case was one in which an aneurism pressed upon the chiasm (Journal of Nervous and Mental Dis- eases, January. 18S9).
Of diagnostic value in these cases is sometimes the so-called hemianopic pupillary reaction (Hcddaeus. Wernicke), or hemi- anopic inactivity of the pupil (Leyden). With the mirror of the ophthalmoscope we reflect the light first upon the left, Ihen upon the right half of the retina, and observe the pupillary re- action. If the reflex occurs normally, the optic tract must be intiict. and the disturbance must be due to a bilateral lesion of the oplic radiation in the occipital lobe, or in the cortical ccn-
36
O/SSAS&S OF THE CRANIAL NEItyES.
tcr. \{ the reflex is not obtained, we must assume a lesion oE the optic tract of the corresponding side. Light perception and pupillary reflex go in this case liand in hand. In a recent article lleddaeus hitiiseU expresses the opinion that for the present it is not justifiable to base the differential diagnosis be- tween lesions of ihe oplic tract and lesions of the fibres in their central course exclusively upon the absence or presence of this symptom (Deul&ch. med. Wochenschr., 1893. No. 3).
In diseases of the chiasm hemianopia has been repeatedly met wiili, but in ihis ease we have not a homonymous but a bitemporal hemianopia. as in the case of Oppenheim, where gummatous disease of the chiasm was responsible for the dis> turbancc (cl. Virch. Arch., i885, Bd. civ, 2, p. 306), ()uite lately the same author has described an "oscillating" bltetn* poral hemianopia in diseases of the chiasm, which he considers as pathognomonic of basal cerebral syphilis (cf. lit,).
If the tissue injured by the lesion which has caused the hemianopia is capable of regeneration, as may be the case where we have a hasmorrhage or an inllainmation. the defect will pass off completely ; whereas it this is not the case the trouble re- mains stationary, without, however, any additional disturbance of sight. Such a condition, which often develops as Ihe con- sequence of an apoplexy, may persist for years, but no second attack, by which the centers of the other tract also may be disturbed, is to be feared, as such a thing has never been observed.
The examination !n a case of hemianopia may (roughly) be conducted in t he following manner : The patient is to be placed at a distance of about two feet from the examiner, and, if the right eye is to be examined, asked to cover his left eye with his hand, while with the right eye he fixes the left of the examiner who covers his own nght eye. The examiner then holds up his finger between the patient and himself, and moves it in dif- ferent directions as far as the border of his own field of vision, the patient at the same time being asked how far out he is able to see the finger. The examiner is thus enabled to notice every motion of the patient's eye toward the object, and, judging from his answers, can compare the patient's field of vision with his own. Instead of the finger, a small piece of white paper fa&tened on a dark penholder may be used in a similar way. These tests should be made in a good light (Donders, Cow- ers).
I
J)/S£AS£S OF Tim OF TIC NERVE.
37
The more extensive defects can always be found out by this method: for slight uiie^ a perimetric examitialioii t& in- dispensable. An accurate determination of the field of vision
rie, «,— KtKjji or VtnoH or ihk LKrr ami Kicht lire. (Afier FnitirKa.)
with the help of the pcrimelcr can only be attained by prac* lice. A description of the instrument and its use is here
Dc. ^— FiiLU or VtoioH or thk Lkpt and Rkiht Evk w LurT-Hiin) HKMiAxoru.
(Aftn GoWEHs. )
DO! necessary. Fins, 4 and 5 illustrate 0) the normal fields ol the left and right side; (2) the hclds in a case of left-sided bemianopia.
38
DtSEASF.S or THE CKANtAL NEFVES.
I.ITKRATURE.
Ojipenheiin, [)ii; oadllirenJe Hciniupju tHlemporalix als Kritcrium dcr bosakn
Hiriis)]>hili§. Ikriiner Itlin. WoclKnschr. 1887, No. jA. Fnrud. L'clrer H<:mi<>|>ic im fruhcsMn KindcMillcr. Wicnmncd. WochcflschrH
(«»«. No. 31. Siles. VoriibcTgrhcndc Hcmiopie nach Ktuchhusien. Bnljncr Win. Wochen-
Kchr, r88S. No. 43. \ViII>innd. liic hem iojwsc lien (IriichisfelUfonnen und tla.t opiwche Wahrneh-
mungsrcotnmi, AiUs hciiiiopi*chcr nriccie, Wiesbaden. 189a Ulhoff. Deulsche Meet. Zij;.. i8r/>. No. 10. WoHcnbcrjf. Hfmio|)ie aXs Kolge von Tuinoren in dcT hinteren Schadelgrube.
Arch. f. Psych,. 1890, xxi, No, 3. Lcyikn. Ucticr die hcmiopiiclic Pupil Ictiilarre Wernicke's. Dcuieche mcd.
Wochcnsclir., fSgi, No. 1. Wilhnnd. Ein F.itl von Seeicnhlindhcit und H<rmioplc mit Seclloit»l>crund.
UcutKhe Zcilschr. f, Nervciilik.. tSyi, ii, No. 5 u, 6.
The so-called flitting scotoma (amaurosis partialis tugax. or temporary hemianopia) has in all probability also to be regarded as an affection ol the center for vision. The disturbance comes on in paroxysms. At first a dark spot appears in the field of both eyes, which increases in a crescentic or horseshoe form. It begins to scintillate and becomes bounded by a bright zig- xag line of brilliant colors. If this has alter fifteen or twenty minutes reached the border of the 5eld of vision, it disappears from the center toward the periphery and the field clears up again. Most probably in all cases the affection is bilateral. The attacks, which last from a half to three quarters of an hour, occur with variable frequency, sometimes only once dur- ing the whole life, and it is Jnleresling to note that thcv arc almost alwavs associated with attacks of
migraine. Of the
causes nothing is known, although the belief that hard mental workers are especially prone to il is not without foundation; but there arc numerous cases in which we arc reduced to re- garding sexual and alcoholic excesses, cold, etc., as BCtiological (actors. As we are not acquainted with any remedies for the disease, we have to be satisfied with prescribing tonics and strcnglhening diet, quinine, and, above all. mental as well as bodily rest. The so-called night terrors of children are prob- ably to be regarded as due to irritation in the optic center (Soltmann).
The nature and the scat of those forms of amblyopia which develop under the influence of hysteria and of certain toxic substances are still obscure.
DtSBASES OF TifE OFT/C A'SfifS.
39
I I
I
To this class of substances belong mure especially alcohol, tobacco, and lead.
The alcoholic amblyopia is the most frequent form. In the . mildrst cases it manilesis itself .-ts a simple central 3iiibIyo|>ia without distinct scolumata, without disturbances in color vision, and without contraction of the visual field ; whereas in the most serious forms, which may occur after excessive indulgence in spirits, especially in persons of previously moderate habits, there may be an acute, almost total blindness. Alter the recur- rence of such attacks a mure severe form of atrophic disease of the opiic nerve may develop, with which is associated discol- oration of the whole disk. Central colored scotomata and sim- ple scotomata, disturbances in color sense in the whole visual field, are then not rare. The ophthalmoscopic examination does not reveal anything very characteristic. Vision rarely becomes less than ^ to ^, and complete recovery even in the most marked cases is possible. The few examinations of the optic nerve which have been made after death seem to indicate that alcohol exerts a directly injurious action upon the nerve itself. The latter has several times been found in a stale of fatty degeneration with or without compound granular cor- puscles and thickening of the interstitial tissue which contains the vessels (Krismann. Leber, cf. lit.). Since it has recently also been shown that alcohol can act in a similar way upon the peripheral nerves this pathological condition is more easily Dndersitiod.
Similar in its development and in its course is the so-called tobacco amblyopia, which, caicris paribus, is, however, more rarely met with than the alcoholic form, and is more benign, inasmuch as it usually passes off after the cause is removed. The diagnosis is, as a rule, easy enough, as other signs of chronic nicotine poisoninj; (digestive disturbances, palpitation ol the heart, insomnia) arc rarely wanting. The disease seems only to occur among those who use tobacco in some form or other, in smokers or chcwers, while the workers in tobacco, who are exposed to the inhalations of the tobacco dust and of a certain amount of nicotine, seem, so far as experience goes, not liable to the compl.iint.
The one form of amblyopia which has been more carefully studied than any other, but which nevertheless is not much better known or understood than (he affections which we have just treated of, is lead amblyopia (amblyopia saturnina), in
40
mSf.ASF.S O/-- TMH CRANIAL NERVKS.
whici) the field of vision may remuin normal or in which there may have developed central scotomata or contraction of the visual field. Pronounced neuritis, with decided swelling of the disk and with peripapillary hicmorrhagcs, has been ob- served, and the termittaliun in complete amaurosis is not rare.
Under certain still (mlLiiown conditions a sudden bilateral blindness may develop without previous decrease ol vision — amaurosis saturnina. It is commonly preceded by lead colic. The aUcction. which bears a certain resemblance to the amau* rosis of urscraia, may sometimes improve with remarkable readiness after the removal of the injurious cause.
In a gii'en case we should, for the sake of confirming^ our diagnosis, never fail to search (or other cerebral symptoms common to chronic lead poisoning, such as epileptiform attacks, hemiplegia, speech disturbanccii. and so forth.
About the relative frequency of the disease no definite statement is possible, nor do we know which particular occu- pation in the lead industry is the most dangerous, or after how long an exposure eye trouble develops in lead workers. The rJ/c which the su-c:illed individual predisposition plays in this connection seems as important as it is obscure.
In the treatment of the alcoholic amblyopia, local bleeding with Heurtetoup's cups, active purgation, diaphoretics, and Liter strychnine injections are of service. In tobacco amblyopia the lre.itment is the same, but bleeding may be dispensed with. In the saturnine form purg.i(ivcs arc indicated, also opium and subcutaneous injections of morphine. In all cases, however, the prompt and permanent removal of the injurious agent is a sittf qua twtt ; where this cannot be done the outlook for re- covery is always very doubtful.
Besides the substances mentioned, quinine, bisulphide of carbon (Becker. Ccntralblall f. prakt. Augenhcilk.. 1889. p. 138), and mercury may lead to disturbances of sight, which in their course resemble those just described.
LITEkATtlRE.
Gracfe-Sacmbc}]. Handbuch (l«r gr^amniiEn Augenheilkunrlr:.. Dd. v. Theil v. LelKr. Die Krankhciicn <l«t Sehncrvrn, p|>, 757 tl it^. Leipzig. 1877. FrtrUtT. Betichungen der AUEcmFirileiden u. Orguiierkrankungcn lu Venln-
deningcn 11, Krankhriirn <lf* Schorg.ins l.dpiig, F.nKclmann. 1877. Plobin. Des troubles ocuUiru (Unn In m.-Lladics de IVnc£pli«lc. 1'«ri%. RaiI-
lUrc. i8Sa _^MasiHi3. Die BUndheil, ibrc F.ntMehung und Vcrbiitung. Unslau, Kcm, r883.
DISEASES OF THE OPTIC NERVE. ^x
SchoelcT und Uthoff. BdlrSge lur Palhologie des Sehnerven und der Neti-
haut bei AUgemeincriirankungen. Berlin, Peters, 1S84. Jacobean. Beiiehungen der Venlndeningen u. Krankheilen des Sehorgans lu
Allgemeinleiden u. Organ-Erkrankungen. Ldpzig, Engelmann, 1885. Peltesohn. Ursachen u. Verlauf der Sehnervenatrophie. Cenlralbl. f, prakl.
Augenheilk., pp. 45, 7$, 106. 1886. Bergmeisier. Die Intoxicationsamblyapien. Wien, 1886. Nettleship. Lancet, July 16, 1887 (Quinine Amblyopia), UihofT. Untenuchungen ijber den Einfluss des chronischen Allcoholismus
auf das menschl. Sehorgan. V. Gracfe's Arch.. Bd. xxxiii. Abthl. 1. Deulschmann. Ueber Neuritis optica, bes. die sogen. Stauungspapille. Jena.
Fisclier, 1887. Siemerling. Ein FaUvongummdserErkrankungderHinibasismit Betheiligung
des Chiasina. Arch, f. Psych., nix, 3, pp. 401 et stq. 1888.
CHAPTER III.
DI8RA8CS OK THK KP.HVC.« St.'l'PLVING THE OCULAR MUSCLXN — I. t... THK THIRB (uOTtlR OCUl.l), THE FOURTH (PATHETICUS), AND THE SIXTH (aBDUUENs).
The (bird ncn'c emerges from ihc brain al ihc inner margin of the cms clo«e to \he anterior border of the puns; it pa»se« obltqudy forward and outward, readies the outer wall of the cavernous sinus, enters it, and ikcn divider into two branchc§, which, passing through
the sphenoidal fissure, fu.a- — ■■ ^^ — ^"-—^ ^ enter the orbit. The
upper division, which supplies the levator palpebrie supcriorit and the rectus supe- rior, is the smaller of the two. Of the three branches of the lower division, the one sup- ))lying the inferior ob- ti<|ue is the longest; the two others, one of which goes to the in- ferior rectus, the oth- er to the internal rec- tus, are shorter. The f%. &-C»ow Skttiooi mKOfOH tii« Rwiioi. or the , „ branch that
Am. CoBTO«* Qi;*p«i<iKMis.»- longesi urancn. inai
f«.a.ulerinrccq>ara<]UUlrigeiiilna ; f.e. Krajr mallrt armiiwl "' '"^ inferior OD- Ib* aqueduct <if Sjlviui ; ay. aqueduct of Sylviu*: ■/// lil|UC, givcS ofl a nuckni of ihe Ihlid nem ; lU. posieriiH' lonciludinkl bun- <ihort root to the cili- dU: r, t. »d nucku.ftjrna.tum); ». »I-UMi. ..ij^ ' ,;„„ n,^ fi,,.
Qoou Digcr) 1 /, eocbral Mdoode. " ? h ^
mcnis of which are
distributed to the ciliary muscle (tensor choroidea;) and to the COD- sirictoroftheiris(sphinclcrpupillK); consequently these intrinsic mus- cles of the eyes also arc innervated by the third nerve, while the di- lator pupilla;, on the other hand, is provided for by the sympathetic. 4a
/t/SAAUKS OF TUK MOTOR NI'.MVKS OF THK F.YH.
43
»
I
The nuclei of ihc (hird nerve, a column of multipolar saiijEltontc cells, lie above the potiierior longiludinal bundle, between it and the aqueduct of Sylvius, and the rout librcti coming (rum ilicm divide into scvetat fuNciculi, pierce the povlcrinr Iniigiltidinal bundle, the tegmentum, with the red nucteuH and \\\<t iiul>?.iunti.i ni^ra. and emerge Iriim the brain at the place shown above (cl. Fig. 6).
Experimental as well a^ clinical ob!>crvatioiia seem tu indicate ihjii In tile coltectian of ganglionic cells of this nerve nucleus there exist three centres, the anlerior of which is the centre for the ciliary muscle (accommodalton); Ihc next the centre for reflex stimulation of the iris b]r light \ the third, by fur the largest, the centre fur the extrinsic ocular muscles (Gowcns). Observers, however, by no means agree with regard to the number and puiiition of the indi- vidual oculo-motor nuclei or centres. The view held by Guwer& is diagrammatical ly illustrated in Fig. 7.
That there exists a cortical centre for the ocular muscles and the levator palpebrarum is beyond question ; nuthing certain is, however, known about its situa- tion : moitt probably it lies in the upper or low- er parietal lobe (cf. Ex- iicr, Untcrsuchungcn Ubcr die l.ocalisation der Funclionen in der (iriisshirnrindc dcs Mcnschen. Wien, Brau- mQIIer, 1S81, p. 41).
The fourth, the trochlear or pathetic nerve, is the smallest of the cranial nerves, but
the longcht course within the skull c.ivlty. It leaves the
n cloKc behind the corpora quadrigcmina at l^ie upper sur- face of the valve of Vieussens; from here it takes a lateral and downward course, winds around the outer side of the cms cerebri, and reaches the ba&e of the brain. Its course is now forward ; (Hercuig the dura mater behind the anterior clinoid proces:^, it reaches a small channel of the cavernou'i sinus, and runs alongside of the third to the sphenoidal tissurc, pierces its fibrous membrane, and finally enters the superior oblique muscle.
The nucleus of the fourth lies behind the collection of cells from which crtinnales the third nerve (Wernicke), to the ventral side of the aqueduct of Sylviuw, on the (M)Slertor longitudinal bundle, in the Itrajr matter around the aqueduct. From this nucleus the loot
t^HE- 7.— nMOftJlMATIC \ja»a\tVb\*M. SeCTIOM TIIIUIC«II THK PWS WITH THK NUCLEI OP THE OcUljUl BKKVU.
(Aficr GowKHK) C. 0- Coqiota qiudrtetmliM ; at' tV and I c npmcni ihr tenlrei asd tbc >wrvc-nbn3 ; a, for •axmniDilaiion, b, («t ihe tHIo iictlvliy of thi irU, t, fni IliD ntrlniic nruUr muicki : all dim .irr cimUiiud in ibc oculoniotorliu, /t'. palhctlc. 1'/. kbtluceni.
DISEASSS OF THE CRANIAL A'EfirSS.
oriicinates, which, pa&ainc (o the mc&ial side of the descending root of the fifth (Fig. S, Vd), extends as a round bundle (I V) to the pos- terior corpus (|uadrig«minum ; in the substance of the valve nf Vieus- Bcns it is cru)>»«d by the nerve of the opposite side, and emerges finally in the above -described manner on the Mde opposite to that in whkh hs nucleus is situated.
The sixth nerve, the abduccns, leaves the brain at the pcisie* rior margin of the pons, between It and the anterior pyramid. It
Fig. K^Cnoa^ttrTKis THaounH thr S-toicik or meTtMUTirnnt. (After Sckwalkc.) tf. palhflicuKTonlDC. /I , I*alh«lu;uasl iu ciiL /)'' ctom iMttoftol ikc piMlwltai* la iu <niina (o Ih* nudcuKi K'- daandine rnM of the iri|;Fmluta (iiimi ■iiilmi) : nf, ■qunduct. f . t, cmlnl eny RutMUno annind the aquodurt, i./, lubmoida (emieip. t, Mpk pcdUDclr of onvUrlliiin crunlac '^< '• ''■ raphci /-r. lonaulo reUcuUtU, iJ, pa»- Urlor lODciludiiul bundlr.
takes at once a forward course and passes into the cavernous iiaat, piercing its posterior wall ; it then runs, surrounded by the dtiral shcalh, alongside of the internal carotid, and, emerging through the sphenoidal fissure, enters the external rectus, in the substance of which it breaks up into branches.
The nucleus of the ahducens, which was at one time thought to be connected with the rout of the facial nerve (hence the facial- abduccns nucleus ol Meynert and Stiilini;). lies m the fioor of the fourth ventricle, from which it is separated by the cpendyma The abducenit root, passing through the peduncular portion of the pons to the outer side of the pyramids into the tegmental region of tt pons to the median side of the upper alive, finally enters this nucleuti (cf. Fig, 9). The tegmentum behind the lemniscus is divided into three parts by the abducens (and facial) root, the inner two of which Meynert has called the motor region of the tegmentum.
0/.1£ASSS OP THE MOTOR XERVLS OF THE EYE.
4S
The aflections of the nerves supplying the ocular muscles belong, strictly speaking, also to the domuin of ophthalmology. Since, however, they are of such iinporlance for the diagnosis and the prognosis in certain nervous diseases (e. g., labcs), it is necessary to devote a few pages at least to the description of ihcir symptoms and the proper methods o( examination.
The independent diseases o( the muscles of the eyes may be of a paralytic or of an irritative (spastic) nature, the latter
mVnr Yu I Vila rila
na
Flf. ^ — CwiiA^BCTKM' TtlNol-o» THt roNH iMU-t SCHWAi.nf..) ■ I V. abdiKVi)* nq- dcMl F/, abdufcnf. C>..V., Upprr olive, at', ucendinE "xil «( IricvTninut. iC//, •Kleiuni (>daL nt'/lt, vnitlarj nuclcua (uxalM <tlvmal nuclfui). tV/. VRiirEinK pMUon n< lacUl nxA. /->. irinnrnt libna iif tht piiiu which are dIvicM intu «up(rlidal I JW Mid dtcfi ^. fy, fjnattisA tract.
class, however, l>cing by far the less frequent of the two. Their seal may l>c central or peripheral, although we should state that an undoubte<l central alTection of the abducens and of the paiheticus has never been observed. Of ncuhvmotor paralysis, We are .icquainted with n peripheral and a central form.
A peripheral affection may have its seat in the stem or En ttK branches; a central, in the nucleus or the (supposed) cortical center of ihc nerve. The former will be characterized by the absence of all cerebral symptoms, which, in the central form, arc nlni(»st always present. It can be brought about by patho- logical changes in the orbit, in which case the eyeball not infrc<iucnlly protrudes and becomes immobile. Further, it may develop as a rheumatic paralysis Irom exposure to cold
46
tUSEASes OF THE CKASIAL NERVHS.
{a /rig»re); also in constitiitiunal syphilis, in diphtheria and other acute infccltous diseases, in meat poisoning, and as the result of alcoholic excesses ; exceptionally it is seen alter Irau- n)attsm. In one oi my cases a man was kicked by a cow in his right eye ; after the acute symptoms had passed oH, a pa- ralysis of the levator palpebral superioris remained for months. Power of vision was not interfered with.
The central paralysis is met with in the course of meningi- tis, multiple sclerosis, progressive bulbar paralysis, and. above all. locomotor ataxia. It rarely afTccis all the ocular mus- cles at the same time, but cither the extrinsic or the intrinsic alone (cf. Knies, Ueber die cvntralcn StUrungen der willkUr- lichen Augcnmuskcln, Arch. fUr Augenhk., 1S91. xxiii, t, p. 19). Although the diplopia of tabetics is neither a constant nor a pathognomonic symptom of the disease, the occurrence of transient double virion in otherwise apparently healthy per- sons ought always to make us suspicious, and ought to induce us to subject the patient to a more careful examination. The nature as well as the anatomical seat of this oculo-mntor pa- ralysis occurring in tabes is entirely obscure. A monocular di^ plopia may occur in hysterical patients ; owing to disorders of accommodation two or more images are thrown upon the retina ([Jouveret ct Chapctot, Kcvue de m6d., 10 Sept.. 1892, p. 728; and Durct ct Dujardin. Sur la diplopie monoculairc comme sympt6me c^r^bral. Journal des sciences m^d. de Lille, 1892).
01 the cortical oculo-motor paralysis we know little or nothing ; the only well-established fact is that an isolated paralysis of the levator palpebne superioris may be associated with cerebral afJeclions— for instance, with a cerebral haimor- rhage, but the location of the center is not known. Grasset and Landouzv thought it to be in the second temporal convo- lution (the pli ccurhf of the French writers), but Charcot and Pitrcs have adduced important reasons against this view. Lately the subject has again been taken up by l^moine (Revue de m£d.. 18S7. vii. ;). This " blepharoplosis ccrcbra- lis" needs much further investigation.
Isolated ptosis may be unilateral or bilateral: it may be ac- quired or congenital. Of the latter form Siemcrling has pub- lished a case, with autopsy, in which he found degenerative changes in the main cell group of the ventral as well as the dorsal oculo-motor nucleus (Arch. f. Psych., 1892, xxiii, 3, p.
0/SEAS£S OF THE MOTOR NERVES OP THE EYE.
47
I
764). It is interesting to note that some patients with ptosis are able to open their eyes if they put into activity certain muM:Ics supplied by the trigeminus— for example, the muscles of mastication.
Acquired ptosis is not always due to an aQection of the third nerve, but may be the result of a primary atrophy of the levator palpcbrx supcriorts. Fuctis has reported a num- ber of such cases (Arch. f. Ophthalm., 1S90, xxxvi^ 1. p. 234). Diitil has described two cases of ptosis in the same family. (Note sur unc forme de ptosis non congenital ct h^riditairc. Progr^s m&<\., 1893, 2 S.. xvi. 46). The duration of the dis- order varies. 1 have notes of several patients in whom ptosis existed for years, and in whom no other, spinal or cerebral. symptoms developed. A very complete paper on the a;tioIogy and the aeliological diagnosis has lately been published by Dali- chow from Senators clinic (Zcitschr. f, kUn. mcd.. 1S93. xxii,
4. SV
In studying the symptoms of the paralyses of the ocular muscles we shall tirst consider those of the oculo-motor pa- ralysis, more especially of the complete form, in which all branches of this nerve are implicated.
The upper eyelid droops completely, and the eye can only be opened slightly by the aid of the frontalis ; the movements of tlie eyeball arc also at fault ; the eye. deviated outward as it is. can not be moved toward the nose ; similarly any up. ward motion is impossible, as such depends upon the supe- rior rectus and the inferior oblique. On the other hand, the outward movements arc unhampered (rectus externus). while the downward motion is performed by the superior oblique, the pure action of which can here be well studied, the rectus iDferior, which otherwise also assists in the downward motion of the bulb, bein^ now inactive.
From the different directions of the axes of the two eyes there results a very apparent symptom, namely, strabismus, which may be convergent or divergent, acconiing to the mus- cles affected. This strabismus, due to piiralysis of the ocular muscles (paralytic), diflers from that caused by spasm (spas- modic), inasmuch as(i) in the latter the deviation exists with ■II movements, while in the former only with those which call into action the paralyzed muscle; (3) in spasmodic strabismus the secondary deviation of the sound eye, of which wc shall presently speaic (cf. p. 51). does not occur.
48
DiS£ASES OF THE CRANIAL NERVES.
The double vision, "diplopia." which is associated with strabismus, is especially marked at the beginning of the dis- turbance, before the patient has learned to suppress the " false image " seen will) the aQected eye. and only to pay attention to the "true image" seen with the healthy one (cf. Amon. Ueber Diplopie, Mtiiichener nicd. Wochenschrilt. 1S90. 46). At first these double images cause him much annoyance, until later on he learns to close the affected eye by contraction of the orbicularis, or to put the head into a position in which the affected muscle is not called into play. By these devices he not only avoids the unpleasantness of the double images, but also the consequences which the erroneous projection of the visual field entails, namely, a peculiarly disagreeable feeling of dizziness, the so.c;ill«d ocular or visual vertigo, to which we shall have occasion to refer again.
Wilh reference to the pupillary symptoms we must keep in mind the reactions present in a normal eye: the pupil reacts directly to changes between light and darkness, contracting if light is thrown into the eye. and indirectly in that the pupil of one eye dilates if the other is covered; it also reacts on •mti' tions of convergence and on forced accommodation, contract- ing in either case. All these reactions are lost in complete paralysis of the third nerve. The pupil is moderately dilated and gives no response to the influence of light or accommoda- tion ; if the paralysis is incomplete, and either the sphincter of the iris or the ciliary muscle, or both, are intact, so that in the latter case only the extrinsic muscles do not perform their function, the size of the pupil can vary and accommodation be retained.
The reflex immobility of the pupil (Erb), also called the "Argyll-Robertson pupil "—that is, where the pupil has lost its reaction to light impressions (reflex), but has retained its power of accommodation — is very frequently observed in tabetics. Besides this, the pupil in tabes is often very small, pin-head pupil — spinal myosis.
Ineijualily of the pupil, anisocoria, is also seen in the course of tabes, in general •paralysis, in hemicrania, optic atrophy, separation of the retina, accommodation paralysis, etc. Recke, in the ophthalmological clinic of Magnus in Breslau. has lately pointed out that this symptom need by no means have the ominous significance which has formerly been attributed to it, but that not infrequently it is found associated with asligma-
DiSRASES OF THE MOTOfl X/SKrSS Ot' THE EVE.
49
*
tism, myopia, and wiih presbyopia, especially in men, wiihout the existence of any central disease (Oeiitsche med. Wochen- schrift, 1893. '$)■
LITERATURE.
Lecsrr. Dir PuplUaibewrgvng in physiologischcr unit p;itho1ogiBCI>(T B«(eK-
nag. Wtethmilen. Bi^rf;mann. iSSz. HnblMait. Die I'upllUm'jiction aii( Lictil, Jhre Pnifung. Mcflsuns tincl Uinlscbe
Bcdcutiine. WbwbiKlrn. DcrgmAnn. r886, Kmukiicui. l1i)'Mok>g»e und Pailiologje dcr PupilUmeaciion. Wiener Klintk.
ISBS, Hcfl 4- flnliUcu't. Rttlexcmjifirnllichkeil. RcHenaubheit und rdleclorixche Pupilleiw
siarre. Brrimi-r kliru Woclitnichr., 18&8. 17, 18. Scg^L Arch. I. Augcnlit:.. 1893. xxvi, 2. jk iji.
Paralysis of the ahdticcns, unilateral or bilateral, which also comparaiivtrly freqiieiiily accompanies locoinotnr ataxia. oElen constituting here the nnty initial symptom for a \ong lime, is to be recognJK'd by nulidiif; that the eye. which is slightly turned inward, can not be moved outward, while all the other move- ments are unimpeded. In exceptional cases this is found asso- ciatcd with facial and trigeminal paralysis. The condition is ununlly congenital. Bernhardt (cf. lit.) has reported cases u( this kind, and M(>bius in an extensive article gives a careful study of the inlanlile nuclear degeneration, and has especially called attention to the fact that a large proportion of all ocular paUics are congenital or acquired in early life (MUnchener med. .\bhandl., 1892. 6. Rcihc. Heft 4).
Unilalcral paralysis uE the abducens has iihn been ob- served after fracture of the ba.<>c of the skull (KOhler, Ber- liner Iclin. Wochenschr., 1891, 18).
Unilatenil paralysis of the paihcticus, which supplies the superior oblique muscle, is always difficult to recog^nize even when the muscular system of the other eye remains perfect, and can only be di.ignosticated after an examination of the na- ture of (he double images. When there is paralysis of the oculo-mniorins in the othor eve a diagnosis is impossible. The examination ought to be made by an ophthalmologist in order to establish the absence of power in the superior oblique (cf. Halm, BcitrUgc znr TrochlcarislHhmung. Tilbingen. Moscr. 18SS). Extremely rare is the bilateral pathciicus paresis, which has been noted in some cases of ttiinor of the pine.-il gland. The anatomical conditions directly underlying it are not known (Rcmalc). 4
so
n/SEASES OF THE CHANIAl. NERVES.
A paralysis of the p»lheiicus. superadded to a paralysis the ocuIo-nKilorius, may be recognized by the absence o( the cliaracteriitiic rot.iliim around the sagittal axis, wliich would otherwise occur on looking down (Wernicke).
If several muscles o( one eye which are supplied by differ- ent nerves arc paralyzed, or if there exist paralysis of the mus- cles of both eyes, we speak of an ophthalmoplegia (Hirschbcrg, Mauthncr). and we distinguish an external ophthalmoplegia if only the extriusic. and an internal ophthaltuuplegia i( only the intrinsic, muscles of the eye are paralyzed (sphincter, dilator, cil- iary muscle). The so-called ophthalmoplegia p;ogressiva (%'on Gracfe) will be described in the eleventh chaplcr of this part under the name of pollencephalilis Miperior ( WcrnicfceV Quite lately attention has been drawn to a so-called recurrent pa- ralysis of the third nerve, of which Mauthner has analyzed four- teen instances. This disease is characterized by the fact that only one. and always the same, oculo-motor becomes afFcclcd, and that the paralysis is always complete — that is, takes in all Ihc branches. Females, especially those of a nervous or hys- lerical temperament, seem more predisposed to the afTcction than males. The duration of the individual attacks varies from one, three, four, to even six months. They may recur after an interval of from four weeks to a year. Other nervous symptoms— migraine, vertigo — may or may not accompany them. The attacks may recur during the whole life o( the patient, and even in the intervals traces of paralysis may re- main ( Milbius. Kcmak). Whether there arc instances in which the disturbance is only functional, or whether in all cases there exists a distinct organic basis, we arc with our present mate- rial unable to <li'ciiie defuiilely, and wc arc equally in the dark with reference to Ihc scat of the affeciion. as td whether it is of peripheral or o( central origin. That there are instances where the former is true is proved by a case published by Kichter (cf. lit.), where a new growth in the nerve itscK was found.
In a suspected paralysis of the ocular muscles wc endeavor to make out in our examination any defects in the mobility of the eyeball. For this purpose Ihc patient is asked to follow with his eyes the finger of the examiner indifferent directions without moving his head. In this way every asymmetry in the move- ments of the two eyes can be noted. If the mobility in the direc- tion of the action of the affected muscle is defective ("primar)*
DtSEASES OF THE MOTOR XERVES: OF THE EVE.
51
deviAtioii "), nystapfintis-like Iwilching is sometimes observed on attempts at cxircmc rotation in that direction. But it may happen that the paresis of a mtiscle is not recognized if its innervation is particularly strong ; then we have in the corrc- spondinor muscle o( the other eye so abnormal an innervation that in the latter the effect is excessive, and wc get a so-called "secondary deviation " of the sound eye. This can easily be demonstrated if the presumably healthy eye is first covered with the hand and the patient endeavors to l\x with the paretic eye a point which it can not reach at all or only with the ut- most exertion. II, then, the fixing eye is covered, we observe whelhrr the healthy eye be in a proper position or not. and i^hall find that the latter has been moved too far in the desired direction. If this method docs not give any satisfactory re* suits, we have to examine into the nature o( the double images. One eye of the patient having been covered with a colored Iflass, he is asked to follow with his eyes (of cotirse, again with- out moving his head) the flame of a candle which is moved to and fro. If there exists paralysis or paresis in one eye, the patient complains o( seeing, on the side toward which the affected muscle moves the eye. two flames, which become the farther apart the more the affected muscle is exerted. But if now. for instance, the patient looking toward the left complains n( diplopia, this may be due to paralysis of the left external or the right internal rectus, as both of these muscles move the eye- ball to the left. To determine which ni these two is not perform, ing its (unction properly, we ninst ascertain from the patient whether the double images are homonymous or crossed — that is, whether the colored picture be on the s:ime or on the oppo. site side to the eye covered with the colored glass (homony- m<M]sand crossed diplopia respeclivelv). In the former case the abiluocns (rcct. cxt.) is the nerve affected : in the latter the ocul(»-mi)lorius(reci. Intern.). For a minute study of the double irnajes the reader is referred to the plates and the work of L^indall, of Paris, which has been translated into German by M.igniis 'Landoll-Magnus. Brestati, Kern, tit!t7 ; also Landolt, Les ch3tni>9 de fixation monoculairos, le champ de fixation binoculiiirc. etc.. Arch. d'Ophthatm.. 1893, No. 5).
The associated lateral movements of the eye to the right and to the left may be interfered with in the following ways:
I. There may ciist a so-called conjugate devi-ition of the eyes — that is. a permanent fixation of both eyeballs t4> one side —
52
DISSAS£S OF TME CRANIAL NERVES,
which can only be overcome, and then but temporarily, by the strongest effort. We shall refer (o this symptom again in our account of hemiplegia.
2. Motion of both eyes toward one side may be permanent- ly lost. In this case wc have a paralysis of the abduccnsof the one and paralysis of the internal rectus of the other side, and the cyfs arc turned not toward (he affected but toward the op- posite side. In such cases the lesion is situated in the lateral portion of the pons, near the abductor nucleus. If the centres of both sides which lie cKtsc together are paralyzed, ihc eyes which arc fixed in the middle can be moved neither to the right nor to the left, but only upward and downward, the up- per eyelid moving normally (Wernicke),
3. The upward and downward motion of the eyes may be lost and only the Ltteral motion be possible. This form of the a&sociated ocular palsy, in which also both upper lids niuy be paralyzed, is ciiuscd by a lesion of the centres situated in the central gray matter of the third ventricle and the aqueduct of Sylvius — that is, in the region of the oculo-motor nucleus. II this be accompanied by a hemiplegia, we are justified in diag- nosticating a lesion of the pyramidal tract at the level of the upper corpus quadrigeminum, the posterior commissure, and Ihc adjoining portion of the optic thalamus (Wernicke),
The treatment of the ocular paralyses is very problemat- ical, and rarely produces unquestionable results. Ustinlly a trial is made with iodide of potassium, a course which may be justified if there is a history of syphilis; but this drug is frequently of no avail whatever. Electricity is used either by applying one electrode over the closed lid of the diseased eye and the other over the base of the neck, so as to pass the current through the whole course of the eye muscles, or by allowing the current to pass transversely through the head from one mastoid process to the other. Medium-sized elec- trodes should be used and a weak current be applied about four times a week, each session occupying from one to two minutes. Now and ;ig.-iin after prolonged galvanization we are really fortunate enough to perceive an improvement in the paralysis, or even to see it disappear. That much of this is to be attributed to the treatment seems doubtful, if we remember that it is utterly impossible to stimulate the ocular muscles with the current: (or the same reason an electrical examina- tion in ocular palsies is impossible (cf. Hirt, Lehrbuch dcr
J}/S£ASSS OF THE MOTOR NERVES OF TUE EYE.
53
Electrodiagnostilc und RIectrolherapie. Stuttgart, Enkc, 1893.
P- 75 0-
Passing over the different spasms of tlic eye muscles which occur in sornc brain diseases, we shall p;iy attention here only 10 one form with which the neurologist ought to make himself familiar, viz., nystagmus. This consists in a to>aiid-fro motion o( the eyeballs in a certain plane, usually horizontal {Hyitagmus oiciilatorms). which continues on voluntary movements o( the eyes, but which is itself not under the control of the will. These movements arc usually present in both eyes, and vary quite markedly in frequency and extent, according as the pa- tieni is made to fix a p{»int or to change the direction in which he is looking. The c<indition is supposed to be due to weak- ness of sight of both eyes, dating from early childhood — that is. to impairment in ihe functions of the retina at a time when these have an important regulating influence in the establisln. ment o( the normal fixation of the eyes (von Graefe). How- ever, there are undoubtedly cases which do not belong to this zXaxf-. for it is a wellknowii fact that nystagmus may be an oc- cupation disease, as it is often observed in miners who have to use their eyes in the dark (Schroder, Moorcn. Nieden, Focrstcr, Snell [British Med, Jour., July 11, 1891J; Priestley Smith libid., Oct. 15. 1891], and others) : and, secondly, it ap- pears in the course of certain nervous diseases — perhaps in connection with repeatedly occurring cerebral anaemia (Knoll, Ueber die nach Verschluss dcr Hirnartcricn atiftretenden Augenbcweguiigen — Sitzungsber. d. Akademic d. Wissen- schuften in Wien, Abthcilung III, iSSfi). In both these classes of cases sight is often not diminished at all. and some other than Ihe one given above must be the underlying cause; and, AS a matter of fact, this nystagmus of the miners is simply due to overstrain of lf)C eyes in an insufficient light, while the nystagmus occurring in the course of nervous diseases, more especially of multiple sclerosis, but also of tabes and epilepsy, is to be regarded as a symptom and attributed to the same in- Ruenccs as the main disease. That nystagmus, finally, may also be a symptom of hysteria, and may persist during the whole course of the disease, is shown by a case published by myself {cf. Deutsche mcd. Wochenschr., No, 30, 1887, lit.). C. S. Freund has observed nystagmus in a case of Basedow's disease (Deutsche mcd. Wochenschr., 1891, No. 3)1
54 DtSEASES OF THE CKASIAL XEKVES.
UTERATUBB. I. tialaUd Ocal^-JHot^ f»iulym.
Richter. Typiwh-KcidivireiMle Ocukiniu(oriusbhniun); mit Scctrnixbcfund,
Atch. f, Psyih. II, Ncricnlilf., 1887, nviii. 1. SucktiiiK- ilrain. 18S;. xxxviij. p. 141 (attacks of migraine (btlownl by iraitu-
(orir oculo-muior p^ls)). Sen;itoi. Ucbcr p<-riO(lixche OculomotoriutlKhmung. Zdischr. f. klin. Med..
1887. xiii. No. 3 u. 4. Jonchim. Fall vnn periodischcr OculonioloriusMruung. Jahrb. f. KtiuWttik.,
188$, xxriii, I. Ucmhiirtlt. Kecidtvirendi! Oculoinoioriuslihinung. Derliner klin. Wochenxlix.,
1889, No. 47. Mai)'. Die rcci(livir«-n<k OculomoioriuxIShitiung. Berliner klin, WochmKhr..
1889. XXII. No, 34. Visscrini;. L'eber ciiien Fall von rc('i<livin'ititcr Uculomotonu&lUimung. Mun*
chcner med. Wtuhenschr, 18H9. xxxvi. No. 41. Muu. UopiMlseitiijc UculoTnoioriu^liniuiit; bei ccrvbraler Kindeiliiliiriunt.
Wiener kli^, Wochcnschr,. 1893, v, No. 41, Goldichniid. Ein Kull von IrAumatischer tolaler Oculomoloriuxiahitiung.
Wiccier med, WVtheiisthr . 1893. xliii. No. 7. Dalichow. Actiologir und Ntlologi.sclie IJi.-Lgoostik def Oculodnotonutjiaraljse
^frotu Senator's clinic). Zeitschr. X. klin. Mnl.. 189}. xidL
9. PahUt !•/ Ihi Fyt Afnutri in GrtHttl.
Mauthii<-r. Die nicht nuclcSrc AugrnmutkdlShmung. Wietbadeii, Rcig-
mann, 1886. Mauihncr. Die ntieleSrc Augcni'ntiskclTStimung. Wiesbaden, tterj^nnn. 1886, MObius. Ucbcr die Localisation ilcr Ophthalmoplegia exterior. CcnIralbL f.
NervenhL, 1886, \x. No. 17. Westphnl, Arch. f. Psycli. u. N'ervcnhk.. 1887, xviil. 3. p. 846. Landolt-. Magnus. Uebcr^ichtliehc Zuiuimii>en«tFllung der AuKenbewegungrn
iin j}h>sioloj{i>chen und patlioloj-iscticii Zuitaivle. Brcslai), Kcm. 1887. Kemak. K. Doppebnilge Trochlea risp.irr«e. Neurol. Centralbl., iSSS. Mautliner. DilTcreniialitiagnosiik der Lihmung tier Krhebunt^muskcln dct
Auges. Wiener meil. WoehenjictiT.. 1888. No. J4. Landoli. Unc fonne pariiculiirc de Paralyse dcs muxcleE ocuUires. Cleiinoni
(Oisc). 1889. Boitigcr. Arch. f. Pnch.. 1889, xxi. 1, p. 517. Bcmlurdt. Zor Lehrr Ton der nuclcSrcn AuKenmuskelliShmunjt und ihrw
Cumptlealionen. Bnlinrr klin. Wochcnichr.. 189ft No. 4). Thomtien (Bonn). Zur |iatholo)iisL-hcn Anatomic der progrcMiven Ophlhalmo-
plejpe. Fcsisehrifi. Hamburg. 1891. Bafth. Beitrag nirchtonitchcn progrcutven Ophlhalmoplegie. Jahrb.d.Hani<
burger SL-uiit Kmnkenimtduies 1893. li. p, 100. Schlciinger. Augenmuskcliahmung nach Herpes «Hter. Wiener in«i. Pr«ae.
1891. xxxiii. No, 43' Slower, Ein F^ill von iluppelseiiiser Augenmutkclllihmung. Munchcner med.
WochenKhr,, 189], xixiv. No. 48.
« DISEASES OF THE MO TO J! NERVES OF THE EYE. 55
S<.hlesinger. Zur Diagnose derchronischen nucleSren Ophihalmoplegie. Inaug.-
Dissert.. Tubingen, 1S93. Cheneys, Frederic. Boston Med. and Surg. Journ., June 24, 1893, exxviii. Bach. Cenirall)!, f. Ncrvenhk. u. Psych., N. F., 1893. iii, p. 57. Koth. Doppelbilder bei AugenmuskelUihmiing. Berhn, Hirschwald. 1893, Bar<ibasch<^w. Wiener klin. Wochenschr., 1893, vi. No. 17, Uraunstein. Peiersburger med. Wochenschr,. 1893. Dalichow. Die Aetiolc^e und die Sliologische ]>iagnoEtik der Oculornoiorius-
paralyse mil Beriicksichtigung der paihologischen Analomie. Inaug.-Uis-
serl.. Tubingen, 1893. Hotz. Arch. f. Augenhk., 1893. xxvi. 3, 4. Jackson, Hughlings. Lancet. July 3, 1893, ii.
3. Paralysis of the Aidacent.
Purtscher. Traumalische Abducenslahmung. Arch. f. Augenhk., 1888, xviii, 4. Benneii and Savill. lirain, July, 1889, xlv u. xlvi (nuclear paralysis uf the
abduccns). Ulocq ct Guinon. Sur un cas de paralysie conjugic de la sixi^me paire. Arch.
de nicd, exp^rim. et d'anat. path., i39t. i. Bloch. Hiatistisch-casuistischer Bcitrag zur Lchre von den Abducenslahmungen.
I naug.- Dissert., Berlin, 1S91 (43S cases oC paralysis of the abduccns).
CHAPTER IV.
THE DISEASES OF THE TRIGEMINAL NERVE.
The trigeminus, the stoutest of all the cranial nerves, leaves the brain by two separate roots — an anterior small, exclusively motor, and a posterior larger, the sensory portion. Its point of exit is situated at the base of the pons, where the transverse fibres of the latter are prolonged into the middle peduncle of the cerebellum. Both roots lie in close apposition, and pass into a recess — the cavum Meckelii — formed by the dura mater, and situated over the inner end of the superior surface of the petrous portion of the temporal bone. Here the posterior root forms a somewhat crescentic swell- ing— the Casserian ganglion — from which pass forward the three somewhat flattened divisions, the ophthalmic and the superior and inferior maxillary nerves, the last being joined by the smaller motor root. These three branches leave the interior of the skull by the sphenoidal fissure, foramen rotundum, and foramen ovale, respect- ively.
The trigeminal nerve possesses two nuclei — a motor and a sen- sory one. The first — the smaller — is situated in the outer part of the tegmentum, and its ganglionic cells are characterized by their relatively large size {60 to 70 ft. in the greatest diameter). The larger — sensory — nucleus lies external to the motor ; in its collection of gray matter there are found very small ganglionic cells {20 to 30 /* in diameter).
With regard to the origin of the two roots there exist very different views, and but little is definitely known about the sub- ject. It can not be doubted that the motor root springs from what has been decided upon as the motor nucleus, nor that there exist a number of small bundles of fibres which arise high up in the region of the anterior quadrigeminal body, and descend outside the aque- duct to the level of the exit of the fifth nerve, where they help to form the motor root. This is the so-called descending anterior, or, as Henle terms it, superior root, the section of which, a crescentic, externally convex, internally concave figure, at once strikes the eye in frontal sections of the pons (cf. Fig. 8, Vd). That the sensory 5&
THE DISEASES OF THE THICEMIXAL f,-ERVE.
57
root arises from the iibovc-tncntioncci sensory nucleus \% probable, btit not certain. Oit the other bund, it mn*\ be remembcretl that as low dnwa as the neighborhood of the second cervical iiervc there can be demonMrated in the caput cornu posteriori^ a layer of longitudinal mcOulIatcd fibres, the highly characteristic transverse section of which, cre»centic in shape, may be followed upward, as it gradually iacrcases in sise, as far as the level of the exit of the trigeminus. Suitable longitudinal sectionit pbiuty thuw that this longitudinal bundle forms a large )Kirt of the sensory root of the nerve This is ' die su-called large ascending root of the fifth, the position of vhich
— ii,r».
Vr
nt »— NOCLW or T1IK Tmamisui. Nwvk. (Afwr Scmwm ob.) a, V.i.. nucleui at tb«i— otj. o.I'.ii., nackn of Uunratarooc ^, fibm pOMini; lo the raph*. V.t.,
I
m transverse section is represented in Fig, ii. The cortical area of the innemiiuis is not dclinilcly known as yet; Mill, from c!(|>enmcnls un animalft. a» also from the few clinical observations which we pott- tew^ there \% reason lo conclude that, at least so far as (he motor poriioa of the nerve is concerned, it is located in the region of the antcriof portion of the fissure of Sylvius; as regards the sensory por- tion we know nothing.
We shall divide the affections of the trigeminiis into ccn. \n\ and jK-riphcraL In the first class wc recognize cortical ontl bulbar diseases: in the second class we have to deal with cither intra, or extracranial lesions. The trigeminus being a mixed nerve, containing in by (ar its larger portion only sen.
58
DISEASES OF THE CHAStAL ICEftVES.
sory, but in its Ihird branch important motor fibers, we arc obliged, as there may exist in any case conditions ot irritation
or ol paralysis, to distinguish clinically between hyperais- thcsia (neuralgia, neuritis) and an:usthcsia of the sensory pari of the nerve, and between hy- perkincsis (sp.ism) and akinc- sis fparalysis. paresis) of the raolur portion.
I. The Central AiTtcriONS OK THK Trigeminus.
hi dealing with the corti- cal affections o( the trigeminus we discriminate between irri- tative and destructive lesions I p of the cortical centre. In the
■^ ^^ former case we get spasm, in
DutL* 0RUO1TO.T*. (Aiw scHWALBEi ""^ '^"*^'^ i)arahsi!,oI thc mus. *.!'. BMndine mrt tx the fifih. n.xii, clcs of mastication. l>adauD(lh*hnKvlr>»u*. m.Xxnin.X'. SpaSm of the muSClcS o(
««r«. A N>m«y tunicwiu. ir»pi.,.ory Hiastication {trismus. mastiea. fudcuiut). /, pyramidal tract. #, oiivt tory facial sp.ism — Romberg)
Sa^rn-.'^-.'^ictrSr --■■« frequently as a par.
of general coiwnlsions {St-na- lor, Petrina, Seligmiiller). and much more rarely indepen- dently, unaccompanied by other spasms {Lupine, von Pfungcn. Langcr). There arc two forms: atonic, in which the tcelh are pressed linnly together and the muscles of mastication, usually of both sides, are hard as wood to thc touch : and a clonic, in which the lower jaw is moved to and (ro horizon- tally or vertically, and spasmodic masticatory movements arc induced. In a case in my practice, in an old gentleman who had sulTcrcd from repeated slight apoplectic attacks, the pa. lient (or scvend hours every day goes through well-marked chewing movements without eating anything, which at times arc so vig<»rous that he often while smoking bites throngh his cigar unintcnlionally. The origin of the disease is often of a reflex nature. Toothache, periostitis of the inle- rior maxilta. or face-ache may give rise to il. Sometimes, it may be. a cortical aflection lies at the bottom of it, but for
THE DISEASES OF THE TRIGEMINAL NERVE.
59
I
this ihcre is at present no evidence furnislied b>' post-mortem examinations.
ParalvMS of tlie muscles o( mastic.ilion \% oil the whole, less ircquciitly observed than spasm. Oarlow, Oiitmoiit. -ind Kirch- hoff report cases of it, recording in some only corlioil lesions. Imt in others changes in dccper-ljing portions o( the brain as well. All the C3SCS had this one anatomical [(mature in common, vit., that the cortical lesions always occurred bilaterally, thus in every case invohinjj both centres. The first instance in which a unilateral lesion of the cortex was fmind was published by myself (cf. lit.)- It contirms the supposition that the cortical motor area of the trigeminus includes the lower third of the Ulterior central convolution and the adjoining portion of the second and third frontal convolutions, and demonstrates that a untblcral lesion of the cortex (in this case it was left-sirted) is ^uflicicnt to paralyze the muscles of mastication on both »ides, The legion was due to the presence of a psaiumoma the size of a fillwrt, which was situated upon the dura and cortex at the spot indicated, causing a depression and softening of the tatter. The paresis of the muscles of mastication had reached a high degree, and was the more interesting from the fact that it was accompanied by periodical attacks of pain in the face and spasm in the area of distribution of the left facial nerve. Pa- reus and paralysis of the muscles of mastication arc occasion* ally observed among the symptoms due to progressive bulbar paralysis and to pscudo-bulbar paralysis. The idea that these may develop as the result of a peripheral affection in an isolated dbease of the motor portion of the third part of the tngeminiis oui not a priori be considered as impossible, but there have been up to the present no such cases observed. The dilTcren- tial diagnosis between a central and peripheral affection could be made only by means of an electrical examination. The lesion is central if there are neither qitanlitaiive nor qualitative changes iti the reaction to the faradic and the galvanic cur- rents. If snth changes, however, exist — for instance, if there be the " reaction n( degeneration " — the lesion is peripheral.
Only the latter form of the disease is amenable to treatment (by electricity), and then with but slight chance of success, Against the central variety we arc absolutely powerless. With regard to the allectinn of the nuclei and roots of the fifth nerve in the iions, the anatomical relations of which are. as wc have seen, not as yet sufliciently well understood, we know little
6o
D/SEAS£S Of THE CXAX/AL XERVES.
or nothing. Whether they ever occur independently, or, as is more likely, only as concomitants of diseases of other bul* bar nerve centres, has not bct-ii determined, However, the supposition seems Justificfl tliat the centres in question, in the course o( certain general diseascts of the nervous system — (or in- stance, in miilltple sclerosis and particularly in tabes — are a(< fectcd relatively early. Thus Erbcii reports (Wiener nied. Blotter, Nos. 43, 44, ii!86) that he has obser\-ed very trouble- some paresthesias of the sense of taste in tabetics occurring in paroxysms, beginning in the pharynx. These were especially ' pronounced at the anterior edge of the tongue, and were ac- companied by anxsthcsia in the second branch of the fifth. This condition is presumably to be considered a disease of the nerve of taste, being analogous to the so-called gastric crises which are attributed to an affection of the vagus centre. A cen- tral anaesthesia of the trigeminus may also occur. In its symp. toms it would not differ from the peripheral except that it may be bilateral. The central nature of the trouble one would infer from the simultaneous participation of other nerves, both sensory and motor (Kombcrg). The interference with conduction may take place at the base of the brain.
LITER ATt; RE.
Romberg. Lehrbuch dcr Norvcnkratikheiten des Mcnschoi. 3. wrandcrte
AuHai^. Deriiti, 1S53. p. 367 rf seg, Senaior. Berl, klin. Woe lien whr,, 4. i879' Pttrina. Prager VieridJAhrschrifl. Bd- 133. Sclijjmtillct. Archiv fOr I'lychiaUie. Bd. vi. p. 815. Crth.nrdl. Fcitschnd dcr Wtlraburgcr Universiiai. Leipzig, i88a. n.-irlow. Brit. Mrd. Joiitn.. July iS, 1877. Oulmont. Revue niciwuclk-, 1877. KinhholT, Aceh, ( Psyrhi.iiric. Bd. «i. p. 133. Hin. Zur t.uc.iti^niion d» coriicdcti KaurnuskclcfflinjiDs bclm Mmschen.
Beri, klin. Wochcnsclir,. No. »?. '887,
11. PeRIPHERAI. APFKCTtOSS OK Tllli TRIGKMINUS.
In its pcriphera! part the nerve may become diseased inside as well as outside of the cranium. If the lesion is one of the stem, and extends to all three branches, it may be diflicuU, in- deed impossible, to determine its exact site, because we do not as yet possess any means which enable us to definitely decide whether the nen'e is diseased centrally from the Gasserian ganglion, whether the ganglion itself, or, finally, whether the
THE DISK ASUS OF THK TRICF.UtNAL S'ERVE.
6l
Three individual branches are alt uflected at ihdr exit from the skull.
An affcclion of the nerve stem lo Ihe central side of the Casscriun gjinglion can only he assumed with any degree of certainty if tlie norve is diseased in its whole sensory distri- bution and if extensive trophic disturbances arc also pieseiit. The aRcclions of the Gasserian ganglion itself (inflammation, ncitpliism, softening) have as yet but little practical importance. II the disease does not take in the stem, but only the terminal jHtrliuns ul the individual branches, it is easy to determine the Kat, and while we have in the intracranial diseases to consider those of the finer branches of the nerve in the dura, in the ex- tncranial we have (he branches distributed to the face and those to the nasal cavity.
A, Intracran'Ial Diseases.
Htaiiatht — Cephalalgia.
Since it is very likely that there are only exceptional cases o( idiofiathic headaclic in which the fifth or its terminal branches in the dura (cf. page 3) are not implicated, it seems advisable to speak of headache here. At the same time we must expressly state thai we are lorced thus to take up differ- cnt diseases together, which are etiological ly as well as patho- Ingically to be strictly separated from one another.
The main point to decide in a given case will always be tthciher the headache is to be regarded as merely a symptom n( another disease or .is an affection by itself. Nobody ever would assume a headache which occurs at the onset of a severe illness— (or inslancc. an acnic infectious disease, or in associa. linn with organic brain disease (c. g., tumor), or during grave dtMrders of nnlrilion, anxmia, and chlorosis — to be an affcc- liiin by itscli and treat it .is such. I'hese headaches will ■Iways be considered as a mere symptom of the underlying disease ; but when we find an otherwise healthy person suffer- ing from protracted or paroxysmal headache, while on repeated careful examination we are unable to discover any other dis- ease, then we are forced to assume an independent affeclion and we have lo endeavor to detcriuinc the following points: («} The scat of the headache : (p) Its peculiarities and its course \ (f) its srliologv ; iti\ ils appropriate treatment.
(<t) The anatomical situation of the headache can hardly
I
DISEASES O/-- THE CRA.V/AI. .VEXVBS.
■ be determined; but we are jusli6cd. since vie < know wliat part the braiii substance takes in it. in bclievinf^ that the sensory terminal branches of the trigeminus in the dura (the dura receives at least two branches from the tri- geminus) arc always implicated, and arc thus in some measure the seat of the headache. L'nder what conditions these nerve endings arc thrown into a state of irritation — a state upon which the headache depends — is not well understood, and all we know about this question is more or less hypothetical. The most prob- able explanation is that the amount of blood in the brain or its membranes at the time being is an iinporlnnt (actor in the pro. duclion of the morbid condition, whether there be a permanent increase or decrease or frequent, perhaps very slight, changes in the amount. An increase constitutes what is called cerebral hy- pcncmia. a decrease cerebral anarmia : and we assume the former condition if (ull-blooded individuals, who are liable to rushes of bliMxl to the head, complain of paroxysmal headache; the tatter, i( it occur in ]>ale, anxmic patients who are subject to fainting spells. However, we do not know anything positive, and we shall have occasion to deal more in detail with this in another place. Of the greatest interest, and perhaps ol the most com- mon occurrence, arc the fluctuations in the intracranial blood pressure, which possibly are the cause ol' the irrit.ntion of the ter- minal branches of the trigeminus in the dura and pia. If such fluctuations appear frequently, so as to give rise to an unequal distribution ol the blood in the two halves of the brain, the irritability of the sensory endings may become abnormally in- creased, so that slight causes arc sufficient for the production of the pathological condition. The clinical observations even go to show that wiihoiii any demonstrable cause from time to lime there may develop an increased irritability of these tcr. miniil branches ol the fifth, associated with simultaneous Huct!ia- lions in the blood pressure. If 'he attack ol headiiche tlius pro- ^^ duced is accompanied by vaso-moior symptoms, cither of a para-^| lytic or of an irritative nature, it is designated as migraine or " hemicrania, tlie latter name being given to those not very cora-^^ mon cases in which the patn is strictly confined lo one side of ^| the head. Ov\ ing to the vaso-motor disturbances just men- ^^ tioncd, some have been inclined to locate the seat of the disease ^j in the sympathetic system, without being able, however, toH show that the symptoms referable lo the sympathetic are not ^^ perhaps only a secondary result of the pain, and therefore reflex
TUE DtSKAS/CS OF THE TK1CE.V/.VAL XEXVE.
63
I I
in nature (Mubius) : nnd until this is actually demonstrated not to be the case we are justified in looking upon migraine as be- longing to the affections of the trigeminus. In some, as it seems quile exceptional cases, ihc seat ol the headache is to be relerred to certain muscles, which present at their origin and insertion as well as in their course poinis ol tenderness. Among these, besides the frontal occipilal and temporal mus- cles, are the sterno-clcido-mastoid and the upper part o( the trapezius. This myalgia, which is occisionally produced by an unnatural posilion during sleep, and which is easily diagnos- ticated on ciireful examination, is said under certain circum- stances fo be the cause of headache.
(A) With regard to (he jH-culiLirilies and the course of the headache connected with the aflcctions of the trigeminus, we know that in its character as well as in its situation it presents IK) inconsiderable number nl variations: thus, while one pnlient cnmplains of a dull, boring ache, anoiher describes his pain as xharfjand burning: while in the one it is worse in the forehead, unotlier refers it chiefly to the occiput, vertex, or temples, etc. In some instances the patients designate sharply circumscribed places of the hairy scalp as the seat ol iheir pain. The head- jchc also varies much in degree— from a dull sensation of pres- sure to » pain which allows of no sleep. In some cases the mUering is increased by a louch or a tap on ihc head, while in others it is soothed by a firm bandage around the temples. .Seldom do we find a headache lasting for days, weeks, or even months without intcrrupiion ; usually there arc times when it i» less severe f>r when it ceases completely. There is no regularity i>r uniformity in the occurrenc-e or duration of the attacks. Two cases are scarcely ever alike, and almost always eich presents certain peculiarities of its own : thus in the one. slight febrile movements, absent in another, may occur; one patient enjoys a splendid appetite during the most viulcntpain, while another is tm.-ible to eat a ihinf::. etc.
(r> i-F.lio logically, heredity plays a certain r6le, though this is far less important than in the c:ise of migraine. Frequently the parents of the patient, especially the mother, have from their ymiih u[> suffered from headache without atiathing much miportance to it or consulting a physician for iL Mentid over- work in young people is somclimes a factor, and rapidly grow- ing youths n<it infrequently suffer from headache (cephalxa udoleMrenrium). In anasmic and chtorotic conditions, in chronic
64
D/SEA5SS OF THE CKAS'lAI. S'EKVES.
dyspepsia, after acute alcohol intoicication. headache is of com- mon occurrence; i( may also be caused by diseases of the pharynx and Ihc middle car (I^gal). The etiological impor- tance altribuiable to errors in accommodation ur refraction has been pointed out by Bickcrton. Certain poisons, if introduced into the body for a long period of time, lead to habitual head- ache— c. g., lead, tobacco, and olhcm; the headache iound in lues and malaria in all probability also belonj^s under this cate- gory. The reflex origin of headache due to affections of the nose and the sexual organs, especially the uterus, has only of late years been sufficiently appreciated. It is most important that the nose should be carefully examined for swellings (Bres- gen. Milnchcncr mcd. Wochenschr.. t893. No. 5>.
In exceptional cases migraine-like attacks are met with in cases of gout, and it would appear as if ihey were also in some way connected with the excretion of uric acid, since it has been found that before the attack no uric acid can be detected in the urine, while alter it the amount is very perceptibly in- creased, and later on (or a time markedly diminished. The polyuria, which occurs (requcntly after the attack and lasts (or several hours, with an acid urine, light yellow, almost as clear as water, of a very low specific gravity (1.005 *o '-OO/). has been mentioned before. To the fact (hat migraine-Hke attacks may also occur in the initial stage of tabes and may be of importance for the diagnosis and prognosis, we shall have to refer later.
It is difficult, indeed at times impossible, to give a reliable prognosis in the cases now under consideration. So far as life is concerned, it is always favorable, if the case is of a purely functional character — where the headache exists by ilscll as an independent affection, and where it is not to be regarded as a symptom of organic diwasc. The patient recovers from his severest attacks comparatively readily, and even after IrcquenI repetitions of them it is exceptional that the digestive disturb- ances and the loss of strength which these entail induce a really serious condition.
But is ihe prognosis lor recovery as good as for life ? To this question we must answer without reservation. No. One can not deny that the outlook (or a complete recovery is. on the whole, very bad, and that the chances, ctetrrU fiarilmi. arc so much the worse the longer the .iffcction has lasted, and the more difficult it is to find any tunj^ible cause (or iu occurrence.
TUB DISEASES Of THE TlilGBMIXAL .VBRVE.
65
»
The worst cases arc those in which the trouble is inherited ; in these recovery is very exceptional, Al any rate, the prognosis in all cases should be guarded, and little should be promised. There is hardly any other condition which is so liable to injure the physician's atithorily and the patient's faith in him and his medical skill as migraine and hnbitiinl headache. On the other hand, spontaneous recoveries arc not unheard ol^a fact which we ought to remember, if all our drugs leave us in the lurch.
(rf) The treatment ol habitual headache is generally very tedious, and puts to a severe test the perseverance not only of the patient but also of the physician, it is therefore abso. lutely neces»;iry. before undertaking to take charge of a patient ol this kind, lo lay down, after a most careful and minute ex- amination, a definite plan of treatment, which must be rigor- ously adhered to. Il is not sufficient to use to-day one drug and tomorrow another, of which we have possibly read in the last journal as being effectual against headache, and with which we may accidentally obtain a transient gi>od result. The treat- ment must rather be sysleiuatic. and the outcome of certain well-considered conclusions, which we shall now briefly dis- cuss. In the first place, we have to decide whether there exists some underlying disease which causes the headache. If, as is frequcully the case, stomach symptoms are present, a slay at Carlsbad or Kissingen may do much good. If the acidity <)f the gastric juice is incrcised. the regular ingestion of alkniiiie drinks or o( lukewarm water is indicated. In all cases much allcniion is to he paid to the diet, and the p.ntiei»t should especially be warned against overloading his stomach at night. The regulation of the bowels is effected by massage or the use ol large enemaia ol water, or of small injections ol pure gly- cerin (5 to 6 cc. — ni Ixxx 10 c. — at a time), or by vegetable ape- rients, such as rhubarb. Any degree of constipation may be attended with bad consequences. Diseases of the middle car Of of the pharynx should be treated by a specialist. If the pa- tient have a gouty diathesis, the use of lithium and the regula- tion ol the diet should constitute the main treatment. The eyes should be examined for any possible errors ol accommo- dation or refraction that may exist, and these, when found, should be corrected by means ol proper glasses. Cases which had resisted all other treatment have been cured in this man- ner (Blckcrton. Hrailey, Weir Mitchell, and others).
11 no coexisting disease can be detected, our chief efforts %
66
P/SP.ASES OF THE CRA.VIAL ifEXVES.
must be directed lu buildinf:; up the general constitution. From the oold>watcr treatment, general faradization (according to Deurd and Kockwelt), franklinization with the Holtz ma- chine, systematic gymnastic exercise at home— from any <inc of these measures we may. under certain circumstances, obtain the desired result. In some cases lasting advantage has hcen seen from a change of cliniaie. from travel, and a slay in the mountains or at the seaside. With regard to the combating or the shortening ol the attacks, aniipyrine, i.o gm. (15 grs.) at a dose, or 3 to 4 gm. (45 to 60 grs.) a day, 01' phcnacctin, 0.25 gm. {4 grs.) at a dose to 1.25 gm. (20 grs.) a day, may be given. Tho exhibition of these drugs is frequently followed by good results, although this is rarely lasting. If vaso-motor changes point to the existence of a pathological contraction or dilata* tion of the blood-vessels, we may in the farmer case — in that of contraction — resort to the careful administration of nitrite of amyl. three to live drops of which arc put on a handker. chief and given the patient to inhale : or to the internal tisc of nitroglycerin (one drop of a one-percent alcoholic solution three times a day). Great care has to be exercised in the ex- hibition of the latter drug, and, if the pulse indicate it. wc ought to begin with minitnum duse^t. Such a precaution is more especially necessary if the pulse is full and the arterial wall tense, in which case a quarter or half a drop is sufficient as an initial dose (Trussewitsch). It is, moreover, not advisable to continue its administration any lunger than one or two weeks, as it is liable to give rise to cerebral symptoms (buirxing in the bead, vertigo). In the second case — that of vaso-dilatalton — ergot is indicated, which may either be used in the form of hypodermic injections of ergolin [ergotini dialysati, 1.0— grs. 15; aqua; destill., 4,0 — 3j. Sig. : Half a syrtngelul); or by the mouth (cxtr, sccal. corn, (Denzel), 2.0 — ni xxx ; aqua: cin- namomi, 180,0 — 5"). Sig. : A tabtespoonful every two hours). If no such indications arc furnished by the condition of the blood-vessels, wc have to try which medicine will do the most good, and may begin with the citrate of caffeine (0.15 — about two grains — three times a day), which wc have found to be eRectual. The pasta guarana, 2.0 grm. (grs, xxx) twice a day, gives similar results, but often interferes with digestion. Sali- cylic acid is in many cases, especially at the onset, followed by surprising results, but its continued use is disagreeable to the patient on account of its bad after-effects. Application to the
J
THE DfSF.ASBS OF TUP, TKIGF.JUtXAL NF.KVP..
67
^
painful spot ol an alcoholic solution of menthol (three 10 twen> ty) is often both agreeable and refreshing to the patient, the migraine pencils, also prepared with menthol, having a similar cSecL This, according to Goidschcider. gives rise to a hypcr- ieslhe«ia to cold which is associated or followed by a diminti- lion in the excitability of the sensory ner\*es. If painful points can be discovered on the scalp or on the muscles {vide supra), a slight pressure and kneading of the same, later a more energetic nuMge to the head, is advisable.
Electricity may be used (i) in the form of a constant cur- rent passed longitudinally or transversely through the head or by applying it to the cervical sympathetic, and {2) in the form o( the laradic current. In this case it is best for the physician to ftpply his own hand, previously moistened, to the forehead of the patient, this taking the place of one electrode. In the other h.ind he holds one of the electrodes, the other being placed on the back of the patient's head, the sternum, or some other in- diflerent point. With this mode of application, whirh Is called the ■' laradic hand," only very mild currents i^hould be used (cf. Hirt, {..chrbuch dcr Electrodiagnostik und Etectrotherapie, Stuttgart. Enke. 1893).
Numerous as are the means at our disposal for combating the diAe.isc, quite as numerous are the patients who, after hun- dreds of unsuccessful trials, give up all medicines and all physi- cians. They retreat at the beginning of the attack from the world and from their families, darken their rooms, lie down quietly, and take simple domestic remedies, among which Rus. Man tea with lemon juice has obtained a prominent place. Ab- solute rest is what always docs most good to all these patients. Finally, wc should not forget to dcprccile, especially here, the use of all hypnotics, more particularly morphine, as they never do any good, and arc often capable of producing serious harm.
LITEKATURE,
Kctlrr. Dclaceplt.iUedcsadolrftcrnt^ Arch, ite tx-urol., 16, 17, 1SS3. KvatMrh. NrrrtMe Cutmij-nsis itls cine eigen«. gcnnu clMtakieriiirbarc Foira
(Icr Drsprpue. I>rut»ch<-s Arch. f. klin. Mrd., xxxv. p. 38J. 1884. LqfL tJelier rine dlierc Unactic drr SchlJlfe-llitii^cl^niiptihopfM-limermi.
tVtitsiito ArdL C IcIiiL M«d. xt. 2. 188;: lirri].ur/tl_/:(riijclir.,viii. », 1K8;. faoM. W. Antifchrin gcgcn KopruhnKn. Deulsrht rami. WochcnKhT., No.
16. 1887. BKlirrton. On llnKlMhe due (o [Errors of the Kcfntciivc Media of ihr Eye
Luicn. Aujfuit \y iSH?, p. yity
68
I>/S£AS£S OF THE CRANIAL S'EHVES.
Truucwiisch. Ucbcr Anwcn<lunK und Dosirung des Nilroglycrnns als Atxnd-
iiitttd. I'cCenttwrxcr med. Wochen«chT.. No. j. 18S7. Bibustte. Deutsche med. Woehcnsthr,. No. 37. 1888 (reeginmcinb phenxetin). Day. HcadachM, Their Nature, eic. London, Churchill. 1888. Nosirom. Ce|>h:LlaJgic ci masui^c. I'uris. iS^a
B. Extracranial Lesions.
The extracranial lesions arc, on account of their great fre- quency, of an cminenll)' prnciical significattce and ot scientific importance, inasmuch as valuable information about physiologi- cal questions — that is, the course of the trophic and the gusta- tory fibres — may be gained from them if the individual cases are carefully observed and accurately recorded. We shall first treat of the diseases of the facial branches of the nerve, and again separate in our consideration the paralytic from the irri- tative affections.
/. Trigtmmal Nturalgin — FothtrgiU's Fatt-ackt — Tie Doutourtux
— Prosopalgia.
Variable in its degree of intensity, beginning with a moder- ate, dull, boring, but always distressing and uncomfortable feel- ing of pain, and sometimes reaching a pitch of severity experi- enced in no other kind of neuralgia, tic douloureux forms one of (he most common affections of the lifth nerve. I( appears, its a rule, unilaterally, and by preference fastens upon the first and second branches. The sensory division of the third branch seems, at least by itself, rarely to be the seat of the pain, whereas it is not uncommon for alt three divisions to be simul- taneously attacked.
Almost every patient gives a difTercnt description of his pain. One declares that it feels as if a red-hot wire was being driven into the bone, another as if the face was buried in a heap of stinging nettles, a third fancies that the nerves are be- ing pierced with a sharp instrument, etc. Almost every case presents its own peculiarities as regards the frequency and duration of the paroxysms, between which there are often inter- vals free from pain, but the course of the disease follows no hard and fast rules. The tender points of Vallcix {poinCs dou- lonrfux) can almost invariably be demonstrated. Almost al- ways there is one on the supra- and another on the infra-orbital foramen, a third over the exit of the subcutaneous mala.*, a fourth over the mental foramen, and a fifth in front of the ear.
THE DISHASF.S OF TtfB TKICEMINAL NRKVK.
69
where the auriculo-lemporal passes over the zvgonialic arch. The so-called palpebral point on the upper eyelid, the parietal point on the parietal eminence, the liibiiil point on the upper lip, and many others arc not always present. Firm pressure on these points is always, even in the intervals between the paroxysms, disagreeable to the patient and even liable to pro- duce an attack.
The neuralgia of the first division of the tifih nerve is nH»stly an aflcclion of the siipni-orbilal nerve, with pain in the fure- hcad, the nusc, the upper eyelid, and the eyeball (ciliary Dcrves). The other terminal branches are hardly ever affected. The neuralgia of the second division attacks the cheek, the lower eyelid, the nose, and the upper lip. often also the upper row of (he teeth (n. alveol. sup.) and the pulate (spheno^palatine branch). The branch most commonly affected, sometimes also by itself, is the inlra-orbital. The neunil^ia of the third division embraces the lower jaw, the chin, the cheek, sometimes also the auricle and the external meatus. The tongue and the mu- cous membrane of the mouth may be affected by themselves (glossodynia). and this may give rise to the fear on the part of the patient that he has cancer or ulceration of the tongue (Le(- fers. imagin. ling, ulcerai., Med. News, i8t^8, xi, 17; cf. also Bernhardt, Neurol. Centralbl.. 1890, No. 13). Other isolated affections of this third division arc compamlively rare. The ooly exceptions are the n. buccinatoriits, the affection of which manifests itself by pain in the anterior part of the ear, which radiates to the check (Tillaux). and the inferior alveolar branch ; the btier is not nirely attacked separately, and the consequent toothache has often induced patients to have one tooth after ler extracted — of course, however, without any improve-
11.
That the vaso-motor and the trophic fibres of the nerves are also at times implicated is evident from certain symptoms, viz., intense flushing, liyperidrosis. strong pulsation of the temjKiral artery on the diseased side, together with increased secretion of tears and saliva, affections of the hair, which has a tendency to turn gray and fall out. especially over the most painful places. Such symptoms are nut uncommon. Herpetic erup- tions, especially zoster ophthalmicus and frontalis of the af- (ectett side, have been repeatedly described.
Pathology.— 01 the pathology little can be said with cer- latuly. Ihe iliickeniug and swelling of the neurilcmm:i, the
;o
DISEASES OP TtlK CKAA'lAt. .VA/tfU.I.
(I^eneration of Ihe Uasscrian ganglion and o( ilic nerve trunks, the .small inorganic concretions which have occasionally been seen on Ihc neurilemma — all these arc changes which have some- times been observed, but whicli quite as otlen were absent. At all events no particular importance can be attributed to them. Whether cortical lesions and aflections ol the nuclei and the ro4}ts arc capable of bringing on the disease we do not definitely know, yet such possibilities can not be excluded (cl. the cose published by myself in the Hcrl. klin. Wochenschr., 1SS7. 27).
The i>:ipcr ol Dana (Journal of Nervous and Mental Dis- eases, 1891. xvi, p. $4). in which he claims that disorders in the blood-supply, produced by arterio-sclcrosis, are often the cause o( the affection, is interesting ; and it is very desirable that the vessels should be carefully examined in such cases. Thoma also calls attention in the fact that he has lound diffuse arte- rio-scierosis. which was more marked in the neuralgic area [Dcutsches Arch. f. klin. Med., 1888, xliii, 4, 5).
Course. — The course of the disease is on the whole extreme- ly (odious, and attacks which harass the patient to the end ol his days are to be observed here as in migraine, the only differ- ence being that in Ihc disease under consideration the suffer- ings of the patient are still more unbearable. The disease throws a shadow over his whole existence far more gloomy than in migraine, and so wc can well understand why again and again he tries all sorts of remedies and frequently even the most heroic measures to relieve his pain at a lime when a migraine patient would have given up all medicine and all doctors.
Treatment — Unfortunately, here also therapeutics is often powerless, as has already been indicated by the remark that the disease is often ol life-long duration. Hope of recovery is only justifiable in cases where we have an underlying disease, as, for instance, malaria, in which case the neuralgia is to be regarded as 3 symptom, or where local causes exist — for instance, bone diseases, the presence of foreign bodies, or neoplasms which can be removed, etc. Such cases will repay the efforts of the physician, and a cure can be effected by proper internal medi- cation or by surgical interference. In cases, however, where a primary cause, which would furnish us with data (or our treat- ment. can not be discovered — where wc. therefore, are forced to experiment with the nervines and the so-called specifics — let us beware of raising our expectations too high, lor too often
TUB DISEASES OF THE TklGEMlNAl. ffEJit'E.
;>
all our efforts will be in vnin. Arsenic, sttiic. quinine, the bro> midc and iodide of potassitim. asafa'tida, castorcum. valerian, and many other medicines now completely obsolete have been tried, and still to-day sometimes arc tried at random. The one uses this, the other that drug ; under favorable circumstances each one docs good once, but rarely is the improvement last- ing. Here also the most confidence may be placed in :tniipy> fine and phcnacetine, and, if chlorosis be present, in iron (best administered in the form of Bland's pilts), quinine, arsenic, and iodide of potassium: if these leave us in the lurch we can re- sort to salicylate of sodium. 4.0-6.0 (3}- 3 jss) a day, in cap- sules, or to salul or gelsemium. giving the latter in the form nl ihe tincture, and pushing il perhaps until slight symptoms of intoxication appear (twenty drops every two hours). I have Uftcd corrosive sublimate. 0.05 (live-sixths of a grain a day) in pill form, several limes successfully. Of butyl chloral I am un- able to say anything favorable (bulyl chloral hydr.. 7.5 (3}ss.- 3i)>: glycerin., 20.O (3.SS.); aqua:, 130.0 (siv). Sig.: A table- spoonful every ten minutes). In all my cases it proved very uosucccssdil ; Ihc same holds good for methylene blue, which was administered in capsules of 0.1-0.5 '"'^ '^^ P**" ''i^ (2-7- 12 ffrs.). This drug has, besides, disagreeable effects upon the urogenital system, giving rise to strangury and pnin tn tlie glaoK penis, etc. Other anxslhetics, chloroform .ibovc all. do at least as much good, and the narcotics are decidedly better, as Trousseau has already upheld, who declared large, or wc should rather say huge, dos<.-s of opium or morphine to be the only effectual treatment. Whatever wc may think about mor- phine, in aises of tic douloureux, especially in severe instances. we can not dispense with it. The combination of morphine with atropine, or the alternate use of the two separately, has been recommended (.Mthau-s) ; chloral hydrate alone, 4.0-6.0 ( j}-3j*s-) " day, is uncertain in its action, but in combination with morphia often acts very well. Cocaine may also be used externally or given internally (a teaspoonful of a one-half-per- cent solution three limes a day). The so-called revulsives (daily repeated cold-water enemata (Gussenbaucr). cold or warm poultices, sinapisms, superficial cauterization, the elec- tric brush), often act splendidly where we want to produce temfwrary amelioration of the pain ; but unfortunately this Is only transient. The same is true of electricity, which may be uMd according to the polar method (steady application of the
72
D/SF.ASES OP THE CRANIAL ffKMVSS.
anode over the painful place, cathode at some indiflerent place, weak increasing and decreasing currents being used), or ac- cording to the method of direction of the current (descending steady current). Zichl (Berliner klin. Wochcnschr.. 18S9, t3) recommends the application of electricity for as long as an hour at a time. Galvanism to the neck has also been advised. The constant current may be given a trial, combined vrith the action of chlorolorm, as Adamkiewicz has proposed in his pa- per on cataphortsis. I have several times used the " diflusion electrode," which he recommends, quite successfully (cf. lit.). HofTmann is also satisfied with the results, but thinks that these arc not to be attributed lo the electricity (Neurol. Ccntralbl., 1888. 21). The faradic brush, the unpleasant action of which may he somewhat mitigated bv putting moist blotting-paper on the skin, is often very satisfactory, and 1 can recommend the strong cutaneous faradization very highly even during the paroxysms. Operative interference (neurectomy) has recently more and more, and justly so, fallen into disrepute. The re- sults are often entirely negative, and where some success has been obtained with it this did not prove lasting. For an ac- count of the method of resection the reader is referred to the surgical journals : the nervus buccinatorius is resected accord- ing to the method of Zuckcrkandl (Arch. f. klin. Chirurgic, 1888, 37. 2). In order to avoid relapses it is necessary to con- sider the advisability of resecting neighboring nerves (Oba- linsky, Wiener klin. Wochcnsclir., 1889, 41). Repeatedly the Gasserian ganglion has been successfully extirpated (Rose, in London, Lancet. 1893. x, 32, and Krause. IVulsche mcd. Woch- enschr., 1893, 15). The same is true of the resection of the tri- gcminus Irom the foramen ()v.ile {Sulzcr, Arch. f. klin Chir., 1888, 37, 3>. Baths, especially at the non-medicated hot springs, a stay at the seaside or in the mountains, cold-water treatment, and vapor baths may be advised, but wc are unable to state definitely which of these modes of treatment are indicated in any particular case.
i^tiology. — About the reliology we know little worthy of mention. That heredity and exposure to cold have something to do with the disease we must .idmii : hut this is not peculiar to neuralgia of the fifth. However, affections of the pulp of the teeth, which arc determined by an examination of the sen- sitiveness to temperature changes (Boennecken. Berliner klin. Wochenschr.. 1893,41), and anatomical changes (exostoses, nar*
THE O/SBASBS OF THE THIGEMINAL N£ki'E.
73
I
rowing of bony canals due to syphilis, etc.), arc here frequently ol moment. Age. sex, and occupnlion do nut seem to exert any particular influence ; slill. the disease is on the whole very rare in ^niall children, and i( present it is always inherited.
LITERATURE.
Pcynwnet de LaronvMlfe. De la neuralgic ilu trijuineuu el en particulitr At
KM inlteineni par les initv^risalions de la chlorure <le mflhyle. Thi«c de
l*sri>, 1886. CuiAcnlMurr. t/'eticr Behandluri); dcr TrigetninuKnruralgic. Prng. mcil. Woch-
eitKhr.. nl. 31, 1&86. Schech. Kkonidclte Kr^mpre dec wcichen Gaumrat mil objcctivem OhrgcrSusch
in f olge von lUMitcr TrigcDMniUincunilgie. Mimchcnet mod. Wochentchr.,
3). 18S&
Ailunikicwici. Die DifTusionwU'krrodc. Nfurol. Centralbl- No. lO, 188&
Hwi. BredUuiT SmI. Zeiliclir. No. I!. i886l
Knrsrr. Ctnirilbl. i. kliii. Med.. 44. 18S6. (Anlifcbnne.)
Sclfarrt. Uelier AntifebKn al« Ncn-inuHT. Wirntt med. Wochcnschr, 35. 18S7.
Von Fnuikl-Hixliwatt. Cenmlbl. t d. rm. Therapie, 1888. \4. 9.
ZtetiL Bcrltncr klin. WochMisihr.. i8«9. ij.
Each. EndrcsultAie Axx Nr«r«rio(nic bd Quiniuinruralpen. Inaug.-Divicn.,
BctUii. 1889. M. Itrnedict. Ueber Nmnilgle und ncuralgHuhc AITcctloncn und drren Bc-
handluni;. ^^'>cn. ItintimilUer, 1891. Bin. Lxlkrbuch do HlckumJiagiiMtik. etc. Stuilgan. Enke. 1893. p. 147
3. AmrstkftM 0/ the TrigfmiiHS — Paralysis 0/ the Trigrminns.
Paralysis of the sensory branches of the trigeminus is on the whole less frequently met with than neuralgia oi the face. Only exceptionally are all the divisions (the motor portion of the third included) affected equally : but most observations ji" to shnw th.1l, as a rule, oidy individual branches suffer, and these not in their whole extent, but only within certain areas. The smaller the number of fibres in the distrihulioti of which an.'Chihesia obtains, the more peripheral is t!ie scat of the cause (Romberg), and we may assume an affection of one whole branch to entst " where the loss of sensation is found not only in certain areas of the surface, but also in the corresponding cavities of the (ace " (Romberg). Whether the branch is a0cct> ed before or after leaving the skull we have no means of de- ciding.
A lesion of the first division also causes anxsthesia of the surface uf the eyeball. Since, in consequence of this, influences from outside (.foreign bodies, dust, tniumatism) are not per-
7A
DlSEASeS OP TUF. CRANIAL NEKVES.
ceivetl, not infrequently a keratitis, which begins in the lower segment of the cornea, is developed. This may run into an jnflammatiun of the whole ball nnd bring about destruction of the eye {pphtluilntta paralylka). That, to explain this condition we must not assume a lesion of special trophic nerves has been shown by experiments on animals (Scnttlcbcn). An affection of the second division deprives the nasal branches of their function, and the nose becomes not only insensible to external touch, but certain pungent smells — :is, for instance, that of
Pie. la— ninmiMinPN '1 ^m :^. 'bv Citaxtwhs TJkbv» ox twb Hmu. r,. ^n
(',. |1» ihrtv bramlii . \ \'\. l: i. . i:iiiiiu, •!/. aurfcuki-ii'nipcml. w, Miinaoriiiut, jf, tu|]ratruchlur. il. itiiuinKiilrAi. /, Isthryni*]. m. eiciilitl. 4, biKdnatOr. *iK, aarbuUtl* mkcniii. j«. lubmuncun nuke, cwid mid <9mj. <>cclpt(ii]i« pajor and minor. tt, uipcrficlal nmul.
sniiff— are no longer recognwed on (he affected side. In lesions of ihe third division the corresponding half of the tongue, but only in its anterior two thirds. loses its sensation, and the pa- tient has no longer any sense of taste in this area (n, lingualis); since, however, loss of taste in the anterior portion of the tongue has been observed in some cases where the function of the third division of the fifth was found to be perfect (Heus- Dcr), we can not exclude the supposition that the fibres of the
^P TttF. DISEASES OF THE 7HtCEMINAL NEKVR. 75
chorda tympani {ur at least a considcrabk' part of them) }oin ihe facial from ilie second division of the iiltti. Certain it is that the fibres which pass to the chorda return again to (the second and third branch ot) the trigeminus alter having proti- ably run with the facial as far as the geniculate ganglion. From Fig. \2 the distribution o( nnsfsthcstn over the skin of the lace may be learned. Vaso-motor changes, subjective sen- sations of hent and cold, sensations of swelling, and disturb- ances in the movements of mastication and difficulty in open- ing the mouth (paresis of the external pterygoid and the ante- rior belly of the digastric), are sometimes met with (M(lllcr).
The course of the disease depends upon the seal of ihc lesion. In peripheral aflcclinns the prospect for recovery is usually comparatively favorable; yet this Is frequently only {Kirtial. and several of the qualities of scn<iation remain per* maitenlly lost, the sensibility in general is dulled, and tactile [narxsthesias persist — in a word, recovery is imperfect.
The treatment chiefly consists of excitants, among which the most efficient is the application of the faradic and Ihc galvanic brush to the skin. Transient improvement may be ihus obtained after a short while in the peripheral affections. The electric brush is the best excitant lor the skin, and is to be preferred to all liniments and the Itlcc, which arc supposed to jict in much the same w:iy. Inlcrnal treatment, provided there be no definite underlying disease, is absolutely super- fluous.
I.ITKRATURK.
Multcr. Zwri FIlie von TngcminuiIHhmunK. Anrh. C Psych, u. Nervcnkrankh.,
ilr, 3. J, tSSj. •
UlhofT. Fiill xsta Nniritit d«« rechlcn Trif^Rimut mit AITcciJon dct Lacrynulis
uiul ctnsrltigetn Aufbdren iter Thfaniriisecmion, Deutsche mcd. Woclien-
»chr.. xii. 19. i88f>. Cwu. A Oueuf Paralysniiftbc Trijifeininui (bllowrtl by Allernaic llemiplq^
— Its KcUliim to the Nnvc of Tasic, Jouni. of Mrnl. nrtO Ncrv. Dim-jims,
xiil. J, p. A;. 1886. Ilmwirr. Klnr IleotMchtunt; iihet den Verluif der GeschcMcksncrvcn. Bcr-
lm« kiln. Wochenschr,. \t\:\. 44. i88ti. ('rrrlrr IjimtM. vol. J. No, 1, iMlS. 2Ktil. Virch. A(i:h„ 1889. cxvii. Heft ii (Cas^ of I'jiralysis of ihc ThJrc) llninch
uf xXve Tri|{rtiitni»*l, ZMiL KUi neucr Kail von isntinei IJilintunK ilu (Jriilcn Trigcnunuusin mit
((ncbnuekMiOruoi;. VIrcli. Arclt., 1801, cixi. Hcfl IIL Thutti^orti, MraM. A Cist of Aiimihrfia of ihc Trigcminu*. Nord. med. Ark.,
1891. new w«)uence, ii. 6. Na j8.
76
DiSSASES OF TUB CRA.WIAL ffEKVBS.
J. Trigtminal Cough.
Finally,
call
reflex neurosis, which
alieiiLion t< was rtrst described by Schadcwald, and then studied by Willc. This is a paroxysmal cough which, occurring in individuals whysc respiratory organs arc perfectly sound, is entirely due to an irritation of the trigeminal fibres distributed to the nose. pharyns, and the external auditory meatus. These two wri- ters (lislitiguish accot'djiigly a nasal, a pharyngeal, and an au- ricular trigeminal cough, and declare the Brst (nasal) to be the most frequent variety. According to them also, this neurosis is by no means rare, and the possibility of its existence ought always to be thought of where we have to treat cases of an obstinate paroxysmal cough, which is liable to be produced by the aciion of pungent odurs and by changes of temperature, and which is accompanied by hypersecretion of the nasal mucous membrane. The treatment consists in the use of the nasal douche, the application of weak induction currents di- rectly to the nasal Givily. and the administration of potassium iodide. Further observations arc still needed to decide whether we actually have to deal in these cases with a neurosis ol the trigeminus, or whether the vagus has not something to do with the affection, or whether, finally, as Hack suggested, the erectile tissue of the nose is responsible for it.
Quite lately it has been claimed that peripheral irritation of the trigeminus (by inhalation of pungent vapors, new growths, etc.) may reflexly give rise to sensations of dizziness (" ii.asal ver- tigo-" Joa')- Uitlil more confirmatory evidence is brought for- ward, it would be well to suspend judgment on this question,
LITKKATL'RE.
HcrK)|t. Dcr acwXe. und clin>iL Naicncitan-h mil brsondcrcr Elcroeksiehli(pini;
tits ncrvosi'ti Sdintipfcrii (■■ Kliiniii* vn-tomoloria "). I. Aufl.. (inu. 1SS6.
Lcuschicr & l.uhrnski, WJIc Iltr TnitcrniniiihuMcn. Dcvl^che mcd. WochcnKhr.. n, 16. 17. iSBj. Jen). Nasal Vcriigo, L.jinccl. Kt-tiruarj* 1. 1887, p. 31. BniKclmanii. Ucticr NascnKchwindcl (a^trorcxia nasalis). Tbetapeul. Monalt-
hefte. KcbniJity. 1889. iii. p. 5?. Baumgjnrn, A. nip Ntun>vn und Rtflexncurosen dw K3searaclunnuui».
VoIbtnann'sSammluiiK Klin. Vonr., 1891, N. F. 4+
4
CHAPTER V.
DtSKASM OP THK FACIAL NRRVK.
I
I
I
TiiR facial nerve eroeigei at the bane of the brain from the Itilla oblonj^ata by the side of the abducens and behind the tri> tinus on the pnslerior margin of the middle peduncle of the cere- bellun. The auditory nerve is situated close behind it, and between the two a separate bundle of fibres is placed — namely, a Kccond root oi the facial, the KO-called nervus intermedins or portio inletmedia Wnsbergii. With the auditory nerve the (actal then pastes for- oard and outward into the internal auditory meatus, at the bottom of which it enters through a small opening the Fallopian canal {cf. ¥ig. 15), tn the hiatus of this canal it makes an almost rccian- ttvlar turn (genu nervi facialis), passes backward and then down- vard, and leaves the skull through the stylo-mastoid foramen to divide inside of the parotid gland into the terminal branches, the temporo-facial and the cervico- facial, which form together the plexus iBscrinus major. At the so-called genu the nerve forms a gangli- forra swelling — the ganglion geniculi — from which the larger sug>cr- licial petrosal nerve is given off (cf, diagram. Fig. 15). These are the fibre-« which communicate with the trigeminus and have the (unction of gustatory fibres for the anterior two thirds of the tongue (cf. page 74).
Tlie nucleus of the facial, a group of large multipolar ganglionic cells, lies four millimetres and a half beneath the iloor of ilic fourth *cntricle. in the region of the formatio reticularis, dorsal to the upper olive (cf. Tig. ij). From this illustration it is also apparent that the ascending root of the trigeminus has the emerging portion of the facial root to its mesial side, while the anterior root of the auditory lies external to it. The axis cylinder processes of the gan- glionic cells of the nucleus are united in a larger fasciculus, forming the fir»t part of the root (Ursprungsschenkel of Kfau«). which at the Hoor iif the fourth ventricle becomes a compact bundle, the in- termediate portion (VII, a). At the anterior end of the emincntia teres this is bent at right angles (genu ccrebrale). and becomes the etncrging portion (Austrittsschcnkcl) of the facial (VII), which
7J
78
J>/SEASP.S OF THE CXAA'/AI. NfiKyKS.
reaches its point of exit, before mcntifincd, through the transverse fibre* i)f the pons.
Quite lately experiments; on animals by Mendel have »h»vrn that
«. rr F// »
n.nrf .-
riu
He. ij.— DutOMAM movriNO tiik Covnw or thi I'a> ClALFlnncsittTiK Potc9. (Arur Schwa ldk.) k.VU. (acbJ oDcleu*. C//A, root-bundli of the lodil pudcua. f// «. InlcniKdlMepnrtinn(cn>u->«cilon), Vll.tramf iSK fititlon flf (lin fjiciil. a. I'/, alxlufant nudnu. *. i'ltl. nudeiu, and I'///, rnni o( Ihr Aiulitaiy nervt. /. fibrrs eiimine (ri::m Ihr ntpluj. x. fibmeoniine from theabduani nudtiu. *. i.. uppsi ulive. «. r,asMnd- Inc root of Uw Irltemiaiu.
panily^i^. Wc shuU discuss e;ich clast;
in rabliits and i;uinea- \itgTi. the facial branches to the eyes take their origin in the oculo-mo- tor nucleuH. Whether this is the cane »r not in man our present patho* logical observations do not allow tin to decide with certainty.
Just as in the case of the irigcniintis, so in the ladal, wc must distinguish between central (conical and biiU>ar) and peripheral (intra- and extra-cra- nial) lesions, which, Dwinj; to the purely mnlur functinns of tlie facial, may give iis, clinically, spasm or separately.
I. Facial Spasm—" MiMif Faciat. Si'asm "— '• Tic Convulsif."
l-esions which give rise to facial spasm may be central or peripheral in their situation. In the first case either the cor- tcx or the nucleus (or ihc root) of the nerve in the medulla obloiig:ita is concerned. Accurdin}; to otir present ideas the cortical area for the facial is located in the lower half of Ihc anterior and the lower third of the postfrior central convolu. lions, and il is also supposed that the posterior halves of the two lower Irontal and the anterior part <tl the supramar^inal convolutions have some, although a less important, connection with il (Exner).
It is not known whether stimulation of these centres can produce a facial spasm, or, in other words, whether there exists a real conical facial spasm, although the experiences of Cadiot,
OrSP.ASSS OF THE FACIAL NRRVB.
79
^ alo
lb-
\
I
to
and Roger (Kevue tie m^d., Mny lo, 1890, No. 5) seem to leave but Utile doubt upon this point. It seems, how- ever, well cstahlished that the disease can be produced by rc- Rex slimulaliun of the (acial niick-us (,ci. the case of Ilcrger and Hs treatmenl)- Undoubtedly, disease of the per)])heral por tiona of the nerve is the most common, in which, just as in Iri. geminal allcclions, either the whole facial area or only indi- vidual branches may be affected. \Vc distinguish a clonic and a Ionic variety of spasm.
A patient suflcring from clonic diffuse facial spasm has lost itrol over his facial muscles, either on one or, more rarely, m both sides. The muscles affected are in irregular motion, K) that against his will the patient makes the oddest faces, minklcs his forehead, raises the ala: nasi, screws his eyes up, ric. When the attack has passed )ie has a temporary respite, ]ret often enough the pause is very brief, and even during rc> missions spasms Hash across his face, so that his features are never for any time entirely at rest. On the slightest provoca- tion, by speaking, often also by eating, quite violent paroxysms uc excited, so that the patient would lain cover up his dis- torted face.
II the spasm is tonic, the allccted side of the face is singu- luly rigid and takes no part in the facial movements, but is ftlorlcd. The muscles arc distinctly hard to Ibc touch, the comer of the mouth is pulled toward the diseased side, the ■Oulb firmly cluficd, the eyebrow drawn up — signs suflicicntiv *ukcd to distinguish it from facial paralysis, in which also the »1cctcd side docs not take part in the movements of expres- •ion. Vaso-motor and trophic changes are. as a rule, absent.
Id cases where the sp.-ism is conlined to some branches of ■ie brial only, we find that the muscles around the eyes are ilniost always the ones affected. The eyelid is attacked by a oOBicor tonic sp.tsm, and conditions arc developed which go lUKJCT the names ol spasmus nictitans and blepharospasm.
Tlie s/^ifnius mclititHs consists of spasmodic blinking, in *liicb not only the eyes arc rapidly closed and opened, but ibo the neighboring muscles (frontalis, zygomatic!) participate to die spasmodic movements. In a mild form this spasm is seen in many people where it is only to be regarded as a bad habit. BUpkaras/Msm consists of a paroxysmal spastic contraction of the orbicularis palpebrarum, lasting a few seconds or min- utes, which completely clo:»cs the lids- In rare cases the attacks
So
OfSCASBS OF THE CRANIAL NBHyP-S.
I
follow each other so quickly and are so prolonged that the patient has to be treated as a blind man ; even a transient amaurosis has aclually been observed (Silex, Klin. Monatsbl. f. Augcnhcilk.. Marz. i88S). The attacks appear unexpectedly and quick as lightning. They are often precipitated by volurw ■ lary firm closure of the eyes, eye-strain, or by the action of light, and the patient is utterly unable lu raise the lid until the attack has passed. The physician, however, will succeed at times in cuttiii>; short the paroxysm if he be able to discover any oi the so-called pressure points, which, according to von Graefe, who lirsi discovered them, arc often present. More or less firm pressure exerted at these points is capable of pro- ducing an interruption of the spasm and a cessation of the attack. Unfortunately, however, such points are often entirely absent, and when ihcy exist their position is so uncertain and changeable that they may only be accidentally discovered. One of the few which is present with some constancy corre- sponds to the supra-orbital foramen. We should, however, look for them over the whole distribution of the trigeminus, over the spinous and transverse processes of the cervical vcrtc bne. and even in the region of the brachial plexus. It is our duty to make a frequent and untiring search tor them, as we may thus be able to afford our patients very great relief.
Course. — The course of the disease, be it in the form of a total or a partial spasm, is usually very tedious, and a progno- sis for recovery must be very guarded. The outlook is cspc. ctally unfavorable when the affection is complicated with other motor disturbances, as I have observed, for instance, in two cases where the facial spasm was associated with writer's cramp. Of late a number of cases have been observed in which various motor disturbances were associated with lie COiivulsif ; these conditions have been described as a new dis- ease under the name of la maladie des tics convulsifs. We shall have occasion to speak of them in our chapter oa hysteria.
iEtiology.— We know little about the a:tioIogy of blepharo- spasm. That it may be of reflex origin can not be doubted. The most varied discises of the eyes, affections of the nasal mucous membrane, or of the trigeminus, especially tic doulou- reux, carious teeth, intestinal worms, or uterine troubles, may ■ lie at the bottom of it, and the origin of the disease is cleared up only if, after removal of some primary cause, the spasm
I I
DISEASES OP THE FACIAL NEKVE.
8f
^■tiddcnly ccn<ic!>. An examination of (lie ni>sc shonid never be
^neglected. Il has repeatedly been noted that the tic disa)>-
jicarcd alter swellings or tumors ol the miicoii<i membrane o(
Ilhc nose h;id been removed (B. Friinkcl. Pcllewihn), I saw a case of blepliarospasm, which hnd persisted (or fears and was considered hopeless, cured after a coexisting ■exion of the uterus had been materially improved. Diseases n the blood-vessels can. furthermore, produce the spasm, as we see from the case of Uuss ii:.\. Hi.), where an atheromatous i,»rtcry, and from that of F. Schultzc. where an aneurism of the \\. vertebral artery by pressure upon ihe facial nerve brought [tin the spasm. Finally, hystericil conditions can lead to it. as (h shown by the latest communications of Charcot o» the so- I oiled hemispasmus glosso-labialis. which has been described by Marie (Progrfes m£d., June 6. 1887).
Treatment. — .All these points we must keep in mind in de. dding upon a line of treatment, and not imagine that we can ture a facial spasm, whether it be total or partial, clonic or tD&ic, with indiscriminate galvanization, for without system we shall only meet with success in rare cases, and then only by
kgnod luck. The mosi promi:4,iiig plan of Ireatiiient i« the appli- atiiinof the anode to pressure points if such be present, while Ihealhodcis pl.iccd on some indiderent region, the back of the neck or the sternum. Weak currents applied lor one or 1*0 minutes, with careful avoidance of make and break, give the best results. The application of the anode to the back ol flwhcacl. keeping it at the same point, also sometimes meets •ilh success (Berber), but too altcn leaves us in the lurch; and Ihit will hardly surprise us if we remember that even when tbt mode is placed on the back of the neck the abnormally simulated reflex centre in the medulla is by no means always 'Mclied by those curves of the current which really do pene- tote deeply.
Cures, such as that reported by Berger, undoubtedly de- Pnid upon a happy coincidence of circumstances. The me- ^1 oblongata, above all, where in such an astonishingly small •pKca number of the most important nuclei lie close together. *«»» lo be the most unfavorable place for local electrization 'fbckcnnc), by which we aim at affecting individual nerves or ■wtc mots. We may reach all or none, no matter whether we UKimall or large electrodes. Still, even this method ought to be (tied, since we have no positive remedy. Should the gaU
S2 DISEASES OP THE VKANiAL .VEXfES. ^
vanic treatment fail, the internal treatment is still mure vague, and it is well to inform the patient of the uncertainty of this procedure. Ol course, ttic usual nervines and antispasmodics are to be given. Hammond has seen especially favorable re- sults from the use of coniin and alropin (Med. Record, No. 41, September, tSy;). As a last resort, neurectomy ol the supra- orbital or stretching of the facial nerve (Bernhardt, cf. lit.) has to be considered, yet even from this we can expect no lasting success.
UTERATUKE.
Bergtr. NeuruloK- Ccntralbl.. 10, 1883.
Bernhardt. An:h. f. Psych, und Ncrvciiktankh.. xv, j, tSA^.
Busa. Neurol. CenimlbL. 14. 1886,
Hensclicn. Keurtiatick lie convuUif med thnioeking arnervj rAci.-iliti sum.
ul.i lilkareforcn. Uirh. 1887, xxiii, 3. Ctiilion. Tic* convulsifs ct hyrtfric Revue <!c mill.. June, 1877. Cf. bc^ci the Icxt-books of StriiinpcU, Scciiginulter. EichhorM. Eulcnbutt^. etc.
2. Facia], Paralysis— Mimic Facial Paralysis— Hemi- pi.KGJA Facialis — Prosopoplkcjia.
Facial paralysis is an affection the relative frequency of which makes it of the greatest practical importance. In this more than in any other nervous disease any Liyman can easily judge just how much the art of the physician has accomplished in a cfitain time in a given case, and on this account it espe- cially behooves us at our first examination to be very careful in making a positive statement as to the prospects of recovery or the probable duration of the disease. Both these points de- pend chiefly on the seat of the lesion, which, as in tic convulsil. may be central or peripheral.
A. CKNTUAI. KACIAI. PARALYSIS.
Symptoms and Diagnosis. — Central facial paralysis may be produced either by a cortical lesion (cortical paralysis) or by a lesion of the facial fibres in the brain between the cortex and the pons (intracerebral paruiy sis /nir rrceUfficf): or. finally, it may depend upon a disease of the nuclei and nerve roots in the pons. Corticil facial palsies may be caused by tumors, ab- scesses, or chronic inflammations in the region of the motor centres. Those ol intnicerebral origin may be produced by I syphilitic arterial disease or by rupture of a vessel in the region of the internal capsule and the crus cerebri. The third
DISEASES OF THE FACIAL NERVE.
83
i
^
I
form, that originating in the pons, is found in Duchennc's paralysis and, more rarely, in tabes. There exists a lorm o( iacial paralysis the pathology and the seat of which is as yet very obscure, and we can only say that prolxibiy a " nervous predisposition " is necessary for its development. It may oc- cur in several members o( the same family, may be congenital, and may be associated with paralysis in the region of the sixth nerve and of the trigeminus. It sets in without any appre- ciable cause, is wont to recur, and may last for an indt'fiiiite period of time: probably its anatomical scat is in the nucleus (•■ infantile degeneration of the nucleus," MObius), but, as was said above, this is by no means proved. It is quite possible thai some cases may have a peripheral origin, as is the case in the recurrent oculo-motor paralysis (of. page 50).
The clinicil picture differs but little in these three forms, and only at times do the accompanying symptoms make a dif- ferential diagnosis possible. Thus, for instance, the intracere- bral paralysis often appears with an apoplectic attack, and is iccompanied by hemiplegia and speech disturbances, while if facial paralysis is found in connection with spinal disease it is Always of nuclear origin.
All three forms oi central paralysis have usually, however, two features in common which can almost be regarded as pathognomonic and which distinguish them from the periph- eral paralysis, namely : 1. The presence of a normal electrical excitability in the nerves and muscles to both currents. 2. The escape of the upper facial branch. While in peripheral paraly- Its all three divisions arc equally adccled. we lind in the cen- tral form the upper branch usually intact, and the patient can ■rinkle his forehead and close both eyes.
Wc say usually, not always, because there are undoubtedly exceptions, where wc meet with a central paralysis in which the upper branch has not been spared. It is quite probable that the naso-labial and the orbiculo-frontal fibres of the facial have 1 separate cortical origin, and we can well imagine that if the cause of the paralysis — e. g., a small focus in the cerebrum — is iftiuted above the union of those two branches, one remains intact (in the large majority of cases the upper), whereas if it is bdow their point of union both branches are affected.
A further guide to localization is the condition of the move- ments of expression (Bechterew). If these arc lost while the Toluntary innervation ol the iacial muscles is intact, we have to
84
D/SKASfCS Of THK CRAKIAL NERVKS.
assume a focus in ihe opiic thalamus, the centre for facial ex- pressions, or close to it (Bcchtcrcw), while a faoinl paraly&is with rcUiined power of f:iciul expression allows us to exclude a lesion in the thalamus and its coronal connection with the hemi- spheres. In the case of Kosenbach (Neurol. Cenlralblatt, n. lS86)therc was an isolated paralysis o( mimic expression in the left facial and right-sided bilateritl tiemiai)opia, and the lesion was taken to be in the right thalamus.
In differentia ting tR-lween a cortical and a bulbar facial pa- ralx'sis the lollowing points must be taken into c<itisideraiion : Thai the lesion is cortical is probable if Ihe facial alone with- out the corr<Mipondi»g halt of the body is panilyzed (monoplegia facialis), and if Ihe affection is confined to the lower brandies of the nerve, while the nor- mal reaction to the electrical current remains undisturbed. It is easy lo undcrsiatiri that the hypoglossua often takes part in the lesion if we remember in how close proximily the centres of the two nerves are situated in the cor. tex. and in a given case an examination of the mobility of the tongue will show whether we actually have to deal with a so-called monoplegia facio-lingualis. Sometimes a disturbance of s|>cech points at once to this combination. In every case in which we assume a cor- tical lesion, the sensation in the distri- bution of the facial and the hypoglossus ought to be tested, because it is just in these cases that wc find not infrequently sensory changes — e. g . analgesias and nnsesthcsi.is.
We shall be led in a facial paraly- .sis to think ol an affection of the pons when not only the nerve, but with it one whole half of the body is para- lyzed : and there are two types of pon- tine facial paralysis according as the lesion is situated in the upper or lower part of the pons, In the first case (focus a in Fig. 14) the facial and the same, in the second (focus *) the
fif. 14.— OUORAM miOWINO
TiiK OncvauTtOH or thi FiMiia ootira ttt mx
EXTHKMiriKII, AKD Of TIKm OOIMC TO Tint
Pack, im riiE Pnvn amd
tlCblrLLAODLOXr.JtTA. F,
(«cial iibm. B. fibm p>- iiiK (II llic ninmllic*. P, piiiw, O, mtilulU otilen- (lU. fyx. decuMMtna o( Uie prranildi) tncU. a, ■ focun In the upp*r. i. a (ocu* ill Uie lonei. put ol tilt poiu (thi bitcr U iltu- M«l below tlie ibcuMMUon o( Ihr facial fibmi.
DJSEASEft OF Tl/B FACIAL XEKVB.
ss
I
I
facial and the opposite lialf of the body arc uflcclcd (hemiplegia altfrniins, Gubler, itt;9), because i)ie facial fibres cross in the puns ami we may have a lesion above or below this crossing, and in both cases thi^ will be siiiiated. ol course, above the crtwsing of the fibres going to the extremities.
The facial paralysis caused by the lesion in the upper pnrl of the pons, and that found in connection with hemiplegia after « lesion in Ihe internal capsule, arc in so far alike as they arc boib accompanied by paralysis of the extremities on the same side. But (here is one point of difference which will influence our diagnosis, namely, that after pontine lesions the facial pa- ralysis, very much as in the peripheral form, takes in all three branches of the nerve, while in a lesion of the capsule or the basal ganglia only (he lower branches of the nerve arc affected : but in contradistinction to what happens tn the peripheral paralysis the electrical condition may, ai least in some cases, rvmain normal.
The mosi striking symptom of centra! facial paralysis is the relaxed and ex press ion le-ss appearance o( the affected side. The rwso-labial fold is more or less distinctly flaliened. the cor. Dcr of (he mouth is slightly open and hangs down, the mouth leeins to be drawn to the well side, the patient is unable to rat»e his upper lip or to whistle. On inllating the cheeks ihe air escapes ; drinking and speaking are difficult, the latter espe- cially, because the labial sounds are defectively formed. Dur- ing eating the food gets in between the cheek and the teeth on Ihe allectcd side, and the patient has to bring it lo the right place again with the lingers. In biting, the mucous membrane of Ihe check is often caught between the teeth. The upper p:irt oJ the face is in by far the greater number of ciscs normal ; the forehead can be wrinkled well in its whole extent, and the pa- tient can frown and close either eye perfectly.
The condition of the velum palati and the uvula varies, and in, therefore, ol no value, either diagnosiically orprognoslically. The uvula may deviate to the sound or to the affected side. Of mav occupy its norm,*)! position. With our still im;»erfccl btuwlcdge of the innervation of the muscles concerned, any attempt to explain the different pc^silions of the uvula must t>cedh be hard, but we sh.ill be less surprised at our difTiculty when wc consider that the levator pal.ili is supplied not only by the facial through the large superficial petrosal, but very probably also by the vagus accessory, the tensor palati, how-
86
DfSEASSS OF THK CKANIAL HEKVES.
ever, by the third branch of the fifth. In other words, at least three cranial nerves arc concerned in the motion and fixation of the uvula, and besides, even under normal condtllons, the uvuta is occasionail)' found to deviate to one or the other side. The only thing of which wc can, perhaps, be sure is that if during phonaiion paresis of the velum palali and deviation to the sound side becomes apparent, the large superficial petrosal is most likely affected (paralysis of the levator palati and azygo? uvula;). Of greater importance lor the diagnosis of centra! facial paralysis is the persistence of the reflexes, which in peripheral paralysis arc often diminished or sometimes completely lost.
Furthermore, the disturbances in hearing, the alteralions in taste and in the salivary secretion, so frequently observed in the latter, are almost always absent in central affections.
The existence of a bilateral facial paralysis — diplegia facialis — points as a rule to a central lesion, and more especially to a bulbar affection. It certainly is one of the greatest rarities lo have a simultaneous paralysis of both as the result of a periph- eral lesion.
Prognosis — The prognosis depends upon the anatomica} basis of the disease, lesions of the cortex and the pons often bring about facial paralyses that arc incurable, while those ob- served in conjunction with cipsular hemiplegias, especially in the eartv stages of the latter, frequently present a decided im- provement after a time. .As was staled above, it is impossible in the cases which depend upon a neuropathic predisposition to make any statement either with reference to duration or with reference lo a possible recurrence of the trouble.
Treatment— The question of treatment arises only when the primary lesion is amenable to therapeutic measures. Since this, however, is only very rarely the case, it is best, at Icist in the central facial paralysis, to restrict ourselves lo the expecN ant treatment. The measures that will be recommended as in- dicated in the peripheral form are here of very little avail.
n. I'KKirilERAL FACIAL PARALYSIS.
In its peripheral course the facial may be divided into two portions — an intracranial and an extracranial. The former is lew frequently affected than the latter, which is more ex- poted to atmospheric influences, especially cold. For prac- tical reasons %vc prefer to consider the diseases of these two •egtncntft neparately.
j>/seAsss Of TiiF. facia!. NRRX'K.
87
1. Thf iHlraeranial lesion.
This form is dislinguislied by tlic (act that besides the con< &tant existence ul paralysis of all the facial branches, we have
xs—txtt* DlwilUH Fcni FAi'tAt. pAKALveis, Ktrmsollni; lh« onuraf of ihp fidal jtnak fcom tlw bata of ih« iliull in ih« pc* miutriDin. ;V. a., audiionr nr«TT. A'. /., tol »n*r. A', /. 1.. \iat:f topFtficUl pvlronl nirrvt. C /.. E"iim<'>' cangUoa. K. t. t. f. {., omoiunidtinc bniiidi tii IjrmiMiiic ptnu). A', tl.. ilupnliiu iwrve. Ct. /„ dla«da Ipnpani, G. /,. i-tMUUnr lilin*- Sft,. ■rcnui«T iwrre (o nllmy (lia^ f, tt., myto-mtiloU formmrD. X.t.f,, poaurkit audnilat tnnt,
odcn certain concotiiitnnt symptoms, which can only be fully understotxl it wc picture to ourselves the exact course of the
88 DISEASES OF THE CRANIAL NERVES,
nerve. This can be done with the help of the diagram (taken from Erb) here represented, which permits an accurate locali- zation of any given intracranial lesion.
{fi) [f the lesion be between the exit of the facial stem (from the pons) and the geniculate ganglion, we shall find a paralysis of the velum palati, abnormal acuteness of hearing, and dimin- ished salivary secretion.
(*) U the facial be affected in the region of the geniculate ganglion itself, then we find in addition to the just-mentioned symptoms alterations in the sense of taste.
((■) A lesion between the geniculate ganglion and the stape- dius nerve produces the symptoms described in a and b, but no abnormality of the velum palati.
((/) A lesion between the origin of the nerve to the stape- dius muscle and the giving off of the chorda tympani gives alterations in the sense of taste and diminishes salivary secre- tion, but no abnormality of hearing or of the velum palati.
if) If. finally, the nerve is diseased below the giving off of the chorda, in the Fallopian canal, we only find paralysis in the distribution of the posterior auricular branch without any trouble with taste, hearing, the condition ol the velum palati, or the secretion of saliva. We should state again, however, that in all cases from a\Xi e all the facial branches take part in the paralysis.
Valuable as this diagram is, undoubtedly, regarded from a theoretical stand-point, yet in practice we but rarely meet with opportunities for observing cases which exactly correspond to it ; nevertheless, in every instance we should not fail to attempt to Uxrate the lesion with as much accuracy as possible.
A physiological explanation for the appearance of the above- mentioned ciincomitant symptoms is not always easy. That alterations in the sense of taste are due to lesions ol the chorda tvmpani can not be doubted, and if they are present the lesion is situated fjctween the geniculate ganglion and the giving ofi of the chorda : if thev are absent the lesion must be sought below this region. The disturbance in the sense of taste is limited to the anterior two thirds ol the tongue, and exists, of o>urse. only on the paralyzed side. Sensory changes \a the tongue are not necessarily present. Less clear is the cause of the diminished salivary secretion. Its occurrence is said to p<.iint to a lesii^n above the geniculate gaogHoa (WacfasmuthV Mendel has obseni-ed increased salivary- secretioii in an instance
D/SS4SES OF THE FAVIAL .VERVE.
89
in which it was also diflfictilt 10 find an adequate physiological explanaliun (Neurot. Ceiitralblftli, 11^90, 16).
Amung the most common and best known symptoms arc the dtsturbanccs in hearing, which consist cither in an abnormal Acutencss of hearing (hypcractisis, oxyacoia) or in a decrease in the power of hearing. In the first case, where we have a kind of hypeneslhcsia for alt musical tones, the alteration is supposed to be due to a panilysis of the stapedius mu&cle (which it supplied by the facial) and a consequent ovcractinn of the Icnsur lympani I.Luc;ic. Ilitzig, Rous). The latter — the hard- ness of hearing — can be due 10 several causes. We may either have a disease of the middle ear and the adjoining portion ol ihc temporal bone, which has aflcctcd the facial nerve by con- ifguily, or a simultiinei>us aScction of the auditory nerve, which, in ihc inrernal auditory meatus, has been exposed to the same delelerious influence, and become affected by the same disease as the facial. Quite lately again the frequency of this combina- tion of facial paralysis with a slight paralysis of the auditory nerve bait been pointed out by U. Koseiibach (cf. lit.).
s, Tkt Exlrotramal Lesion.
The peripheral paralysis of the facial after its exit from the skull is, as we have already said, the most common. Ol this class ihc so-called rheumatic form, which is attributed to the influence ol cold ( a jrigvri). and the traumatic, often observed alter operations, gunshot injuries, etc., or which may be caused by the pressure of impacted cerumen in (be car and mastoid cells (Dalbey, New York Med. Journal. Iiv. 3. l8ql). arc the two chief representatives. When any one. heated as he is. passes from a warm room into a cold wintry night, or is ex- posed to draughts in the r.tilroad cars, and hnds himself a few hours later taken with a paralysis of one side of the face, this ill ihc ^o-callcd rheumatic form which has attacked Ihc stem of the nerve alter its exit from the Fallopian canal. Dut the influ- ence of cold in such instances must be regarded only as the precipiuiting cause in individuals with a neuropathic predis- position (Neumann. Arch. d. Ncurolc^ie, July. 1S8;. xiv. 40).
In these cases all three facial branches arc affected, and the appearance ol the patient is changed in a very material and linking manner. Rvcn the layman notices that the patient now wrinkles only one half of his forehead, and that the folds aiid furrows generally present are obliterated on one side : that
90
D/SEASSS OF TflE CkANIAL NEKVES.
be can shut one eye only while the other remains wide open and can not be closed despite the strongest eflorts. If the attempt is made, the eyelids remain gaping, the eyeball is rolled inward and upward, and the pupil disappears behind the upper lid, a position which is also maintained during sleep (lagophthalmos). The inability to shut the lids prevents the tears from running into the tear ducts and interferes tvith the process by which foreign bodies, particles of dust and the like, arc removed from the eye. It happens, then, that the tears arc always running down the cheeks, and that a conjunctivitis, even an ulceration of the cornea, may be developed through the mechanical irri- tation caused by such foreign bodies. The appearance of the lower part of the face has already been described. In mild cases the tongue does not deviate at ail : in grave cases it is turned toward the well side (Hitzig. cf. lit.)-
It is interesting to note that in the first stage of rheumatic facial paralysis the patient often complains of pains the inten- sity o( which seems to be proportional to the degree of the paralysis. These arc usually localized in front or behind the ear and radiate toward the forehead, the temple, and the cheek : sometimes they last but a few days, in other cases they persist tor weeks. They must be referred to an affection of sensory branches belonging to the trigeminus.
The hyperidrosis associated with facial paralysis, as ob- served by Windschcid (Miinchencr mod. Wochcnschr., xxxvii. $o, 1890), as well as the frequently noted puSine&s and the porce- lain-like induration of the aflecled side associated with vascular dilatation and elevation of temperature (von Friinki Hochwan, Deutsch. mcd. Zig., 1891, 35). show thai vaso-motor fibres are also implicated in facial paralysis. I have observed the appear- ance of CL-dematous swcllin<{ especially in the recurrent forms. The implication of trophic fibres is shown by the not rare oc currcncc of herpes zoster, which has recently been described by l-etullc, Strllbing. Voigt, and Perrin (cf. lit.). Whether this is due to an inflammation of the peripheral endings of ihe fifth, which is transmitted to the facial (Strilbing). or whether the stem of the facial contains in parts fibres, an inflammatory irritttion of which m-iy produce herpes zoster (Eulcnburg), (s oot clear.
I have only in rare instances seen this complication, and have found that whenever it was present the cases pursued an niuuiully protracted course.
D/SHMSes OF THE FACIAL S'KRl'F..
9'
^
N
I \
Duration and Course.— The duration and course of rheu- tnalic facial paruly5i<i arc extremely variable, and it is of great importance for the physician to be able tu give nt the begin- HQg an approximately accurate opininn a^ to the length of time ry for recovery. This we can, however, only do il we investigate the electrical condition of the paralyzed muscles, ud hence it follows that it should be our invariable rule to Bake an electrical examination before venturing upon any <x]>ression of opinion. The following are the chief points to piidc us:
I. If we find no changes either in faradic or in galvanic ex- cital>iliiy the prognosis is favorable ; recovery in from seven to twenty days (light form).
1. If we f^nd the faradic and galvanic excitability of the ncrre diminished, but not lost, the galvanic excitability of the auKlcs, however, increased, and the usual formula of contrac- IMB changed {A. C. C. > C. C. C). then the prognosis is rela- livcly favorable ; recovery in from four to six weeks (intcrme- diue lorm of Erb).
5. If the reaction of degeneration be found — i. e.. if the far- adiciitd galvanic excitability of the nerve and the faradic ex- ciiabiliiy ol the muscles be lost, while there is an increase in Ik fralvanic excitability of the muscles associated with quali- tative changes and changes in the mechanical excitability — then the prognosis is relatively unfavorable, and for recovery two, iMr, six, eight, even twelve months, may be required (gnive V""' These arc those bad cases in which secondary con- tectures and spasmodic twitchings of the muscles also appear, *hJch, according to I litzig's opinion, arc to be referred to an objure abniirmai irritation in the medulla oblongata. It is *cll ro know that, as convalescence begins, voluntary motion lur return long before the electrical excitability, so that often llic patient is able to perform some slight voluntary movements Mure laradic stimulation provokes the leai^t contraction.
The palholtigical changes have been studied by Minkowski (Berliner klin. Wochenschrjfl. iSyi. 27). and quite recently by Oarkschewilsch and Tichonow (Neurol. Cenlralblatt. 1893, 10). The tatter found a jKirenchymittous neuritis in the peripheral portion ol the nerve, and in the central portion the signs of lecondary degeneration, with many perfectly atrophied libreg \ the nuclei also the signs ol a well-marked atrophy were nt.
92 ■ /f/SSASes Of THE CKAXIAL NERl'BS. ^H
1
Diagnosis. — With regard tu the diagnosis there is even (or| the beginner no more easily recognizable disease. Slill, therej arc casts whi-rc it is difficult, not to s-iy whether there is any; paralysis, but, strange as it may sound, which is tnc alTectedi side. One is particularly liable to mistakes in old people, iul whom the wrinkled, inelastic skin has produced a stereoty|»ed expression, which, even when the facial muscles contract, isi but little changed. Suppose now the muscles to have lost their' innervation, the paralyzed side lakes on ilic soft fcamrcs of an earlier period of life, aiid this may go so far thut the patient) believes his rigid, wrinkled side to be the paralyzed, and iho; affected side the healthy one (Gowers). \Vc also must remcm<i bcr that the non-paraly/cri zyiromatici pull the (ace sharply] toward the well side, a condition which easily produces in the layman the impression of somclhing nbtinrmal, so that he takcft the side thus distorted for the dist-ased one. In general, how» ever, we may say that the diagnosis of a peripheral facial p»«, ralysis is one <i( the easiest imaginable in ncuro]>;ithology.
Treatment. — In the treatment we m,iy in recent cases rec- ommend tor trial steam^baths and counter-irritation to the skin j but never, unless there is a special indicalion. should iniernall remedies be advised, because in a non-com plica ted rheumatic facial paralysis they are absolutely superfluous. In more pro* tracted cases the methodical use of electricity is strongly indi^ caied, (or even though it is tnidoubtedly true that the disease^ if the prognosis is at all favorable, gets well of its own accord^^ and really requires no treatment at all, there can, on the nihen hand, be no doubt but that the electrical treatment hastens the'; cure in n marked degree: therefore, electricity should be used' under all circumstances. Just which method should be em." ployed can not be definitely laid down, but we shnuld keep ini mind that not only the galvanic current is beneficial, but thatj the faradic brush applied to the stem and the individualj branches of the facial gives good results, and the ]>alienti should, therefore, be persuaded to submit to this sonicwhatl disagreeable procedure. The places from which the most im- portant facial muscles can best be stimulated are seen in Fig, 16. At these points the molor-ncrve branches to the muscles concerned lie very near the surface. They arc called " motor points " (Xiemsscn). In galvanization every specialist has Ida pet method of application and his own ideas about tlie strcngtli and direction nf the current. The one prefers to apply the
0/SEAS£S Ofi rtlE FACIAL NERVE.
93
electrode over the mnstoid proces». placing cither the anode ur the c:ilhf>de on (he afTccted side of the face ; another treats at
he same time the sympathetic in the iicck; a tliird. again, ap- plies the anode over the affected nerve and the cathode lo an
ndiflerent point, and so forth. Whichever method we may
Un>lmKko<
Elcclono(th*MD-
K«jiom o( the iipet<:li centre.
Upper brinch of
F4ici'al u«m.
Middle bruKh ol ttw UciaL
<K amnorlui^
Supradarautar
Kim I pla. ■cli.t.
f%. tl— Sown or TKi »<«i.LEi> "UoTOK Potvra" oh thk Facs ako Nkck.
pnltr. the main thing, after all, is to produce by repeated opcnitig nml closing <if llie current contractions of the mus- <lnby which the tonus of the latlcr will soon be improved. Ith'xild tike to mention, loo, that t have seen the application "flbtfpilvanic b^ush and the use of the combined current (de VCMIcwille) repeatedly atlendetl with satisfactory results (I iirt, tefcrbuch, etc.. toe. at., p. ro2 et uq.).
LrTKKATirKK.
(WlUwit. op. iil . pp. Ji(> ft trq.
IwiUt Arelt (k I'hysiol. !nic »«r.. \\. p. 66]. iSSj.
ftitrtgrg. Uebcr Complicjllmven von pcr^phcrrr Fnmliftlllhfnung mil ZoMer bdd Centralhl f Nm-rnheillc. ;. iBSj.
94
D/SEASES OF THE CHANIAL JVEEI'ES.
VoiKl. reierehurger med. Wocheruchr.. ix. 4{. iSSj.
Kttnak. Onluibl. f. Ncrrrnhdlk.. 5. 1B85.
Stnibttig. Hcutsches Arch. f. klin. Med., ixxvii, p. 513, i88j.
DarKuud. De I'h^niipljfjie (acriale iliins lu p^riode Mcoodatre de b sjrpbiic
Thisedc Paris. 1885, No. 178. MUbitii. Ccntralbl. t Ncrvcnhcilk.. ix. 7, 1885. Djuiuand Wilkin. Joum. of Mental anJ Nerv. UiMaus. Na J. 1886. EJchhorst. tiandbuch drr ftpccicllcn Palliologie und Thcrapic, Bd. iii, y Aufl.
WIen. I SB?. Ctiisolm. Arch. f. Augeiihoilk.. xvii, 4. p. 414. 1887. (Congeniul PnTalj-M* of
ihc SixCh nnd Soenlh Pair q( Cranial Ncr\«,) Mendel. Ueber den Kemutsprung (le& Augcnfacialis. Neurol. Ccniralbl,. No.
aj. 1887. Huet. Hysterical Facial Paralyse. Weckblsi) v. d. Ncderl. Tljdschr. v.
Ccneesk., 2$. 1S87. Mi>biu«. Ueber die angeborcne doppclsdligt Abducent- KacialiaUhmung.
MOnchcnrt mcd. W<K:hen%chr.. 188&, 86. Routland. A jirupoa de qut'lques failx <le paralysie« des nouveau-njs. Paris,
Sieinheil, 1889. Foucher, Dc la coniracturr sccondaire des muscles dc b face. TUsc de
Pari^ 1888. Slephan. De la paral)-sie bciale des nouvcau-nis. Revue de mid.. 1888. 7. Denioulin. De la paralysie fAciale tardive dam les fractures tlu tocher, Gm.
mii. de Paris. July 14. 1888. VIziolL On Ihc .^JUoiogy of Facial Paralysis a frigart. Riforma med.. 1888,
pp. a79- 180, nernlunli. Ucber .inKcborme cinseiliKc Trigeminus.. Abduccns-. Facialit-
lUhmurtK. Neurol. Ccniralbbit. 1890. No. 14: L'eber Facial i^l&hmung und
Faciaiiskrainpr. Berliner klin. Wochcnschr.. 189;. xxtx. N'ol 51. Pcrrin. Journ. des maUd. cut. ct syjih., November, 1S91. Decomi. De la p;iralysc facUle hysi^rlque. Cajt. de Paris. 1891, 47. HUiig. Die Slellung der Zungc bd peripherer Llitunung des Facblts. Berliner
klin. Woctictnichr., iSgz. Jo. Darkschewiticti und Tichonow. Pathological Alterations in Peripheral Facbl
Paralysis. Med. OboM,, 1893. tS(Ru»suin). Stintfing. Urber Diplepa facialis (ProsopoOiplegia). Munchcner med. Woch-
sucht.. 1893. I.
CHAPTER VI.
milRASI'.S op THK AUDITOKY Sf.KVW..
\
I
I,
I
The auditory nrrvc emerges at the base oi the brain, alonji^ide o( ilic facial, and lakes with this latter a forward and outward course. After having entered ilie internal auditory meatus, it divides before todiiRfE the cribriform plate, which separateK (he internal meatus (fob the internal ear, into two main branches, an anterior inferior and a posterior superior. These nerves pass as small lilamenta thioagh the openings in the plate, to be distributed respectively to thccochlea and vestibule, and are hence called ramus cuchlearis and nrnu vestibularis.
TV cortical centre of the nerve is probably to be sought lor in tW Innporal lobe; the fibres are .lald to run through the laM third o\ tk« posterior division of the Internal capsule, through the middle inmlale l>ody, through the brachia conjunctiva posteriora. the PMttnor corpora Quadrigcmina, and the inferior lillet (v. Monakow, Bifintky),
About tile situation of the nuclei of the auditory nerve there Mtmt still to exist a difference of opinion among the anatombix. (''■utlly two nuclei arc distinguished, an inner or principal nucleus ■"■lu outer one situated laterally from the first. En their structure •''•« present material differences. While the former — the inner "■Xtfu*— only contains scattered, small, slender, giLnglionie cells (t5 la 10)1 long), the tatter contains cell* of considerable sixe (60 to 100 t ituig and 15 to >i fi broad). The situation of the two nuclei may ^understood from the accompanying diagram
Of the two roots, the superficial terminates in the internal audi- '07 nucleus, while the deeper one passes between the rcstifomi body h4 the ascending root of the fifth, and turns towani the outer one. Tht». alMi, the diagram, which ts taken from Wernicke, and which tfciiKrnsi rates the views of Mcyncrt, illustrates.
Although the diseases of the auditory nerve are not, as a. rule, treated of in neurological text-books, they arc found .sotne- ttmcs so closely conticcted with other nervous diseases, and
gg DfSEASES OF THE OfA.VlAl. fifERySS.
arc, notwilhstanijiiig their coinparalivc rarity, of such decided practical imporiancc, that we feel not only justified but com- pelled to consider them here, at least briefly.
The nerve. :is we have said, nirely ever becomes primarily diseased, but diseases ol the middle and internal ear— that is. secondary affections — arc by lar Ihc most common causes o(
Fif. t;.— Dmcnakhatic Stcnoji Timoirdii the M»:r>i;i.i.« Oki^noata tx niK Rramt or T»iE (LowKM) Uuvt. The ilelii half rrpmriiu ■ 1<iH*t pbnr. /, pynmidi; m, lower ollv* ; /, Icmnucui: m/. moUic rcglmi <i( (lir i>.|:inrni<im -. j. atanAittti roiX ol lb* flhti ; ti., oiqi. tmil,; l^r., eilemBl, H-i.. luwnikl niKlruii nl Iht uidilorr : tt.. rnnin. lens; 11, nuclriu and ro-)! al (he hrpagliiHUA; lo, roiit -A llir vom* : X.a., aMcttor, X.f., poMcrlot v«K<" Duclcui ; X.f . combinaj rmit ui tlir "laUnl mixed qrMtfn " (e(. p. loj) ;*.(., iup«rAcUl. »-/., <1<^ rool of thcauilltnrr nrnw.
diminution op loss of hearing. We may distinguish between condition!) of irritation and those of paralysi;^ so that on the one hand we shall have hypcrjcslhesias, on the other parescs or paralyses.
I. Hvi'f.R/Hsthf:sias of the Auihtorv Nkrvk.
We speak of a liypera-slliesia of the audilr)ry nvrsti wher the patient experiences a painful sensation in his car when per- ceiving certain sounds or noises. For instance, in excitable and nervous individuals who suffer from hcmicrania or tic douloureux, such .1 seiis.ition tnay be produced by high musical
DISEASES OP THE AVDITOKY XERV&.
97
I
whistling', and ilic like. Quite a (HfTcrcnt aReclion is an irmnl aculciicss ol hearing, whicli i.'i extremely r.irc, the &o-
catlcd ox^'iicutn ol which we have spoken in the chapter on
facial par,-ilysi<i.
Frcqueiiily one hears nervous patients complaining »( sub.
^ctivc auditory perceptions, roaring, buzzing, hissing, singing.
httmining, and the so-called nervous tinnitus aurium, which
Buy persist during the whole life without a sign of any other diuurbunces of function, This symptom may be due to a |iurcly functional disorder or il may be the forerunner of n iii>Jdle-ear sclerosis.
Therapeutically, we may. alter the removal of masses of cerumen or epidermis which may have obstructed the outer laaal. with benefit make use ol blisters, tittmulating lotions ap- plin! to the mastoid process, subcutaneous injections of mor- phiac, the bromides, digitalis, and atropine. If abnormalities cri tcnMtjn in the sound-condurttn}; apparatus and coosequeni risciif pressure in the labyrinth be the cause of ihe disorder, llicnilie inflation of the middle ear and the rarcfacliuti of the win the outer canal is to be reoom mended.
II. The pAkESKs and Parai-vses of the Auditorv Nerve.
Antilogous to the rheumatic facial paralytus wc have a con- liilioii in the auditory nerve which manifests itself in either a ikcrosc or a loss of the (unction of hearing, the so-called rhcu- ouiic acusticiis paralysis. It is less frequent than Ihe former, itlhou^h the cause of both, namely, cold, is the same. Central P^fJiyses are always connected with decrease of hearing power O One side only. Absolute unilateral deafness, as a conse. IWnre of a focal lesion in one of the hemispheres, has up till '"•* liol been obser\'ed (Wirnickc). Whether the disturbances Rihtaring observed by Baginsky in railway spine are of a cen. 'nl nr periphend nature remains yet to be studied (cf. lit.).
Next in order we have to mention in ^his connection the Jnxjihcsia and paresis of the auditory ner\*e. which somelimes *;'|>e:ir (]uitc siiddridy in the course of hysteria, and often as *i«idciily disippear agaifi after a longer or shorter period o( ifiM. (H Interest from a pathological standpoint is the nervous
deafness ix;curring after an epidemic cerebrospinal meningitis.
il is Itiia lorm which has been so thoroughly studied by Moos.
98
D/SEASES OF TUB CRANIAL SERVES.
There is liardl>- any doubt but th.it it is caused by (he passage of purulent mits&i'S from the meninges aluufj^ the shciitli of the audilory nerve into the inner car. The prognosis is unfavor- able. A diminution of liearinfj, probably due to trnnsiiory cir- culatory disturbances, occurs somclimes after epileptic attacks. Although nut common, this alTeclioii is certainly well autheii* ticated.
Ol especial interest a'liologically are the disorders of hear. ing which wc find in cngint'crs and firemen on the railroads as ji consequence of their occiipiiliun. This must priiuiipalty be attributed to the noise, aided, however, to some extent by the abrupt and severe changes of temijeralure and the exposure to all kindsof weather. We do not know anything positive about the relative frequency of this afTeclion, which consists in a mure or less pronounced decrease of hearing, but in the general in- teres! of the public it certainly deserves as much attention on the part of the companies as the color-blin<lness which h.-is for years been carefully looked into. Lucksmitlis, blacksmiths. and boilcr-makei's, whose audilory nerves are also being c<m. stantly uverslirnulated, sulTer from similar disorders. In rare and exceptional cnscs it has been observed thai mechanics who are "hard of hearing " hear belter during the usual noise con- nected with their work than when everything around them is quiet — paracusis Willisii. This very remarkable phenomenon is probably due to a decrease in the vibratory power of the auditory ossicles, owing to which the sound is conducted with more difficulty, a ccuidilion which is obviated by a more forci- ble concussi<m (Buerkner, HoosiU. We would not leave uf»- menlioned the fact that an overtaxalton of the audiKuy nerves lusting for years causes great nervousness, and may even pre- dispose to mental diseases.
In the treatmLiil, cndermic inunctions of slryclmine (o.l to glycerin 10.0 |gr. jss. ; glycerin. 3 ijss.l — sig., ten drops) over the mastoid process, and funics of sulphuric eiher conducted by a catheter into the tympanic cavity to act on the distnbi.ti<m of the acListicus. deserve recommendation. A beneficial effect fiom the galvanic current can he expected only if cxaminaiiim assures us that the current has a modifying influence on the subjective noises or upon the power of hearing. This treat- ment necessitates a knowledge of the investigations of Brenner on the galvanic reactions of the auditory nerve (c(. Htrt, Im. (it., p. 109).
I I I I \
1>/S£.1S£S OF THE AUDITORY NERVE.
99
lIII. MfiSifeHK's Disease— M^NifeRE's Vertioo — Vertico ab AURE L/i:sA — Vertigo in General.
When we spenk o( M(Sni6re's disease we mean a combinu- lian of symptoms which is made up (i) of subjective noises in (W car, \z) a fcellnj: of dizziness, uccumpuiiicd with vomiting, a gradually increasing difficulty of hearing, sometimes end- deal ne:^, 'On account of the cx-ccptionally practical importance which hu 10 be attributed to the so-called vertigo \le verfigt, Sckwm- itige/iikl), we may be allowed to make some general remarks on tbii before considering the special form, viz.. M£ni£re's disease. By vertigo we mean a subjective feeling of motion appearing or gradually without any loss of consciousness, at- by a simultaneous sensation of los^of equilibrium. The lubjcctivc sense of motion is cither referred lo the body or parts u> il. or to surrounding objects. The motion is in dilTcrcnt directions, sometimes in horizontal or vertical circles, revolving *ilh their crinvcxity sometimes forward, sometimes backward, ttd tlic older obsen-ers distinguish accordingly a vertigo litu- hns, fluctuans, etc.. from the nutatio— that is. subjective iiiovc- ■nus in a straight line. As concomitant symptoms we note htadichc, espcci.Tlly in the iKick of the head, anxiety, tremor, mU sweat on the face, nausea, vomiting: in grave cases, tnnjtenl clouding of consciousness, as in the prodromal state o( ua{ioplcct!c attack. If consciousness Is completely retained, uhappens in the m.ijority of cases, the !>ubjeclivc sensation of miivetnenl often gives rise lo objective voluntary movements, l"> bo regarded in a measure as instinctive efforts against the t^itaicntng danger of falling. The patient plants his feet firm> Ijr (in the ground, stretches out his arms into the air. seizes lAh hi* hand any object within tiis reach, etc.. but, in spite of lfl.lw may, notwithstanding the perfect retention of cnnscioiis- Be», fall, owing to the feeling of disturbed equilibrium — vcr> tifn caducii.
If the |iaticnt is unconscious— e. g., asleep — then he cxperi. tnces & sensation o( falling down from a great height, down Urp\ or out of the winiiow : he imagines himself sinking into ■noprning in the ground, etc. This so-called nocturnal ver- ti^ {TruHmiclni'intifl) usually torments those who sulTcr frotn igo when awake. Two exquisite examples of this vertigo observed in Bright's disease.
[Ten
have
100
D/SEjtSES OF THE CRANIAL /t'ERVES.
By far most atmmoiily ihe vcrligo occurs in paroxysms which appear without regularity and arc of vamlilc duratiun. Between Ihe first and second sometimes hours and days, more rarely manlhs, and indeed whole years, intervene, and only except iunally — e. g., in cerebellar alfections — do the subjective sensations of movement persist uninterruptedly, and thus render the vertigo couslniit.
The p<)sitian r)f the body has rarely any influence on the vertifto, for althuiiKh at rimes some amelioration is (clt on sil- ting down, there arc cases in which the vertiyo continues even when the patient occupies-lhe horizontal position in bed. The pathogenesis of the trouble— that is to say, the organic changes in the brain whitli are necessary for the production of the sen- sation — arc but little understood. It is generally supposed that changes in the blood-pressure, due, perhaps, to stimulation or paralysis of the vaso-motor nerves, are the chief cause of s-ertigo, just as a lasting decrease or increase in the amount of blood in the brain can probably give rise to attacks of dizziness. Until the conditions under which vertigo can ai)pear in other- wise healthy people arc more accurately understood, our knowledge of the pathological influences at work can be only imperfect. Of great interest are the experiments of Purfcinje. undertaken seventy years ago. as to the influence of swing- ing, and especially of circular movements, in the production oi vertigo. These were published in Kust's Magajtin (Ur die ge- sammtc 1-Icilkundc, part i:.\iii, 1827, and have been reprinted in Romberg's Ncrvenkrankheiten (/oc. t//,, p. iiS) with this addi- tion by the author : " From all these experiments we see that, taking the head as a sphere, around the axis of which the true motion takes place, an imaginary plane through it determines in every cuse tlie apparent motion of the objects in the subse- ()uen[ position of the head at rest. The same holds good in attacks of vertigo."
Johannes MlUler also h.is made experiments on vertigo, and is inclined to attribute it to the after-effects of visual impres- sions on the retina. That this, however, is not always the case is shown by the fact that vertigo may appear in people whose eyes arc closed, and even in the blind.
We have already spoken about its occurrence in the paral- ysis of the ocular muscles (p. 4^!). Here let us add that this ocular or visual vertigo disappears if the patient closes the aflected eye or holds his head in such a position that the
I
DtSBASBS Of THE AUDITOBY NBRVB. loi
I paralyzed muscle does not come into play during the act ol
! seeing.
In the present chapter wc shall discuss more especially hnw (jr diseases ol the internal and middle car are connected ivitti vertigo. It has repeatedly been observed that affcclicins o( the nasal mucous metMbiane. swellings (if rh« creciile tissue, as well as ailcctions of the mucous membrane of the larynx associated with violent cough (laryngeal vertigo), hnve produced it. If, ihcn. we add that it has been claimed that the intestines {in. teitinal wuritis. txnia. ascaris) and (he stomach are rcspunsihle for feelings of dizziness, which Trousseau calls "vrrlign a ttematko Itts-o" we can not f.iil to be impressed with the com. jitcxity and the lack of cleariiess in the letiology of this affec- tion. We must, however, always keep in mind, no matter where the remote cause lies, be it in the faulty movements of the ocular n)U!«cU-s. in the n(»se. in the cars, or in the stomach, etc. wc must keep in mind. I say. that ihr influence of the cerebrum ami the cerebellum is under all circumstances quite essential for the prtxluction of vertigo. Whether the characteristics cf the vertigo vary or not with the different organs affected is nut yet clearly known.
[The dif.cAf'C cle«crib«<l by (lerlicr in Ferncy, which shows UscK by y prnmitinred dizzy feeling, appearing in paroxyiini^ — the so- called "paralyiinc vertigo" — is accompanied by other symptoms, ninicly, a we;ikness, resembling a paralysis, in ihc exircniJlies, droop- ig of the eyelid)^. an<l extraordinary lassitude wittioui any loss of coasciousncss. T))is condition, which has been repeatedly observed in ibe canton of Geneva, where it occurs epidemirally among labor- |. crs and herdsmen, ts xltologicalty mystennuK. (lerlier uttribiiten it (ti iiii.i^m:ilj from marshes nod stahles, F.pcroii (o ilic working in the «un wliicli produces hyperemia of the meninges (Keviie. mt'd. de la Suisse ronufule, 18X9, ix, 1) ; but neither of these hypotheses explains the immunity nf the female sex. For this new and as yet entirely (trange neuri»*is tJerlier has proponed the name verligc paralynant (Progr^M miA , 1K.S7, 36: Lndame, Revue mM. dc la Stiisse romande, Janojirjr. 1887 ; Deutsche Med. Zeitung, 18S7, 44, 1888, 14).
Middle life and moderately advanced age (especially in the
■ female wx, and so in them the climacteric period) seem to pre. dispose to attacks of vertigo, which choosett by preference Its victims from among vigorous and fult-biooded individuals. Its ircqucnt occurrence in advanced old age will not surprise us if
I02
D/SBASES OF THE CRANIAL NBlfVES.
we remember ihe atheromatous condition of the arterial walls and the consequent irrcgiilaiirics of the blood supply to the brain substance. Amon^ the excititif; causes, poisons— c. g^., tobacco (smokers" vertigo)— unaccustomed circular rocking movements, such as we feci on board ship, play an important rHe ; yet it is by no means clear how these causes act. and every attempt to explain, for instance, the nature of sea-sick- ncss. or to prevent and cure it, has thus far been futile (cf. Painpoukis, Etude pathog^niquc et expirimentalc sur Ic vertige marin. Arch, dc Neurol.. 1888. xv, xvi). The di/zincss ex. perienced on looking down front a height — the " height dizzt' ncss" — which has erroneously been attributed to a fear of danger, is ]>robab]y a reflex movement evoked by a wrong conception of our position in space, the result of a purely optical illusion ; for its production not only the cerebrum and ccrcbcltum, but also the action n( the retina, is needed.
The prognosis in vertigo depends upon the nature of the primary disease, and IJoerhaavc's expression, " vertigo est om- nium morborura capitis levissimus et facillimc curabilis," has to be taken cum granc salis. In an organic lesion of Ihe cere- bellum— or more especially of Ihe vermis — wc can expect no improvement in the vertigo, while if it is attiibutable to an anxmia of the brain, occurring as a symptom of a general anxmia. the outlook is decidedly favorable.
In the same way the treatment will be different in different cases according to the primary disease, which always has to be taken into consideration. For the symptomatic or prophy. lactic treatment, the repeated administration of mild laxatives, the frequent use of strong stimuli to the skin, such as cold douches, brushing of the neck and the back, mustard plasters, regular bodily exercise, and well-regulated diet, arc to be rec. omiiiended. while any overloading of the stomach, especially in the evening, should be strenuously avoided. In spile of the much-lauded remedies (cocaine, etc.). we do not possess any reliable medicinal treatment for sea-.iiickness and height diz< ziness.
After this digression we will return to the consideration o( that form of vertigo which is especially connected with aural disturbances. Notwithstanding the fact that it is by no means settled that the above-mentioned combination of symptoms constituting Meniere's disease can be produced by a pure ncu-
DISEASF.S OF TtlE AUDITOKV NF.KVF..
103
roMS of the audiiary nerve, wc will take it up here, because under all circumstancctt this nerve plays a prominent part in ihc pathology of the atTeclion.
Since Meniere in 1861 first Hescribcd the disease, it has been
repeatedly observed and carefully studied by German physi.
dans- All have, however, failed as yet to give us a clear un-
I ilerBtanding of its pathology. Mt-niftrc himself believed that
V u extravasation of blood or an nculc exudation lakes place
V into the Inbyrinth, which produces the $:ime symptoms as P occur in animals afier injury lo the semicircular canals. This
vnm is in so far incorrect in that cerebral alTeclions, accumuln- tions nl cerumen, and diseases of the middle ear, can undoubt- edly produce the same symptoms; and ihen we have lo re- member that not the ha:morrh.ige nor the exudation, but its Ktion upon certain parts of the membranous labyrinth is ne- ceaary before the symptoms occur (Politzcr). It can easily be I iniS);iDed thai, whenever the extravasation stimulates the nerves of Ihcampulhe, M^ni^re's symptoms are produced, while they I areaWnt if the ha;morrhagc does not directly press upon the
nervrt of the antrum or the ampulla; (l*olitzer). ^m More reccnlly Brunner (cf. lit.) has put forward a supposi. H lion Khich we think is u-urth considering, namely, that we may bedcjlinji "'''h a vawj-motor neurosis of the vessels of the laby- rihlb. According to him. the pressure in the labyrinth acts ba Minilar way as pre<isure in the cranial cavity, where con- >i(ienble changes are borne so long as the normal expansion ollhe subdural and subarachnoid space is not interfered with. He tbinks, therefore, that narrowings of the labyrinth could produce a predisposition to Mt'-iiiire's disease.
This hypothesis is extremely plausible, especially as the
ipnptomsap{K-ar paroxysmally.and in ihc intervals the patient
i»apparcMtly in jicrfcct health. In this way also the favorable
jaion of quinine can be explained if wc suppo.sc that it dimin*
itbes the hyperxmia in the semicircular canals, just as Horner
»bown to be the case for the retinal vessels. He observed
large doses of quinine constantly produced considerable
bchntnia in the latter. The question is, however, by no means
fettled, especially since cas«s have been observed where, in
ilc of the absence of the circular canals (Politzcr). or in spite
the fact that they were filled with bloud-clots (Lucae), no
disturbances of cquilibnum were noted during lilc. Ilcnce il
nay also be possible ihat vertigo can be produced by pressure
104
DISEASES OF THE CRANIAL NERVES.
changes wtlliin ihc cranial cavity (Stcine-r, Deutsche mcd. Wochciischr.. 1889, 47).
The view expressed by fVugnicr and Fournier (cf. lit.) that M^nit^re's vertigu is n cerebnti altectiun, nnd is only tiiel with in individuals who arc already insane or who will later stircly become insane, certainly needs hirlhcr coiitirmalinii and does not at all agree with our experience.
There are hardly two cases in which the sytnploms are ex- actly the s:imc. and the course is so iar from being uniform that we can not be surprised if often great uncertainty about the diagnosis prevails. The onset even is very variable. Now it is sadden, with loss of consciousness and apoplcciiform symp> toms, etc.; again it is gradual, first, subjective noises in the ears being noticed, sometimes comparable to the whistle of a locomotive, sometimes to the rustling of the leaves in the forest. Next comes a feeling of dizziness, at times only moderate, at limes so pronounced that the patient in spite of all his efforts falls to the ground. Vomiting may be present or absent. Finally, a decrease in the power of hearing, first in one, then in the other car. becomes noticeable. Some cases show a de- cided progressive tendency. Alter short remissions the symp- toms always reappear with increased severity, the vertigo gains so much in intensity that now the patient repc.Ttedly falls with great violence, vomiting becomes more and more fre- quent, and the patient becomes at first incapable of following his calling. :md tinalty Is reduced to the si;ite of a useless mem- ber ol sftciely. In rare instances periods oi marked improve- ment, which may indeed last for years, occur. In these even the ditTiculty in hearing may be gradually diminished, and the prognosis becomes rcfalively favorable. Finally, it is at times observed that with the lull development of (he deafness all llie other symptoms, buzzing in the ears, vertigo, and vomiting, disappear. In other words, we liave wh.Tt we ciill a relative recovery or recovery with defect. In any given case we are never in a position to predict the outcome, and have always to be very guarded in our prognosis.
Of considerable diagnostic importance i«. the fact that usu- ally the examination of ihe drum and the (Eustachian tube does not reveal any changes, and that neither cranial nor spinal nerves present any disturbances of (unction. Rinne's test gives variable results in M^niire's disease. This test consists, as is well known, in applying a vibrating tuning-fork with mod-
DISEASES OF THE A CD! TOR V ^'EKVE.
los
I
rratc pressure first over the mastoid process, leaving it there milil ihc patient no longer hears the sound, and then as quickly as possible brin^iiit; it immcdialely in front of the external meatus, avoiding all contact with the head or car. If the pa- tient then is able to hear the sound of (be luuing.forlc once mure, this is a sign that, as \% normally the case, (he conduction Ibrnugh the uir is belter than ihruu^h the bone. If, on the iilher hand, he does not hear it. the conduction through the air must in some way be inierfcred with. In the diagnosis these aic points to be considered.
In Ihc treatment, above all. the action of large doses of quinine — 0.7-1.0 (gr. x-xv) /»/-tf //»/~must be tried, a procedure warmly recommend*^ by Charcot, and later used with gratify- ing results by Fir«5, Moos, and others. In many cases, as we h»vc said, the cfiect is very marked, and there is no need to >eek further lor other medication. At times, however, this will liil, and then we are forced to resort to a two-per-cent solution u( pilocarpine (nine to ten drops subcuianeously). The result it oflcn Surprising. I h.ivc seen grave symptoms completely uiltskle after three or lour days' use of this medicine. The in- jections arc to be continued every second d.iy for three or lour weeks, and. as a rule, after the fifteenth dose the treatment can be discontinued, at any rate for a time. We need not add that on administering this drug the general cnndilion of the patient must be carefully looked .ifter, and any symptoms o( colla]>se yarded against by ihc timely exhibition of stimulants, wine, and the like. Whether the view of Field {British Med. Jour- nal, 1890. xvii, ;) that the action of pilocarpine is to be attrib- uted to an increased secretion of cerumen is correct or not is as Crt uncertain, although it must be acknowledged that in all cuKs of labyrinthiau deafness the cerumen is absent.
l.lTI-;RATtiRE.
MoM. ITclxr Mcninglili crrFttrospliinlii epidetnica, insiltnondcrre lihrr die luch ^H ilrrtrlbrn /urucl(l>k-lhrn(1cn combintrtei) (iehi)r»p u. Gltkhgcwichlsttdnin- W em. llriik'IbenE. '»<■-
Xluo«. F.rknnl.un);(ii tin (ichoniiTifiinev hei t^ncoipotivfuhrrra un<l Hci/ern. ^ ZcUKhr. r. Ohrmhfilk.. t. 4. 1881 ; xl. a. 188). ^KColtMdn u. Knyscr IlretUucr Antl. ZcilKchr, ii>, 18, i&Si. H^riincr. Arch. (. Ohrcnhcilk.. xvii. 1, i, p. 8, iliSi. ^BHUty. IN>t.. Kt\\. 4. p. ]^S. 1881.
Rurckrurdi-Mrrian. .Schnri/cr CorrpspondmiM.. iriv. t. 6, 1884. L Zeiitchr. f. Ohrtnlwilk.. mii. 1, 3. 1884.
I06 VISMASSS OF THE CRANIAL NERVES.
Finkelstein. Wratsch, No. I, 1886.
Baginsky. Ucher Ohrerkrankungen bei Railway-spine. Berliner klin. Wo-
chenschr., 3. 1888. Loeb. Ueber den Antheil des Hbrnerven an den nach Gehimverletzungen
auftretenden Zwangsbewegungen, Zwangslagen und associerten Stellungs-
Snderungen der Buibi und Extremiiilten. Pfiiiger's Arch.. 1892. 1, p. 66. Krcidl. Beitriige 2ur Physlologie des Ohrlabyrinihsauf Grund von Versuchen
an Taubstummen. Ibid., 1892, li, p. 119.
Miniin's Disiase.
Charcot Klinische Vortr^ge iiber Krankheiten des Nervcnsystems. Deutsch
von Feiier, Abthlg. ii, p. 343. Stuttgart, 1878. Guye. Arch. f. Ohrenheilk., xvi, 1, 3, 18813. FfirS et Damars. Revue de mM, i, 10, 1881.
Woakes, Edward. Remarks on Verligo and the Group of Symptoms some- limes called " Meniere's Disease.'' Brit. Med. Joum., April 28, 1883, p.
801. Bechterew. Neurol. Cenlralbl,, 9, r887 (anatomical study on the origin of the
auditory nen'e). Brunner. Zum Morbus M^ni^re. Zeitschr. f. Ohrenheilk., xvii, 1, I, p. 47,
1887. Grasset. Du vcrlige cardio-vasculaire ou vertige des artirio-scliraui. Clin.
m£d. de I'Hdp. Saint-Eloi, Paris, 1890. Buzzard. Lancet, 1890, i, 4. p- 179- Peugnier et Foumier. Vertige de Mfniire, etc. Revue de m*d., 1890, 11:
iSgr, 3, 3, 4. Mijller. Ueber Lahyrinthschwindel. Deutsche Med. Ztg., 1893, No. 1, p. 9,
fAPTER
I
DISEASES OF THE ULOSSO-PHAKYNCEAL KKKVK.
The glosso-pharyngcal nerve leaver the brain between llie root fibres of the auditory ;iti<l thot^e of the vagtm, at the siJe of the DKiluUa oblongata, by five or wx ritaments; these soon unite to form u tnienor (dinull) anil a posterior (tarccr) bundle; i hey both pass amnrd, andrr and in front of the flocculus, to the anterior division of the jugular foramen, through which ihe nerve leaves the skull. Vhrther the so-called jugular ganglion which the nerve pre*ent» «ble rtdi inside the skull has to be looked upon as a special gan- fknoronly as a grnup of nerve-cells which have separated (hem- mIvcs from the petrous ganglion, which is seen on the nerve immedi- UdT after Its exit from the skull, remains to be decided.
The gloMo-pharyngeal ha» nu nucleux of it* own, but originates biUrge collctiion uf nerve cells, which are regarded as the nucleus nmniin tu this nerve, the vagus, and the accessurius. Hiis nucleus Wuluaicd midway between the anterior and posterior spinal ro«i», la (he manner in which its root fibres originate it corresponds partly lo (be motor, partly to the sensory type (Wernicke). It is thetcfore tei|[Uted a» the mixed lateral yyittetii ([)eiters), and it is supposed An the glo»so- pharyngeal originates in the upper, the vagus in the OHldlc, and the accessory in the inferior portion of the nucleus (cf, •T '?. 1>. 96)- 'I'hc manner in which this common nucleus is com- P»»til is not yet underKtood, nor do we know how many modes of ongin tor root fibres of this " later.il mixed system " we have to as- ttat. Exact data inay be found in Wernicke's text-book, 1, p. 155
The glosso-pharyngcal, which, according to our present
Aw. las to be rcfiardod as the only genuine nerve of taste, is
tbc third one which is lo be taken into considcratiim in the
'wmination o( llie (unctions of taste. The trigeminus (Ihc
Hiird branch (lingual), possibly also the second branch) and the
^tal (thortla tympani) we have treated of, and it remains,
l^inHoix, to determine whether and if so under what condi-
■07
io8
DISKASES OF THE CRANIAL .VERVES.
liuns diseases cunlincd to the glosso-pliaryngcal occur, nnd in what manner taste is aliercc) by them. Since it only supplies the posterior third of the tongue wilh sensory fihrcs (rnintis tingualis nervi glosso-pliarynKfi), it is not to be wonderetl at ttiat, it) detcrmitiing vca isolated aHcclion of the ner^-e, we not rarely meet with considerable difficulties.
We know but little about central diseases of this nerve. It is supposed, however, thai there exists a bulbar afTeclion, a gray degeneration of the nucleus which is found in (.ibes (Er- ben), also that the gustatory paths may be in a state of irritd- lion which gives rise to alterations in t.istc-pcrccption analogous to the panc^thesias which occur with irritation of the p:iths of tactile sense in (he posterior columns of the cord. Conduction anasslbcsias arc also said to occur, although it is impossible to decide whether only the gtosso-piiaryngcal or whether in ad- dition the trigeminal and the facial paths arc concerned (cf. l-VUnkol. Berl. klin, Wochcnschr., No. 3, 1875). .\ centrAl imralysis of taste manifesting itself solely on the jjostcnar third of the tongue has never been observed. With the cortical centre of the glosso-pharyngeal we arc not as yet acquainted.
Peripheral anicsthesia, anxslheiiia gustatoria, ageusia (a priv,. 7«crw, sense of laste), impairment or loss of tasic pro- duced by affections of the peripheral nerve endings, has been met with in diseases of the mucous membrane of the (onguc, and has been known to be produced by the action of low tem- peratures (ice) or acrid substances (vinegar, chewing tobacco, r^ pepper). In testing for such allcr-itions the patient is asked to close his eyes, open his mouth widely, and protrude his tongue : then a sinali portion o( sugar or quinine, etc., is placed up<m that part of the tongue the function of which is to be tested, and the patient is to indicate with his fmgcr where he perceives the taste before he rctnicts bis tongue, and tell us by signs what he has tasted. The test is made wilh biiier, sour. sweet, and salty substances, and for the purpose any one, as long as it is not poisonous, may be selected. Further, 11 is \vc>s~ Sible (o accunilely determine the boundaries of the area with normal and that with disturbed function of the tongue by means of the galvanic current. As we know, a sour, metallic, the So-called galvanic taste is perceived if the electrode is placed upon the tongue and the current is closed ; the same taste is experienced during galvanization of the throat, the neck, or head, and is probably produced by the current acting upon the
DfSEASES OF THE ClOSSO-PflAXYXCEAL NERVE,
109
lasle nerves in their peripheral or central course. The use oJ Ik galvaoic current is ais<> 10 Iw recommended in ihe treat- nicnt of the alTeciions uf ihc nerve. The siMintaneous appcar- aace of a sweet or sour taste in the mouth (parageusia) has ■■(ten been observed in cases of diabetes, though we are igiio- niit ol the cause of this svmplom. Therapeutically the leaves olGymnemasyUestrc. or the gymnemic acid coiuiiineil in ihcin, lave been recommended in this condition (B Acidi gymnc- mici (Merck), 0.1 (ijgr.): spin viii..g.5 {jijss); iheae nigr. I'l'koc, 4.0 (3i): cxsicca Iciii calorc ; scattila lignen. D. S. : One 10 [wo wafers to be talcen into the moulli repeatedly dur. ini: the day and allowed to tncit (Oefcle, Aerzll. Rundschau, iByj. Nos. 37, 38).
I.ITKRATUKE.
RtoberX' Of>. cil , PI). 148 it le^.
Bfc llandliuch tier Kf.inVheiicn dcs NeTvrn»>^1em». \i\i. 219 rt ti^., 1876.
HfutBcr. Eine tkolMclilung ubcr den Verluuf dct Gctcliiniiclunervco. BcT>
iintr kllli. Woclirnsclir.. No. 44. 1886. ^nrr, Ktiniiclirr Itcilnij; ubcr ilcn Vcrl.-iiif dcr lieticliiiiackMierveii- NeuniL
Couralhl. t888. Nr 16. I'oiw. TliromlMMis of vcricbril artery pTMiting on yla«K»-phar}'ngral nerve;
wiilaiml Idm ur taMc at buckul' lunijui:. Utiliih Med. Jouni.. Nuvcmbcr
CHAPTER VIII.
DISEASES OF THE VAGUS (PNEUMOGASTKIC NERVe), "VAGUS NEUROSES."
iHUEDtATELY behind the superficial origin of the glosso-pharyn- geal on the post ero- 1 ate rat aspect of the medulla oblongata, the vagus appears, with its ten to fifteen separate bundles, which soon unite to form one trunk. This is a flat band which, accompanied by a process of the dura, passes outward below the flocculus, together with the accessorius, to the anterior division of the jugular foramen, inside of which is to be found the ganglion of the root of the vagus, or, as it is also called, the jugular ganglion. After its exit from the skull the vagus receives a part of the accessorius, and forms the gangli- form plexus or the ganglion of the trunk, which, however, only trans- mits a part of its fibres.
About the difference in the further course of the left and right vagus we shall have a few words to say later.
That the nucleus of the vagus is only a part of the nucleus com- mon to it. the glosso-pharyngeal, and the accessorius, has already been stated in the preceding chapter. The cells of the part belonging properly to the vagus are spindle-shaped, multipolar, 30 to 45 n long and 12 to 15 /A broad (hence much smaller than the cells of the hypo- glossus nucleus, which we shall describe later). As another impor- tant origin of the root fibres of the vagus, a compact round nerve bundle following the longitudinal axis of the medulla oblongata must be mentioned. It has been described by Meynert as the solitary fas- ciculus, while Krause designates it as the respiratory fasciculus, be- cause it connects the va(;us with the origin of the most important respiratory muscles (cf. Fig. 18). The so-called nucleus ambiguus (in the diagram «. am) is held to be still another nucleus of the vagus. This is a oolleciion of peculiar nerve cells situated within the forma- tio reticularis to the mesial side of the nucleus lateralis.
Just as most of the cranial nerves, the vapus may be d*' eased in its centre as well as in its peripheral course, first class of cases arc usually met with as partial ml 110
£>tS£Ali£S OF r/f£ yAGVS {PNEUJiOCASTKii: XE/tfKi. |||
%T
lions of other, general, diseases (tabes, liysteria). The latter are distinct affections in themselves, which may occasionally be due to |>i,-riphfr;il causes, such as indigestion, catching cold, or reflex influences, diseases oC the intestines and the uterus. Very frequently, it is true, the seat of the disease remains ante as well as |x>st mortem obscure, and this is nut to be won- dered at if we remember that we know little or nothing about the pathological anato- my of the vat;us. Aiiiuiig the cases hitherto observed, many were not fitted to throw any light on the symptoms mani- fested during life, as in nu- merous instances no abnor- malily at all was found in the* nerve, so that we arc led to assume that the disease was purely functional (i. e., a dis- cisc without appreciable an.v lomical basis). The pathol- ogy of the vagus, Iherelore. belongs to the most obscure J"*- ' nar chapters in the pathology of Hg. ■s.-C'.o«^«m''»T..»<woM thk hb-
the cranial nerves, and the following can only he consid- ered to be an imperfect at- tempt at giving a compre- hensive exposition of the high- ly interesting diseases con- nected with this nerve.
Since the symptoms may sometimes be the same whether the disease is of central or peripheral origin, we shall, so as to avoid repetition, deviate from our usual method of division, and give our attention chiefly to the question h()W lesions of the vagus may influence {a) respiration, \,li) circulation, {c) digestion, (unctions which, as is well known, are chiefly under the con- trol of ibis nerve.
DULL* OnUISOAT.t, d.r. uccndlne root of Ihc (iflh. m.X/l, nuclnuof the tafpnt^owis. n.X ani i.AT, nucleui of ibe nfiitt. X//, hypi%\osal nerve, /f, KdlLuf (unlculm (ropliatary fucunilui). p, pfTimliat imt. », olive. >- A'. (i;rr>mldtl nucleiu. /I. a.. anlprior lini> pludinal litBun. «.«•», nudmi unbicum. «. /, , Dudttiui l>Ur>li*,
113
I>/SEAS£S Of-' TUB CRANIAL NERVES.
A. AnliCTIOKS OF THE A I R- PASSAGES DUE TO LESIONS OK
Tiiic Vagus.
t, riic larynx, alio^'c alt, interests us in this connection. Thla organ it innervated liy the vagtis and Ihc acccssorius, though it is dttll a mailer of ili>iil>l whelhcr all the motor fihres originate from the laiter or only tliose iliat innervate llie musclc« uh>i] in the pro- duction of voice, while the vagus prcsitles over tlic respiratory move- ments of tlic vocal cords; the sensory fibres of the larynx certainly all helonjr to the vagus.
'I'he branthCK of the vagu», wliicli come olT in ihe cervical portion of the nerve and innervate the laryngeal muscles arc the superior laryngeal and the inferior or recurrent laryngeal. The former leaves the vagus at the lowtr end of the gangl'tform plexus. and divides into a motor branch, which goes to the crico-thyrnid muscle, and into a sensory branch, which conlainH the librcs for the mucous membrane of the epiglottis and the whole laryngeal mucous membrane abovii the vocal cords.
The rccorrent laryngeal is shorter on the right side, because, with- out going beyond the ii[ipcr aperture of the thorax, it curls aroumi Ihc subclavian artery, and runs hack in a groove between the trachea and the wsophagus upward to the larynx, while on the left side it has to make the lon^ course around the arch of the aorta. It* terminal branch (K. lerminalis) dividt-s into two twigs, which together supply nil the muscles of the larynx, with the exception of the above-men- tioned crico-thyroid, with motor nerves, and the mucous membrane of the parts below the vocal cords with sensory fibres.
(.Jf the laryngeal muscles, the jiosterior crico-arytenoids draw the vocal conls apart — that Is, they are the abductors or openers — while the lateral crico-arytenoids in conjunction with the lateral thyro- arytenoids draw Ihcin logcthcr, and arc therefore called adductors of closers. Of these muscles, on each side (he "abductor " arises at the posterior surface of the cricoid cartilage and passes upward and out- ward to the end of the muscular process of the arytenoid canilage, while the otlier. the "adductor," arisen from the upper margin of the cricoid cartilage and is inserted at the outer side of the muscular process of the arytenoid cartilage. It moves Ihe muscular proccsft forward, being thus the antagonist of the abductor. The crico- thyroids provide for the elongation and tension of the vocal cords; they are assisted by the internal thyro-arytenoids, which run parallel with the vocal cords.
In the LTryngeal muscles paralysis and, thougli compara- tively rarely, spasms have been observed.
■ OtSEASKS Of THE VAliVS {.I'NKUMOGAHtltlC .V/iftfKy 113
^1 The cliicf lurms uf jiaralrsis, which we shall here cunsidvr, ^Hie (I) the paralysis i>f the recurrent laryngeal, in which case ^nll the musclcii supplied by this iiervi- are pnraiyzfd (or weuk- ^(mcdj ; U) the so-called abductor paralysis — that Is. paralysis t>l ^■tbe posterior crioo-arytenoidti, the openers of the glottis ; (3) ^kulysis ol the internal thyrn-arylcnoids. ^^^Withoul going into the much-discussed and still unsettled quejiion as to the mech;inism of these paratysics, wc have at-
■ temiilcd to give a succinct and clear summary u( the clinical symptoms, including the appearances found on laryngttscupical examination (cl. tabic on page 1 1€).
I The existence o( a cerebral centre for the laryngeal muscles is ihown by the fact that in dificrent cerebral affections — c. g., ptrudo-bulbar paralysis and certain brain tumors — but only hi tare instances (Rougi, Progris mid.. 1892. 36), paresis or pa. nl|ug o( the vocal cords has been observed. In chorea addiic- iiir paresis has been noted. A most curiously perverted action olthe vocal cords has been observed hy Krause in the course nl hysteria ; on inspiration they were apprwiched. while on ex pinlion the glottis tvas wide and gaping.
I Another form of central paralysis is the nuclear. In com- plete paralysis of one vocal cord a lesion in the acccssorius nticlcus of the corresponding side has been found : the usunt CMiK n( this, however, seems to be a peripheral affection of the trunk uf the vagus, or of the recurrent laryngeal (by pressure, cinilusion. injuries, surgical operations, tumors, and aneurisms). )d wf arc not often in a position to speak with certainty as to the seal of the affection, and to say whether this is central or peripheral. The ruiturc of the laryngeal p;iratysi-s which occur in general neuroses (hysteria, epilepsy), intoxications (lead), in- fectious diseases (diphtheria, dysentery, cholera), is quite i>b< »ci>Te. The easiest to understand are those acquired thnnigh Unining of the voice and diseases of the larynx itself (catarrh, (Ktidiondritis). (B. Frilnkcl on mogiphonia, cf. lit.)
The prognosis ought to be guided by the consideration of Ibe nattiFc of the primary affection, but wc should also take into considenition the functions of the affected muscles, and not focitet that, for instance, in abductor paralysis, danger o( sulTn- ouioQ may arise at any moment. It is always unwise to prc> diet the exact time of rcco>'%ry ; the course of such ]>aralyses i» Qsually very protracted.
be treatment of most of the cases has to be conducted by
114 D/SBASES OF THE CRANIAL NERVES.
a Specialist, and consists in touching the vocal cords with the SDund (Rossbach). and in the external or intralaryn^eal use of electricity. Faradization of the different laryngeal muscles necessitates a dexterity which can only be attained after a thor- ough acquaintance with the laryngoscopical technique. The general treatment of any primary affection need not be dis- cussed here.
Spasms of the laryngeal muscles, we have said before, are very rare, and are in general, with the exception of the spasm of the glottis, of not much practical importance. Most fre- quently the spasm affects the adductors, and the condition then resembles very much that of abductor paralysis, with this excep- tion, that the spasm is generally quite transitory, while the paral- ysis is often of long duration. The aphonia spastica described by Schnitzler, a disturbance of co-ordination of the muscles of the vocal cords, which, on an attempt at phonation, contract spasmodically, is found occasionally in chorea and hysteria.
The spasm of the adductors, which occurs especially in early childhood, is called spasm of the glottis (laryngismus stridulus, laryngospasmus, asthma thymicum sive Millari). Its paroxysms usually occur unexpectedly without external cause. They consist in the main in a total arrest of respiration lasting from several seconds to a minute and a half, and are ushered in by a deep inspiration which is accompanied by signs of suffo- cation. Only rarely does the child die during the attack; usually a few deep, very audible respirations indicate the cessa- tion of the spasm, and the child seems completely well after a comjiaratively short while. No definite statement can be made with regard to the number and intensity of the individual at- tacks, because innumerable variations can occur. The anatom- ical seat of the disease is entirely unknown ; yet the fact that not rarely eclampsia or epilepsy complicates the affection rather speaks for the possibility of a temporary irritation of the corti- cal centre for the laryngeal muscles. The remarkably frequent ucciirrcnce of it in conjunction with rachitis has led to the idea (Ivlsiisscr) that we are dealing with a rachitic softening of the posterior part oi the skull, which has rendered possible pressure upon the brain. Nothing definite is known about the cause. In the treatment early hardening of the child and rational nutrition play an important rSIe. Robust, well - nourished children who can stand changes in temperature without at yncc catching cold, etc., are hardly ever affected with laryngis-
0rSSAS£S OF TUK VAGVS ^.PMEUMOGASTKIC NHHVBY. 115
P
nns stridulus; only delicate children with a convulsive tcnd- raty, who have been fed on larinnccous foods and oilier inap- Iffuprbic substilutcs for ihc mother's milk, fall a prey lo (he disease. There is no medicinal treatment lor the affection. During; the attacks we have to avoid the danger of suffocation bf carefully watching the epiglottis, sprinkling the body with ic&water, brushing and tickling the soles of the feel. After Ihc attack wc may give nervines (belladonna, bromide) and, pcrtia{>s to avoid a too Irequcnt repetition, narcotics (morphine, 1 10 3 milligrammes — gr, '/to-'/iu subcutaneously). The treatment dthc rachitis should never be omitted.
Sensory disturbances ol the larynx manifest themselves tiiWr in anii-slhe^ias, or, what is less common, in hypenesthc- tie fit the mucous membrane, and arc especially found in the 'ii&tnl>ullnn of the superior laryngeal. They are not rarely rambined with motor changes, paralysis or paresis of the pha- rngcal muscles (cf. chapter xi), but often they appear alone. The most common lorm is the ana^thesia attending diphlhc- niic |ii;iralysis: it is characterized by the absence «1 the rc- Att tCiigging and cough which normally follow touching the Ivyugeal mucous mcmbr:inc with the sound, the finger, or the '''yiiKDscope. In such cases it may happen that liie Inod on (lq;hititiun enters the larynx, and, through faulty closure ol 'fcf glottis, can not be removed by coughing, and thus gives w lo dangerous attacks of choking, and even to aspiration Cnnitnonia, The latter docs not seem to occur in cases of purdy hysterical ana'sthesi;).
Thchypcriesthcsia is found in ulcerative processes, or in bad,
^■CDlc catarrhs. Although it seems to play a prominent rdU in ^ntcrical patients, it is in realily not present, but is erroneously ||d lo exist by patients who are forever worrying ihemselves Handing ntiw ailnieuts, or is produced by autusuggestiun. The annrsthesia calls for electrical treatment, galvanization <if(lic larynx and the palatal muscles, the fanidic brtish to the llirual, etc. To meet the hyperarsthcsia, narcotic remedies may be of service, but in hysterical patients often no other IreaU nnK but a good sensible lecture is needed.
ti-iri:k.\Ti;HK. WVgnwf. I'cbcr Krlilktififmuskcmihniung jiU }>ym|itoin cl«r Tal>e». Inaug.- Ot«rn . IlrHlii, r887. , FitnkrL IWmh, Url>cr dbe DeschtriiitunKSSchwSchc <Ier Slimine. Miitp phonic. Ucuurhc met) WoclimMhr.. 1S8;.
It6
DISEASES OF THE CRA.WIAL NERVES.
TABLE OF THE MOST COMMON PARALYSES OF THE LARVN- <;EAL MUSCLES.
|
KiDdof pAimlyib. Complete |
Occurrence. In compression |
Symptom, |
OphthjilmoKopic picture. |
|
|
Voice not clear. |
Vocal cords slightly ab- |
|||
|
recurrent |
paralyses of (he |
Patient is easily |
duc(ed, (he so-called |
|
|
laryngciil |
vagus or the re- |
tired on talking. |
"cadaveric position " |
|
|
pOsy. |
current laryngeal |
Coughing impos. |
(Fig. iq). In forcible |
|
|
(carcinoma (Eso- |
sible. |
phonation (he healthy |
||
|
phagi), often uni- |
cord reaches beyond |
|||
|
lateral Qed). as |
the middle line. Over- |
|||
|
initial symptom of |
Hding of the arytenoid |
|||
|
aortic aneurism. |
cartilages (Figs. 3o, 3i). |
|||
|
In tabes. |
||||
|
Abductor |
In diiieases of the |
If bilateral: extreme |
Glottis appears aa a nar- |
|
|
pBialysis |
nerve itself, the |
inspiratory dysp- |
row slit, becoming still |
|
|
< |
(paralysis of |
causes of which |
ncea; if unilateral: |
narrower on inspira- |
|
the posterior |
are often un- |
inspiration ham- |
tion (Fig. 33). In- |
|
|
> |
crico- |
known. |
pered,! ong-drawn , |
ability to abduct the |
|
1-1 |
arytenoids). |
noisy. Dyspnea |
paralyzed vocal cord |
|
|
on the least ex- |
(Fig. 33). |
|||
|
B |
ertion. Speech |
|||
|
M |
but little affected. |
|||
|
Paralysis of |
In catarrhs of the |
Voice hoarse; speak- |
Glotds does not close |
|
|
the internal |
mucous mem- |
ing an effort. |
completely on phona- |
|
|
o |
thyro- |
brane of the lar- |
tion (Fig. 34). If a( |
|
|
o |
arytenoids. |
ynx. After over. |
the same time (he aryt- |
|
|
a |
exertion of (he |
enoids are paralyied. |
||
|
I |
voice. In hys- |
the glottis presents an |
||
|
i3 |
teria. |
hour-glass outline (Fig. 25). Neither anterior nor posterior portion is closed, but the vocal processes are in their normal position. |
||
|
Adductor |
Rarely isolated. In |
Absolute absence of |
Nothing characteristic |
|
|
paralysis |
hysteria. |
voice. Power of |
||
|
(paralysis of |
coughing retained. |
|||
|
the lateral |
" Phonic paraly- |
|||
|
crico- |
sis'' (TUrck). |
|||
|
arytenoids), Paraly!iiR of |
Voice rough ; high |
|||
|
o 3 |
After diphtheria. |
Excavation of the vocal |
||
|
gg |
tlic crico- |
(ones impossible. |
cords. Cords do not |
|
|
thyroid*. |
1 |
vibrate visibly. |
MSEAS/iX OA 7J/£ fAUt/S {PAUVMOOASrjf/f A'tHVl^ 117
u*. Oii«>TiillDe u( tb* arytaioid c*r>
KiK ». -fAHAiviii or iKyiM PonvHQK CmcoAKyTRKiiiiHi (In liuplntlaa).
fk Ik— riULnttorTHRRioHTPMT. CBK-K-tRmMND (ni iMpiniUeai.
riK. >4. PAULma or torn IsmRHAL
TirVM>^IIVTUN>IM [•CIlH iMTBfltlll.
IT(, as-—'*"*'*''- "' >■■ ' " IM»:">"*1. TltVTIi>*Hint»OIIM,
■MHcMtd Willi puvm ot Uir arytrnciid mutcW. n^ •O'^S— Pully atlm STHt'MrViJ.. (d^iOy Alter KiniHOVm-.
Il8
ff/S£ASSS OF THE VKANIAt SERVRS.
Ilolmn. (lurdon I'Mralysii of ihc Abductors of (he Vocal Bands. Lanni. Ocio-
twr 13. 1B87, Kidd. DiUtirr.-il I'aralyiis of ihe Dilator Mtisclei of ihc filoilis, with Sub!tH|u«it
I'jrcsiaurttK Coiisinciors. Lancet. July 16, rSS?. |i. 108. Kuuncr. Zur Kcnntniw clcr VaguMj mpionii- lici tier Tabc» donal Beflincr
klin WochenicliT., So. ». 18S?, Zlems^rn, V, Ucbcr diplithrritisdte LtLhmung und dcrrn llch-intllung. Kiln.
Vorrr, Iv. Lc>|Mig. Vogcl. i887. Newn^ann, Olasgow Med, Joum.. September, 1S87 (\''iiKU!i Sxinpiwrnx in Cajtc^
or Aortic AncuriMnl. Elscniohr. Zur Putliologic cicr ccniralcn KrhlkopHHhniungcn. Arch, f, Psych.
u, Ncrrctihli,. 1888, %\x. 1. 314. Schech. Vebcr Kccurn;nsllthiiiun)[. Munchencr reed. Woclieiuchr,, 1S88.
x«xr. 51. Laitd^jraf. Charlli Annalm. 18S8. xiii. p, 150 (lj;ri-cidcd Paialysin or the
Vwal Cords in Pericardii in). Meymann. Zwei FSIIc von LSIiinung d« M. crico-lhyreoideMs, Ucutwhes
Arch. f. klin Med.. i8»9, xUv. r>. Itut|[cr. Die Frajrc der I'oslicuslShniung. Volkniano'i Samml. klin. Vorlr,,
1891. Ncuc Folge, 57. Kalnnsttriii. Ucber die Mcdianstclliing dcs .Stimmbande:! bci Kccunvndttli-
itiunj;. \'irchow'» Archiv, iSyj, cxxviii. Heft i. L«hr. M. Deutsche med. Wochcnsehr, i8<)3. 45.
a. The lungs receive from the thoracic portion of the vagus the pulmonary or bronchial nerves, the so-called anterior branches of which, in conjunction with filatnentsof the sympathetic, form a plexus on the anterior wul! of the bronchus, and enter with the latter the tungs wliilc the (luateriur branches, together with those coming from ihc four upper thoracic ganglia of the sympathetic, are distrihuied in the same way m\ the posterior surface of the bronchus. They are the motor nerves for the unstriped muscles of the bronchial tree.
The diseases of the bronchial nerves, which produce, as it seems, a (aully innervation of the circular muscles of the bronchi, give rise to the morbid condition which has lately been the subject of much controversy, and is describ«l under the name
Brenthml Aithma, Asthma Bronthiale s. Com'u/shvm s. AVrri*- w«i, Sflasmus BrvHchialis {Rombfrg).
Pathology. — Opinions about the nature of bronchial asthma ftre slill divided, While some fSttjrk. FrUntzel) maininiii lh;il it is due to an acute .swelling of the bronchial mucous mem- brane, others {Bamberger. Winlrich) consider a tonic spasm ol ihc diaphragm to be responsible for it ; still others (Trousseau. Biermcr) believe it to be a vagus neurosis, supposing, in conse-
WS£j4SeS OF run vagus {PKEUMOCASntlC Xf.ttVK).
"9
I
i
quencc of a disturbed innervation (va<;us), .t Ionic spasm to take pbcc io the circular muscles u! the mcdium-mcd and tine bronclu. tlius producing an acute pulmonary emphysrm.'i. M\cr Berl had shown, in 1870, by experiment that a contrac- tian of (he medium-sized and finer bronchi could actually be produced by irritating (he vagus, later Hicrmer worked out histheory so thorouglily. and has defended it so successfully, ihii, ia spite of the objections recently raised by Schmidlborn fVolkmann's Samml. Idin. Voriragc, 1889, No. 328). who con- Milers a vascular spasm in the distribution of ihe pulmonary attery to be responsible, we arc probably justified in accepting it as correct, especially as with its help alt the characteristic t]riip1onts. the sudden onset and the sudden disappearance ol Ihc attacks, the expiratory dyspnoea, the low position of the dikphragm. etc., can well be explained. It is clear that this btiMdiial spasm forms an impediment much more easily over- come by inspiration than by expiration, and that this difliculty acipiration must of necessity not only influence the alveoli, but also the smaller bronchi, from which the inspired air can only imperfectly be forced out; hence arise dyspnoea and mphysema during expiration. On auscultation, sibilant rhon- <Uare heard all over the chest. But all this does not ex|>lain tbe cause of the spasm. This may be sought (or in an inde- pendent aSection nf the bronchial mucous membrane, a view which possibly may be supported by the presence in the sputa ol aithmaiics of Ihe su-called "Curschm,tnn*s spirals" (spiral libnads which must be looked upon as casts ol the finest bron> tUoles^ and of so-called ha^mosiderin cells found by v. Noor- <l«i. which are identical with pigment cells (Zcitschr. (. klin. Med.. XX, I. 2). Or we may assume a reflex origin. Thus Ley- dm maintained thai certain pointed octahedral crystals which ticdijcovered in the sputa of asthmatics irritated the mucous "wmbrane. and produced the spasm. Many observations, how- ewr, allow us to doubt the correctness of this latter view. Uhiabecn established, on the other hand, beyond doubt (Vol- lolioi, Hack. Sommerbrodt). that certain diseases of the nasal '•"Koiis membrane (polypous growths, chronic catarrh, etc.) •"Tjive rise (o asthmatic attacks — reflex neurosis : possiblv "•f part in the production of these is played by the reflex <iiUuiioo of the vessels in Ihe bronchi.il mucous membrane, ■tch was by Stilrk and Weber supposed to take place in con- ■eclioii with the bronchial spasm, a theory which was after-
130
WSSASSS OF THE OtA.VfAL .VEMVES.
ward cuiitirmcd by Sommcrbrodt. With reference to this con- nection I have convinced myself from lon^ experience with such cases that the above-mentioned affections only lead t» uathnia in persons with a nervous prctlispusiliun : they are only the "agrals prvvocatturs" not the real cause (Uris^^and. Rcvuc de mid., likjo, 12). This is especially the ose in children (Blache. I^tiidc siir Ta-sthmc chcj; Ics etifaiils, Paris, 1890).
Symptoms. — The cbanicteristic leatures of the disease are the paroxysms of distress and dyspn<i:a. previous to which the patient may for days complain of general malaise, be low-spirit- ed, and troubled with digestive disturbances, diarrhcea, etc. The attacks begin quite suddenly, usually at night, more rarely in the daytime: during them the respiration is changed, so that Ihc breathing in inspiration, but more especially in expiration, becomes labored and accompanied by a loud wheezing. This may last only a few hours or may continue for days, and may be repealed at varying intervals. Toward the end of the attack moist riles can be heard on auscultation, and there is expecto- ration which contains the above-mentioned spirals and crystals. Del ween ihc attacks the patient enjoys perfect comfort.
i£tiology. — The xtiology of the disease is but little known. No doubt hereditary predisposition does exist, and persons with a neuropathic family history fall, usteris parOms^ more easy victims to asthma than others. Just of what nature the exciting cau^s of the actual outbreak are we are as yet unable to say. \Vc have repeatedly observed thai hysterica! persons suffer from asthm.itic conditions, which, on examination of the respir* atory organs, prove to be of a nervous origin. In these in- stances the patients are for days troubled with piimxysmal dyspmca, their expiration is diflicuti and wheezing, while noth- ing abnormal is found on auscultation and percussion. We shall later on have more to say about this hysterical asthma.
Thul the inhalation of certain kinds of dust muy give rise to asthma, while not a frequent, is certainly a welLaiilhenticated observation. We may especially find this connection when the same obnoxious causes have been acting frequently and through a rather prolonged period of time, as is the case in those who follow certain occupations (millers, bakers, etc.): in the same way it is well known that repeatedly drug!;;ists have been af- fected regularly with asthmatic attacks while occupied with the pulverization of ipecacuanha root, and that the dust of certain kinds of grain--lor instance, of oats— causes such disturbances
DISEASes OF rt/E t'AGVS {PXEVMOCASTKtC .\'£JtyE\. \2\
\
t I
Id Ihose enga^^ed in thrashing (cf. Hirl. Krankhciten dcr Ar- bdier, 1S71. Bd. i, p. 12).
The asliima which <levclops under ihe influence of certain fefccins has tu be classed amun^ these cases, and in this con- ncdjoii the so-called lead asthma (asthma saturninitmjisdeserv- rocntion. This is a very peculiar disease, which Is in vt^ry acutely only a few minutes after the has been taken up. Though to the highest degree dis. Imping !■> the piitieni.:i fatal ouicotne in it has never been oolccl icl. Ilirt. (?/». ((■/.. Bd. iii. }«. 40). This trouble is, however. CTcn among leiid- workers, quite rare, so that we may assume Aat among one hundred affccti<)n5 due to working in lead two ioftsnces at most ot this above-described asthma occur. As to iWinode of origin, wc do not know whether to refer it to the ictioi) o( the poison on ihe central nervous system, or on the peripheral nerve-endlnys of the vagus.
Treatroeat. — We are noi acquainted with any specific (or bronchial asthma : the much-recommcnded iodide of potassium Ux>-5.o(xxx to Ixxv grs.) a day) often fniU. and, as a rule, wc do ■Dt Kcomplish much with the usual nervines, arsenic, quinine, bromtde. etc. From Ihe use of electricity we have never seen Uf lasting heneht. Wcllconducted hydrothcrapcutic meas- am may produce a decided decrease in the frequency and the WKiity of the attacks. For the treatment of the attack itself Wean foremost recommend pyridin, which w.is suggested by S(t. It i& a product obtained in the dry distitiation of organic wUlances. a colorless fluid which easily evaporates in the air. F« ibe therapeutic tis« half a teaspoonful of it has to be poured Misballow dish, and this inhaled three to four times daily in sdoscd room. The smell is horrible, and often disgusting, but *i» many instances the action was found extremely beneficial. AtMwn as the pyridin evaporates the patient becomes easier, 'he frriings of distress arc relieved, the heart's action is more f^pilar. The effect is not always lasting; still. I have seen tats ill which daily regular inhalations used for several weeks lure nut only cut short the individual attacks, but have also dctreued their frequency. Of course, with this, as with all othfrrrmedies, we may be disappointed. Krom the inhalaiion t^ the lumes of burning saltpetre paper, which has recently aftatn been recommended by Kochs, I have only seen transient. ne*fr.inv tasting effects. The same holds for the well-known sinmunium cigarettes, for amyl nitrite, and the vapors of tut-
122
I}/S£ASES OP THE CRAUIAL JVH/ffES.
]>cntinc. More good may be expected from the administration af linct. lobeliEB, which often works like a charm (linct. lobcl.. 5.0 ( III Ixxv) ; ai\ux lauroccr.. 1 5.0 ( 3 iv). Sig. : 1 5 to 20 drops every two hours). An alkaloid " lobeliii " has been used by Nunes {Rio de Janeiro, 1889). With the extract o( que- bracho, which has been recommended by Fenzoldt. I have no large cxiiLTicncc ol ray own. Hyoscyamine, together with small doses of strychnine, given several times a day, has been used by Walker (Lancet, August 20, 1 887. p. 368^
LITERATL'RB. IlicrmCT. Uebcr t^ronchialAnihina. VullcmanD'tche Sammtung klin. Voriii^r
Muhuux. The I'athogLTic§is of A&thmalic Aiuckfc. Jogrn. <le Bnix., vo\. luiii,
p. 305. 18S1. Hi<-i{cl unil Edinjier. IJcutschc Zcitschr. (. klin. M«l.. 1881. HJick. Ucbcr ricic upcratirc RailicAlbchandtung bmiitimicr rocinm von Mt-
grttne, Asthma, Heulicber. sowie tAhlrckhcr verwandter Entchrinungcn.
|8»3. Schech. Die sogen. Kettcxncurosen unci ihre Ilciiehuni^n lu den Krankhciicn
d«r Niiw and <la Kachcni. Uaycr. Xnil. IntelligenibL, Bd. uxi, p. ja.
1S84. SchiifTcr Auider i'raxisi Naticnleiden und Kcllcxncurocen. Ucutach. m«l.
WotlicnKhr.. pp. 23. 14, 1884. Sommctbroilt. Miiihcilungcn von llciliingcn palholog. Zusifinde, wclchc dufch
RellcxvorK*ngc von der Naw lier beiucrkl wurdcn. Bcri. klin. Wochen'
icht., pp. 10. 11. 1884. .Sommrrlirodi. I'ebcr N;i*cntrflcxncijro»cn. Ilml.. No. 11. 1885. Siv. lrt:rm:iiti. Bull, dc TWr4|K'iil.. June yo. 1885, vol. cviii, p. {19. (Recom- mends pyridin.) Uicmicr. Bc-riincr Win. Wochen schr. 41, 1886. Kochx. Beittiijf /ur Ktnntnis.i der Vetbreniiungsproducle des Sal|>rten'^l>ien»
und dcr Uruchcn dct Asilima broiii:hialc. Ccntralbl. {, kilo. Mud.. Bd. irii.
p. 40. 1886. Grocco, I'ieiro. Sulb |)a(oIO|^a dci nervi cardiaci. Riviit. cRn. di Rolo);ru. p.
11. 1886. Duweaud. Dc I'asihme d'nrigine naxale. Thisc dc P.tn£. r887. Calineltes. Le* nevrosc* rirtrxe* d'oripne iiosnle. I'rojir. mid.. No. 28. p. 30.
1887. Vnaa^. On Dyipniv;!, e»j>ecially on the Dyxpncca of Axlhma and Bronchitis,
and ihe Eflccts oi tht- Niintrs upon it, Lancet, July 9. 1887, p. 51, Sit. Germain. Die cinUchi-n Liingcnkninkhdlcn, Translated into ticrman Ity
M.Salocmin. Berlin, DUmmler, 1887. Bragclmann. lleher Asihma. Deutsche Medlclnal-Zcitung. 39W«y.. 1888L V. Ua*cb. Wiener Mnl. /Ag.. 1S88. 33. 34 Granc her- Uai bier. Dc t'astlime cbu In cnraniv Ga«. mid. dc Parii,
1SS9. 16.
0/SJSAS£S OF THE fACfS {PATgl/AfOGASr/t/C JVexyXy. 133
I
Hsch. Uk logenanntc na»ate Fi>nn dea Bronctiutlnlluna. Vulkminn's Samn»-
bitig kiln. Vonrtl),f. 1889. No. 344. Sdinlilt. Ad. Zur Kenntnivi dcs Asthma branchUlc. CcnimlbL f. tilin. Med..
it^i, 3$ (Exjkinbuiicin ol Asthmatic Spuu (or Tibrin).
B. CaKIJIAI- AhTECTIONS DUE TO LESIONS OF THE VaCUS.
riie !iU|>crioT and iiiferior cardiac branches are given off from the UTflcal and ihorairic purtiitns uf the va]{us ; they join the cardiac bnachcs tif the syin{>aibctic to form the cardiac plexus (superficial and deep). It has nut yet been (Ictermincd of nhat character these Mmare: there is, however, no doubt hut that we have to distin- |nbli Inhibitory fibres, the slimulntion of which diminishes, and Moderator tibre^i. the Ntimulation of which increa»^« the number of bcirt beats. The sensory nerves of the heart are also (umiKhed by
tJKVIgUS.
An^na Pettoris.
Among ihe neuroses of the hcurl which probably are caused b>'> 4)^'urbance in the vagus, wc shall lirst consider angina hystcricii or angina |i«ctori» (sleiiucardin. cardi:iu neuralf^ia. nervous heart pain), a disease of the true nature ol which our kaourledge is as yet ijuite imperfect, though its symptoms have been rcc(^nizcd for more than one hundred years (Ileberden. l"/2). Its cardinal symptom is a piercing, burning, paroxysmal piin in the region of the left nipple, attended with a sensation 0* impending death : it often radiates into the left arm, and even <k>«n to the finger ti|)s, and may continue lorminulcs or hours. It inuaily begins without any premonition, and surprises the [otient by day at his work, or wakes him up at night out o! his •Itcp. The severity cA the pain diEfers; in some cases it is moderaic, in others it reaches an insupportable degree. Dysp- WHi is not always present ; the respiration remains somciimes reguhrand quiet, although the patient suffers from a distress, iflg feeling of anxiety, and his skin is covered with a cold sweat. Darinfr the intervals, the patient feels perfectly well, unless there is a co-exisling lesion of the heart muscle or valves.
The diagnosis may present snnie difficulties, since intcrme- diiie conditions between angina pectoris and bronchial asthma an met with, or a combination of the two conditions may occur.
The prognosis depends mainly upon the question whether "e have to deal with a vagus neurosis, or whether some com- pfiation co-exists. If the myoairdium. owing to disturbed iii< tractrdial circulation (caused, for instance, by athernma of the coronary arteries and insuflicieni blood supply to the myocar-
■
124
/>/S£AS£S OF TflR CRANIAL .VSfifES.
diuiii, or by syphilis), lias undergone pathological changes, death may occur during an attack. Such cases are not rare, and I have recently again had occasion to observe an instance of this kind, in a matt ol ruhust appearance who sutlercd from stenocardia, and who, while in apparently good health, died suddenly in an attack within two minutes after its ons«t ; the arteriosclerosis was very pronounced. Sudden death, however, is never to be feared unless the heart is organically diseased. It is impossible to give an absolutely favorable prognosis with regard to recovery, because here also we do not possess any remedy which is capable of doing away with the attacks en- tirely. But the same suggestions as have been made (or the treatment of bronchial asthma apply lo cases o( angina pectoris, and about the same results have been obtained in both. 11 in- ternal treatment can not be dispensed with, digitalis may in the first place be tried, rhen strophanthus, and finally arsenic, which latter mav with advantage be combined with strychnine. With the linct. piscidia: erythrina;. which is supposed lo lower arterial tension and which has been recommended by l.i^geois. I have no personal experience. It is prescribed as follows: Tinct. pise. (■rythr.,6o.o(3 tv) ; tincl. veratr. virid., io^(3ijss.): tinct. aconiti, 1 5.0 ( ill 225). Sig. : 1 5 to 20 gtt. t. i. d.
For the attacks, freshly prepared amyl nitrite, a few drops (5 to to), to be carefully inhaled by the patient, is the most use- ful trcatmcni : besides this, inhalations of chloroform and hypo, dermic injections of morphine deserve recommendation, as they relieve the patient at once from the intolerable torments ol his condition. The severe states of collapse following these measures, observed by Bamberger, are probably, after all. quite exceptional.
Murrcll recommends a systematic treatment with nitro- glycerine (Therap. Monatshcftc, [S90, iv. 11), beginning with 0.0001, increased gradually 100.003 p. die. From external meas- ures, such as the application of hot. water bags or ice-bags over the heart, as well as from hot baths. 1 have seen no good result.
The a;liology of the disease is as obscure as its nature : here we must again carefully discriminate between the cases where the angina pectoris is merely a symptom of some orgimic heart disease (disease of the coronary arteries, fatly hearr, valvular disease), and where it appears as an independent affection — i. e., where no heart lesion can be demonstrated, The latter form is disproportionately less frequent (Gauthier), Males and those
MSJtMSXX OP Tllf. VAGUS il'MFASMOQASTItiC JVAXI'A). 125
■
in age seem especially predisposed to llic disease [(Crautbier) ; yet the author hns atsu seen cuses where displace- l^tof the ulcrus was accumpanicd by stcmitaniia. as well as io( undoubted aiiguia pei;lom in children ttiirireti ti> til- tttn years of age. Psychical disturbances, such as are found ill hvNterical pntietits. also the inntience of ct-riain poisons — e.g., tobacco— deserve some considcrati'm. Pcycr (Ziirich) claims to have observed a ctmncction between stenocardia aad tpennatorrhcea (Wiener med. Pressc, 1893.35). That an- gina pectoris is a vagus neurosis can reasonably be accepted, as the sensory hbres of the heart arc furnished by the vagus, ami a% pnin is the most prominent symptom of the trouble. I'lTjiumably the sympathetic is, however, also concerned, nnd siRic are even inclined with Lancereaux. who several limes luiiiid this nerve vascularized, to regard the cardiac plexus of the sympathetic as the chief seat of the disease; but e%'en were ihii so, wc could not exclude some participation of the vagus. A publication of I-croux, who found at tbe autopsy a bronchial gUiid and the right vagus grown together in a case where an. iginal seizures bad existed until just before death, appears also l|u ipeak in favor of an implication of the latterncrvc. Fre- LqDCotly no anatomical lesion can be found.
I-ITKKATl'KK.
LhbV Zwt L.ehrc •ran den vuomolor. Neurotcn (Anf^ina peciorii). Inaux.
Dm.. Hrraliu, 187$. iUkui I^dinli. Med. joum., March. iSSt, vol. xxvi. p. TfSg. UKkduic. Jnhn N. A Oinintiviiion lo the Pat liology and Ttr.it mcnl of llie
RofNratory V*»omotor NeuroiM. Nt:w York Med. Jouni,. t'civ z6, 1887. Hwtud. The Weekly Med, Rev.. St. Lou^, 7, 18S7. (Recommends perw-
■mnoc wilh mliite*— iodide of nxlium. gr. nv-xk daily for a >«ar or a year
Ml a halfk
iLi OkK: L'ongine de poiirine h)-it^nque. O. Ooin. P.iTis, 1887. fVwBMdL Die untitle l>y«pnoc unit das cardulc Atthm.i. Klin. Zeh- und
Snafrjijen, 1, 3. 4. '887. ^•fbrta Traill dc I'angiiie dr poltrinc I'ari*. Dekhaye, 1887. MwtgmiiiB, BdlraK iur Kennlnim der Heraneurown. Deuische meil, Wo-
dwiHChrH 1K88, 45. [LilahMty, DcT Nerv. vagtis und d'K An^tia prclori^. tictliner klin, \V<t-
Atiurhr.. 18S9, jx ^f tinkit. VnTiiiilt 1-/ 4/. Vrrtwndliingen de« X. Congresses fur innere Medicin.
DniiMrhe Mrd--i^ig,. 1891, y}. \> ^ytt trf. (InlenntinK dlticuMiun,) rl IhrrtmpT kiin. WMlinmhr,, 1891, 21, LHv. Otr nrrvMr 1 1 iTjschnai; ))<■ 1 Nrunulhenia VAxomoloria) und Hire Be- (uadliinc. WmlMden, Bcrgninnn, i89i-
126 DISEASES OF THE CRANIAL NESVES.
Nervous Palpitation of the Heart.
Secondly, we have to speak of the so-called nervous palpi- tation of the heart, palpitatio s. hyperkinesis cordis, by which term we designate a paroxysmal increase in the frequency and strength of the heart's action, which is not only objectively noticeable, but also subjectively felt by the patient. Pain is absent, and in pure cases at least there is no dyspnoea. Palpi- tation appears more frequently as an independent affection than angina; the attacks usually begin suddenly, often at night. If the patient be lying on his left side, he is seized with a feeling of oppression and anxiety, the pulse is accelerated, and its rate may be increased to more than two hundred beats to the min- ute; sometimes the second heart sound is curiously clicking (cliquetis m^tallique) and the first extraordinarily weak, the carotids throb, the radial pulse becomes hard and full. Dehio (cf. lit.) has examined the pulse curves by means of a Dudgeon sphygmograph, and found the pulse waves higher, the decline steeper, the first elastic elevation decidedly nearer to the base line of the curve, and the dicrotic elevation lower than normal. He attributes this condition to an increase in the frequency of the beats, and a decrease in the duration of the individual ven- tricular contraction. Besides the palpitation, the patient com- plains of ringing in the ears, dizziness, and faintness. The attacks usually pass of! in a few minutes, disappearing as sud- denly as they came on, and the patient soon feels perfectly well. Their frequency is extremely variable ; they may appear once, twice, or more often daily, or only after long intervals of weeks or months.
That here we also have to deal with a neurosis of the vagus seems only a rational assumption. The seat varies; it may be either central or peripheral, but in most cases we are unable to positively say which it is. Sometimes we arc justified in as- suming that such conditions depend upon a central, bulbar nuclear affection, just as we may probably refer a temporary diminution of the vascular tonus to a transient paresis of the vaso-motor centre in the medulla oblongata (Dehio), The pub- lication of differ (Revue dc mod., 1890,4) shows that neiiritic conditions of the vagus may also be found.
it is very important in these cases of palpitation to look for further coexisting affections, after the removal of which the nervous palpitation often disappears snddenlv, and never re-
»
OfXXASXS O/-' THE VACUS {rXF.UMOCASTJtlC A'EKfE). 127
[cun. Tu this class belong chiefly the aiiiemias of the young, Liantiugmus juvenilis, habitual constipation, gout, and malaria, [Ud accordintjiy we are able lo bring alxiut a marked improve- xtatal in the palpitation, which in such cascii is only symp- |.b>inatic. by improving the condition of the blood, by proper Irc^tbtion ol the IkjwcIs. by promotion of the excretion of uric Mcjd.aiid by combating in.ilaria by means of quinine, according jhilbc indications in each. If such indications (or therapeutic ;iire-« are wanting, we have lo fall back upon the narcotics Incrvinc!!, unreliable as they arc in their .iclion. In hyslcr- al i>crM>ns certain mechanical manipulations, pressure on the [ibdomen, momentary compression on the neck, and the like. I may be of service. Applicaiiun of the ice-bag to the cardiac {Rgion may occasionally be beneficial ; the psychical treatment [bhlie patients, repeated assurances that these attacks are never |bul, and that they arc quilc amenable to treatment, is not to [be underrated ; in the case of children ejspecially this has been liuund very effectual.
The aetiology is. unless the palpitation is secondary lo an underlying disease, quite obscure. Under what conditions individuals in other respects quite sound, with a good family bislory, and who present no symptoms of neurasthenia, can be attacked by such transient pareses of the vagus we do not know. In suspicious cases we should think of masturbation.
uti:rature.
Ter. Ud)CT TcRcclorischc Vagtisncumnc. DeutKhex Arch. f. kliti.
Med. ntvli. J. 4. P- ^7. 1880. LnpT.L UebcrVainitUIi'nuni;. Wiencrmrd. Wocl)enKhr..kX]d,}0.3i, iSSl. IVi IVagcrmcd. Wochcnschr,. No. 44. ■'^84. fMoglll The Ciouty Ncunucs of xhr^ Heart. Edinb. Med. Joutn.. xxx, p^
Ml, November, 1884. Sanmiab, Mar, [>r I'aUtir |>aral)-|jque du ctrur, d'origine bulbaire. l.Tnc^
pkale. ri. 6. IL4I], iS&ty OAta U«b« netvtiMs Hcriklopffn. IVlcrth. nicd, Woehcnschr. August S
m<l9. 1BS6. <*>(Wiuic Nol. A Contribution lo the f ailiology and Trealnient oi the Kcspln-
••H Vaso-nioior Ncurows. New York Med. Joum.. Kcbryaiy 36, 1887, (MtL Urber iwrrtees Mcnklopfen unU sunsiigc viuf InncrvalionMlorunjfci)
bmhoHk HcnaflectloncD. Detiixche Mcd.-ZiK.. 1890, 49^
TMhycitrtiia.
In rare otses, in pcopir otherwise healthy, but more fre- quentlv in those a0ected with heart disease, wc meet with a
128
JifSBASES OF THR CKANtAl. NP.SVR^
transient acceleration o( the heiin's aciiun {lachycardia). which usually lasts for several hours, after which the pulse rate again bccotites normal. These attacks are acconipnnied by a feeling III great aiixicry, ami are iishrrcd in by vawi-tnotor disturbances ^-e. g., circumscribed tlusliiugs. The number of the pulse beats may reach 200 or more. Pressure upon the vagus in the neck, a dr^iught of cold water, or similar slinmlaiioi) o< the peripheral ends of the vagus often may cut short an attack against which we possess no other remedy. Whether in a given case irritation of the accelerators or a paroxysmal paraU ysis uE the vagus is responsible for the attacks has. according lo Notbnagel (Wiener mcd. Blatter, i, 2, 3. 1887), to be decided in the following way: A great increase in the frequency ol the pulse, accompanied by a weak heart-beat, and perchance another disturbance of some nerve path belonging lo the vagus, speak for paralysis of this nerve; whereas a strong impulse, fullness of the peripheral arteries, with high tension, associated with other symptoms of vaso-motor irritation, is in favor of stimulation of the accelerators, Traube assumes that some cases are due to a temporary ansemia in the medulla oblongata, in consequence of which a paresis of the inhibitory nerves en- sues. To this class seems to belong the ctse related by Dehio {<{. lit). The affection is met with equal frequency in both sexes; it is more liable to occur in advanced age; in women the climacteric period seems to predispose to it (Stokes, Kisch).
The mode in which nicotine acts upon the vagus is uf great interest, and certainly deserves a closer study than has been given to it hitherto.
Chronic nicotine poisoning, as it is found in smokers, and only occasionally in tobacco workers, is not always well adapted lo throw much light on this subject, for. whereas it is well known thai the nicotine when brought into direct cont.tct with the nerves paralyzes them rapidly, it is by no means common to find paralysis of ihe vagus in the course of nicotine intoxication. As a rule, it is true that the hearl's aclion is increased, yet cases occur in which there is a slowing, so that we are led to think of a stimulation of the vagus, such as happens after drinking cold water, where the pulse Rite may be reduced to thirty or twenty beats. Owing lo the miserable arrangtrments for ventilation in tobacco factories, we have from lime to time occasion to study the action of nicotine in th(»se employed in them, although the disease is, as has been said, by no means frequent. Kisch has
i>/S£/tSSS OF THE VACUS {PXEUMOOASTK/C yRlfl'K), t2q
recently called attention to a form of tachycardia whicti oc- cnrs at the menopause, and which he is inclined to attribute tOcliangcR in the ovaries (Wiener mcd, Presse, 1R91. 19).
GiMTs which, in consequence of a vagus neurosis, present a uDultaneous disturbance in the circulatory and respiratory apparatus, occur, but arc rather unconunou. A case to the point has been published by Tuczck (Dcutschcs Arch. f. klin. Med.. 1877, xxi. I), and two others by Kredel (ibid., 1882, xxx. [L 547). For the respiratory apparatus acute emphysema, with il;>|)tio»t »m) symptoms of calarih, were noted; they were Rf- locutcd with tachycardia (asthma cardiacum, according to Kmlel), and the existence of a paralysis of the va^us fibres tt|;ulating the heart, in conjunction with a stimulation ol those picsidtng over the lungs, whereby spasm of the muscles ol the bnHKhi was produced, was assumed. At the autopsy the auM was found to be pressure exerted upon the vagus trunk bf a rapidly swelling lymph gland. The attacks lasted from ivtJvc to thirty-six hours. Some of the patients had organic faon disease.
LITERATtJtcE. La|a. U«ber WagmAAtaang. Wttiier meil. WochirnKhr.. nnxi. yi, 31, 1881. ^V^t%. UtbrrTarlij^antk. DruiK-h. Arch f. kim MeiL.Ihl.xuti. 11^^.311.4. U)(riM. Neuriti* ol ihe Vagi cmiwqueni upon the Action of Alcohol 80c
dr MM. <fe PmK July 16 and 33. 1887. Mb Tachrnnlic MCh drr Punclkm rtnn H)<trop*-AKim. IVlrrab. tned.
tl'tdwntchr,. I. M<T 14. 1887. Fmw|Uk IJrtrr Ok chrtinuchc TilMhvnxiflunj; tiiul ihrcn F.infloM auf du
Hm and doi Magm. Wkncr n>«L WochcnKhr., No*. ii'i4. 1SS7, Spijlrt IkDtKhr tnrd WodMmchf.. No. 38. 18S7.
h^. OHrW-Auulm. iBM. nli. p. 193.
BwM. RevM At mU. 1889. 9^ Ia
IWMM. DcbTad^avdiribMbTabanlaKpalmiL TUMikl>Hk.iS89.
^^^ft. nops wtfl^ 1890L 37'
Bm Kriwl) M«d Jon. iSqn i{. 3.
Brsdycardta i/^aSvf. slow) is. on the whole, eren lets often nd with than tachycardia : io this cooditioo the Dumber of t^ pvlw beats mar (all to hall the normal— i. c to 3S-42. a cnxStioa which maj also be found io perfectly healthy iodi' *^ii>ls> Sooetiaa bradycardia seems to be a peculiarity niMiaua to aevcnl a»eaben ol the same family. After pro- ^{n) fattia^ aad is the poerpeial state, it may occvr with- out aajr oiher aboorsalttr. SoaetiacB K is aasocialcd with f
130
D/SSASBS OF THE CRAKIAL /SERVES.
cerebral nCTcctions, with chronic articular rheumatism, with dis- eases of th« digestive, circulatory, and uropoctic organs, or with certain intoxications (lead, alcohol, cotlcc). Lunz, among others, has recently called attention to the association of bradycardia with epileptic attacks, the so-called Adams-Stokes disease (Neu- rol. Centralbl., 1893, xii, 4, p. t.|2). In old men it is sometimes seen as an idiopathic vagus neurosis, a condition for which no physiological explanation can be given (cf. Grob, Deutsch. Arch. f. klin. Med., 1S88. xlii, p. 574; also Ricgcl, Zcitscbr. f. kiln. Med., 1S90, xvii, 3, 4, p. 231: also Dehio, Petcrsburger med. Wochenschr., 1892, t. In these articles also the theories of the pathogenesis of the alTection are discussed). We have thus far no means with which to treat this condition successfully,
It scarcely belongs within the scope of this book to treat of disorders of the cardiac rhythm, arrhythmia cordis, which is sometimes found in obesity, more often in the course of brain diseases, in intoxications (tobacco, coRcc, digitalis), and above all in organic diseases of the heart. Baumgartcn has published a comprehensive study treating of this condition (Disturb- ances of the Heart Rhythm with Reference to their Causa- tion and their Value for Diagnosis, Transact, of the Assoc, of American Physicians, 18S8). Kummo and Ferranini have at- tempted to investigate this condition experimentally (Riforraa mcd., December. 1887, 278-287), but much is still obscure.
C. TUE D[STURll.\NCES OF THK DiGESTtVE ORGANS DUE TO
Lesions of the Vauus.
The vagus forms two sastric plexuses: the one, the anterior, situated on the anterior surface, and the other, the posterior, sitti- aled on the posterior surface of the smaller curvature of the stomach. The first plexus is formed by the left, the second by the right, a somewhat stouter nerve. The t)riinche!( of the»e plexuses asst^ciate with fibres from the sympathetic which accompany the ramifications of the coronary arteries; a part of the fibres which appertain to the right (posterior) vagus go on to the cccllac plexus, and can in a careful dissection be traced to the spleen, the liver, the kidneys, and small intestine.
The muscles of the cc^ophagus and stomach are also innervated by the vagus ; its sensory fibres conduct the impulses concerned in the reflex actions of deglutition, sobbing, and vomiting.
Among the disorders of the digestive organs caused by dis- ease of the vagus, the so-called stomach and iutcstinal neuroses,
mSE^SSS OF THF. I'ACt/S IPATFOWOCASrA/C Xf.xr/C). 131
I
M find affections of the motor, sensory, secretory, and perhaps ib(i of the trophic fibres. Among the motor neuroses we have, ucordiiig to Glax (Klin. Zeil- und Slrcilfragen, 1887, i. Heft 6), irritative and dcprc!«sive forms. The former mniiilcst ihem- aJtes in simple perisialijc unrest of the stomach, or in nervous belching or vomiting, the latter in nervous atony of ihe stom- ach, or insufliciency of the cardia or pylorus. Merycism, or niminalion, must also be claiiscd among the motor neuroses. Among the sensory disorders we find cardialgia and hepataU pA. Of the secretory neuroses, nervous dyspepsia is the most inporlant. To this chiss also belongs, in all probability, the illed oesophagismus. The claim of A rnd t ^ Deutsche med. chenschr., 1886, xiv, 5) that the round ulcer of the stomach ihoold be t^arded as " originating in a neurotic affection, an ■ifio>ortropho-neurosis(of the vagus)," is deserving of further ttmtigation.
TbeK vagus neuroses are rarely met with alone in other- wbc healthy persons ; more often they appear in conjunction ■ith other diseases, especially general affections of the nervous sjfteni, particularly hysteria or tabes. Sometimes they arc ■uodllcd with affections of the uterus, such as displacements (l^edti, Thcrap. .Monatsh., 1892, 2) ; finally, ihcy are met with liipr^;naiicy. Possibly some have a reflex origin. According lo Leva (MUnch. med. Wochcnschr., 1S90. 3o, 21) this is the CJK ta merycism ; but here we also find anomalies in the score- tin of the ga&tric juice, a circumstance which may be of a:tio. Icgicil Importance. In most cases of rumination which have ben observed the patients have eaten copiously and rapidly ■od have overloaded their stomachs ivith imperfectly masli- cainl food (cf. Alt, Berlin, klin. Wochenschr., t8S8, 16, 27: B<iii,ibid., 31 ; jUrgcnsen. ibid., 46; also the above-mentioned ■nicic ol Leva, and one by Singer in the Deutsch. Arch. f. Hin, Mfd.. 1891, li. Heft 4. 5, articles in which especially the Kiatiiin of rumination and vomiting is diiicussed).
Tbc other motor neuroses of the stomach and intestinal tna will be discussed iit the cha[.ter on Hysteria.
Cardialgia fgastralgia, gastrodynia) is a disease of the sen- *wy nerves which occurs mostly in paroxysms. Romberg, diflinguishing two forms, assumed the one to be due to a lifpervstheua of the vagus branches going to the stomach
I3»
D/S£AS£S OP THE CRANIAL NERVES.
{*'gastrocl>'iiia ncuralgica"), the other to a hypcrarsthi'siaof the solar plexus (neuralgia cmliaca). There have been, however, cases coming under noiicc which can not be classed under cither ol these heads, and cvrn more which do not permit of a deci- sion as to which of the two forms we are dealing with.
The characteristic symptoms of gastrodynia are violent paroxysmal constricting pains, starting in the region of the stomach and radiating to the back; the face becomes livid, the hands and feet cold, (he pulse smaller and intermittent, attd a feeling of unutterable anguish and distress lakes possession of the patient. If in the presence of these symptoms careful ex. amination has excluded the existence of any organic stomach lesion — e. g.. acute or chronic catarrh, gastric ulcer or tumor — if there is no evidence of gall stones, and ihe patient has pre- viously at times been subject to neuralgia in other parts of his body, we make our diagnosis with some amount of certainly, Bui in alt cases this can only be done after careful and repeated examination before and after meals ; not uncommonly we find that pain, which is present while the stomach is empty, is re- lieved by the ingestion of food, and the patient states that uniform firm pressure on the epigastrium has often a beneficial alleviating effect, both conditit>ns not generally observed in organic diseases of the stomach.
In the treatment of these cases we must first of all endeavor to remove any primary cause, and in this connection mental and physical overstrain, excesses in vencry, masturbation, or uterine affections, must be thought of.- Besides the external application of blisters to the epigastrium, arsenic given for sev- eral weeks is to be recommended. During the attack morphine can often not be dispensed with. The diet has to be care- fully regulated, but not restricted : on the contrary, it is ad. visable for the patient to take four or five times daily sub- stantial but easily digested food.
I
I.ITEHATUliE,
Sawyer, J. Clinical Lecture on Ihe Trcalmcnt of Castralgia. 13. 1887.
Lancet. August
I I
Of great practical importance is the so-called hepaialgia or nerv- ous biliary colic, which was lirst described b^ Andral in 1817, and which has been studied more recently by Frertchs. Fllrbringer, and Talma (cf. I'ariscr, OciHsch, mcd. Wochcnschr.. 1S93, _ni). Thi* allectioii i» usually seen in anKinic women; it manifests itself io
O/SeASSS OF THB VAGUS (P/fEUMOCASTXlC A'EJtf/i). 133
[itroxysinal pains, which arc as severe as those of a true biliary colic; thej ue, however, more reKtricied to the hepatic region, and never, nen after recurring for yeant, lead to febrile inllainmatory affections of the liver, ihc gall-bladder, or the gall-duc(& (Fiirbrtnger). Anti- neurasthenic treatment is often of no avail.
I Nervous Dyipcpiia.
The disease known as nervous dyspepsia is an extremely common netirnsis of the vagus, especially in females. It is charactciized by a loss of appetite, painful sensations in the region of the stomach, frequent vomiting, and stiti more fre- quent belching: besides these the patients generally .sutler from other nervous symptoms — dull headache, vertigo, palpitation; they are easily tired, complain of a lump in their throat (globus hystericus), at limes have a voracious appetite, and obstinate constipation is seldom absent. The motor functions of the K slom-ich are, as a rule, more or less disordered, and sometimes " secretory anomalies are observed ; indeed, only rarely do both the motor and chemical functions remain intact (Herrog, Zcilschr. f. klin. Med.. 1890. xvii. 3. 4). In rare cases periodical spells of vomiting have been noted (twenty to thirty in the tweniy'iour hours), accompanied by acute circumscribed swell- ings ol the skin (angio-neurotic tcdrma. Striibing. Quincke). Although the patients feel very poorly, their state ol nutrition remains, nevertheless, for a long time remarkably good ; only in a few cases do we observe a rapidly increasing and marked ansmia. It is still doubtful whether the condition is essentially a disease of the peripheral nerves ol the stomach or a general netirosis (neurasthenia dyspcpiica. Ewald). We would refer the reader to a most intere».ting and comprehensive article which has been written on this subject by Lcubc(Berl. klin,
■ Wochcnschr.. No. 21. 1884). In making our iliagnosis we are brought face to face with no inconsiderable difficulties. The claim of Leube that wc arc, in the presence of the .nbove-dcscribed symptoms, justified in thinking of nervous dyspepsia if a stomach- w.tshing six to •even hours after the meal shows the stomach to be empty, ha* been opposed bv Ewald and others. These have shown that, on the one hand, the stomach may be empty seven hours alter a meal in cases of ulcer, and. on the other hand, may contain remains of food in nervous dyspepsia after the same ac. To be sure, an increase of hydrochloric acid (hyper-
134
DJSF.ASES OF TUE CKANIAI. NEItVEt.
acidity) is a common condition in gastric ulcer. The results of stomach>washing arc, however, certainly not always pathog- nomonic, but we must rallicr for the purpose of diagnosis take inio account the course of the disease and the general condition of the patient. But in spile of the greatest care experienced men not seldom in these cases are led into error. Under cer- tain circumstances the hyperemesis nervosa, a motor neurosis of the stomach occurring in pregnant women, especially in the lirst mtmths of pregnancy, may closely simulate the disease.
In the treatment our attention has chiefly to be directed to the proper nutrition of the patient. Of medicines, arsenic, quinine, chloral (i.o (grs. xv) several limes a day), should be resorted to. Saline purgatives, a course of treatment at Carls- bad, as well as the use of electricity, are of no avail, A stay in the mountains, hydrotherapy, sea-baths, all should be tried in succession, and last, but not least, the possibilities of psy- chical treatment must not be forgotten.
I.ITEKATURE.
Cherrbewsky. Contributiona 1 la pathologic d» nerrotes inlalinales. Reme
(le mc<l., 3. 1S84. Schule. Arch. f. t^'ch. a. Nnv«nhrankhcii«i, xv, 3,818. 1SS4. (Nervous Dysprp-
sit. wtih A Kcrtex Vagus NeunKtt&uft Coinplicaiian.— -Respiratory UiAciiiiy.) Alll>uil. Xisccral NcurosM. Lancet, i. ri, 13. 14, 18S4. Ihrin^ Pic nrnijfn; Dy«pcp»ic um) ilire Folgckrankhdien. V. Vol]un»ui*«
SdminlunK klin. \'orlrtls«. No. 183. NtiffUb. NcuriMM of the Stomach, Russ. Mnl.. 36-iS. 1887.
(F.tophag%smms.
Spasmodic dysphagia, known as oes<">ph3gismus (spasm the gullet), is an affection which sometimes follows dyspeptic symptoms and protracted vomiting, sometimes irritation of the fauces by hot fix>d. irritating subsLinccs (mushrooms, red pep- per, etc.). Sometimes the spasm is seen to occur retlexly in consequence of uterine diseases, and quite frequently in hys- teria. As an independent affection it is rarely ever ob5;er\'ed. In all cases it is characterized by the fact that the patient from time to time (periodically) finds it difficult, or is even un- •ble, 10 swallow his food : thai when it reaches a certain p4Mnt it is regurgitated, and that the sound which is intro duced for the purpose of ex.imination ts stopped at the same place: if this point is situated in the upper portion of the cesophagus. usually violent pain is experienced on the tnges-
DtSKASES OF TUB VAGUS {PNEUMOGASTRtC NERVE^. 135
I
tion more espccinlly of cold food, a circumstance which makes the patient object to inking his nourishment, and consequently leads to emaciation, although the loss of flesh is here consider- ibly less than in stenosis of the oesophagus caused by new growths, because in the former case the patient is able at times to swallow his food without any diBicuIty.
Predisposed to uisophagismus are nervous, easily excitable, hysterical persons, in whom the affection often suddenly makes its appearaoce after some emotion without the previous exist- race of any symptoms referable to the wsophagus. It has olten followed the suppression of the menses, or has appeared during pregnancy and lactation. Sometimes no other :etto< logical (actor could be discovered than injuries to the gullet ,vear9 previous to the spasm — bums, injury by sulphuric acid, Clc. No definite statement is warranted as to the duration and the course of the disease, as both vary greatly, but this much may be said with certainty, that in pure cases the prognosis is ilways good, that complete recovery is almost always eflcctcd by the repeated use of the sound and by the application of the laradic brush.
LITERATURE.
ChMMfltac Joum. tie mM. ci de chir. pnt.. p. 31 1, 1846.
Uuihira. Gnt. mfd. dc l.yon. p. 101, iSji.
I.enilnin. Arch, i/Jknbc.. jme fix., I. xi. p. 293. 1858.
Vigr^ Cu. do Mp.. Scpicinbrc 35. 1S69.
Aunfdd. L'Union. 73. 1S71.
Koike. TniiiAAct. uf the Clin. Socidy, t-ol. ri. 1873.
Rous. Th^ de faria. No, 10;. 1873.
Srniili. DttbL Quan. Jotirn, March, 1864.
IVUT. C^i. d(«hA|>. 83, 1S75.
Uockenxlc. Murcll. Mvit. 1'i(ncs and Gae.. OcIol>cr 11. 1S76L
Eto)-. ConiribuiioR to the Knowledge »( (Esophajpsmus. Cai. hebct, imc
\t'ne. L xrii, 46. 47. 50, tSSo. Stnbing. Ucbt-r ai-um angloncuroiischcs CEdem. itcitMhr. lur klin. Mnt., Bd.
hi. 5. "Ms- Mdlm. Ein Fall vun DyKph«Kie nebtl Bcmerkungen. Birrl. klin. Woc)i«ischr„
8, 18S8. (.Symptoms of (K«<ipha(;us Sl«ni>si« lasting for Nineteen Ynn.1 Lcwin. DcJtrSgc »ur P.nhologk d« V-igu* Inaug.-lJiMerl.. rctersljurn, iHSB, EdlaccT. Vaxiiuimrosen. Krprinied rrom Eulenburg's Rctl-Encyctopadie,
X Aiill. V Schkrti. Zur EWIijindlunK dci nervown MaKenkr^inkhritcn. Itcrl. klin.
WochffiMhr.. 1891.10. Holm. Ilanld. Den dprulc VngiiskJlme« Anaiomi og TathDlogi. Nonk Ma-
gaiifi (. Liefer iilenitk.. 1891, p. 1. BocMmU, E. UriirMgc «ur Kcnnlniss dcr Vagiunmiotcn. Inaug.-Uuert.,
Delw, 1893.
CHAPTER IX.
THE DISEAGES OF THE ACCKgSORV NKRVR.
The acceSHorius consists of two pnrtK, both of wliich have n scpa- raie origin and exit. The upper one belongs entirely lo ilie vagun, emerKCft with it, and is hence called acce-isorius vagi. The lower one begins at the level uf the frnl cervical nerve (cf. Kig. i6), and can be traced as fur down as the level of (he sixth, sometimes even of the
to a.
tjfC.II
Fit t&.—C*om MCnOH THaoucii thi CsHvtCAt. Conn. t.f.C.II. pdrtcrior cool' tlw ■nond CwImI ncrrc XI. fibia of Acc«wriu>. r.<>..interlnt honl. C/.,pane- rior hom. C. I,, laleral horn. //', Onll't column. H*. Butdoch'f toluiDa. S, Ulenl oduiDD. r, anicriDr column, g. lubsuntU e^UnnH of pcaierior born.
seventh cervical nerve roots; this is the spinal portion, the accei>Mi- rius spinalis. After having passed upward to the foramen magnum, close to the cord, it unites inKide the slcuti with the portion belong' ing to the vagus to form for a while a common trunk, the accessorius communis, which, soon after leaving the skull through the jugular foramen, again divides into two branches, the accessorius vagi then becoming the inner, the accessorius spinalis the outer branch. '36
77/Jr OtSEASES OF THE ACCESSORY NERVE.
137
The nuclctit of the former portion has been Oescribed in the two previous ctiapier*; that of the spinal portion is in the region of the anterior horn uf the cervical cord. Since the latter is pro- vidcd with motor cells, tlie purely motor nature of the spmal por- tion ifi evident (Schwatbc). According to Decs (AUgcm. Zcitichr. f, I'liychiatric von Lachr, bd. 43, Heft 45. '887). the nucleus of the acceRSorius i« divided into three portions, the upper being situated in the centre of the anterior hum, just above the first cervical nerve; Ihc middle at ihe lateral border of the anterior horn from the sec- ond to the fourth cervical nerve; and the lowest at the base of the lateral horn from the fourth to the sixth cervical nerve. The large multipolar (motor) nerve cells which form the nucleus are arranged like a ronary.
We may have centnii as well as peripheral diseases of the acccssoriiis, and. as is the case in other motor crania) nerves, the diseases may be of a paralytic or of aii irritative nature (hyperkincsis, spasm — akinesis. paralysis).
AtXESSORIUS Si'ASM. SPASMODIC WRVNECK, SPASMODIC ToRTtcoi.t.is {T'ti Hotaioire, Niel-kramff).
Since the accessoriiis supplies the sterno-cleido-mastoid and the trapezius (with its posterior larger portion), it is these two muscles which present disturbances in affections of the nerve. Either of them may be affected by itself, by a clonic or a tonic form of spasm ; hence there exist quite a variety ol clinical pictures, especially as the disease may also be unilateral or bi- lateral. The stcrno-clcido-mastoid is about as often the seat of a clonic spasm as the Irnpe/ius, whereas the tonic form is very rarely seen in the latter muscle.
By the rhythmical contractions ol oncstcrno-cleido-mastoid the head is moved to one side in a very characteristic manner ; the chin is turned toward the opposite (well) side and is ele- vated, while the ear is approached to the clavicle. Contracture ol this muscle (the tonic spasm) fixes the he.id in this position — caput obstipum spasliciim. If both stcrno-cleido-mastoids are affected, the head is drawn alternately first to the one, then to the other side (clonic form), or it is pulled strongly forward and bent t<)ward the chc*it (tonic form of the spasmV
Contractions of the trapezius draw the head backward and toward the diseased side, elevate the shoulder, and approach jlhe scapiiln to the vertebral column. .\ tonic spa.sm in the 'same locality entails fixation o( the head in this position.
138
D/SSASSS OF THE CRANIAL NERVES,
A simultancnus spasm of the stcmo-clcidn-mastoid and the trapezius of the same side, in which the facial muscles also sometimes lake part, is known 1o occur more frequently than an alTcctiun of both trapezii or of both stemo-clcido-mastoids alone. The directions of the movements and the positions which result from such spasms can be made out from what has been just said.
The occurrence of such afTeclions is either in paroxysms or else wc have permanent contractions, only ceasing or abating during sleep. Recovery is exceptional. All therapeutic meas- ures, not excluding the electrical and chirurgo^orlhopadic treatment, are usually unsuccessful. The thermo-caulery may be tried. Any internal medication would have to be con< ducted according to the principles described in the treatment of facial spasm.
The causes of the disease differ widely. Cerebral tumors, meningitis, foci of softening, as well as caries of the cervical vertebra;, new growths in the medulla oblongata, may give rise to central, while cxtcnial influences, cold, etc., may give rise to peripheral affections of the nerve. There are, moreover, well- authenticated cases on record of rcfies spasm in the distri- bution of the accessorius arising from irritation by worms, uterine trouble, fright, and other emotions. As a rule, no ^etiological Liclor can be detected. An epileptic who came under my observation, a single woman, twcnty^seven years ol age. presented at times a sp-ismodic loriicollis. the contnictions being extremely violent, sometimes lasting for weeks, and again being almost entirely absent lor the same length oi time.
Accessorius Pai*%lvsis.
This very rare affection may take in one or both of the above-named muscles. Unilateral paralysis of the sterno-cleido. mastoid produces a wry position of the head, in which the chin is somewhat elevated and directed toward the diseased side. Turning of the head is difficult but not impossible, as other muscles arc brought into play. Bilateral paralysis ot the muscle causes the head to be held straight, and is characterized by the absence of (lie |)romincnce which the normal muscle produces.
Unilateral pandysis of the trapezius allows the scapula to sink downward, causing the distance between its internal mar. gin and the vertebral column to become greater. As a con- sequence, the arm falls forward, the clavicle becomes more
TltR MSHAHES OF THE ACCESSORY NERVE.
139
I I
prominent, the supraclavicular lossa more marked, and tbc puftteriur upper angle of the scapula can be distinctly IcU. 'oltinlary elevation of the shoulder and the motion of the ipula toward the spinal column is ititerlered with, and bc- oomcs only possible with the aid of the levator anguli scapulK and the rhomboidci. The arm can not well be raised' above the hprizonlal position in spite ol Ilie scrratus which acts nor- mally, because the action of the upper third of the trapezius is lost. The paralysis of both trnpe/ii ,iIlows both shuulders to unk outward and forward, so that the back appears more curre<) ; the ability to support the he-id in the upright posture is sometimes interfered with. Simultaneous paralysis of the slcrno-ck-ido-mastoids and the trapc/.ii gives a combination of both clinical pictures. If, in addition, the inner (sm.-it]er) por- tion of the nerve takes pan. the resulting paralysis of the laryngeal muscles, the velum palati, and the jiharyngeal mus- cles manifests itself by hoarseness, the nasal tone of the voice, and difficulty in swallowing. The increase in the {re<iuency ol ihe pulse, which has in such cases been observed by Seelig- mlUler. must be attributed to the simultaneous affection of the cardiac branches of the vagus. Prognosis and treatment arc ibc same as in the spasmodic affections, and little more can be .|Md about the aztiolc^y. These forms of paralysis have been known to occur in consequence of certain occupations, e. g.. in watrrcarricrs (Sectigmllller), and in the course of tabes it has been seen as a bulbar affection, We tnay also imagine an injury lu Ihe nuclei of the nerve during difficult labor, and if we find tyiapioms of paralysis in the muscles of the neck in new-born children, who (or the first ^^"^ J'cars of life are unable to hold the head simight. such a possibility ought not to be forgotten (Cowers).
l-lTflLVTUKE.
Swlfmuflcr. Arch. f. Psych, lii. t. p. 43J. 187J.
KnpB'. IlrolMchi. ubcr Krnmpfc im llcmchc dc« AccessorUis und dcr obercn
Cnvtcalnerrcn. Diss. In^iUK.. Gottinxen. 1875. ■tnult. Doppdodligr t^hriiuny dcs Acccssorius Willisii. Dnitschr mwl.
W«hrn*cl>r,. 17, 1885. ™hrtinr Wrniltke. l"h)wolcnjie iler Bcwc|;un|[fiv. pp. (88 tl of. Catsci U.
"'niui. UcHliM-r Uin. Wochcntchr.. No. 8. 1887.
^ KrfWr. Druische ftted. Woclienichr.. 1887. mii. »;.
^«*«1L TanKotlH ocularis. Dull. mM.. 1890. jo.
^>^n. Ciampe ronciiuivcik du cou. Kcvuc dc miA., 1S91, 4.
CHAPTER X.
DI8RASKS or THE HVrOULOSSAL NKRVt.
The ten to fifteen bundles of fibres of which the hypoglossal nerve consist*, ax it einergei> from the medullit oblongalii in the groove between the anterior pyramid and the olivary body, unite to form two lart;er bundles, which leave the dural space separately, and. after their entrance into the hypoglossal canal, the anterior condyloid foramen, become a single stem, which leaves the cranial cavity by this canal. Outside the base of the sktiU it passes along to the mesial side of the vagus, at lirst obliquely downward and forward, then obliquely upward, runs on the outer surface of the hyoglossut muscle, and »oon reaches the region where the genioglo&sus muscle radiates into the tongue. There are various communications be- tween the hypoglossus, the vagus, the anterior branches of the upper cervical nerves, and the lingual branch of the trigeminus.
The cortical area of the hypoglossal nerve is found, according to Kxner, in the lower portion of the anterior central convolution and the adjoining portion of the inferior frontal convolution, as shown in Fig. iS. Its nucleus is i^iiuated in the Door of the fourth %-entri- cte, where its very large nerve cells which measure up to 60 ^i in diameter, closely resemble the large multipolar cells of the ante- rior horn in the cord. After the closure of the central catial it is situated to the ventral side of the latter.*
The root fibres of the hypoglossus certainly arise in pari from the nucleus of the same r^ide. To what extent the nucleus of the opposite side, as well as the group of nerve cells situated in its neighborhood and the above-mentioned nucleus ambiguus, can be considered sources of origin for them, and, moreover, whether direct fibres of the hypoglossus have thdr origin in the cerebrum, is still undecided.
While in certain of the cranial nerves^for instance, in the facial — peripheral affections occur at least as frequently as cen- tral, in the c^isc of the hypofiiossal ibis is not tnic. Often as its nuclei lake part in the mo« diverse diseases, especially of the cord and medulla oblongata, it is rare that a peripheral 140
[
I
D/Se^S£S OF THE HYPOGLOSSAL NERVE.
141
afleclton comes under observation. Thut, in a given case, the disturbance is peripheral and not cenlral, more especially not bull>ar, wc may conclude from the absence oi other nympioms of bulbar disease, and irom the possible presence of complete
e»
' >!.~Sltn:Krtci«L OtitOIX «F niR CHtnui. Nkrveh. I^Xtf, the min cnaUl ■<"•. Ct. intmoT root of Ihc linl orrvital ncrrs. tit, anierlcir column nt Ihn Kpiiial <o>i ct, bleni o>luiDa, f». antprim pmmidx. 0. aliviUT body. P. I'., \nmt Varolii. < feMUal ccnICBUU bod)*, t. Ulpnl crnicuUt* bodr. Ic, tubei dnsr. k. |il(uiUit7
, ^tt^. P, trnbnl fieitHKle. Sy, n^aa of the linun of Sjtnui. a, curian klUontii.
I r. MmmI of KMl. 7», ofMic (baluDiu.
^^^ciion of de^neration, as Hrb (cf. lit.) has done in his rccenU [y'lticribcd case. The sycnptoras otherwise are the same as '"the central disease.
Central paralysis of the hypi^lossus may be. in the first plscc. of cortical origin. According to Exncr, as has been Wted. the cortical area for the tongue is situated close to the
142
DISEASES OF THE CRANIAL NERVES.
point whtrc the middle and inferior fronlal convolutions join the anterior central convolution, and it is very probable that injury to this region causes a motor disturbance in the tongue. In a case ol tubercular meningitis, Matthes (NEiinchener med. Wochcnschrift, 1892, 49) has observed a hypoglossal paralysis,
Fimirt of [iotaiuio
Parirl'it M-f
Pie- 18.— COKTICXL CBNTBn OF TKK L.EFT HEKI4PHEHB. (Aftct COWCR&)
which he attributes to a localized tubercular meningitis at (he convexity over the centre for the hypoglossus. On the whole, central palsies of this nerve are rare.
The bull>ar lesion of the nerve, or rather of its nucleus, is somewhat better understood ; it has undoubtedly been ob- served, if not frequently, at least repeatedly, that this lesion can occur unilaterally. There is then an atrophy of the nu> cleus. in which the nerve cells and the medullated fibres be- come decreased in number or disappear entirely, while the roots appear as line threads. In such cases (see especially Fig. 29) the tongue is protruded, not straight, but deviates toward one side, and be it remembered toward the affected side (m. genioglnssus and gcniohyoideus); it shows fibrillary twiich- ings. and an atrophy of the diseased side — hcmiatrophia lingux —which in such a case looks flabby and shrunken in compari> son with the full and firm healthy half: it is wrinkled, con- tracted, and much smaller than the latter (cf. Figs. 29 and 3a showing my two cases). The electrical examination shows either normal reaction or reaction of degeneration; that the
J>/SeAS£S OF THE HYPOGLOSSAL NERVE.
'43
bttcr may also occur in central lesions lias been demonstrated by one of my cises, which, however, did not come to autopsy. Speech, mastication, and deglutition often sutTcr considerably ; on the other hand, the heulthy half of the tongue may develop so satisfactory and vicarious an activity that little disturbance ii observable.
Unilateral paralysis of the hypoglossal nerve, due to periph. cral causes (Birkctt, Neurol. Centra Iblatt, 1891, 24) has been ob-
Flf. a^— HKMtATitinniiA Lmou-c ipenonal oliMrvatlon).
•frrcd as a result of traumatism: further, also, in diseases of
klhe vcncbral artery, as the result of newf growths in the me-
'dulli oblongata and in caves of embolic softening in the region
<^ the nucleus (lltrl>. Whether it can be also of saturnine
b*n|>jn Mcms to me to be doubtful, in spite of the report of
i^tauk. In a recently published article by Koch and Marie
'ct lit.) may be found all the cases observed up to the present
lime collected and minutely annlyzcd. A case of congenital
k.^pOflossal panilysis has been observed by [-"rancotte (Anna!.
1
■44
DISEASES OP THE CRANIAL NERVES,
de la soc. mSd.-chir. de Liige, 1889), which is undoubtedly sn instance of infantile nuclear degeneration (Mobius).
In bilateral paralysis of the hypoglossal the longttc, atrophic, wrinkled, and shrunken, lies uhnost motionless on the floor of the mouth; the patient can not protrude it, and has entirely Inst control over it. Speaking and chewing are rendered diffi- cult, even quite impossible. This sad picture is seen not infre- quently in Ouchcnnc's pr<^rc5sive bulbar paralysis, occasionally
FIR' jo.— llBMuniOPHiA LiHOirx (ptnoiuJ obwrvMlon).
in progressive muscular atrophy, very rarely in tabes. The hemiatrophy of the tongue, too, occurs much less frequently in the course of tabes than, to judge from the communications — for instance, those of Ballet (cf. lit.) — would seem to be the case.
The peripheral form of the affection may yield to electrical treatment (faradization and galvanization); the central, so far as we know at present, is not amenable to any treatment.
Hypoglossal spasm occurs sometimes unilaterally, some- what more frequently bilaterally. U is an exceedingly rare
D/SEASSS OP TUE HYPOGLOSSAL IfESVH.
MS
_ (iisa ■ alta
affection, in regard to wliich (iierc have been but few good
publications. There is a paroxysmal, invoiuntary spasm ol the
tongue, by which it is protruded and retracted, roiled violently
around in the mouth, and so roughly pressed against the tccth
(bat it may be quite severely injured. In some instances there
occur short rhythmical twitchings in the whole tongue which
(iUappcar at times. Bcrgcr observed an aura before such an
attack, which consisted in a sensation of tension and swelling
Ihc tongue. In Dochmann's case the attacks occurred espe-
lly at night, and were so violent that the patient was awak>
CDcd from her steep by the sudden spasmodic protrusion of the
loogue. In one o( my own cases the muscles of mastication
took part in the affection in such a way that before the actual
Iqrpogtossal spasm occurred, the lower jaw was for half or a
whole minute spasmodically jerked to and fro. up and down.
Aiwr these movements had ceased the moulh remained half
open, and the turning and rolling movements of the tongue
OMiincnced and lasted for about one tninnte. These attacks
reclined ten to twenty times a day ; they came on for the first
time three days after an epileptic 6t. and have lasted unaltered
cwTjjnce (for three years). The patient is otherwise perfectly
healthy, and h.is a good family history. The pathogenesis of
llw disease, its an.itomical seat (irritation of the hypoglossus
centre? cortical or bulbar?), is obscure. As an accompanying
V'plo'n of chorea and hysteria it is by far more common than
u in Independent affection. Possibly the so-called auctioneer's
1«MB (Zenncr, Berliner klin. Wochcnschrift. 1887. 17). which
it aused by overexertion (speaking and shouting), should be
taxied as a form of hypoglossal spasm. The treatment is the
ame as in paralysis of the tongue.
l.ITHKATtniE. I. PtmMi */ Ihf //fjvgLutal AVtv. fffitatrt^i* lingm*. '•"liKlailc. A TTMlt»e on ihe Dvwram of Ihc Tonpic. London. 1873. ^^. ltdirj]c tut t>iAgnoM.il( il«r LaKf und IlcBchaTenhclt vt)ii Kt.itikhcttv-
•wtlrn iln OliUin^la. t>rol*clwt Aieh. f. klin. Me<l,. xxiv. p. 418, (884. ™t Df llifciiinirDphie At la 1.iiik*ic Arch. Ac Neurol., vji, to. 1884. '"''• ITrtirr HrtnUimphic dcr /ungc. BH. klin. WiKlienwhr. Na 14, 188$. " CiB scltcwrr Fall von .-iiro|>hi<chrr IJIhinung Att N, hypogl. Tleuitches
Afch. t klin. Med., xmvii, p. 16;, t88;. '^'fcn. Dc Hi^inijirophic ik U Inngue. Kcvue titens. <)« Uryngolnglr,
•I'oiolngip, et lie r)uiiot4)|;ie. ""■ik. E, Ifehcr utuminc Hemiairophie dcr Zunge. BerL klin. Woclicn- Khr., luit. 3j, 1886, 10
146 DISEASES OF THE CRANIAL NERVES.
Sauer. Fall von traumat. Hypoglossus- u. Accessoriusl^hmung. Inaug. Diss.,
Gdttingen, 1886. (Unilateral Luxation between Atlas and Epistropheus.) Peel. Beri. klin. Wochenschr.. No. 19, 1887. {Hemiatrophy of Tongue, wiih
Left-sided Recurrens Paralysis.) Koch et Marie. H^miatrophie de la langue. Revue de m^., viii, i, 188S. Morison. Brit. Med- Joum., July 14. 1888. (Unilateral Paralysis of the Hypo-
g'lossal in Consequence of Traumatism.) Limbeck, Prager med. Wochenschr., 1889, 16.
Pasquier et Marie. Simiiologie de la langue. Progiis mid., 1891 , 1 1, Birkett. Neurol. Ceniralbl., 1891, 34. Lange, F. Ueber Zungenbewegungen. Arch. f. klin. Chir, 1893, xlvi, 3,
p. 634.
a. Hypeglosial Spaim.
Berger. Ueber idiopathischen Zungenkrampf. Neurol. Centralbl., i, 3, i88z.
Dochmann. Petersb. med. Wochenschr., i, 1883.
Wendt Unilateral Spasm of the Tongue. Amer. Joum. Med. Sc., clxxvii, p.
173. Jan., 1885. Erienmeyer. Centralbl. f. Nervenheilk,, ix. No, J, 1886. (Case of Idiopathic
Spasm of the Tongue.) Bernhardt. Ueber idiopathischen Zungcnkrampf. Ibid,, No. 11, 18S6. Lange. F. £in Fall von beiderseitigem idiopathischem Hypoglossuskrampf.
Bin Bciirsg zur Lehre vom Riiter-Roltett'schen PhKnomen. Arch. f. klin.'
Chir.. 1893. xlvi. Heft 4.
CHAPTER XI.
lUICtTAKKOVS AFFECTION OF SEVERAL CRANIAL NF.RVES — MULTtPLR PAKALYSIS or TMB CRANIAL NE8VE6,
V AtTER having thus considered the lesions of the individual cnnial nerves, it remains for us to inquire under what condi* tions several o( them may be sinniltancously affected, and into iV symptoms thus produced. Accordinj; to the observations coAectcd up to the present time, an affection of this kind may blvc its scat in the peripheral or in the central course of the nerfeSjas well as in the cortical or nuclear centres. Only cer- uinof the affections of this latter kind are to be ref^rdcd as Independent diseases, while the peripheral lesions arc always Qiilj p,irtial manifestations of other conditions. In rare cases isidiultaneous peripheral lesion of several crania! nerves may
t occur in consequence of traumatism, operative interference, etc. A case in point, in a patient operated upon by Israel, has hetB published by Rcmak (Bcrl. klin. Wochcnschr.. 7, 1888). Aarciooma of the neck was extirpated, and by the operation 'l>e Bcccssorius, the hypoglossus, and the sympatheticus were "'iuT«l,or rather resected. The symptoms caused by the acci- itM were accurately described by Rcmak. Other instructive
|t»n.duc to iraumatisiij, have been described by MObius (c(. AiiKJng the ^nera] diseases in which multiple cranial nerve Wont may occur are chiefly tuberculosis and syphilis. Tnbercular mcninj^itis ntlacks. by preference, the mem- "Ow al the base, and implicates most of the cranial nerves **«fging in that region, as we have seen in our account of the <li«ases of the mcninKes. I-:itcly Kahlcr {of. lit.) has again ("reeled attention to the fact that, in consequence ot syphilis, . >)*ril>hcral neuritis of the cranial nerves sometimes de%-elops, "tl titti we may. besides general cerebral symptoms, have a pTDgreuive slow parulysts, which attacks one cranial nerve
147
I
l^g DfSF.ASES OF THE CRAXIAI. NBUl'RS. ^
after the other in irregular succcssirm (cf. also Rnthmann, Deutsche Med.-JItg.. 1893. 46).
Alter diphtheria peculiar forms of paralysis are observed, which chiefly take in the muscies uf the soft palate and the pharynx. Since these muscles arc innervated by certain of the cranial nerves, and the disease is unquestionably — e.g., when the paralysis is unilateral — often of peripheral origin (central diseases can nut in alt other cases be excluded), we shall devote a few lines to the consideration of their nerve supply.
The innervation of the palatal and pharyngeal muscles Is by no means one uf the clearest <.*lia|ilcrs in neurology. W'c do not know exaetl}r which of the cranial nerve* arc cimcerned. nor their mode of ■ distribution. Of the palatal muscles the levator palati is the most important. This receives motor fibres throuKh the large su|>crf)cial petrosal (of the trigeminus) from the spheno- palatine KanKlton, which come from the facial and which also innervate the aiygos uvuIec. Whether or not, however, the vago-accrssorius and the gtosso-pbar- yngeus arc also concerned in the innervation of iheiie muwlcs. as Cowers, for instance, seems to think, basing hi> argument;* ujxin clin- ical observations, is not as jret decided. With regard to the pharyo- ■ geal muscles, it is generally assumed that the stylo-pharyngcus and the middle constrictor are supplied by the gto.tso- pharyngeal nerve, and that the palato-pharyngcus, the superior and inferior constrict- ors, arc innervated by the vagus. The participation of the accesso- rius isdouhtfgl (Schwalbe). Wc sec then that the nerves concerned in a paralysis of the pharynx arc the facial, the glosso- pharyngeal, the vagus, possibly also the fifth anil the accessonus.
Pharyngeal paralysis may be cither unilateral or bilateral. The unilateral form can only be diagnosticated if the patient is made to move the soft palate, for instance, in saying "AIi!" While during rest it appears to be perfectly symmetrical, the base of the uvula deviates somewhat on motion towards Ihc affected side, so that on that side a little way from the median line there is a slight depression not present on the well side ; sometimes also the soft palate is a little lower on the para- lyzed side even during rest. In the bilateral complete paralysis of the soft palate, the latter hangs down flaccidly and the uvula appears elongated ; on deep respiration and on phonaliun it remains motionless, and the reflex movements evoked by tick- ling the mucous membrane arc lost. Speech becomes marlc< ediy altered, the voice acquires a nasal tone, due, of course, lo the cavity of the nose not being shut oR during pbonation;
PQST-DiPHTtlERiTJC PARALYSIS.
'49
I
I I I
betice also the pronunciation of the explosive consonants "F" and "B" becomes tmpo^iblc, owing to the imperfect compression o( the air; they sound like " M." Closure o( the anterior tiarcs removes, as Duchcnne has shown, this disability. Front the same cause also Hiiids are regurgitated throiigli the aose on attempts at swallowing, and deglutition in general becomes difficult.
Recent examinalions of the nerves (Arn- heim. Arch. I. Kindcrkrankheilen, 1892, xiii : and Hochhaus, Virchow's Archiv, 1892, cxxiv. Heft 2> have demonsiraled that lesions arc present in various peripheral nerves, not only those going to the muscles of the palate and the fauces. Hansemann also has described (Virchow's Arch., 1889, cxv, Heft 3) the condi- tion of the cranial nerves in diphtheria. .'\b. sencc ol the knee-jerks has been repeatedly found associated with paresis of the palate in diphtheria (Bcrl. klin. Wochenschr., March 3a 1S85, p. 304).
The prognosis in post-diphtheritic paralysis is not unfavorable if the velum palati alone is paralyzed. If. on the other hand, the muscles ol the ucsophagus also take part, the outlook becomes graver on account ot the inability of the patient to take nourishment, and all the more so if feeding by the stomach-tubc is not constantly and airefully practiced. If this is not done, aspiration pneumonia or inanition may bring about a fatal issue.
The electrical treatment ought lo be begun as early as possible. It consists in the direct faradisation or galvanization of the velum and the frequent excitation of reflex movements ol deglutition by stimulation of the throat. The uvula, the pillars of the pharynx, etc., are di- rectly touched and repeatedly stimubted by means of the curved button electrode (cf. Fig. 31). The movements of deglutition are ob- tained if the anode is placed on the neck and the cathode (button electrode) is quickly drawn
Flf. 31.— PHAHVlf-
CEAL aud Ladti'-
OMU Et-El-TMIIMt
UtCXT rVK MAKIIM <tll> HKCAKI'IU niB
Ctj'MKXxl. <Afl*r Km.)
ISO
DISEASES OP TUE CXAA'iAL A'ERVES.
over one of ihc lateral surfaces of the larynx, six to ten cells stilficing for the purpose. These gymnastics of the phar- yngeal muscles constitute an excellent remedy which can not be replaced by any other. It oltea leads rapidly to rc> covcry.
Central diseases of several cranial nerves at the same lime may also occur, and that. too. not only in their intracerebral course — which for but few uf them is known, and for those only imperfectly — but also in the centres themselves. As a matter of fact, our knowledge about the centres situated in the cortex is also very incomplete, since we must again confess our comparative ignorance of the anatomy. Still, we shall not go too far if we assume that extensive cortical lesions may impli- cate several ccntre<> together, and there is no doubt but that they may be affected after or rather during an apoplectic attack by " indirect action."
IJTERATURE.
Reinlurd. Deutsche med. Wochcnschr. 1885. No. 19. (Subcu(an<xHia Injec-
lions in the Rfgion of the Neck nf 0.001 (gr, ^) of Str)'chnia daily.) Koihmann. lUiil . itlS5. Na ;z. (t'aralynis of the MuKJes oi Respiration after
Diphihtri.!.) H.-inscmann. Virchow'* Arehif, 1889, c«v, Heft 3, HallagFT. The I'aralyses adet IJiiiiiiheria. IIoi|i. Tid., 1890, 4. Garcia y MansilU. Nature and Tivaimcnt of ilie I'osvdlphlhefitlc Paralyses.
Rivisiadin. cte lot hospilalcx. 1891. 31. Suckling. Uni. Med. Jouni.. Mxy iS, [891. (Three Cases of Taraly^s of the
Diaphragm aficr Di|>hthcri.i.)
Of eminently practical importance are the nuclear aflecttons of the cninial nerves. Referring the reader to the preceding chapters for the anatomical position of the individual nuclei, wc will only remind him of the fact that these nuclei are situ. atcd in the gray matter, partly ol the mid- and 'tween- brain, partly in the medulla oblongata. The portion situated above the latter extends from the posterior wall of the infundibuluiD in the third ventricle to the level of the nucleus of the abdu- cens. and embraces the nuclei of the eye muscles (Wernicke). The other nuclei belong to the lower portion.
Clinical observations now leach us that either of these por- tions may be allccled by itself, and we may with Wernicke call the disease ol the upper, polioencephalitis superior; that of the lower, polioencephalitis inferior. According to the course, we distinguish in cither case an acute and a chronic form, so th|
POUOESCEPUAUTIS ( WERNICKE).
'51
there are altogether four clinical pictures of these nuclear nffeclions.
Polioencephalitis superior acuta has only been observed in very few instances. The b<-st observations we owe to Wernicke. According to htm, this is esscntialty an acute inflammatory dis- ease of the nuclei o( the ocular muscles, and proves fatal in from ten days to a fortnight, the focal symptoms consisting in an associated paralysis of the eye muscles, the general symptoms \xxn^ grave disturbances o( consciousness. The walk presents a [leculiar combination of spasm and ataxia. Anatomically, foci of acute softening arc found in the region of the nuclei, which are cither due to obstruction of the blood-vessels or to inflammatory inflltration of the tissues, ^tiologically, the abuse of alcohol may be mentioned.
With reference to the diagnosis, the presence of n tumor in the region of the corpora quadrigemina should be considered IB. Sachs, New York. Di5.eascs of (he Mid-brain Region, Am. Jour, of the Med. Set., March. i8gi).
Polioencephalitis superior chronica was described in iS6S by von Graefe, and called by him ophthalmoplegia progres. UTi. The first published case presented, according to von Graefe (BcH. klin. Wochenschr., ii, i86S), a peculiar clinical lecture :
"Gt^dually all the muscles concerned in the movements of the eye become paralyzed, so that there results first a diminu- tion in the range of sight, and hnally complete immobility o( the eyeballs. The levator palpebrfe superioris is wont to be implicated, although the consequent ptosis is rarely as marked u that occurring in complete oculo-motor parnlysis. It is re> narkable that, on examination for reaction to light and accom- otodation, the sphincter pupillae as well as the ciliary muscle prcKittno changes. This condition, which we very rarely find ■n other extensive oculo-motor panilyses. seems here constant "ul ctiaracterislic of this disease. Another feature which dis- linpiishes this form from other associated paralyses in the dis- ''itHltion of the third, fourth, and sixth nerves is the progress of tbedisease f^ari passu in the antagonizing muscles. Thus we wrerfind a marked strabismus divcrgcns owing to a dominat- '>% oculo-motor paralysis, because here the external rectus loses ■U functions sufficiently to neutralize the tendency to devta' t'O'l.aiid the si^ht of the patient is therefore, in spite of the HUciued paralysis of the eye muscles, affected much less than
IS2
DISH ASKS OF Tin: CRAHHAL SERVHS.
in simple oculo-mutur or abduccns paralysis, . . . Still, a ccr- tain degree of asymmetry in the affection of the difTcrcnt mus- cles of one eye, as well as in the development of the whole dis. CISC in the two eyes, may at times be iouiid." (Cf. Wernicke. loc. cit., vol. iii, p. 463.)
With the exception ol this associated ocular palsy, which, developing progressively, may remain stationary without being completely symmetrical, the patient enjoys good health and complains neither ol headache nor of symptoms of increased intracranial pressure. In isolated instances bitllur paralysis has been known to be later superadded, and in others the dis- case wus found associated with multiple sclerosis or with gen- eral paralysis (Dallct, Progress m£d., 1893, 23). Anatomically, the aflection depends either upon a primary disease of the nerve nuclei or upon a diffuse sclerotic process In which the nuclei take part. In exceptional cases, which in their na- ture are as yet entirely obscnre, no organic changes what- ever have been found, although the cliniKil picture corre- sponded exactly to thai described by von Graefe. (Hiscnlohr and OppL-nhcim.)
Not less interesting, and at the same time of far greater practical importance because relatively far more frequently met with, is the fourth and last of (lie affections under consid- eration— ii disease the first accurate description of which we owe to Duchcnne, ol Itoulognc, and which after him has been carefully and successfully studied by German investigators (Wachsmuth, Kussmaul, l^cyden) — the chronic progressive bulbar paralysis.
Progressive Bulbar Paralvsis.
PaMfytit tf On T9iigut. tkt So/I Palalr. and Ike Ufi {liiulttitnt. 1960), CUll*-latUl i^rynxtal Pantfyiit ( Tnnm/aii\ ('.Anmu Pnigr/itint HuJtar Pctraiyiit ( ff W4/- mttl\, 181V4I, Atnf^u BmUar Pamiyiii {tjydin), tlidi^r fftuttar Paralyiii (Kuii- mau/f, PtAttHiefAxiilii In/trttr Ctrtnua { tVtrnitkt).
Duc/if fine's Disiase. Symptoms and Course. — In the majority of instances the onset of progressive bulbar paralysis is very gradual, and only rarely do we meet with cases in which it is ushered in by an apoplectiform attack. After having complained for weeks, perhaps months, of drawing, tearing pains in the neck and the back, the patient discovers of his own accord or froiji the re. marks of his relatives that the enunciation of certain words.
BULBAR PARALYSIS.
■S3
I
ft
especially those containing /, r, and long e. has become very dif- Gcult. W tie happen 10 use a word containiiii; all these letters (for instance, reel), he becomes painfully conscious of his indis- liiict enunciation. In vain he alleinpts to repeat (he trouble- tome words over and over again in order to correct his mis- take. He only becomes more convinced that the movements of his tongue have become clumsy, and that he has lost his former ease and fluency o( speech; and, in truth, it is the on- aiming paresis of the lingual muscles which is the main cause of the disturbance.
The tongue, which can not be raised to the normal extent, ao no longer be approached sufficiently to the hard palate, uid thus the long e, lor the pronunciation of which the move- ment is necessary, can only be pronounced with difficulty. In the same way all the finer musctitar movcmcnis required lor the formation of the Unguals are imperfect, and con&equcntly the enunciation of these sounds is bad. The disease progresses and the articulation becomes worse and worse, the less per- lectly the lingual muscles arc innervated, and other letters, ij.g, finally also i/and n. begin to suffer, so that conversation *lth the patient becomes very uncomfortable, as certain words areslroost unintelligible and others at least difficult to under- tOnd.
The lips also begin to do their duty badly, so that the enun- citlion of the so-called labials — o. u. a, b,p — gradually becomes iodininci. The presence of stnmgers with whom he has to eaovcrsc cicitcs the patient, and. avoiding all society, he pre ftn the quiet monotony of the family circle, where nobody WaBto pay much attention to the change in his speech {"ala- liiiad anarthria"). Moreover, a change in the features of his lKt:tt first slight and only noticed by the patient himself, but Iftiinore perceptible and evident also to his friends, gradually Viilests itself, which serves as an additional reason for "dudon (Ftg. 32). When laughing, it appears to him as if ■ Certain tension in his lips prevented the usual play of the ■WBth. In the attempt to whistle, the lips can not be puckered • •ell as formerly: the muscles of the cheek have become •■ote rigid and inactive, and as the disease projiresscs the *ioic lower half of the face assumes a characteristic appear- •■ce— a peculiar lachrymose and astonished expression — which, "i» easily seen, is due to Ihe drooping of the lower lip and to ^^ deepening of the na&o-labial fold. The upper Italf of the
>S4
J>/SSASES OF THE CRAKtAL XERVBS.
face, the forehead and eyes, do not take part in the change, but remain entirely iionnnl. Nevertheless the |>atient*s lace is much disfigured, and later ou in the disease may have become almost unrecognizable.
While thus quite gradually symptoms have arisen which i make the patient a very pitiable object, and which arc bound ^ sooner or later to interfere with his position in society, the sad
Kl(. JJ,— FaCUL ExratMIOTI IK PRnoRFMivr Bl'LBAS pAKALVSR. (After LEVDKH, KICIIIIORST.J
truth dawns upon him that even the functions absolutely neces- sary for the exisicnce of life arc failing. Eating, in which up to this time no trouble was experienced, he now hnds difficult. It takes a longer time to swallow the food, and in a later stage even mastication becomes impaired. Not only do the move- ments of the lower jaw become weaker and less energetic. ■ owing to paresis of Ihc muscles of mastication, but. since the powerless tongue is unable to get the food (rom between the
BULBAR rAKALYSIS.
ISS
checks and gums into the n^ion ol the pharyngeal muscles, Ibe iormatioii of the bolus is impossible. Spoons, fingers, and Ike like, have to be used instead, or the patient has to hold his head far back to get the fuud to slide down. Even drinking auses much discomfort, as the liquid may get into the larynx ind thus give rise to violent coun:iiin{r, or may be regurgi- btcd through ihc noKc, either condiiion being due (o weak- Dcss ol the pharyngeal and laryngeal muscles.
The implication of the larynx is very distressing, and may indeed become dangerous. Tlic voice at times fails, speech becomes irksome, and the tone is monotonous; production of tte higher notes as in singing becomes impossible; later on a mirkcd hoarseness and finally aphonia follow, so that the pa- tient can only express himself in whispers, which, owing to the above-descnbcd motor changes, are quite unintelligible. At t^ utae time the absence of a firm closure of the glottis, and Ihcrclorc the inability to cough forcibly, gives rise to various dblurbances in the respiratory apparatus, owing to the dis- abllily to dislodge mucoid masses which may have collected in the air passages.
Another symptom which, though not constant, is frequently met with, is ihc marked increase in the secretion of the sali%-a. This occurs usually rather early in the disease, and not infre- lly such patients are seen going around constantly holding _ r handkerchiefs to the mouth to prevent the saliva from trickling away. On examination, the secretion is found to be nKid. This flow of saliva is due to an actual increase in the woittit secreteil, as several careful investigators ha%'c shown, tl»«^ they do not agree as to the exact amount.
Two, three, even five, years may pass before any new symp. *«»arc added to those just described. These, however, pro- pwivcly gain in inrensity. and it is especially the change in Ac katurcs which becomes more accentuated, owing to the fQAHinily Increasing atrophy in the muscles of the lips and the Aeelu; the palatal reflexes become markedly decreased and Swlly lost; ibc tongue, shrunken and distinctly smaller, lies •■Boblle on the floor of the mouth, and can neither be pro- "wfcd nor moved in any direction. Fibrillary tremor is then ■< tneommonly marked. On the electrical examination (»Wch is, by the way, very hard lo make), we may find reac- liMi <W degeneration in the lingual as well as in the pharyngeal niiscle&.
'56
mSRASKX OP THR CRANlAl KSK^RS.
The inability to lake food properly is usually ihe cause of death ; the patient pines away, and gradually dies (rocn inanj. tton without having the blissful benetii <>( a dulled conscious- ness to guide him insensibly through his tormenting suQerings. Only in occasional instances disease ol the respiratory organs, caused by aspiration of food, hastens the tennination (aspira- tion pneumonia).
Pathological Anatomy. — There is hardly another disease of the nervous system with the anatomical basis o( which we arc better acquainted than bulbar paralysis. Duchennc pronounced the process to be a primary pigmentary degeneration, and
I 1
►iS' iV- (. ^■ -I ' iiiJI THRllVOW -IMC. UPKKH IVlttllON OF T»IK MEIIl't t.1 OXLOMOATAi
On ih« Ipft Ihc healthy, on the hchi iI'f dlK.u«t mnlulla. kk un Ihr tell ihr noroul, kk on ihp righi Ihe dueawd hj-pocloHUi ducIciu (tile ncne celli are olmou entlnly «b- not on the richl ude).
atrophy of the large nerve cells in the nuclei of the me- dulla oblongnia, an a,ssertinn which has received complete con- Armatiun from all subsequent investigators. Microscopical examination shows atrophy of the nerve cells. This is shown in Fig. 33 in the nucleus of the hypoglossal ; the cells have in this case completely disappeared, having previously di- minished in sii!e and lost their processes. At the same time we hnd the connective tissue increased, the walls of the vessels in the nucleus thickened. Similar changes arc found in the nucleus of the vagus accessory and Ihe glosso-pharyngeal nerves (the so-called lateral mixed system, ci. page 107}. The former may become diseased in consequence of an ascending
I
I
I
BULBAR PARALYSIS.
'57
iiH^'
neuritis : a myelitis may be caused by a similar process in the nerves of the luwer extremities (Cupfer. Revue de m^d., 1890). Since, as we have said before, the upper part <>( the face always remains normal during the di^^ease, wc have to assume ihal llie 6t>res tonervaling these muscles arise from a special centre. This is supposed to be a part of the abductor nucleus (Mey- i»ert), which has thereh)rc come to be designated by the com- puMtc name of (aciaUabdncens nucleus. This and the rcmain- infrtiuclei, with the exception of those mcniinned above, were always found to be in- icL The atrophy also cx- endntoihcrooi hbres, which the naked eye olten a]»- tr smnllcrand of a grayish "AoT. F-'roro the lajKijiraph- poMtionof the nuclei bc- Ihc floor of the fourth tricle, us it is approxi- ilcly represented in Fifi. . wc caa easily understand , nn the one hand, the ■gical process, alitr ..f4 attacked the hypo- ft>liMH.us. next implicates the •rinj; vagus, and, on Iter hand, how the mo- tor part of the trigeminus uually remains unaffected. 10 that paralysis of the mus- clcv ol mastication is very ninr. But why the auditory Mc'instantly exempt and the IkU (Kirlially affected are drcuriKlances which need to be further investigated. A com- pter counterpart to bulbar paralysLs is found in the so-called P«>Bres5ivc muscular atrophy, a disease in which, as we shall •« Utcr on. the gray anterior horns of the spinal cord and 'wir nerve cells arc aflccted precisely in the same way as Ibc bulbar nuclei in the disease wc are now discus-sing- The "^r" cells ol the anterior lu.rns constitute the troplioki- "•ciic centres (or the muscles supplied by the spinal nerves, an
■>K' 34.— THK fyMTKRtOR (tteaSAIJ ASMCT
OF no. Mei'uu^Ohloikiat*. i. pmwf-
ot oiiBmiNrilr*. >. |ifclun(li><d pinral ctind. J, oonxiniquidnpniina. 4. mptncv |i(dan> clc J. mlddtc pnluncle. b, inlcrinr pedun* cIf of cFntctlua. 7, itrl9> acimlo. H, lu* nk. icm. 9. obci. ■«, fvniniL cnciL
»S8
D/S£^S£S or THS CflAXlAt. ^VEKVES.
office which the bulbar nuclei fulfill for those supplied by the craninl ticrves. In both diseases there .trc atrophy nod decrease in the functional power, and in both the disturbance is strictly motor, while sensation is absolutely intact. This essential simi- larity between the two diseases explains why not rarely one is associated with the other — in other words, why they may com- plicate each other. \Vc may, indeed we frequently do, meet with cases in which bulbar paralysis is accompanied by atro- phy o( the muscles of the extremities, while, on the other hand, in progressive muscular atrophy, bulbar symptoms, disturb- ances in deglutition and speech, may be found.
Another analogy exists between bulbar paralysis and amyo. trophic lateral sclerosis, a disease in whii;h not only the nerve cells of the anterior gray honis, but also the motor tract in the lateral columns of Ihe spinal cord arc affected. All these diseases, viewed from an anatomical standpoint, if not identical, certainly arc closely related to each other, and only differ in the position of the lesions; it is therefore advisable to consider and study them from a common point of view, as the understanding of the individual symptoms will thus be much less difficult.
Diagnosis. — As to the diagnosis, we need not be doubtful if we always remember that the disturbances are confined to the motor functions of the nerves governing the muscles of the tips, tongue, pharynx, and larynx. Oppcnheim has recently called attention to rhythmical twitchings of the velum palati and of the internal and external muscular tissue of the larynx, which he considers to be of diagnostic value in diseases of the posterior fossa of the skull (Neurol. Ccutralbl.. iSScj. 5), If we find any well-marked sensory changes, if the patient complains of pain or paraeslhesias and the like, we either have to give up the diagnosis of bulbar paralysis, or we have In search for some complication. The peculiar facial expression, the increased flow of saliva, the tremulous atrophic tongue partially or even completely immobile as it is, the disturbance in speech and deglutition, when taken together are so characteristic that, if intelligently observed and studied, they will make our diog. nosis clear.
There is only one case in which we may be doubtful ; cer- tain foci of disease in the brain may produce symptoms simu- lating bulbar paralysis, so much so indeed that the name pscudo. bulbar paralysis has been given to the condition (which later on
BULBAR PARALYSIS.
^%^
will be described more at length); nevertheless, with due care> (illness we can avoid a mistuke. The most important point to observe in the differential diagnosis is the course of the disease. While in progressive chronic liulbiir paralysis this is slow, but always progressive toward the latal end. in the spurious torm rcmissiuns may occur, su that for years the patient may be im- proved, though he finally also succumbs to Ihcdisc.isc. Besides this, pseudo-bulbar paralysis is often attended with cerebral (Yinptoms, headache, apoplectiform attacks, etc.
Prognosis.— The prognosis, as we should expect after what has been said, is altogether unfavorable. There is, according to iiur present knowledge, no cure lor the true bulbar paralysis, and one ought to be carelul. therefore, not to deceive the family *itb promises. As suun as the diagnosis is made they ought lobe informed of the unfavorable outlook.
Treatment. — The only treatment from which any success may be expected, if begun early, is the systematic use of elcc- liidty: faradization and galvanization of the threatened mus- dts, especially o( those of (he tongue and pharynx, frequent lalion of the movements of deglutition, according to the Detbod already described, arc the only measures which deserve ctmfidence. With the exception of this local treatment, there i>im(bing that affords even a temporary benefit, I have never Kcn any lasting cSect from hydrotherapy, but stilt this trcat- neot is very trequenlly advised just at that stage of the disease "hen electricity might do some good. Internal remedies are Li( W) avail ; the occasional symptomatic use of atropine ('/, (o i iniUigramme ('/,„ to ',/„ gr.) daily) to diminish the salivary secre- tioa may be indiaitcd. It scarcely needs to be mentioned that Ihr chief duly of the physician in the later stages of ihcdisease i*tupay the most careful attention to the general nutrition of the p.-iiient.
Etiology.— The ailiology is still obscure. It is true that Ihertare patients affected with the disease who. owing to their MQiptlion, have made rather excessive use o( the muscles of llie tipc. tongue, and palate (glass-blowers, musicians). These CMC*, however, are so rare that it would seem very forced to Mlriljutc any ^etiological importance to this factor. The same ■»iy be said about syphilis, the truth being that, in most cases, tbeause b absolutely obscure, and all we can say is that males
K persons adv.inced in life seem to be more frequently at- !d by the disease than others. Heredity but rarely plays
l6o DISEASES OF THE CRAfflAL NERVES.
a part, and the influence of cold remains, in connection with this disease, as obscure as with all other nervous affections.
LITERATURE.
Mobius. Ueber mehrfache H i rnn erven la hmung. Erlenmeyer'sches Centralbl.
f. Nervenhk., 1887, x, 15, 16. Oppenheim und Siemerling. Die acute Bulbarparalyse und die PseudobulbSr-
paralyse. Charitf-Annalen, 1887, nii, Unverrichi. Ueber multiple HimncrvenlShmung. Fortschr. d. Med., 1887, 14. Pel. Berl. klin. Wochenschr., 1887, xxiv, 29. Mobius. Centralbl. f. Nervenhk., 18S7. x, ij. 16. Aclamkiewiez. Halbseicige fortschreitende GehimnervenlShmung. Wiener
med. Wochenschr., r889. 2. Scheiher. Berl. klin. Wochenschr., 1889, xxvi. 28. (Unilateral Bulbar Paral- ysis.) Reinhold, Deutsches Arch, f klin. Medicin, 1889, kIvi, Heft i. Mendel. Neurol. Centralbl, 1890, 16. Howard H. Tooih. Study of a Case of Bulbar Paralysis, with Notes on the
Origin of Certain Cranial Nerves. Brain, 1S91, 56. Senator. Acuie BulbSrlahmung durch Blutung in der Oblongata. Reprint
from CharitS-Annalen, xvi, Jahrg. Senator. Bulbarlahniung ohne anaiomischen Befund. NeuroL Centralbl,
1892,6. Remak. Beri, klin. Wochenschr., 1893, 44.
PART in.
DISEASES OF THE BRAIN PROPER.
The more autopsies we see the more ll>e fact is brought boDC to us that brain lesions arc Ircqucnt))* present which not diagnosticated during life. This is by no means irily the fault of the di<ignostician, (or undoubtedly Unr focal lesions ol the brain may exisi wiihotil giving rise hi uy symptoms. Rccenily G. Schmid has published an in. tcresting collection o( such cases (Virchow's Archiv. 1893. ctniv, i). On ibc other hand, of course, we frequently sec tases presenting symptoms which make us at once suspect the niitence of a brain lesion.
la such cases we have to ask ourselves two questions: Ir) Wkweis the scat of the lesion.' (2) What is its pathological Mttwt? To the physician both of these questions are of in- iwcil; to the patient, more especially the latter.
The examination which searches lor the seat of the lesion ''ill gire us ihc topical diagnosis (mrof = place) : the exam- faadon concerning the nature of the lesion, the pathological %w*is.
The endeavor to localize cerebral lesions— that is, to make diagnosis — has only of comparatively laic years re- Ttttcntion, and tnuch uf the work so far done can not be '^^^ more than an attempt, in many c:tscs indeed only a weak <•<• The celebrated discovery of Uroca (rS^n). that certain <liititfbances uf speech were often found associated with lesions *lk third left frontal convolution, the discovery of Fritsch •■J Hiuig(i87o) that stimulation of certain areas of the cortex pfWlKc* contractions in certain definite groups of muscles on '••f opposite side oi the body — these and various other, patho- ■fiol, observalions, lo which reft^rence will be made later, 'ttltcttraost probable, nay. almost certain, that definite puns or jrcM of the cortex are always connected with certain func-
II i6t
i62
DISEASES Of THE BRAIN PFOfKR.
lions of the brain ; in other words, that these functions can be localized ; and, notwithstanding; the many uncertainties and niinierous contradictions between the results of experiments on the one hand and those obtained from clinical observutiuns on the other, it is this doctrine of cerebral localization which, though still undeveloped, must be considered as the basis of all further investigation in ihc ticid of cerebral pathology.
Equal stress must, however, be laid upon the examination into the nature of the lesion. A certain symptom — for instance, a persistent hemiplegia — is always the result of a lesion of the motor tract ; a lesion, however, which can be produced in quite a variety of ways. It may be due to cerebral hwmor- rhasje, to a tumor, an abscess, etc. It is therefore, especially with regard to the prognosis, of the greatest importance to determine the exact nature ol the lesion in a given case, but both questions ought always to be investigated with equal care if we wish to arrive at as exact a diagnosis as circum- stances permit. In the following pages these two modes of diagnosis will be considered separately, and we shall first speak of what is known about cerebral localiz.ation, while in a later chapter the pathological side will be discussed.
I. The SrtJDV of Ckrebrai. Lesions with Refkkrsck td TiiKiR SiiAT— Toi'iCAi. Diagnosis — Doctkine of Local- ization.
Two classes of symptoms produced by cerebral lesions must be distinguished: first, general or diHuse (Griesinger). and. secondly, local. The former, so far as they concern the subjective feelings of the patient and the disturbances of the vegetative functions (temperature, pulse, respiration, condi- tion of unne), are to be observed and described in this con. nection in the same way as in diseases of other organs. The latter— the local sympioms^in.iy be divided into two classes, namely, the direct and the indirect. We call those symp- toms direct which are produced by a persistent disturbance in the functions of a certain part of the brain. They are also called focal symptoms (Oriesinger). By indirect symptoms wc mean those which arc only produced by transient conditions —changes in circulation, by compression, etc. — and which arc in a way concomitant symptoms of the former. They may be entirely absent : on the other hand, they may be so prominent as to make a topical diagnosis impossible.
CEKEHKAI. LOCAUZATlOh'.
163
»
Destruction of a circiimscnbed area in the brain gives rise to symptoms of paralysis, or less frequently to sympLonis of irritation. The former, where wc have to ^jcal with a loss of function, are also (after Goltz) called syinptums of destruction {AHsfallssymptcmt), and if the funclion is not lost but is only impaired, symptoms of impairment (Hemmungssympfome). The latter — namely, the irritative symptoms — are usually due to a so-called indirect action.
It is not always possible to say whether a sycfiptom is of a direct or of an indirect nature. For instance, if wc tind a pa- tient in an unconscious state with a hemiplegia, this hemiplegia may be a direct focal symptom or it may have been produced indirectly. In the latter case it will disappear in a few hours or days, in the former it will be persistent. Or, if a patient suHer- inf from the wmsequences of a cerebral ha:morrhaKc presents, as is often tfie case, disturbances in speech. This may again be a focal symptom or not. If, after consciousness has been regained, the speech becomes gradually but steadily better, then the aphasia was produced indirectly. If, however, speech remains unintelligible for months or years, it is clear that we have to do with a focal symptom. Therefore, in acute lesions we can only alter a certain time lias elapsed discriminate be- tween direct and indirect symptoms.
The Irrilaiive symptoms consist either of general epilepli- lorm convulsions or of partial, mvolunlary movements of the extremities (liemichorea. athetosis). of tremors, contractures, or forced movements of the whole body. Wc shall repeatedly have occaMon to refer to these phenomena.
Not all of the symptoms have an equal value for the lo- calization of a lesion. It is important first to note their mode of onset, whether this is sudden or f^radual : whether several symptoms have made their appearance at the same time or ooc after the other, and so on, for in acute lesions, for instance, only those symptoms which appear synchronously are of im< ponance. If n patient who has a hemiplegia presents a paraly- sis of the uculo.motor of the opposite side, and wc learn that thi» latter has existed before the onset of the hemiplegia, no- body certainly will think of connecting the two or look upon them as being symptoms due to one focal lesion. This would only be allowable it both had set in at the same time Rafter an scute lesion).
I6^^ D/SEASSS OF THR BRAttf PKOPEK. ^M
BuC. even apart from the mode of onset, the symptoms are not of equal value in the localization. Some, it is true, as hemiplegia, together with contra-lateral oculo-motor paralysis, are almost pathognomonic (for a lesion hi the cms), and their simultaneous appearance is therefore extremely important : white others. a» the conjugate deviation in severe hemiplegia, are found in different lesions, and are therefore less sifrnificant; still others, as oplic neuritis and all the general symptoms (headache. v(;rtigo, unconsciousness), are absolutely valueless.
We see. therefore, thai by no means all cases can be used for the study of the topical diagnosis, but only those in which the affection, in the first place, remains chronically station- ary; secondly, in which it is circumscribed and isolated (Noth- nagel); and, thirdly, where the surroundings of the locus are as little as possible implicated. These three conditions are best fulfilled in instances of haemorrhage or embolus, or rather in the cases ol softening produced by these accidents, and the largest contingent of cases which permit a topical diagnosis i% therefore made up of these. They are rendered more suitable lor our purpose the longer the time that has elapsed after the first onset (according to Nothnagel. six to eight weeks), as only then, as we slated above, arc we able to separate the direct from the indirect symptoms. In other cerebral affections — c. g., meningitis, encephalitis, and especially tumors — a local diagno- sis should only be attempted with the greatest circumspection, and even then errors can not be altogether excluded.
Sj-iH/ifoms Rf/erabtf ta Cortical Ltsions.
In speaking of cortical lesions. " surface lesions." it must not be forgotten that the clinical meaning of the term is differ- ent troin the anatomical one. Anatomically, it implies that the medullary layer situated below the cortex is intact, while clin- ically we speak o( conical lesions even if the white matter lakes part in the pathological process as well ; but so little at. tcniion lias been paid to this difference in the autopsy reports, which have been published, that it seems an almost hopeless endeavor to distinguish whether the symptoms reported in a given case were due lo changes in the cellular elements of the cortex itself, or to changes in the fibres of the medullary layer situated immediately beneath. Pick (Zeitsch. ftlr lleilkunde, 1889. X. I) has shown how important it is to make a micro- scopical examination ; this is even more necessary if we find
COKTlCAt. /JiS/OXS.
165
I
I
I
ndary degenerations in the spinal cord — macroscopically ihc cortex may present no abnormality in stich cases.
We possess quite a considerable amount of material, but it a by DO means easy to make a judicious and successful use o[ it. Certain methods have to be employed in order to arrive at correct conclusions, methods which have been developed in such an excellent way by Exner (cf. lit.). It would, for exam- ple, be incorrect to assume a certain cortical area to be the centre (or the motor (unction of an extremity sim|tly because in many cases a lesion of this area was found where a paralysis in that extremity had existed during life. This " method of positive cases," as Exner has called it, is therefore uncertain, because there are quite different circumscribed cortical regions, a lesion in which gives rise to the same symptoms: and since, moreover, facts go to show that such a method may lead us to wrong conclusions, it ought to be discarded. Much more pref- erable, however, is the so-called " method of negative cases " (Exner). according to which " we have to mark out the lesions, lound in all the cases in which a given function was not inter- fered with, and unite them on one hemisphere." U the number of cases is sufficiently large, while on the remaining parts of the cortex we find markings indicating lesions, the area for the (unctions in question will remain free.
Still better results are obtained by the method of percent- ages |lixner). The cortex is divided into arbitrary helds, and for each of these fields we determine, first, how often it has been diseased in a given number ol cases ; secondly, in how many of the cases the symplom which we are studying was present. The ratio between these two results is best given in percentages. Only through this indispensable, although some- what tedious, method can we ascertain ih^t the fields o( the right cortex arc different from those of the left, and that cer- tain areas exist of which a lesion always, and others ol which a Icftioa not always but frequently, produces a certain symptom. The former Exner calls " absolute," the latter " relative." corti- cal areas.
Wc do not always find cortical lesions at the autopsy in cases in which certain symptoms, which would have led us to suspect their existence, have been noted in life. On the other hand, they arc found in cases where we have hardly 'elt justi- fied in expecting them. There is no doubt that no inconsider- able part of the cortex can be diseased without giving rise to
l66
mSSASKS OF THE BHAIX PROPFS.
Fie. ^— RMiin Ki:ni.ii-iiuiil (Aticr Kxam.i Tha pawlfBi tbaAri In KpitMM the« poru of tb* aiHGi whiili can lie injured wiihoDi civlBB rtM lo Miiuiy ur molar dhiafb- MICH ; the tiUnk tntx >re tiKiUit <nd Mnaoff.
ft- ,16 - l-Krr Hrmsn'oiK. pAIWr tKXBB." Thih ilitKmm iihnm tliat ihf mirtoc < tciuory orcu U« of ^rulcr cilvnt uii Ihc Irfl llimi on tlin iiKtil hcmi'iiliFiv
THE BKAIN CORTEX.
167
■y symptoms. It is this part which h;LS been called the cor- tical area of latent lesions (F.xncr), and it is certainly a matter thy of note that rhc extent o( this area \s smaller on the than on the right hi;mispherc, whereas the motor area — that is. the area in which a lesion is followed by motor disturb- -is larger and more developed on the left than on the It side (cf. Figs. 35 and 36). The first represents the right, tlie second the left hemisphere. On both all the lesions are indicated which have produced neither sensory nor motor disttirbnnccs. The blank hclds are iherelure sensory and motor — their g^rcater extent on the lelt side is at once ap. parent.
F^ jj.— CoMvouiriun avd Pmu'H» or nit Laikral A>v«ct or tiik fiMAia. (AA« &CKIK.t PuaKtUunlK = tnnUkl Iiuur. ot Ant ittnpotal fiuure.
Before we go into the description of (he individual lesions o( the cortex wc will briefly refresh our memory on the unat* omy (il the parts.
The thin gray covcrins which surrounds the white matter, and *bich lias txrcn called brain cortex, picsenls on each heint»|ihere three kurfacc* — n lateral, a iMKal, and a median. The two lateral (arm the cnnvcxity, the two hutal the base of the cerebrum. The
rliriim is divided into lobei. which can a};aiii be subdivided into lution& or gyrL To t>c able tu loualixc and corrcetly describe
|68
DISEASES OF THE BRAIN PROPEK.
cotiicat lesions wc must be thoroughly familiar with the position, as veil as the names, of the dilfcrciU convolutions. The following illustrations arc intended to facilitate the study of the convolutions and the fissures or sulci separating them. Kig. 37 representti thou on the lateral surface (convexity), Fig. jfl (hiise on the ba«al, aiul 1''<S- 40 those Oh the median :ts]iect of the cerebrum.
Pig. jBl— CowvaLUTioHH AHti Fissures ax nvc R<s>; ot' die (iKitia, (Diac aJUt EcKEH.l lllrDKhcakcl = trura Mrvlitl. tlalUn onrpm (allmuin
In Fig. 37 are included the frontal, parietal, temporal, and oc- cipital lobes, so far as their convolutions and iissures belong to the lateral surface — in other words, belonging to the frontal lobes, the three frontal and the anterior central convolution (gyrus centralis anterior, pit frontal aitemlani'). and belonging lo llic parietal lobe, Ihc posterior central convolution (gyrus centralis posierior, or pli pariftiU af(tHi/ant) ; between the last two it seen the fisMire of Ro- lando. Further, a part of the upper and the entire lower parietal lobe are shown, which latter is subdivided into the supra-naargioal
TUB KRAIN COKTHX.
cunvolution in front and llie angular gyrus (/// covAr) behind ; be* longing tu the temporal lube we have the three temporal convo- lutions, of which the first (uppermost) lic» between the Assure of Sylvius und ii vcrjr deep fisstirc running parallel to it, the Ko^callcd parallel fis«ure or first temporal Assure. The fissure of SylviuK has two branches, and Ihe portion of the corlcx between them is called the '■ operculum," Belonging to the occipital lobe, finally, there arc three irregular ami not ain'ays easily distinguishable occipital conviilutions, between which two occipital fissures have been de- scribed. .
In order to determine from the outside of the skull the position of the Assure of Rolando we proceed, according lo Kdhler (Deutsch. /.eitsch. f. Chir., 1891. xxxii, 5, ^ iit the following manner (cf. Fig. 39) : A line, a, is drawn over the mid- ^
die of the stkull from the forehead to the external occipital protuberance. A second line, ^, is drawn at right angles with this, passing through the anterior boundary of the external auditory mealiiK; parallel with this KCond line we draw a third line, c, passing through the posterior margin of the mastoid proce»», so that It cut* the sagittal line, a, two inches behind Ibe line c. A fourth line, if, starting from the point where a and / intersect, and running obliquely down* ward so that it meets the line /> two inches above the external audi- tory meatus, will indicate the direction of the central fissure.
On the basal a>pect we »ee thuxe part» of the three frontal con- volutions which ate included in the base, of which the first (upper- most) is here called the gyrus rectus; then the tractus, with the sulcus olfactorius; next the uncinate gyrus, which belongs to the gyrus fornicatus, and which will be better seen on the median aspect ; further, the basal part of the third temporal convolution (gyrus tern- porali* inferior) and two lobules, which belong to both (he temporal and occipital lobe, the inner (median) one called the lingual lobule, the one more external the fusiform lobule.
The median surface (Fig. 40) thows jn the middle the corpus callosum (in front the genu, behind the splenium) : immediately be- low is the "M])tum lucidum," immediately above the gyrus forni- catus. the temporal part of which is called the hippocampal convolu- tion, and is continuous with the uncinate gyrus. Above the gyrus fornicatus, and separated from it by the calloso-marginal fissure, are the frontal convolutions ; farther back, the paracentral lobule, which
nt-j*.
170
PtSBASES OF THE BKAIN P/tOPEK.
meets ihc centra! convolutinnit. Behind tliin and belonging to ihc parietal lobe is the praecuneua, and still farther back llie cutieus (of
/iMuim Jlijipoe.
Jimbria or ToriAih. Fi(. 40,— COKVoi.uTios* *sr> Fiwure* "f riiK Mi;niA:c Akpbct or riiK Bkaim, Th* putUrior ponlona if thi Ihalannw and llw cnu ccnbri ar> cm (dl.
the occipital tobe). The latter i» bounded by Iwo deep fissures— below by the calcarine, in front by the occipito-parietal fis.iure.
PSb. 4i>— CotrvoLUTian or thr Ulamp or Kkie. (J. K.) nam: vum^ vt rkmovim*
II IK Ol-eXCULUH.
TUF. MOTOR CENTRES.
171
tending from the posterior pan of the corpus callosutn to the unciiiJite gyruft is the liippocampal fissure.
Covered by the above- me titioiicd operculum, in tlic depth o( the fi&sure of Sylvius, i» the lot>u& itilermediuH &. operto>, the Ko-called island of Rcil, on which five to seven small convolutioim are seen. Their position is shown in Fig. 41, whcic the operculum lias been icmoved.
In I-'ig. 42 the topograpliii;:il rclnlions between the surface of the brim aiid the surface of the skull are illustrated.
F^. 4s.— ToroDKAniiCAL KKtA-noii* nKTwcKa mc Kxtciooh or thk Sxvll akd tub SuarArKii*' riiK Brajx. ( Altar Fxxkr.) C. fivunol Rc^ando. f. C. ■sierioi Cdn- tMt // v., pi«lc<r>artvnu«l«<inv»lu>ii<n. SS^S^,, Ojaun of i^jMui. r, (cmpwrnl Itte. f, fmnul kte. P, , aiipsr. P,, , kmsr putsUI loba. O, oodidul tobe. Ch, otKbdhasL
A» Ktnted above, the localization of the motor centres by iFrilsch-Mtl/tj' and (hat o( the speech centre by Brr»ca paved I ihc way for a number ol discoveries which, based partly upon clinical observations, partly upon the less trustworthy ex|>cri> mcnls on animals, eventually will lead to a complete and ac- curate [ihysio.palhi)logicni topography of the brain cortex. Thus farour Isuowicdgc is scanty and uncertain, and tiicceiilrcs which we shall here describe as being determined arc almost all relative, in the sense of Exner (cf. page 165). the only exccp- being the so-called motor region of the cortex. On the [ht hcmtsptiere, the paracentral lubule, the anterior central.
172
DISEASES OF THE BRAIN PROPER.
and the upper half of the posterior central convolution, on the left hemisphere, the paracentral lobule, the upper three fourths of both central convolutions, and a part of the upper parietal lobule, constitute the absolute cortical area for the upper ex- tremities (Exner). The absolute cortical area for the lower extremities is situated, on the right hemisphere, in the para- central lobule, and in the upper third of both central convolu- tions; on the left hemisphere, in the paracentral lobule, the upper half of the posterior central convolution, and the greater part of the superior parietal lobule.
The cortical area for the facial nerve is situated in the lower end of the anterior central convolution ; in front of this and in the adjoining portion of the second and third frontal convolu- tions is the centre for mastication (Hirt), In the region of the island of Reil we find the voice-centre — i. e,. the centre for the movement of the vocal cords (Rossbach) ; in the frontal lobe that of the muscles of the neck (Fraenkel) ; in the angular gyrus that for the external ocular muscles. Haab (Ziirich, 1S91) has attempted to determine the centre for the pupillary reflex.
Of the so-called sensory centres — i. e., the areas in the cortex where conscious sensation takes place — we know the psycho- optic to be situated in the occipital lobe ; the psycho-acoustic in the temporal lobe ; that for smell and taste in the uncinate gyrus (Ferrier). The cortex of the frontal lobe and that of the temporo-occipital region are the seat of the higher intellectual processes (Flechsig).
The so-called thermic centre discovered by Eulenburg and Landois corresponds to the motor region, and the tactile regions for the different parts of the body also are identical with the motor centres (Exner, Tripier).
Furtherinvestigations must show whether the centres which we have been wont to regard as being situated in the medulla oblongata — for example, the centre for salivation, that for deg- lutition, that for the movements of the stomach and intestines (vomiting and defecation), for sneezing, coughing, etc. — are also situated in the cortex. The results of the treatment by sug- gestion make the assumption of such centres necessary. Nev- ertheless, while the " area of latent lesions " (Exner) is still as large as it is at present, an explanation of this kind is pre- mature.
ril& BKAIN CORTEX.
173
I
LITERATURE,
t.'«btr (Icn heutijttn Stand der Frage von der Localbalion im GrtiKihim.
V. VolkiiunnK S.imml, klm. Vonr. l.cip^lg. 1877, 113. Kwiier. Tlvc Kuncii<ins o( ihf Urain. *;. I'. I'ulnam'* Sont. New York, 1686. Kathnag*-!. Topische l>mgni»tik. /«■. est., pp. yjtfet sf<i. (inaiiy rd'eri-otes). Munk. Zw ["hinuiUigic <kr CroxshirnrinHc. Crsummclte Mltthrtlungtn aus
den Jahim 1877-1880. Berlin. 1881. Ctmlratbl. r. Nnvcnhk.. 1881. 17:
1S83. II. f.inrT. Untenucbiingrn librr die t.ocal>s»linn drr FuncUonen In dcr Grou-
hinihndc Ae» Mrnvcbcn. Wicn. iBSi. Golii. L'ChM (IIf Vrrticlitungcn dcs C^rusihirns. Bono, iSSt. llrthikiK. Zur An.iinmic und r.ntwickclungtgefchichic An Leiluiigsbaliiini inn
l^foatiKin) (let Mrmchen. Arch. f. Anal. u. Phyniol., 1S81, i. p. 13, FIrchslg. Plan des nim«chtich«n Gchimv Leipzig, 1883. (lulu. Uetm die Vrmchlungcn dcs GrwshlmB. j Abhandlungen. Arch, d,
ffA. Iliyslol.. 1884, xxiiv. 9, la *, Cuddra Vthrt ilic t'r.ij-c dtrr Localisiition <!cr Funcilonen der Onxt^
himrindc Crntrall)!, f. Ntivcn^k,, 188^, viii. 19,
luni. ;^ur t'h)»iul<)Kic de» Crtnshirn.i. Berlin. 188;. C«nirall)4. f Nrrvcnhk., iSSj, viii. 10. 11.
tl Pltres. Recherchct eipj-iimrnlalrs el cnti<|ucs sur rodl.ibilil^ des ii^tva ctrfbraux. Arclt Ac Phyi-iol.. 188$, 1. 2, Eulenburtr. llcber Am Wumrcvnirum iin Grosslum. VeihandL d. phytlol.
Ccselbcd. In Hnlin, 1885, i& Luaani and Sctillll. Di« LocalUallon auf der Gro»hirnriiide (Gemiin by O.
PMnkd). LetpriK. iSSfi. RoMhach. Ileiiroii nvt I.ocnlixation dr» rorlimten SlinimcenlTums beim Men-
tchen. DcuimIm-s Arch. f. klin. Metl,, iSqi. xtvi, Bechicrew and Mislawskt. Arch. T. Anat. u. i'liysiol.. 1891, J, 6. (Drain Ceiv-
tr^ fur Movemrnii of ihe \',i)pna in Animals.) Fevrter. The Croonian Lecture* on Cerebral Localballon. London. SmMi.
Elder & Co.. iSga HoacI Ptr Ceniralwin'tiingeti. ein Ccnlralorniui der HinierstMnge uml des
TrKftrmitiua. AnJi. f I'lych., t8qi. xxW. 1. Coldstetn. Physiolo);ie. Paihologie und Chirurpe de» Gro«htmft. Schmidl's
Jalirb., iSy.!. ccxoiii. p. 87.
Charcot rt ["itrM. £iude cniiqiie el clinique de la docirine ilct lac.-ili.%.itiun)i RKHricn dant I'teorcc de» hfmispti^rcx ctr&tn-M de Ihoinme. Pans.
IM3-
Deatsches Arch. f.
Vener. Ucber die wnwrtelten Funcilonen dcs GmMhimx.
klin. Med.. 18S3. xxxii. p. 4S6. AlcKaniler. Ein Fall vmi giimiii6ien GeiehwiiUlen in iler llimrtnik. lireslauer
Iml ZeliKhr.. 1884. u- Rinentlul. Fall vnn oorticater Keniiplesic mil Woniaubbcit, Ccnirallil. f.
N«itM>lik., 1B84, vn, I.'
•74
It/SSASSS OF THE BKAJN PROP Eft.
BergCT. ZuT Localisation <ler conicaJcn SchsphXrc bcini Mcnschen. BrtsUucr
3I»tl. Zeitschr., iSSj. I, 3-5. Desno^. Locilii^tiona c^rebmlo, Gai. hebdoni., 188$. xxxit, 47. Runipf. Ucbcr sy[>hiliti»chc Mono- und Hcroiplcgim. Tagebl. d. Nalurforscher-
Vers. in Stmviburg. ittSj. KohkT. Zur Canuisiik (I«t reinen irauinaiischm RindeDlS&ionoi. Cbarii^
Atioftlcn. iSil6, >i. p. 538. JaQcwaf, Juutn. of Nerv. and Menl. Discaan, 1886. xii, 4$. Buiian. Tli<r Muscular Sense, il* Nature anil Conical LocaUuiion. London,
Clowes & Sons. \t9^ tlowtra. a. a, o., 1886, pp. loj '' ^'9- Rcichard. 7,ur Fnge cicr I Jim localisation mil hesondcrer BctuclMlchtJgung der
oorticalen Sehslcirungen. Arth. f. Psych, u. Nervenkh-i 1886, xriii. 3;
1887. xlx. I. Joflfroy, Arch, de Physiol. Fchruar>- x 5, 1887, (Monoplcgi.i of Che Lower Ex-
irtmiiies. Lesion in the I'aracenlral Lobule.) Leydcn. Iteilrag zur Lchre von der LocaliMiion im Cchifii. DrtilKhc mcd>
Wochrnsrlir.. 1887. 47. Bouvercl. Ljon mfd., 1887. l»-i. p. 337. Bernhardt. Ein full von HirTirin<lenuta.\ie. Ibid., 1887, 51. Horsley, Vicior. Brain Surgery, Hrii. Med, Joum.. 1886, it. 670-675. Ceci (Genova). Eniipare^ pro|^e>iriva siniilra inizialJis due mesi dopo di un
traunijk alia regloiieparieialcdcstraegiunia^id eniiplecia cotnpleia. Kinsla
clin,. Setl., 1887. Ilun, H. A Clinical Study of Cerebral Localiution. Amer. Joum. M«l. 5c„
1887. Nolhnagel. Ueber Di;i|(no.itik bci Cichimkrankheiten. Deul:Khe med. Wo*
chcnsiclir., 18H7. xiii, ij. 16. Scngcr. Ucbcnopischc Himdiagnoslik imd Himchirurgic, etc. Dcutsdte mcd.
Wochenschr., 1S87. xiii, 10-13. Chaulfiinl. Ue la cicitf subite p-ir Wsions combinto des deux lobes ocripltales.
Revue dc mill,. 1888. z. Welt. Leonore. l^eber Cb.iniktervcraridiTunEen des Menschen In Folgc «m
Lisionen des Sttmhirns. Deutsrhes Arch. f. hltn. Med., xllt. Heft 4.
(Wcftkcniiig of Intelligence. Deterioration of Character.) Dam. The Cortical Localiulion of Cutaneous Senutions. Joum: Nerv. and
Mcni. Diseases. 1888. xv. tijo~684. Eckhardt. Neurol. Centralbl,, i88g, 3. (Cortical Area for Secretion of
Saliva.) Totnac«-wski. Pctcrthurgcr mcd. Wochenschr, 1889^4. (Cortical Areas for
the Nen*c» of Special Sense.) Ljiwcnth;tl. Deutsche rned, Wochenschr.. 1889. IJ. Haab. Der IJimrindenrellex det I'upillc. Zurich. Miller. 1891.
The speech centre, which, as we have seen, is silimlcd par ty in the frontal, partly in the temporal lobe ol the led hemi- sphere, is certainly ol larger extent than is commonly sup- posed. It is well known that ader Qouillatid in iftsj iiad pronounced the frontal brain, and Marc Dax in 1836 the lelt
APHASIA.
I7S
hemisphere, to be the seat ot speech, Broca claimed that the posterior part of the third left frontal convoltition, the pars opcr- cularis, or, as it Inter was called, thu re<;iuii of Bruci, contained the speech centre ; and, indeed, in speech disturbances a lesion of Ihis very region has most frequently been found at the au- y. There arc, however, other parts of the cortcs. as the d of Keil, the central LX>nvuliitiuns, and, above all. the tem- poral lol>e, more especially its upper convolution, which arc connected with speech and which are of no less importance, us we have, alter much laborious work and alter many carc- iul observations and comparisons, come to the conclusion that a different form of speech disturbance (aphasia) is produced according as the lesion is one of the frontal or ol the temporal lube — (of the left side only). In the former case the patient I buwg [he word which he wishes to pronounce, but can not do f W because he has lost the memory for the movements ncces- oxf lor speech — ^i. c., he no longer knows how to use his tongue >nd tips in the act of speaking — motor aphasia. If the lesion is >itu3ied in the third left frontal convolution (Broca 's region), we *pealc of cortical motor aphasia ; it it is situated in the white mat- icr of the hemispheres, in the posterior portion ot the internal cap<n]le,orin the Icftcrus, we speak of subcortical motor aphasia. H In the latter case — i. e., if the lesion is in the temporal lobe — " 'he patient knows exactly what he wants to say, and he has no •^'fticuliy in repeating it '^ it is spoken for him ; ^\xx he can not find the fJ^piWiSion for himself, ••c has "forgotten" the •■'ird — sensory aphasia. That the understanding "J Words is situated in the —^ l<^ni[ioral lobe, more par- ^Ucularly in the first tern- pf>nil convolution, was ^rsi Mated by Wernicke, who also originated the tcmis motor and senst>ry,
Cortical and subcortical, aphasia. The anatomy ol the subcor- tical sensory aphasia has as yet hccn only imperfectly studied. In the diagram of Wernicke which is shown in Fig. 43,^ repFcitcnU the motor, x the sensory speech center ; the latter
*■•(■ 4* WcBMCKtN ScHtUA foil TIIK COKTICAL UjUnURIlM or SfEIXH.
i;6
D/SEASKS OP THE B ft A I A' PROPER.
is the terminus of the ccnlripetal palh of the auditory nerve a X. the furmcr is the beginning of the centrifugal path / im going to the muscles used in speaking: 4 -/an assumed associa- tion jaCh between both : y is situated in the third (ront.il, x in the first temporal convolution. According as one ur the other of these centres or the connection between them, or both cen- tres, were destroyed. Wernicke distinguished four cardinal types of aphasia :
1. I^estruction of the centre ,i- — motor aphasia. Mobility of the muscles used in speech is retained, but the patient can either not speak at all or only say a few words or syllables. Understanding and memory ni words are intact.
2. lieslrticlioii of the centre x — sensory aphasia, "word deafness " (Kussmaul). The patient can use as many words as ever, but in speaking they arc mixed up. The understanding of words is lost, although the power of hearing is not interfered with.
3. Destruction of the- association path x y. situated in the insula(?)— the so-called conduction aphasia of Wernicke. The patienr can use as many words as ever, but in speaking ihey arc mixed up. The understanding of words is retained.
4. Destruction of both centres, x and y — total aphasia. Power and understanding of speech are lost,
II wc then consider as proved thai a certain group of motor and sensory memory pictures are localized in the brain ; if wc further agree that the former correspond to certain groups of muscles which serve a common purpose, the latter to the dis- tribution of a sensory nerve — ^it is not difficult to conceive that this same arrangement may exist for all the muscles and lor all the sensory nerves. It is certainly easy to understand the occurrence of other motor defects in cases of aphasia. Thus there may be loss of simple movements (c. g., of the power to put out the tongue), or more complex ones (e. g.. writing may become impossible — agraphia ; afhasif dt la main. Charcot). Again, we have a patient who, in consequence of a cortical lesion in the central tcrminniion of the optic nerve, no longer recognizes his letters, and has thus lost the faculty of reading (■•alexia "); or the visual memories may be lost .illogclhcr (not only those nl letters), and a condition ensue which Munk calls psychicjil blindness.
In examining a patient affected with aphasia, with a view of determining which path has become interfered with, we may
APHASIA.
i;?
meet with considembte difficulty, nnd the diagnosis of the par- licutar type ol aphasia with which wc arc dealing is often not easy, fur the cases are not so sharply defined or so well charac- tcriicd as we might be led to expect from the simplicity of the schemata. On the contrary, we often meet with combina- tions of the different types or with transiiion forms of aphasia in which even the most experienced clinician will venture a differential diagnosis only with much reservation. Take, for instance, the different degrees of thai form of speech disturb- ance knuwn as ataxic aphasia, in which the patient is unable to pronounce a word, though it constantly is floating, as it were, before his mind. This inability may go so far that the patient can only pronounce a few words or syllables (monophasia), that he involuntarily confounds words without being in the least uncertain about thtrir meaning; or it may. on the other hand, only amount to a slight disturbance, shown by some misplace- ment or omission of some letters, as in saying dy instead of dry, turk instead of Irutk. and the like. In Ihc latter case wc speak uf syllabte-siumbling <.Sr/Arwi/t>//frH). Likewise we have different degrees of the so-called amnesic .iphasia, where there may be loss or only slight impnirment in the memory for words (sometimes only lor words ol foreign languages which have been learned later in life^ As the faculty of writing and read- ing may often be more or less altered, it is important that it should be minutely examined into; the patient is asked to spell individual words, then to read sentences without spelling, then lo write spontaneously and to dictation, and finally to copy word«. in the case of a patient who is left-handed, his ability lo write with the left hand should always be tested. Every C3»e of aphasia must be carefully studied by itself, and each one gives opportunity for interesting observations.
In general we may be guided by the following rules: t. If we find a patient whose sanity is established, who pos- ts a normal aculcnegs of hearing and understands what is said, but is unable to repeat sentences or to speak spontaneous- ly, and can only utter individual words and syllables, we may BHume a lesion of the third frontal convolution, possibly of the lowest part ol the anterior central convolution.
3. If a patient, although able to speak without diflicutly, docs not understand simple questions, then the first tem]M>ml convolution is diseased (i>r/cA'). If the understanding of words b only impaired, then only a part is aSectcd.
i;8
J>/S£AS£S OF TJIE BRAI.V PKOPf.K.
3. If the paiient has tost the (acuity o( reading, although there is no motor aphasia to be noted, we have to deal with a lesion of the cortical centre for vision (cf. page 172).
4. A disease of the conical speech centre does not exist if the patient grndiially regains speech which he had suddenly lost : if in such a case the hemiplegia, which has simultaneously appeared after an apoplectic stroke, persists, the white sub- stance near the cortex is usually diseased (Gowcrs).
We should be going beyond the limits of this work if we attempted to discuss the aphasic symptom-complcx in all its difficult and not rarely obscure delnils ; there exist » l.trf;e number of interesting special articles on this subject, to the most important of which references will be luutid at the end of this chapter. While recognizing the steady advance which has been made totvard the interpretiition of these most complicated disturbances, we arc ever reminded, by the constant difliculltes which arise, how far we are from a complete understanding o( them. Almost every case shows peculiarities which do not fit into any of the schemata ; and while today a successful investi- gator claims to have cleared up some obscure point in the diffi- cult field of aphasia, to-morrow another one proves that this conclusion was after all too hasty, and that only he, the sco ond investigator, has really settled the question. In a word, there is hardly a single point in the problem of aphasia which is nut still the subject of controversy. The tendency to schema- tize is very prevalent in Germany, and in opposition (o these too schematic conceptions of aphasia, [English and French in- vestigators have pointed out the variations ol the inner speech — i. e., of the thinking processes necessary lor speech — and the differences which may be bound up with the individual peculiarities of the person who speaks, writes, or reads. But these objections are slow to be appreciated in Germany. Whether a person reads by spelling, or whelher after consid- erable practice one may read without spelling, whether the optical images of letters arc necessary in the process of writing or not — these and many similar problems still await their solu- tion, and can be cleared up only by untiring, careful observa- tion of cases.
For the beginner it is not only desirable but necessary to have the matter presented to him somewhat dogmatically, and this, according to our experience, will be best and most easily accomplished with the aid uf schemata, of which, besides
APHASIA.
179
I
the above-mentioned one of Wernicke, quite a number have been brought out. The one we have deemed most suitable and the best fitted for teaching purposes is probably that which Lichihctm has de- veloped (Arcl). r. Psych., 1SS4. XV, 3). It has been here given in Figs. 44, 45.
The reflex arc neces- sary lor repeaiinj; words contains the centre for au-
■ ditory images of words, A :
I
i
!»
»"!«■«-
the centre for motor im- ages, M\ the centripetal parh for auditory impres- sions, a A ; the connecting path, A M; the centrifu- gal motor path, J/w, B b the place where coaccpts are formed — voluninry speech nc- ecuitates a centrifugal (Mh Irom if ^brain cor-
tu) to A/. O is the
ontre for the visual
laages of Icilers. E
iltbe centre for the in-
vrvaiion of the mus-
d« required in writ- ing;. Now, according
toihe path aRcctcd, wc
diuinguish seven dif-
(crtnt forcnsof aphasia. I. Interruplion in
•V point M. Broca's
"Mior) aphasia, J- Interruption in
f'ini A. Wernicke's
(leiiory) aphasia.
3. Interruption in the path MA. Conduction aphasia (Wernicke).
4. Interruption in the path MB. A variety of motor apha>
Pic*. M.45.-LJCH'nii:iU'!l KCIIKH* IU.L'*TIUTtlCO TMK St.VlJI Dirt-KHENT KOKHS OF AniAtlA. •, A, COk-
tripeUl paih r<rr auditory ImpwMloai. A, ccnue lor ■wliiwy inuK**. it, omtic lor mouu touea. M, m, rantrifncal mMot puh. B, the plww *he>c ixsa- npCt art (nnnfd O, Um (cdik lor tUihI Inwcts. B, c«alT« Inmi whidi lb« orpuw ot wridnn are Inner. TMad. iTfac wvto dlfltnnt lorms ol ii^ula ban bam tDdkaudln Fie. 44bT (he numtwn 1-7.1
iSo
mSEASES OF TJ/E BRAW PROPER.
sia: tbe faculty of repeating words and sentences being re- tained.
5. Intcrniptiori in the path Mm. Variety of motor apha- sia ; the power of expressing thoughts in writing being re- tained.
d. Interruption in the path A B. A variety of sensory apba- sia ; the patient being, however, able to repeal spoken language. to read aloud, and write from dictation.
7. Interruption in the path A a. Inability to understand spoken language and to write from dictation, or to repeat spo- ken language. Nos. 6 and 7 have so far been observed only in rare instances (e. g.. by I'ick, Neurol, Ccntralbl., 189a 21).
As to the occurrence of aphasia, it is most frequently sei-n as a sequence to an apoplectic attack, cither as a direct or indi- rect symptom : in the latter case it is transient, and lasts, as we shall Ncc later, a few minutes, hours, or days. In the former it persists, and may trouble the patient, though he may retain his full mental vigor to the end ol his life. The most common form is motor aphasia, which appears in widely different grada- tions ; thus, in some cases the patient's speech may be just a little thick, while in others it may be altered so that it is no longer intelligible. After what has been said, it is easy to un- derstand that these defects chiefly occur after ha-morrhage in the left ^idcof the brain^that is. with a right-sided hemiplegia; but it would be a decided error to suppose that they occur only or always in those cases, for motor aphasia may be found in connection with a left-sided hemiplegia, and it may be want. ing in the right-sided form. Other diseases of the brain also may implicate the cortiail speech centre and give rise to aphasia. Among these may be mentioned general paralysis, psychoses (Lloyd, Francis, Lancet. July 7, 1*88), processes of softening, chronic meningitis, tuberculous deposits, etc., and traumatism of the left hemisphere, in which case aphasia may be the only symptom. Aphasia has also been observed in acute, especially infectious, diseases — e. g.. typhoid and scarlet fever. Most instances of this latter form occur in children. It has also been observed in the puerpend state. Of special interest is that form of total or motor aphasia which sometimes suddenly, sometimes gradually, comes on after a fright. That after a fright, such as makes " the hair stand on end," the voice may refuse to perform its duty, even Virgil seems to have known full well, as we sec from the verse, " Stettruntqtie ama, vox /au-
APHASIA.
181
(Aus httiit." The nature o( this (orm is uncertain, still it is bj no means impossible thai, just as wc tind thnt vasomotor S|>asm acting on the facial vessels will produce pallor, so wc may h-ive u similar coiiditiun in those finest dislriliii lions ol the middle cerebral artery which supply the region of Broca. That the sfMsna in these %'esscls is usually of longer dtiraiioii and pro- duces more serious and more lasting consequences lliau the spasm of the cutaneous vessels, may be explained by the differ- ence in their arrangement, as well as by the difTcrcncc in the (unction oi the parts which they supply.
It is not organic changes of the cortex which produce the symptoms in this case, the disturbancts being entirely of a futicliuna) chanicter, and this frij^ht aphasia lh(.'rcfore consti- tutes a transition form to those instances in which, though the aphasia may have lasted for years, no changes are found at the autopsy, cither in the cortical or subcortical area for speech. No doubt there is, besides the aphasia due to actual lesions in the cortex, also a functional form which wc may imagine lo originate in different ways, and it is at least probable thai variations in the blood supply of the centres play an important part In this connection, Grashey (cf. lit.) has shown, in an in- genious piece ol work, that wc have to recognize a third form ol aphasia, in which neither the centres nor the conducting paths arc insuHicient in their functions, but which is simply due lo a diminished <luralion of the sensory impressions, giving ijsc to a disturbance in perception and association, and thus to an aphakic condition. Maybe it is this aphasia of Grashey which wc find after concussion of the brain and after acule diseases, but it is dilHcult to diagnosticate it. and to diflerenliate a func- tional disturbance of the centres from a diminished duration ol sensory impressions, A correct diagnosis is, however, ol no small importance in the question ol prognosis.
The outlooW is absolutely unfavorable in cortical lesions where the centre is destroyed by processes of softening, tuber- culous deposits, atrophy of the gray cortex, etc., bnl is, of countc, maicrially better if the centres remain intact, and are only temporarily rendered unable to perform their lunclion. for tbea speech returns gradually, if not wholly, partially, and it can not be denied that systematic exercise and regular instruc- tion In speaking are capable of hastening an amelioration, nay, even a cure, especially if the patient be still young.
The aphasia ol children, which wc sometimes find after
182
DtSHASES OF TUB BKAIN PKOPER.
aculc inlcclious diseases, fright, or as n consequence of intcs- linal worms (" reHcx aphasia "), in the course of acute infantile cerebral palsy, or of epilepsy, and occasion ally, but very rarely. after a cerebral hjcmorrhagc, is in no olher way to be disiin- gtiished from the aphasia oi adults except in its prognosis. Q\vi\.- Axcn, tatcris paribus, vXw^'js stand a better chance of improve- ment or recovery from aphatiia than adults, no doubt because It is easier to educate in them the well half of the brain to per- form the function of the damaged one. If tlie disturbance is only functional, as I saw in one case which was due to an o\'er. dose of santonin, in which the disorder in speech only lasted a few hours, the outloolc is still more favorable, and complete recovery may be confidently expecled; but if the function of one speech tract — that is, the left — be impaired by cortical or deep-seated lesions, even then it is in chiklreu usually not very difficult to educate the right side to some vicarious action, espe- cially in cases where, before the lesion, the children have been taught to use both hands equally. The possibility of a cere- bral disease should be thought of in Ihc gymnastic cultivation and development of the body of children; the extremities ol both sides should be exercised and strengthened equally, the children should be made ambidextrous; only then can. in a case of necessity, the right hemisphere fully take the place of the left.
A treatment for the aphasia ns such does not exist. In cases of functional aphasia the only thing necessary is to con- vince the patient that liis condition is not serious. If this dues not lead to any improvement, we should try hypnotism, from wliich astonishing results have sometimes been obtained. If. on the other hand, lite aphasia is due to organic changes, such as hicmorrhage or embolism, in our treatment we must be guided by the principles discussed in the chapter dealing with these conditions.
literati; KE.
Wernicke. Lehrbuch der Cehimkrnnkhciifn. 1881, png. 366.
Kussmaiil. Die Sibrungeii <ler Spraclic. 3. AuH.. t^lptig. i83$.
Charcoi. Dc l'npha«ie en gin^nl cl dt- ragr.i|>hic en jiarticulicr. VrttfgeH
miiV, Kdvr. J. 1888. C-im Dculschcs Arch. f. hlin. Med.. 1888. xliii. a. 3, l..aii<loll. De la ticAi vrrh.i)c. Trav.iil public <Un4 l'ouvra|{e AiX\t A Mr.
Dnndcr* k I'occaiion <!e son jubili UlTcelH, 1888. M^l.Tchowiki, \'crsuch rincr Darstellung unscrtr heutjgen KrnntnUw In <l«r
Lchrc \on der Aphanib Volkmann's Samml. klin. Vortr.. iSHU, No. yi\.
I
CO/tT/CAl UOTOft PAKALYSIS,
183
I
»
Adier. Bdtrilge >ur C«suisiik unit Theorie der Aphssic Dissert. Inaug^
l}n>Uu. 18S91 Berklun. Ueber SliirunKen der Spnche und d«r Scbrift5pr3che. Fur Arrtle
umI Lthrer. Ilcriin. 18S9. EiMitlohr Deutsche ma\. Wochcnschr.. 18S9, 36. SoUiiunn. Ueber Sdirifi und S|>Li-t;cl$clirllt bci gesunilcn und kranken Kindern.
Henoch- FrMKhnri. 1890. Btlld. Die " inni:rliclie Sprache " und die venKhiedenen Fonnen der Aphaaie.
3. Aufl. Cenniin h> Bongers. 1893. Uutie. I'dxT cincn eigcni hum lichen Kail von Alcaic. Zeittchr. T. klin. Med..
1890^ iviii, I, 2. Mills. Churla K. Aphasia. Rcvkw of Inunity and Nervoui Diseases. Sq>-
leinlicT-Ociobcr, 1891. Buonan. On Aphakia or La&& of Speech, eic. London. 1891. Adbr. Bding lur KcniitniH der tclicnen Formcn von KntoriKhcr Aphasie.
NenroL Ceniralbl., 1891, 10. 11. BUnchU Contribute) clinico ed ututomo-patolosico alia dottrina delU ccciia
vcrbale. (AfoaU otlKiil AnnaL dc Nevrot.. Nuoia Set., 1891. Freud. Zur AuiTawiung ilir Aphasien. 1S91. MueU. Berliner k)in. VVochen&chr. 1890, 17 ; and r89i. 48. Lowcnlcld. Ueber iwei F&lle von amnc»ti»chct Aphasie ncbsl Elcmerkungcn
uber die cenualen VorgMnfie beim Le»en uad Sclicciben. Ucuiiclie Zcitschr.
(, Nervcnhk.. 189J, CoUtMrhrMhr. Iterlincr klin. Wochcnschr.. 1891, 10; 1891. 4. ttck. An.l>, t P»rch.. 1892. xiiii, 3. Lnchtenucm. Ucher die SotiicibwciK LinkshXndiger. Deutsche mcd. Wo-
chcittchr.. 1891, No. 41. png. 942- Simoa.J. Ueber oinnenlische Aphuie. Inaug -Dissert., Berlin. 1891. Sachs, Keinrich. VorlrSgc iiber Bau und Thtkiigkcit des Grosshims und der
l.chre von der Apluiic und SeelenbUndltcil. Urcxl.iu. 1693. CuUitunn. Vottckungen utier die Sibruiigcn der Sprache und ilire Hcilung.
Berlin. 1 8^]. CouM). Zwa F>Qle von Aphosie. Arch. f. Pq-ch.. etc., 1893. xxv, i.
KnoUuch. Ueber Siorungen der musik*IIu:hen LebtunicsrahiKkett in Folge Tun HimUUionen. Dcuiichcs Arch. T. ktin. Mcd.. 18S8. xtiii. 4. $.
KJUt. Ueber mtisikalischc btorunj^en bci Aphn-iie, Neurol. Ccnimlbl.. 18SS. 14.
Oppewbdm. MusikaliKlie Au§ilrui:k!il>ewe|;un|[en bei Aphasie, etc. Scliinidl's Jahrti.. t8>/i. cciit. Mcfi 8.
Kunn. D«e Tonlaubheit. Wiener m*d, Woehenschr.. 1893. 9-13.
TndteL Apbask im KinUrsalter. Volkinimn't Snmml. klin. Vortr., 1S93. &4.
We have re|>cate(lly pointed out that the motor disturb- ances produced by cerebral diseases are either due to destruc- tive or irrilaiive Ie5i<ms. The farmer consist of paralyses and pareses, the latter of involuntary movements in different groups muscles — ihc sn-c.illcd spasms. Those disturbances which
dtK to affections of the cortex (cortical motor disturbances)
tS4
D/SEASES OF THE BRAIN PROPER.
present much that is characteristic and interesting. They nil! be considered presently.
The motor centres, the motor area of the cortex, comprise, as has been stated above, the two centnil convolutions, the puracentra) lobule, and the parts lying immediately adjacent. Upper and lower extremities, neck and face, have their own
T
k
I,0ilitml»riiivlaa
Pbiu
"^^^^^^^^ \
Vj-Vrtt — ■.-.jvi, 1
&r~£r'i£.~*il'*'^ Conical Alivt fpvyciin-
I ^— • ^M PifnnMil met.
■ -^— Frontal eQrliD>p0niln«
UvkulL \
_. — i>^^ T(aipiitiMM(li4»1 I'll! I- 1 cv-psnliM UKituli.
bpsnliM Anu uhI p«t. nrcbellu. poo doc laKiculi' ' T«cni4niat mdixion anil lup. peduncle of «tit- bcUuin. ■ Ana hnriculirU.
t
F%. 46.— DiAORAM fflKm-iKO TMK DiHKL-T SrinXH or FmHsa (Ft^nuia, :
Special centres, which are distinctly separated from one an. other in the central convolutions. Thence fibres converge," as is shown in Fig. 46, into the anterior Hvo thirds of the posterior division ol the internal capsule. One thing at once becomes apparent irom this arrangement, namely, that in cor- tical lesions the paralysis or paresis may easily be confined to one extremity, an arm or a leg, while ii the lesion aOccls
CORTICAL MOTOR PASALYStS.
185
^
^
the tract lower down in the brain — for instance, in the region ol the capsule—the paralysis must extend over the whole hall of Ibe body. A paralysis of one extremity only is called a monuplegia (monoparesis), in contradistinction to a hemiple- gia, which means paralysis of one side (half) of the body, and it is a perfectly warrantable conclusion, sufficiently confirmed by post-mortem evidence, that, if the patient presents a paralvMS d only one arm or one leg. we are dealing with a cortical lesion. A hemiplegia is only then likely to be of cortical origin if its dcvclopmeril indicates that liie lesion beginning in one motor centre has gradually encroached uponanother. Ilgoes without laying that in diagnosticating cortical lesions we must not rely on a single symptom, but all must be considered, and especial care must be taken not to confound a paralysis of cortical with ooc of peripheral origin. One great distinction between these two is to be found in the maimer of onset. While a paralysis of. cortical origin may develop quickly in a few hours, a periph. eral one will be more gradual, and only reach its (uU extent after weeks or even months. Moreover, the latter, the periph- eral, is easily recognizable by the changes which lake place in the electrical excitability — c. g . if reaction of degeneration and visible atrophy in the muscles can be dcmonsiralcd. The ab- sence of cerebral symptoms, which are rarely entirely wanting in cortical affections, is also characteristic of peripheral disease. Great pain may be entirely absent in the central, but is com- monly present to a greater or lesser degree in the peripheral variety. Remembering, then, these points, and making it a routine practice never to omit the electrical examination in doubtful cases, we are not likely to make an error in the diagnosis.
In conical lesions the loss of motion is usually not absolute, and we find more frcciucntly a paresis than an actual paralysis. The disorder docs not necessarily affect a whole extremity, an arm or a leg: it m.iy be confined to the distribution of special nerves, or even to portions of these, the so-called dissociated hemiplegias {cl. also Pick. Prag. med. Wochenschr., 1891, 25-27). Sometimes the affected arm or leg can be moved in Mo, though a strong effort may be required, and it is only in the fingers and toes thai the loss of power is complete.
A characteristic symptom is the inability of the patient to execute complicated movements, such as buttoning his coat, cuunting money, and so forth, acts which are performed awk-
186
D/S£AS£S OF THE BRAIK PROPER.
wardly and with difficulty, owing to a loss of the motor im- ages. This condition has been called ataxia, and in these cases we have a " cortical ataxia." The lesion has to be referred to that part of the cortex which contains the sensory area {fuhl- sfiAare oi Munk) for the aflected, that is. the ataxic extremity. The trouble is very dislrcssirig lo a patient in a brachial as well as in a crural munuptcgia.and becomes almost unbearable il the sensory disturbances, which we shall shortly describe, are super- added (of. lit., Observations of Bernhardt).
In infective tumont, gummata, Itibcrclcs at the surface ol Ihe brain, we occasionally meet with symptoms of irritation, such as monocontractures, which depend upon an irrita|ion in the correspond! rift portion of the motor path (Wernicke). They are not seldom accompanied by sharp pains. In such cases the difTerential diagnosis between a hysterical and a true organic cortical lesion may cause considerable difficulty (cf. chapter on Hysteria).
Of the greatest practical importance are the epileptiform attacks which occur, either'with or without loss of conscious- ness, as a consequence of direct or indirect irritation of the cortex. |[ they occur in the further course of the monoplepia, the onset of which was apoplectiform, the diagnosis of a corri- cal lesion can be made with a high degree of probability. In some cases the convulsions are not general, but only appear as localized twitchings or spasms, confined loone half of the body or one extremity ; they may be clonic (that is, an alternation in quick succession oC contractions and relaxations) or tonic (that is, steady contractions lasting for some time), and may be of considerable intcnsiiy : their occurrence later in parts already paralyzed would indicate a disease of the bruin surface, though we m.iy not alw.iys be able to say whether the irritation of the cortex depends upon a direct or — as, lor instance, in tumors, which cause an increase ol the intracranial pressure — an indi- rect action. In the latter case, also, general or partial convuU sions may ensue.
The use of the term cortical epilepsy (or Jacksonian epi- lepsy, after l-Iughlings Jackson, who first described these con- ditions) is liable to give rise to misconceptions, and it must be remembered that the so-called cortical epilepsy has nothing in common, except the name, with the classical genuine epilepsy.
The epileptiform seizures due to conical lesions show cer- tain fundamental differences Irom the classical attacks. Con-
COK17CAL MOTOR PAXALYStS.
187
•
tciousness is retaitied, a feature which ^vcs the whole attack an entirely diflercnt aspect. A ceriain kind of aura occurs here also : the |ia(tenl knows when the convulsions are coming on, cither by slight twitching in the fingers or toes, or by (op micaltnn and other symptoms, which occur only in the nlTected cictrcmity. But all the other symptoms — the cry. the fall, the biting of the tongue, etc. — arc absent. The p-niient sees and watches the twitching of his extremity: not rarely he has x'io- lent pains; he tries lo hold the extremity in a fixed position or asks others to do so. and attempts tu avoid injuring himself. After the convulsions he feels weak and unstrung, but oidy in consequence of the increased muscular work. Headache and all (he various post-epileptic syniptoms arc absent, or. at any rate, are not connected with the attack as such.
The degree, the duration, and the frequency o( the attacks vary considerably; sometimes only a more or \c^ marked twitching appears in the affected limb; sometimes, however, the attack manifests itself in shaking movements, which may become so violent thai the bed shakes and the patient anxiously cries lor some one 10 assist him and to hold him. If violent pains have been present during the movements, they are ivont lo persist alter the attack, and, combined with (he motor weak- ness in the affected extremity, are often productive of great sufTcring. The duration also varies. I have seen cases in which the attack was over in from a quarter of a minute to one minute: on the other hand, I have seen instances in which it has lasted (or a quarter of an hour. If such prolonged attacks occur .It frequent intervals— two, three, or six limes a day—the state o( the patient may be very pitiable ; and, indeed, the car. rying on of the individual's occupation may be interfered with by this partial epilepsy much more than it often is incasesof the classical disease. In other instances months intervene between the attacks. The whole course of the malady is eminently chronic : the patient may suffer for years, or lens of years, with- out there being any other symptom present. Death occurs rither from an extension of the brain lesion or as a result of »«>rae intercurrent disease. Pitres has called attention to the fact that so-called equivalents may occur in Jacksonian epilepsy also, and has pointed out that they may be of a sensory or of a pftvchlcal nature (Revue demW., t888,viii): the former belong to Charc'it's ffiUfsU partieHf sensitivf (Lemons du Mardi h la Salpctri6re. it^. pp. 2oand 368) ; the latter manifest themselves
1 88
J>/SSASES OF THE BRAIN PROPER,
in visual, auditory, Dr olfactory hallucinations without any marked signs ol motor irritation.
With reference to the diagnosis, it should be mentioned that, jn<tt as in the case of genuine epilepsy, cortical epilepsy may be simulated by urxmic attacks if the latter arc confined lo one side {Chauftard. [)e I'ur^mie convulsive ^ forme de l"£pt- lepsie Jacksoniennc. Arch. gin. dc mid., July, 1897). Fur- thermore, attacks which resemble very closely those of Jack- ^nian epilepsy may occur in hysteria: in these cases the >rcsencc of other hysterical manifestations will prevent an error in diagnosis. Mendel has repeatedly observed cases of general paralysis in which Jacksonian epilepsy was the initial symptom. The foci which were found at the autopsy were in each case situated in the right psycho-motor region, and the (paralytic) speech disturbance occurred in the terminal stage. whereas usually this is one of the early symptoms o( general paralysis.
The sensory disturbances which are produced by the aflec- lions of the brain cortex arc remarkable, and by no means fully understood. As we have seen before, they do not, as a rule, cause pain, but rather manifest themselves in alterations ol sensation, known as parscsthesias. Thus the patient may speak of a curious numbness or dcadness; or, again, he may have a sensation as of anis crawling under the skin, a feeling as if the part had gone to sleep, etc. There may also be a distinct in- crease in p:iin perception, a slight "analgesia," a diminution or loss of pressure, touch, and tcmpcralure sense, and oftcncr, as it seems, in disciises ol (he parietal lobes a more or less pro- nounced disturbance of the muscular sense, in consequence ol which the patient can wiih closed eyes cither give no account at all or only a very imperfect one of the position of his ex- tremities. If, as often happens, the above-described awkward- ncss in motion (ataxia) coexists with these changes, we may be tempted to refer the trouble not to the cortex, but to the spinal cord ; more especially arc we liable to think of tabes, although the ataxia is produced in an entirely different manner in the two diseases. However, the differential diagnosis will in most cases present no dilTicuIlies if we take into consideration all the symptoms, and examine into the condition ol the patellar re- flexes, the reaction of the pupils, and ascertain whether there lire bladder symptoms and whether lancinating p.iins are pres- ent or not. These sensory changes, we must not forget, are
THE CENTRUM OVALE.
189
by no means always observed in cortical lesions, and in the cases in which they existed the white matter of the brain has o(ten been found to be likewise the scat of disease; they are tbcFcfure in no way to be regarded as pathogiiomaiiic, and we hive to be cautious in using them (or diagnosis. The same is tVCBit lo a greater decree of the vaso-motor and trophic changes, 1 fclalion of which to the brain cortex is still obscure.
SyMfifoms Referabit lo LesioHs 0/ the While Matter of the Hemispheres anii {jsifHS of Ike Hasal Ganglia.
looking: at the anatomy of the parts, wc notice that the fibres
mniTii; (mm the cortex pass through the while matter of the hemi-
Dhete, which in the region of the frontal and parietal lohes is
Fronts lA*
»f inlmuU cajmult
AW.
PotUrior liat tmpnJt
A'uel eaudat
I
nf.ft.—roKmKt>w mi FintiRS ntoM the Intciuial CAr«t*LB to nii Cuvs Cebbbm, Tte Ifcahiini i» rcjimcnM » tnnsi-ucni. (Dlatp^uDOHiK ifur WKHHiciCit and Cmmmk.)
detlsnated centrum scniovale Vieussenii. Turning toward the hrain- ttvtn, in Its nciffhborhood they appear arranged in bundles placed •idc by side, completing by their convergence what has long been knowfl at (he cotuoa radiata. VVith thit, corona radiaia begin* the
190
J>/S£^S£S OF THE BRAtN PROPER.
eat nerve tract which connects the hemispheres with all parts of the tiruin situutcd lower down, and finally with the spinal cord. That |)art of the medullary path through which the corona radiala is con- tinued into the crura cerebri is called the internal capsule. As is seen in Fig. 47, this is situated anteriorly between the caudate and the lenticular nucleus, posteriorly between the lenticular nucleus and the optic thalamus. The point where the two segments meet is called the genu or knee of the capsule.
Venfiic. tatrr. f'ffifrift ttpt. pttlue. A'urf. eaud, Tornu
■Comoiit$. antrr. Commin. m^ia Tania ttmifireufant Thalamta CuHmiM. potfr. — Piimalflmd JPuleinar Oorpiint
fig. 4S.— View op thb Vehtxicles on Horizontal SBcnov. (Atier Eodkikjc)
From the internal capsule the Tibres reach the crusla (pes pcdun- culi cerebri), whence they pass through the lower (anterior or ven- tral) portion of the pons and enter the medulla oblongata as the anterior pyramids. At the lower end of the medulla most of tbem decussate and pursue a downward courtie in the lateral columns of the spinal cord on tb« opposite side. This, the most important of
THE INTERNAL CAPSULE.
191
all direct syMcin« of fibres, was discovered by Oeiters in 1865, and tnMt carefully studied by FIccIimi; in iS;6. It is generally known IS the lateral pyramidal tract, and it represents the path for the voluniary movcmcnU. A lesion of it is therefore of grave conse- quence fur the motor functions.
tig. 48 reprenents a horixonlal section which shows the relative poiition uf the caudate nucleus to the optic thalamu», the corpus callosum, the fornix, the two white commissures, the anterior and the posterior, the gray middle commissure, the pineal gland, and the corpora quadrigemina.
fig. 49 is a third horizontal section through the cerebrum at a lower pUnc. Both are taken from l!^diiiger.
Tbnite
nf. «o^-KoaBOirr«t Sbcthmi iHULnjoK no ItMAm. Kvtvrc k PinckkI BsKAorn
■BLOW 1HAT lumKKLMl.ll IM t lO. 4S. itUINOkll.)
F>S^ 50> 5t, and 5a arc three so-called frniital 8ection^ of which Ihe first is made ihrotigh the anterior commissure, the Kecond In front of. Ihe third behind.'the middle (gray) commissure. They also fthow Ihe courK of the internal and external capsule, and the situa- tion of the so-called ba»al ganglia, the c;iudatc and the lenticular nii- ^clcus (together known as the curpus striatum), and the optic thuUmui,
192
DISEASES OF THE BRAIN PROPER.
In another frontal section, Fls. 53 (after Edingcr), the dirccti' of the fibres is illustrated diagrammatically.
S^t, ptHue.
Jfurl. rtmdal.
Capf. int.
2lucl. Until
Qenutrvm
nes*
Pities has Tccommendcd a eeries of frontal sections iii order licilitaie in our descri))tions of autopsies a more accurate locali
Jltut. emiA
CarpM rtlhuUB Cntm /»r*. TJiaimn. Jntwta CapK tnt Xiiel. Uutiform. Cfipv. trt. Clatutr.
Ton of Iniona and tumors within the very extensive whiti
of the brain, Nothnagel has modiTied somcwtiat thcae scctiotu
PITXKS- SF.CT/OAfH.
■93
Pilres with regard to their position and desiKDatinn. The table on page 194 contains the necessary explanation. With the help of these MCtions wc need not content ourselves any longer with locating in the
K*r7. eauJ.
TMamtm
CiimmiB*ra ■»<<:
ttKTfnUMft.
/MgAacU.
!■"■«- S*
.9»-S.i.— So-e«LtJ:i>"Fiio!iT*(. Scn'iDMs" Tnmovom Tint Rraih. PIc- <to, ikraoth iJkc anictlorcoincalaure. t'\g. $'■ 1° '"■■>! °l nie middle commluure. h'lc. m. btbiad ilv middle commtaurc. ■''tc. 5.1, ImmedUlely Uhlnd Ihe chUsm. Tbe ndiuing Abn« arc ihown dli^cTaotniaUcallx In Ihe lut lUDsirailoD. (AHet KDinom.) •3
19+
D/SEAHtiS Of TIIH BRAIN PROPER.
post-mortem accounts a tumor "in (he anterior part of the brain," "in the temporal lobe," clc, but u-c give the one or more sections which coiicspond to the situation of the ncoplusm, and so attain an accu- racy which IS indispensable fur the after-use of our autopiiy record*.
PITRE-VNCITHNACEL fltONTAL SECTIONS.
|
DMiBHUioB. |
PdIbu whMc ntilou Me mtAt- Immediairly in rrant of nenu of torpus calla- iiUm. |
CiIM by Ptm* |
rnin|iiim ■ dliii im N«hnta*l, |
|
A |
C<]u])« pr^fraiiialc. |
C«nlri ovalii pan fron(aU> anterior. |
|
|
B |
iiuining «I ihe bcginiiiii)* of litMirv of Sjlviu). |
1 Coupe pMiculo> front «Jc. Coupe frontal*. |
Pws frontolb media. |
|
B, |
BetWMn anierior ecn- ■rml and frontal cod* volationk. |
Pan fronlaJIs |>OTiorio«. |
|
|
C |
Through die litnire of RolandoL |
Part ccninti» aDlcilo*. |
|
|
D |
Ttuongh ascendins parie- la] convojuiion. Through pancul lobo J nn. poslcrior to tJw fiuure of Rolando. |
Coupe pariAolc |
Pan oeotntlit pmloior. |
|
E 1 |
Coup* pMlculo-pa> iteta1«. |
Pan ptrUtaUi. ^- |
|
|
F |
Thiouch occipital loli«. |
Coupe occlpltalc. |
Pan occlpltaUt. |
Fit. S4-— POHTTS AT WinCIt TRR FlTkltS-NmtlHAOKL SRCnOBS AKB MAEIB. Thl^ (Jl
ran parallel witb (be fiuufE of Kotando.
Figs. 55-^10 repreMfiii diagrammatical ly Pitres' sections. From Fis. 54 vre can ^et an idea of the points on the surface of the brain
iSS/OJVS Of CENTRUM OVAi
195
It which the sections are to t>c made (cf. i'itrcK. KechercheB sur t«» Itxionsdu centre ovale dcs hifmisphires c^r^braiix 6tu(li^sau point dc ne tics localisations c'6r(bTjles, ['.iris, 1S77).
,1
!%ciclllill A.
^ SS-— k I, ^ fini, woond, uk) ihlid [tonul omvohiUofiA. «. prxlnaul (uckuliu of
ilw wotrum «nilcn«le.
' WTeean likcwisi; avail ourselves of the charts of the human brain Published by Exner (two plates, with twelve UuigiumN Wicti. Brati- """!«=», iJ(S8). On the plates the disi-ovcrcd lesion (:;in lie easily
^''•cciJoff, and thus the extent and situation of it rcprc*enied.
ScMion B. tB, NolbiiJi:*!.)
(^fl—f Md ^ i*M lad Hcond Ironlal fOQTotocloni. ^ aAiA\i pcdleulo-fKiDtil (Mdra- hk «, ootpos cttbann. ^ Budcui »udaiuL 0. Internul cifinilc. 7. Icnlkuki nuckiK I, Um4 of RaiL ft, Ki. 11, nipertor, luddle. Mid Infarior Irooul fkioaill.
With reference to the lesions in the centrum ovale. !t should 6c itated that, as a rule, the symptoms produced by them are MBitar to those which we find in lesions of the corresponding
DISEASES OF THE BHAIN PROPEK.
SnnioaC.
Flf. JT' — '> 1^1 (maul coavolulinu. a. .<(, 4, luperior. middle. And iafirto* (rontal ftKfcoU. 5, cupiu callomiD. (•. nudmi UkudMiu. 7, ofAtc ituUjuuuiL S, IdUtiuI capmlcu $• k>>' tknbr nudeiu. ■<>, daustrum.
area of the cortex. Thus we shall meet with motor disturb- ances if the fron to- parietal fasciculi of the corona radiata, which
Sectiou u
rie- $3.— >, anierjor milnl conmlutlnn. a. oorpui catlsaum, .1, caiKkto noclaH- 4. op<te Ihilamiu. s- ■"'cnikl <ap«iile. ft, iskod of Rrii. ;, lenliniUr naekot. B, Mttnul <ap«ile. % tompcitiil CobcicuIu*. va, n. ti, «up(ri<>r, middto, inlnior parteUJ lockuB.
LESIONS OP ceyr/tt'M oyAi.E.
W
nke their origin in the motor area, arc diseased : while lesions in the prefrontal or occipital bundles may, and indeed vcrj otien do. not evoke any symptoms. 1 1 the left (inferior) pedic>
SKtiim v..
I> - 1. luf ilaf pvinil tua-iculiu. i, («qnu Mlliouni. j. iuirtvyt pirwu] rucKUlUi. 4 uxlA, caudklc nuclciu. 5. optic Ihalamut,
■'lo-fxonlal bundles in addition are affected, the patient will ***> be aphasic, the aphasia, however, being of long duration ^^^y U the lesion extends close up to the cortex. Lesions ia
SMtiiHl V.
to— I, ocdplttl ooBraluliant. 1, oodiiiul (*iirkuluB of ihr ominrni Minlnnlc. &)-to— FtrBB^NOTUMAOCL iiEcTiOHs, Uic poMiiun 111 which ii muk (icu \tf Ibe
tlir white matter of the occipital lobe may produce hemianopia, iotbe temporal lobe auditory disiurb:inces. Whether, however, diKUCs in the parietal lobes ever produce sensory changes —
iqS
DISEASES OF THE UKAIN PROPER.
an;esltiesia, for instance — and whether, as a consequence of any lesion in the cenirum ovale, vaso-motor-trophic changes may be developed, is unknown.
The idea that the basal ganglia were true motor centren, and that the common form ol hemiplegia was due to lesions thereof, has been given up, and we have learned irom the investigations oJ Flechsig and Wernicke thai direct connections between the motor Lcntres of the cortex and these basal ganglia do no! exist. Moreover, it has been proved by numerous thoroughly reliable observations that destruction of (he lenticular or o( the caudate nucleus does not necessarily give rise to a motor pa- ralysis. One or bolb lenticular nuclei have repeatedly been found destroyed in cases in which there was no sign of paraly- sis (L(^pine. Nothnagel. Ediriger, Heboid). In order that this may not ensue, it is only necessary that the internal and per- haps also (lie outer capsule remain intact. As soon as the for- mer (the inner capsule) is eitlier directly or indirectly im- plicated, we have a hemiplegia which is either transient or persistent, according to the nature of the lesion in the capsule. Whether the lenticular or the caudate nucleus alone is diseased can not be determined from the symptoms.
There is no doubt but that lesions of the thalamus, espe- cially of its anterior and middle part, may occur without symptoms, and it is impossible to say whether motor paralysis is ever produced by lesions of the thalamus, for in all instances in which this may have been the ca.sc the motor paralysis may also have been a result of damage to neighboring parts I pedun- cles, internal capsule).
Better founded is the idea that lesions ol the pulvinar, the posterior part of the thalamus, give rise to defects in sight — crossed amblyopia or homonymous bilateral hemianopia; but the possibilitv that the posterior part of the optic tract is inter- rupted can even then not be excluded. The athetoid move- ments and symptoms of motor irritation (hcmichorea. post- hemiplegic tremor, athetosis) are, even if a connection actually exists between ihem and lesions of the tlialanius(Greif, cl, lit.), certainly not characteristic of such lesions. The same holds good for the disturbances in the muscular sense which have been observed in diseases of the thalamus (Meyncrt. Jackson). The relation between these latter and loss of the movements of facial expression in the course of central facial paralysis has been spoken ol tn Part II, Chapter V. Recently Nothnagcl
THE COKI'OKA fiVADRIGF.MlNA.
'99
has again published a clear case of this kind (Zeiisch. 1. klin. Med.. 1889, xvi, 5. 6. p. 424).
lycsions of the internal capsule produce symploms varying according; as the anterior ur posterior limb is attacked. Pure capsule lesions — i.e., those in which the caudate as well as the lenticular nucleus remain intact — have rarely if ever occurred. Fissures have been occasionally known to occur without hav- ing necessarily produced any motor disturbances in life (cf. Nolhnagel, loe. cit., p. 273). The functions of the anterior limb of the internal capsule arc obscure, and lesions of this pan do not produce any symptoms. With the posterior limb we arc better acquainted, and. above all. this one fact is well estab- lished, that » lesion of the anterior two thirds of the posterior limb gives rise to the usual typical ht-tniplcgia. with paralysis of the lower facial branches. A very small lesion at the knee may produce an isolated facial paralysis. H the posterior por- tion of the anterior two thirds is the chief seat of the disease, the paralysis is most marked in the leg. The posterior third of the posterior limb is occupied by the sensory fibres (/<■ farrt' four sfHsili/oi Charcot), and lesions of that region cause a loss ol sensation on the opposite side o( the body (" hcmiana^sthe- »ta," Oppenheim. Charit^-Annalen. i88g. xiv. p. 396), in which often the nerves of special sense arc impticatcd, and hearing, smell, and taste (on the anx-stheiic side) are. if not lost, at least diminished. Often hemiplegia is accompanied by hcmian.-es- thesia, because, if ihe one portion of the capsule is aflcctcd. an indirect and transitory implication of the other may occur. Usu- ally such a hemianitsthesia soon disappears in the same way as Ihe indirect motor disturbance often soon passes off in cases of persisient hernia na'sthesia. Whether the symptoms of motor irritation (the so-called posl-hemiplegic chorea, for instance), which arc a not rare accompaniment of hemiplegia, are due to disease of the inlernal capsule or to disease f>i the neighboring basal ganglia, is as yet undecided.
By the corpora qu.-idrigcmina wc mean that peculiar eminence which by a crucial furrow is M:paraicd into four parts (bodies), and torm» the potiterior homuUry of ihe third vcncrielG. In front it is bounded by the commissure whirh unites the two thalami-, nn it rests the pineal gland {cnnartum). The anterior pair of brKlieH, which are called the nates, are larger than the posterior, the testes. The appearance and structure which these two pairs of bodies pre- Knt III the lower mammals, justifies the cuncliision that they are tu-
300
D/SEASES OF TUB Bit A I. V PXOPBfl.
tally different from each other. Above the corpora quodrigemina is Mltinlcd ihc splcniiim of the corpus callosura ; between the two is the transverse fissure of ilichiit (ihe fiKKiira choroidca).
The frontal section through the anterior pair of the corpora q u 3d ri gemma (Fig- 6i) shows the three divisions: the cnista, teg- mentum, and qiiadrigcminal ganglia. Toward the outer side is the pulvinar, with the lateral geniculate body. Emerging below the pul-
Carp. ^mlA A»t. mrpBra ,„f^
Atf. kmffiliJ. tuiuBr
Heti nliefeuf
Tig. 6t.— DlAOWLMMATlC CKaa»«£CTIOH ntHOlfOH THK ANrBXIOM COSPORA QUAPRI-
alMiNA. (After f.ninoRR.)
vinar i» the crus, which contains the pyramidal tract. Between it *nd the tegmentum, in which is seen the red nucleus, is situated the sub- stantia nigra. Uelow the aqueduct arc the root fibres of the motor oculi, and in characteristic transverse section the posterior longitu- dinal bundle. The position of the latter is miide still clearer io the longitudinal section rei>rekenied in Fig. 62.
The manner in which the fibres from the red nucleus pass under the posterior pair of the corpora quadrigcmina toward the middle line and then decussate with the fibres of the opposite side — the mj- called "crossing of the brachia conjunctiva" {»up. peduncle* of the cerebellum) — is represented in Fig. 6j,
Isolated lesions of the corpora quadrigemina arc almost ds rare as similar lesions of the cupsule: nearly always neighbor- ing stiiicturcs arc implicated. The data which we possess in this connection seem to indicate that lesions of the anterior pair produce visual disturbances, amblyopia, amaurosis, and toss of
rZ/JT COtlPOttA QVAOttlCeMrNA.
201
;)U[)ilbry reaction. Fliysiologically imporlant is the (act that a root going to the opttc tract is given ofl from this anterior
I
'k- te— IjOHDimiiiMju. Sat-nox TKiKvucti ttiit RKcron of riiii Cobpox* (>u»d«i- oeatKAor • Hmus Fotrt's Twi:<rn--(ioMT WEicn Oui. (Afto Kl'Ikuem.) SIioh« Ukw Ik poMolDc loDKMudUuU bBodk tmniiuHs in ibc Duckiu of ihc (culo-mouit ii«n«.
P*'!". and that radiating fibres pjtss to the niicicus of the third "cvc, so tbat a connection exists between stimulation o( the
ng. ty—DmatuuHmATK II(Mi»m>t4i StK-iinx TKMovOM -me LdtLVMAriOH op thc SumitiM PUKtHcua ur ttit, Ci-HtnuxUM. (A(Ur Enmou.)
302
I?/SeAS£5 Of THE HRAIK PROPER.
nplic nerve and slimulaiion of the oculomotor (pupillary re- Ilex) (Mendel). Authors seem to diflcr, however, abfiut the extent lo which this reflex 13 influenced by disease of thi; ante- rior pair o( ilie corpora quadrigcmina. Impairment o( certain movements of the eyes, especially the upward motion of the Ixdl, has been repeatedly noted by competent observers (Cow- ers). Xolhnagel assumes that a lesion of the same ocuto-motor bmnches on both sides, without the existence of an alternating paralysis of the extremities, speaks for a lesion of the corpora quudrigemina (cf. loc. ti4., p. 230). As to the function of the posterior pair of the corpora quad ligcmina. all explanations arc uncertain and hypothetical. Baginsky assumed them to have n singular significance for the ear. as the anterior pair for the eye — an idea in support of which further evidence is needed: and the disturbance of equilibrium which has been ascribed to disease of these bodies, and which recently has again been studied by Eiscniohr (Deutsche mcd. Wochcnschrift, 1890, 42). may well be produced by pressure upon the neighboring ver- miform process of the cerebellum. On this point nothing posi- tive is known.
TV"
I optirt/0
^■-.
LmutUem tnul
PyramiH'J rrmtt lo
Kit- 6(.— SMITTiM. SKCTION TirRODGII tto.is AKI> W«DVI.t-* OOUJieOAT*. (Aftof Mt»-
DKl~) /. anivriur lonimiminL f,, pulvlnar, i. iuIbUDIU bier*, r. Icirmentoin ol cnii r*rrbn. r,, nd nuclvuK. /, [•» pcilunculL a, poiu. r. hn»Cloa>u> nocleat »ilh fihrw FnuTC>n|: fnmi iu «i, corpiu <iu«dr(emilnum jinlcrliu. "^ oortK"^ quadripaii- num pcBteriiu. >, ann ItnliruUii*. 1, Vici|.d'Affr'i bundle a, 4qHli; rnut. A|. «Mn^ nil ttulannn-mnt of opHc tract. *«. inunMl ItuUmiw-raal al opilc iraci. v, uUvary bnHy, «. ikntfiriar pf nmid. t. poAerinr hiaglludtail bodjr. If. Icxus cxnikm. ». m, valve iif VlvUMm*. m. t, MpfnartH bundk. at, abduocns nudeui vlih rmptElnc llbtw. M, nperior pnlunck of ronbellum. iv, ocuto-mouw nudnu ailh «in«)£in|; fibres.
The crura cerebri emerge (rom the pons Varolii as two thick cylindrical white bundles of fibres; on leaving it they diverge.
ISSJOJV.I O/-' THE CRURA CEREBRI.
»i
ing between them the posterior perforated space and the corpora nibicantia (mam miliaria s. candicantta). The situation o( the crusta and the tegmentum, and the masses ol fibres con> laincd in them, is unce mure shown in Fig, 64, which represents 1 longitudinal, sagittal section made almost in the middle line Kicgmcntum ; 5, substantia nigra; /.crusta). That the crusta (arms the path (or the voluntary, the tegmentum the path for the rcHcx movements, and that the latter also contains the sensory pathM, as Meynert assumes, has not yet been proved by physi- ology. That the crusta. however, contains the motor path — naely. the pyramidal tracts— is a (act established beyond doubt ; hence its lesions will (or the present be of more prac. bail interest. Only a small number o( instances of lesions in tke tegmentum have been reported, A case of Buss (cf. lit.) ted ataxia of all cxtremitic-s, ana:s- ytto..
s, disturbances of tbenuscuiarsensc. and nalection of the right lirpogloKSUS. At the wop&y a local lesion ■» lound in the teg- ttenrnm of the crus ud the pons.
Considering the re*
UIoo which the third
W'TC bears lo the mc-
diu \»t\ of the crus
crcbH, as is shown in
% 65. we can well un-
drruand that in lesions
of ihc tatter the oculo.
niiitor is not rarely im-
plicaied, and autopsies
hafe frequently demon.
Untcd tliat wherever
jfl oculo-motor paraly-
sa tuu been associated with paralysis of the extremities on the opposite side, the lesion is situated in the crus cerebri. For esample. in a patient with oculo-motor paralysis of the right aide and hemiplegia of the left side (if bi^th come on at (he time!), we may without hesitation diagnosticate a focal
Fir 65— Caow wxmow niMUoii tiii: KroMd or
THR AirnttlQM COHrOHA QuADHiaKUIKA. fW.A,
■Mrriot tnfpora qiudrlEOUllw. f. r.. ^jwj mUUf uoynd ihc aqueduct ol S)>lvtiu. «f.. ariuedDit of SjrU ttoi, ■///. nudrui of thf ihlrd nem. kl., posterior lonptudiaal hundlc. r. »., rod nucleus (tctcnwoUim). nr, lubKsnUa oiRn (locui nicM«. /. ctntinl pe- duncl*.
204
DISEASES OF THE BKAIN PXOPKK.
lesion in the right crus cerebri ; if, in addition, anesthesia exists on the paralyzed side, an implication ol the tegmentum must be suspected. Mendel has called attention to the (act that patients with tumors of the crura sometimes urinate frequently. How far this observation may be taken as confirmalory of the view of Budge, who holds that the centre lor the secretion of uriiie Is situated in the peduncles, future studies will have to teach us. The pons Varolii, which coimccts the two hemispheres of tbe cerebellum, contains, us wc have said above, the nuclei for
several nerves and the fibres passinj^ from them to the brain. The nuclei, which are situated in the upper seg- ment, are those of the fifth, the facial, and theabdiicens. Since the pons natu- rally also contains the motor fibres, situ- ated, as we said above, in the lower or ventral segment, while in its dorsal part one meets the sensory bundles, pontine lesions may produce a complication of symptoms as characteristic as those fol- lowing lesions in the crus. As we have attempted to make clear in Fig. 66. the fibres of the facial nerve decussate higher up than the motor fibres of the pyrami- dal tracts. Keeping this fact in mind, wc can easily understand that a lesion of the lower part of the pons concerns the facial fibres after their decussation, the fibres going to the extremities, howev- er, before they cross, and consequently gt%'es rise to a facial paralysis on the side of the lesion, but a paralysis of the extremities on the opposite side (hemi- plegia altcrnans) (Gubler. 1^59). A le- sion ol the upper part of the pons con- cerns both of these paths before (heir decussation, and produces, therefore, hemiplegia, with a facial paralysis of the same side, which, how> ever, is distinguished from the typical hemiplegia in that the facial paralysis in this case resembles somewhat the peripheral type, as it takes in all three branches o( the facial, and as, though but rarely, reaction of degeneration may be present.
FIr. fi&— DIUCHAU SHOIVIMO ■niE DlCVUWTlUNtir THE
Fimiia 001 no TO TtiK
EXTkUMITICX, USD Or
TiiCNa: ooiHo to the
FaCK, I* TIIK VtlKt KHU llEDULUt OnLOKIMT*.. F
fjciol fihroL E. Abn* pv iii( Id ilie (iirtmitlei. /*, pOD*. tK mnlulU oblon- fMU. fyx, itociUMUaii of the p7nimld4l tncti. a. ■ foou tn ilie vpptf. A. ■ focus tn Uie lou'cr^ pari of Ibe pons (Ui« loilpt u iltu- Med belov ihc dniuuilon of th(i fitaii fitucti.
LEStOXS Of TUE CESEBELLUM.
ao5
I(, then, wc meet witli a paralysis which nfTecis the facial
on one, the Kxtrcmiiics oti the op|>ositc side (.altcmaling paraly-
|lis), simultaneously, wc are justitied in assuming the lesion to
situated in the pons, and more especially in its lower [jart.
tralysis first occurs in the face alone, and ricics not develop in the extremities until later, and if the whole process is grad-
»ual. it may arise from a itimor at the base of the brain. If, be- sides the symptoms <lescnbcd, the patient complains of pain tn liie (ace, the trigeminus is included in the lesion. A jKiralysis ol the external rectus points to the implication of the abducens nerve, in which case a paresis uf the internal rectus of the other fjdc not rarely coexists, so that a conjugate deviation of the eyeballs toward the paralyzed side — that is, away from the lociis^may occur.
Bilateral lesions of the pons must be thought of in com> _UMd paralyses of the extremities and cranial nerves, or in ul bilateral facial paralysis or bilateral paralysis of the citmnities (either of both legs or of all four extremities).
(The diagnosis, however, as a rule, can not be made with cer- tainty. Convulsions will be observed if by acute lesions the spasm centre, as Nothnagel calls it. becomes excited. Tonic spasms ia tlM paralyzed limbs arc not uncommon. Anarthric speech dltiurbances in bilateral affections of the pons have been noted b; Marlcowski (Inaugural Dissertation, Dorpat. 1890). Psychi- til changes, which occur in connection with lesions in the pons, •w very irregular in their <jccurrcncc, and assume the most L divmificd lorms. They deserve a more careful study than has H U ret been devoted to Ihem. Their entire absence has been ~ nfpMtcdly noted. Ana-sthi-sias in the distribution of the tri- ^ icminu), as well as in the extremities, are comparatively fre- B 9iKnt. but we arc not at present able to utilize them for the ~ purpose t»l topical diagmwis.
To enable us to |M>int with certainly to the cerebellum as ibeMat of disease, the implication of the venniform process is occcssary, since, as Xolhnagel has pointed out. we may have
tnieanivc disease in the hemispheres without the mnnilestaiion of a ftingfe symptom during life. In the cases, however, in irbtch the vermiform proiT&s is alTecied, marked disturbances of c<»-ordination and equilibrium ensue; the patient staggers and complains of severe vertigo on walking and standing, Thb U almost a pathognomonic symptom, especially if it be as-
MSEASSS OF THE BRAIN PHOPEK.
socialcd with occasional spells of more or less serious vomiting. Since, however, cerebellar ataxia may be absent in tumors of the vermiform process (Eisenlohr), we are not surprised that it is often very diBiciilt to make a diagnosis.
Lesions of the middle peduncles of the cerebellum produce highly characteristic symptoms, so that a diagnosis can be made with a fair amount of certainty. The body is involun< tarily gyrated around its longitudinal axis ("forced movement"). This symptom, however, can only be observed as a consequence of irritation of the peduncles, but is absent if the latter are wholly destroyed — c. g., by hemorrhage. Sometimes the pa- tient li.is an irresistible inclination to lie on one side, and this is, if the remaining symptoms point in the same direction, also to be estimated as a forced movement, or rather a ■• forced posi- tion." It is not uncommonly accompanied by a corresponding twist of the head and eyeballs. 'I'his phenomenon, however, is not a pathognomonic symptom for lesions of the middle pe- duncles. The direction in which the body is turned is some- times toward the diseased side, sometimes away from it, a fact for which no explanation has as yel been found.
For lesions of the other peduncles of the cerebellum (the Superior and inferior) no diagnostic points are known.
The loweat part of the ence|)haIon is called the medulla oblon- gata. It becomes continuous below with the spinal cord on a level with the lower margin of the foramen magnum. On its anterior (lower, ventral) aspect we observe the pyramidii with their decusM- tion, and the olives, while to the outer side of these arc to be found the restiform bodies, the inferior peduncles of the ceccbcUum. The last contain the so-called direct cerebellar tracts, which, coming from the outermost portion of the lateral columns in the cord, pass, through the anterior commissure of the vermiform process, to the cortex of the ccTcbcllum. That a relation exists between the olives and the cerebellum is apparent from the fact that wherever we have a con- genital atrophy of the cerebellum these bodies are also atrophic (Ftech«ig),
On the posterior (dorsal, upper) aspect is the floor of the fourth ventricle, the fovea rhomboidalis (Fig. 6;). which is bounded below by the diverginjt restiform bodies, above by the diverging superior peduncles of the cerebellum. The median columni are called the posterior pyramids (funiculi graciles), They are the continuations of GoU's columns of the spinal cord. To the tracts situated to the outer side of these the name funiculi cuneati, or Burdacb's columns* has been given.
THE MEDULl^ ORLOXGATA,
207
To diagtiosticale the medulla oblongata as the seat of a
sion is only possible if the nuclei in the floor of the fourth
Ventricle are diM^ased. in wbich case we get the clinical picture
[ol bulbar paralyMii. Other characteristic symptoms do not
[ciiu, and more especially it must not be forgotten that foci in
ht^— TiKCoMntCnOM OPIllECrHLUt l.l.l.'M -witlx. th* mMbr&Tn (■upnnnriwdun' iln). 5: '. Iht pooa (niditlc ptdunciMl. 7: c. (he mnJutU obluiiipiu (inlniiit pHlun- dB or raMlIonB ImiUmj. \ i, founh vcniricla. >, »i\w wuMiu. 1, luiiiculi (rmdln. % klDOnciB. R^ CDtporaquwIHip-miiiA.
iV RieHuIln may give rise lo a paralysis only in the extremities, •hich presents nothing characteristic during life. If, however, (lie nerve nuclei of the medulla are implicated, a characteristic picture is presented which can hardly be mistaken. Another putotol which, in making our topical diagnosis, we must not W sight, is the (act that certain brain lesions may give rise loasimiUr combination of symptoms constituting the clinical ^ure of the disease which wc have described above as pKudo-bulbar paralysis. Other diseases of the meduli:i — trau- Hutism, acute and gradual compression. hEemorrhage, and cm> ooliwn — arc of no prjictical significance, since Ihey cause death '''quickly that a certain diagnosis is impossible. Hence wc •fflpass them over without further remark.
LITERATURE.
OfHi Tkalamm.
Die Bedeulung der Sebhiii[cl auf (inind von expcrimcnlcIlcD un<l puholoKlwhcn Ditlni, Virchow's Archtv, 1887, ex, Krft 3, p. 333. K)ihrw. Zur CjuuUlik ikr SeKhugelaJliecUonen. Med. ObMienije. 1891.4.
208
I>/S£ASSS OF THE BKAfN PSOPHH.
1
(Russiiin. Tuinor in iht LcK Thalamus, with Loss of the MorcmflnU f< Facial Expression in ihc Op|)osite Side of ihe Face) Eisenluhr. Deul.ichc Zdlschr. (. Ncrvcnlik., r893. iii, 4. 5-
Cmra Orriri. Brivuiid. Dtgtncralions secondaim dan6 Ic P&loncuk cMbral. PublkatioM
do I'rogcis mid., 1879. TorioijcwkId. Zur I'alhologie des Gruuhtmschcnkcb. Inau{[.>Di«Mrl.i
Brcstau. iSiti. i
Schtadcr. Kin Cirasshirnschenkdhcrd mit sccunilKrrn Dcgencntionen d4
lYramidc und Haubc. Iiiaug.-Dissen., Halle, 1884. •
Lrubc. Dcuischcs Arch. f. klin. Med.. 1887. xl, i. p. 370. Buschke. 7.Mt CuiiiMik der ]1erdcrkninkung<:n det Himichenkeb, Inaug.-
Dissert., llertin. 189!. Bannister. Jouin. of Ncrv. and Ment, Diseases, i8c)0. xr, 9.
Pomi. Senator. Zur Dlagiuniik der HerderkrankungeD in der BfOdcft and den vcM
ISngcnen Mariie, Arch. f. I>s)%h. a. Nervenhtc. 1883, xlv. 3, pp,643<r«fii Bleuler. Zur Ca^uisiik der Hrtdcrkinnkungen der Bnicke. lnau|{.-Di!uert.|
Leipiis- 1885. Mcyw. Beiirag *ur Lchrc der Degentrationen der Schleifc, Arch. f. pRjrch, tt
Nervenhk.. 1886, xvii, a, pp. 439 et stg. '
Markowski. An-b, f. fsycli. u Nervciilik.. 1891, xxiii. a. Delbanco. BcliTJIgc tur Kyrnptnm.tiologie und Diagniwtik der Gochwiilste dea
Pons Varolii. Inau^.- Dissert.. Uerlin, 1891. Poncr. Hrit. Med. Joutn,. April 18, 1891. Btui^ch. Zur Ciuui-ttik der poniilcn Hcrderkraiikungen. Neurol. CenlralbU
1 891, I. DiDcr (Pittsburg), Amcr. Jouni. of ihc Med. Sciences, November. 1891. Moeli und Miirincsco. Arch. f. p»jch., 1891, ww. 3. Kolisch. Wiener klin. Woclienachr. 1893, 14. Siarr. New ^'ork Med. Record, February 6. r893. xliiL
CnrWUum.
KrauKt ITelicr TuI)crkclknoten des Cerebellum. Innug.-Dtuert.. Bcriin. r888/ Bposler, Frank C. Abscess of the Cerebellum following .Suppurative Otili^
Media. Philadelphia Med. Times. August I. rllSS. Gowen. Lancet. 18901 1, 18, p. 9SS, (Functions of the Ceiebellum.) BOhm, Ueber cerebri lare Atanle nebst elnem caauistisclien lieiirag« nir Lchn
von den Kleinliimgcschwiilsicn. In.iug.-Disserl., Strassburg, t89f. I
Cramer. Ueiintgc xur palhologi^chen Aivaiomle und atlgemrincn l'atha1ogl&
Jena, 1891. xi. I. (UniUteral Ain^hy of ihc Cerebellum.) Luciani. I)a» Klein him, Leip^i);. liesuld, 1893.
Spilxka. Deiitadie med. Wnclien»chr.. 1S87, S, p. 157. (Focal I.eslcir» at tbei
I^vel ol the Traniiilan from the Pons 10 the Medulla ObloncJiia.) Goldberg, Lud«ig. Tumoren der Oblongata. I naug.- Dissert,. Jena. 1889.
PATHOLOGfCAi. lit AC If OS/ S.
«9
11. TiiE Study of Cbrebrai. Lesions with Reff.rence to
THEIK PaTIIOI.OUICAL NaTURE.
Pathological Diagnosis.— We )iavc before pointed out tliat ith« qtiestion as to the nature of a bnitn disease is not only of ffnterest to tlie physician, but of the greatest importance to the : patient, as on this the prognosis as well as the mode of treatment rlums. An error in the topical diagnosis may deserve the cen- JMIe of scientific criticism, but does not necessarily entail dam- age to the patient. If, on the other hand, we mistake the nature of the lesion in a given case — if, for instance, a disease of the vcs- »els is taken for a new growth, if the tuberculous or syphilitic DMurc of the aScction is overlooked, nr, again, a severe alcoholic intoxication is diagnosticated where in reality an apoplexy exists —when such errors have intluenced the treatment, not only op- jionunitics may be lost tor the patient which may never present themselves again, but an unfavorable event of the disease may Kiually be brought about or at least precipitated. On these gniunds we ought to be particularly careful and conscientious In forming this part of our diagnosis, and no symptom, how. "er small it may seem, should he overlooked, as we never know ^ that it may later perhaps become of diagnostic value.
In looking over the several pathological processes which \\qtc
Wncera us, we find that their number is comparatively limited.
F'm ol all. we shall devote our attention to diseases of ihe blood-
'*McU, which so frequently arc the cause of cerebral lesions.
"c )h.ill have to determine the nature of these diseases, and
orclully distinguish the affections of the blood-vessels from the
'^Cfiodary changes produced by them. The clinical symptoms,
the complaints of the patient, and the objective signs are a
"Ji^a consequence ol tlie latter only, and it is therefore not the
"'sewcof the blood-vessels which we have practically to deal
*"h, but the changes in the brain substance which they entail.
'^nc clinical manifestations vary according to the seat of the dis-
*•*<! vessel and the portion ol the brain supplied by it. The
*/«iIUoms we shall describe in detail later; but first lei us si>eak
" 'ht pathological nature of the diseases of the cerebral vessels.
•"ttrrlrt-es nr THE nR.MX hue T" disease of THE BI.OOD-VESsr.l-S.
^ Diseases of the Cerebral Vessels and their Conse- ^tlciKcS. — The arteries of the brain ace derived from the internal ^'fiiili and the tusilar, which is formed by the two vcttcbrals.
2IO
DISEASES OF THE BRAIN PROPER,
The internal carotid gives off two terminal branches, the anterior cerebral (arter. corpor. callos.) and the middle cerebral (arter. foss. Sylv.). The basilar divides into the two posterior cerebrals (arter. profund. cerebri). These receive on each side a communicating branch from the internal carotid, the so-called posterior communi- cating artery, while the two anterior cerebrals are connected by an anterior communicating branch, so that a closed circle (or rather a heptagon, according to Hyrtl) of arteries is formed, known as the circle of Willis, an arrangement which is of the last importance for the distribution of the blood in the brain (cf. Fig. 68).
Fig. 6(1. — DiAGMAH SHOWING THE CIRCLE OF WiLLis. The carotids with the anterior and middle cerebral arteries and the baaibr with Ibe posterior ctrebi^ are connected b)^ communicating branches.
The fact that the left carotid comes off from the aorta nearly in a straight line with the blood-current in the arch, while the innomi- nate, which gives off the right carotid, leaves the aorta almost at right angles, easily explains the greater frequency of embolism on the left side. A somewhat similar condition exists in the vertebral^, where the left, often the larger one, arises from the subclavian at its highest point. Thi.i is, however, of less moment for cerebral lesions, as the blood has first to pass the basilar before entering the brain substance.
TtlF. CEKhHKAl. rSSSXiS.
311
Of Ibe three; be fofc- mentioned arteries— the anterior, middle, and
JpOKtenor cerebrals — each one supplies lw<i sets of vessels totally dis..
jlinct from each other — namely, first, the so-called cortical arteries;
second, the arteries of the basal ganglia. The imjiorlanl dillerence
between these two tiystemt; consists in the fact that the former, a»
Heiibner and Durct have shown, p»<«e«K anastntmises, uhile the latter
are, as they have been called by f'ohnheim, terminal arteries — that is,
■ihcy do not communicate with each other, but pa&s directly into the
H'«Api Maries. The signihcancc of such an arrangement is apparent, and
^wt Nhall not be surprised to hnd that occUiMnn of an artery of the
second set almost always produces death of the parts Nup[)licd by it.
_ Of the three cerebral arteries, the middle, the Sylvian artery, has
Bby far the widest distribution and is the most important ; for while
Ihe anterior supplies the corpus callosuni. the gyrus rectus, the para-
, central lobule, and the precuneus; the posterior, the crus, the tcm-
}ral, and the occipital lobe, and the cuneits sending also a few
I
I— The CoRtiCAL nivrKiKrTi"!i wr tiii Uidciu: CHunuL Auriritv. •Mut
HAWMT.) From left tu HeIiI the fire branche* ate nuiwd u lollcm; The Inferior (rooul bnadi la Breca'i (unToluiiun, ihp ucendlOK ttontkl brandi. ib« aRandint; parie- lal bnacti, Itw panrto-iphRiaidal, wid Uk ipbenorftUl bnsdMa.
branches to the optic thalamus {arter. optic. po«lertor,), it remain* for Ihe middle cerebral to supply the whole lenticular and the caudate nucleus, and, above all, the internal capsule. Moreover, the central and cortical motor region, the cortical areas concerned in the process of speech (on the left side), the cortical centre for hearing, probably tiso for vision, depend on this artery for their nutrition.
Its cortical distribution, its subdivixion into the frontal, parietal, parieto-sphenoidal, and sphenoidal arteries, is made clear by Fig. 69.
312
D/SX4^S OF THE BKAIN PKOPE/t.
Its distribution to the lenticular nueleuH is illustrated in Fig. 70. The internal artery of the corpus striatum, also called the tenticolar artery, goes to the first and second segment of the lenticular nucleus, while the external hritnchcs are the so-called Icnticulo-striate and lenticuto-optic arteries. Among the former, the one which supplies the third segment of the lenticular nucleus, the upper portion of the internal capsule, and the caudate nucleus deserves special mention. It is so frequently the seat of hioinorrhage that Charcot has called it "farlir* de rh/merrJutik (/r^raU." Mendel has attempted to show
f\g. 7a.~Vua-irtM. Si»7nu!c TiinnL-XMr TUB Ckrimiai. IICHiiinii>«K«, Ohk Cimtimk- Tiu uKiiiKD Tiic CuusH. Slhonri ihB dkBrfbulbw of tbe middle onliiml may In the knikulBT omcleiu.
eiperimentally the physical reasons why ruptures are es|)ectally prone to occur at this place {Berliner klin. Wochcnschr., 1891, 14). The ac- count of these experiments and the discussion which followed their presentation at the llcrlin Medical Society, in the session of May 37. 1S97. are well worth reading (IJeuti-che Med.-Ze:tg., 1891. 46).
The 'tween-hrain and the mid-brain are mostly supplied by the posterior communicating and its branches, the cerebellum by several so-called cerebellar branches (arlcr. ccrcbcll. super, et infer.) coming from the vertebrals ; the pons and medulla oblongata altto by branches of the vertebrals, which arc the so-called rami iid pontein and rami ad medullam obtungatam.
The internal carotid and the basilar measure 4 mm. in diameter; the vertebrals. 3.5 mm.(l.uHchka). The blood pressure in thccarotid is gen- erally taken to correspond tu from 140 to ibo mm. Hg. How guarded, however, we ought to be in accepting such siaicmcnts has been shown by Loewcnfcld. who drew attention to t lie variations in the development of the cerebral arteries; and it seems at least possible that this itt of considerable aitiologicul significance for different cerebral affections.
I
CEREHKAL UjKMOKItMACE.
213
LITERATURK.
Opclb c BruKia. Arch, di ptichi.itria, science penalc. etc., 16S6, Fmc. i. lOn ibe Action of Certain Dru(^ upon the Cerebral Ciicululiun.)
LoewmfHd. Arch. f. Ps>'ch. u, Nervenkr.iiikh.. 1687, xviir. j.
HdccL Vircbow'i Arcli.. 1890, cxix. licit i.
GdgeL Die Mcctunik dcr BlulvrtMir);uii^ (le« Hirns, Stult);3rl, Knkc. 1890,
Lcwy. Die Krgutiiung dci Illiiibcwcgung im Him. Virchow't Anb., 1S901 cxxii. I, I.
Mrndd. Ncurolug. CenlFalbl.. 1891, 14.
KolUka. Ibi<l.. 1891. 16. (On ihc IKood Supply ofthc Brairt.)
(icuhey. F.xp«rimrn telle Dcilrilgi? xmx Lchrc von der lilutcirculaticn in Act SchSdcl-Kuckgtat Collie. Fesisthrift, Miinchen. 189!.
1. Certbral Htemorrhage, Hamorrhagia Cer^ri {Periartrriiiis
Ctrtbraiis, Miliary Aneurisms of ihe Cerebral Arltries').
Pathological Anatomy and ^^.liology.
Of alt cerebr.1l aCTcciiuns, hemorrhage, the result ol the nipturc of a vcti^cl, is by far the most important and the most (requent. As we should expect, haemorrhages of various kinds Bay be produced by traumatism (itijurv to Ihc skull, with or ■ithout fracture). They may occur between the inner side ol
' Ti.~-CKit[iiajtL Asrear y\uym ah Aiiiruxmc Foci,-*, ma, luituif anmriim. Ut, **>nnMlkiiuo(bkaJiMlutk(iul*eiitillalljm|>hi|M(«. (An«t COH.11L anil k^milit.)
^c sl(u|] and the loosened dura mater, or in the sac of the dura *" that of the pia (submeningeal haemorrhage); but, disregard- ■"6 these, there is one affection especially which gives rise to nrcbral haemorrhage — namely, a diffuse periarteriitis — which
214
DISEASES OF THE BffAW PJIOPEK.
Fie- 7a.— MiuARV AoRUitiaii op A Skau AnrcRv or tiii; t.KXTicuukK Nucleus
wns first described by Charcot and Buuchard in 1868. In this process a ttiickenini; uf the lymph-sheaths and subsequent changes in the muM:iilans take place, by which the formation of miliary aneurisms is favored (cf. Figs. 71 and 72.) Rupture of
these aneurisms then gives rise to h.-emorrhages, and so frequently is this the case that the authors be- fore mentioned found this condition in Kvery one of seventy ■ seven consecutive cases which came under their observation. For the rupture of these aneurisms it is by no means always necessary to have any extraordinary exciting cause, such as aii elevation of the blood pressure, which may temporarily be pro- duced by bodily exertion, sneezing, coughing, vomiting, and the like, or which may permanently exist where the heart is hyper- trophied, as in valvular disease or in cases of contracted kid- ney. In many of the instances nothing of the kind can be demonstrated.
The size of the aneurisms varies from 0.3 to I mm. : their color and consistence often differ grc.illy. Their favorite scat is in the thalamus, the corpus striatum, the convolutions, and the pons, while they arc less frequently met with in the cen- trum ovale, the crura, and the medulla oblongata. Sometimes only two or three, at other times as many as several hundred, have been detected in one brain. On being squeezed they arc found to contain white corpuscles, fat droplets, and amorphous granular masses.
The haemorrhage which is produced by their rupture con- sists when fresh of a dark-colored I()Ose coagulum. The wall of the "focus" is red and spotted with punciiform haemor- rhages (capillary apoplexies), and presents a ragged and torrm. appearance. (>radua11y the dark color becomes lighter, ih) neighboring parts are infiltrated, yellowish, and very sof flemon-colored uedema). As a rule, the locus is later en- capsuled by a layer of neuroglia, the fibrin masses become mixed with the d^br'ti of the nerve elements, and we get £ smooth-walled cavity with liquid contents, the so-called apo^ pleclic cyst, occupying a smaller space than the origina hemorrhage. If the walls approach each other before ih
AirtOl.OCY OF CKKEHRAL UMMORRHAGE.
3IS
!um is Iransformcd. a great increase oi fibrillated con- nective tissue takes place and we get a si^called apoplectic r.
The cflect of the hiemorrhage varies according to its post- iJcm. according to the calibre ol the ruptured vessel, upon lich depends its amoiinl. and according to the rapidity or iwness with which the blood escapes. The favorite scat for hxmorrhugcs is in the large ganglia (Charcot. Andral, Ro- choux): with decreasing frequency thej' are found (Noth- oiigcl) in the rcmaitiing portions of the cerebral hemispheres, much more rarely iti the pons and the ccrcbelhim. The fre- quency is directly influenced by the size of the different cere- bral vessels and by the blood pressure. The dianicicr of the vessels of the brain stem is considerably larger than that of tbofce going to the cortex. The above-mentioned '' artery of ecrcbnil hemorrhage" is of an especially large calibre (i'/, mm.t. and causes therefore when it bursts a particularly large and extensive hemorrhage, because the bleeding is prolonged. " The Iniumulic effect ol the ha;morrhage," as Wernicke calls it. is equal to the product of the mass of effused blood into the square of the rapidity with which it is poured out. which latter depends directly upon the blood pressure in the vessels. I loice it follttws that, as regards the effect of a haimorrhage, titc blood pressure is of more importance than the calibre of * he vessel.
£tiology. — In examining into the etiological factors con- C'crncd in a cerebral ha-morrhage, we must distinguish those ^^liich produce the disease of the vessels from those which *^4ttcily cause the hemorrhage : in other words, the pre<lis- F*Qsii»g from the exciting causes.
About the former not much ts known: nevertheless, con-
**^trable influence in the ciusation of arterial disease must be
■•cribcd to age. as we can not deny that it is decidedly less
'■"^uently to be observed in the young than in older persons,
**»d that the sm:illest percentage of apoplexies is found between
'H«6(ih and thirtieth years of life. Still, to lay so very much
**»wi Upon the signltiaince of age is not warranted by experi-
^'•cp. The fact that cerebral haemorrhage is by no means rare
'•* people fn>m twenty to thirty years'old clearly shows that
'•»»!i;uy aneurisms may occur even at a comparatively early
Period of life : nor are these c.nse<i by anv means always those
^ pcrions laboring under hereditary disadvantages, since even
3l6
D/SEMS£S OF THE BRAIK PXOPEJt.
members of perfectly healthy families, while still young, may (all victims to a stroke of apoplexy. The influence of heredity as well as that of age has undoubtedly been overrated in this connection. It is true there are families in which apoplexy seems to be a natural occurrence, but such instances arc excep- tional, while on the other hand the arterial disease develops in an infinitely larger proportion of cases apparently without special hereditary cause- Sometimes the development o( the disease seems to be favored by a peculiar "habitiis" Thus, corpulent individuals o( medium height, with short neclcs, bro.id tharaces. who on the least exertion or excitement become purple in the lace, have usually been looked upon as particu- lady predisposed to apoplexy, and in many cases with justice; yet those who have in an extensive practice seen how oltcn tall, spare individuals with narrow chests die from cerebral hemor- rhage, will readily give up the idea that an apoplectic habitus is a eondilio sine quS non.
The r6U which sex plays can not be denied. The disease is much more frequently observed in males than in females, while with embolism, as we shall see, the reverse is true. To explain this predisposition in males, other factors — namely, the mode of life — must. I think, be taken into account, and here it is, in the first place, the occupation, and, secondly, the abuse ol alcohol, which roust be considered. Notwithstanding Ihc fact that wc know very little about the Influence of occupation on the for- mation of miliary aneurisms our statistics of fatal cases of cere- bral harmorrhage in the different trades being somewhat unre- liable, still we have some sure grounds, the correctness of which can scarcely be called in i^ucstion. That, for instance, the working in certain poisons, especially in lead, predisposes to arterial disease, and consequently to apoplexy, is indisputa- ble. In his thesis on enccphalopalhia and arthralgia saturnina, prepared under my auspices, Schuiz (Urcslau, 1885) points out the frequency of the so-called hemiplegia saturnina, and calls attention to the fact that Bcrgcr has made similar observations. In the second place, those who are exposed to radiating heal — workers at furnaces, pud die rs — arc in danger, especially if their work is connected with much bodily exertion, and this can hardly surprise us if we remember how much circulatory dis- turbances are favored by such circumstances. The same may be said of occupations which necessitate uncomfortable posi- Lions of the body, as. for instance, is the case in agate polishers.
.ar/oiocy OF cekebkal hm.uokhiiage.
217
I
I
who constantly have to lie on their abdomens, or in coal miners, who bave to remain in a stooping position all the tim«.
In regard to the abuse of alcohol we refer not only to the confirmed drunlcardi^, but much rather to that class of indi- viduals who habitually consume more alcohol, especially beer, ihan is good for them. Such men rarely, if ever, get drunk, but they drink several limes a day one or twoglasses of beer, do not take enough exercise, and become fat and predisposed to fatty heart and arterial disease, especially artcrio-scterosis, which uQection, \vc may say finally, is the real cause of the greater frequency with which apoplexy is met with in men ihan in women. The fatty heart may be present even without iny marked obesity.
The important influence of syphilis in the origin of cerebral
itxiDorrhage is proved by many irrefutable observations, and,
ODKidering the part played by it in disease of the cerebral
vessels, this can easily be explained. We shall mention it
igiin in this chapter, and later dwell more particularly on the
lymptoms peculiar tothesyphtliiic hemiplegia. Exceptionally,
lumiplegta occurs after diphtheria, sometimes in conjunction
■Uh a paralysis of the palate, sometimes independently. In a
girloged fifteen under my care, hemiplegia developed fourteen
days after diphtheria without any simultaneous disturbance of
coucjousncss, and only slight improvement was noticed after
Kvtral years (cf. also Seifert. Neurolog. Centralblatt, 1893,4).
Villi equal rarity is this complicating sequela found after
<tlKr acute diseases — tor instance, scarlatina.
Sometimes no exciting cause can be demonstrated, but if Mch be observed, they are always associated with a sudden ■we or less marked increase of the blood pressure. People •Jlli diseased cerebral vessels are not rarely suddenly attacked lijan apoplectic stroke after strong emotion, hard bodily cxcr- "Dt, during violent attacks of coughing, sometimes also in a ^ bath and after a full meal. Christian (Arch, de Neurol., "^9^ S3), and Hollinger in his monograph on late traumatic •poplcxy (Festschrift fUr R. Vircliow, 1891), have pointed out ihat traumatism may also lead to apoplexy.
How it comes about that the coldest months of the year T*W the largest percentage of victims of apoplexy, and why it ■ thil in the twenty-four hours there are two periods with a ■uitoum and a minimum death-rate, if such be actually the cuccan not be explained. Such has, however, been claimed
2lS
msEASKS OF TItE BHAlfi PFOPEtl.
by Sormnni, who based his statements upon an extensive study ol statistics (Riv. clin., ser. 2. i. 12 Diccmbre. 1871). The same author is also inclined to attribute to the barometric pres- sure some influence on the mortality, as in liis opinion sudden changes in the weather materially increase the mortality from apoplexy.
Symptoms and Course—The rupture o( a tair-sizcd cere- bral vessel is always, no mailer what part o( the brain is afiectcd fay it, attended with more or less violent symptoms.
Only in exceptional cases is it preceded by premonitory indications (pra.'monitorium apoplccticiim of Bocrhaave). Oc- casionally there are temporary sensory disturbances in the extremities of one side, formication, numbness, a feeling of heaviness in the limbs, pain in the soles of the feet, certain choreiform movements in the face and arms (hcmichorca prie- hemiplegica, Raymond), symptoms which indicate that thin^ arc not going in their usual order. The patient may also com- plain of headache and a feeling of fullness in the head, which makes itself manifest on the least provocation, on the slightest emotion, or after a small amount of wine has been taken. Bui rarely enough arc such premonitions sufficiently appreciated by the patient, and only too often are they incorrectly inter. prctcd by the physician. Usually they are overlooked, and arc first remembered when the catastrophe is either imminent or has already taken place.
When the attack does come on, the patient gradually or suddenly loses consciousness, and remains in (his condition for a few minutes, hours, or even for a day or two, according to the severity of the "stroke." The higher the blood pressure, and the greater the rapidity with which the blood escapes, the more pronounced and severe are the general symptoms, which collectively are called " apoplectic stroke " (the " insuk " of the Germans). The way in which the disturbance of conscious- ncss comes on varies very widely in diftercnt cases. Thus one patient may (or some hours before the actual attack present a peculiar excitement, he is restless and bewildered, may even have forgotten the ins and outs of his own house, his speech ts agitated, etc. ; another patient may complain of headache and vertigo; a third of a feeling of hejit in his head and of general prostration ("different forms of delayed stroke"). All these premonitory symptoms which we have described may, how- ever, be absent, and a person apparently enjoying the best o(
THE APOPLECTIC ATTACK.
219
Iwalth muy suddenly, as if "struck by lightning," sink to the ground and lie there unconscious {apcpUxtt fouiiroyanti).
If we WTK called to such a case, the luUowin^ ctmdiliuits will present themselves to us on our first exiiniitiulton : The patient Iks on his bed as if asleep; his respiration is either quiet and deep or loud and stertorous ; he can not be aroused in any way, not even by strong irritatiun of the skin (pricking, tickling) : his eycH arc closed, and the pupils, usually of medium size, neither noch dilated nor much contracted, have lost their power to react With every expiration the checks arc slightly puScd oot, and it is often soon apparent that one corner ol the mouth it lower than tlie other. The extremities arc relaxed, and when taiscd drop loosely. The tendon reflexes are absent in severe Q5C8, and neither the cremasteric nor the plantar reflex can be ntxained. The pulse is full, somewhat slow : the temperature normal, jKrhaps slightly subnorn).tI ; the urine presents no changes, or may contain a (race ol albumin, rarely uf sugar.
This condition may. as we h.ive said before, last several ninuics, several hours, or even one or two days. It is modi> M gradually according as the hietnorrhage sooner or later oooies to a stop or continues without interruption until a fatal result ensues. In the former case the patient gradually begins to react to strong stimuli, and may open his eyes for a short while. M-hen called loudly or when water is thrown over him ; ^ may give a loud yawn and show some voluntary motion '4 the extremities. Grtidually consciousness returns, and the pUicDt attempts to make himself understood by gestures and *onl», and in the most favunible instances, which arc, how- ner. unfortunately very rare, the physician can (eel assured ihjt everything has cleared up. that the patient is again in pos- WioQ of perfect consciousness, of the power of speech, and of •Wtioo. In such cases the "general " symptoms have disap- Ptlred without leaving behind any of those belonging to the •Mood class, namely, the so-called (ocal symptoms (Grie- •■itr), and we speak of a ■'slioke without focal symptoms."
Bat the bleeding may continue, although only under low PQiare. ind only cease very gradually ; then the symptoms •tac but slowly and the recovery is only partial ; the patient ■0 lor days in a slate o( somnolence, and repealed cxatnina- lioM show (hat one comer o( the mouth is distinctly lower uiaihc other, and that the saliva dribbles from it involunta^ '■y. II wc can. by strung stimuli, evoke spontaneous move-
220
n/SHASES OP THH HRAt.S' PfiOPBR.
ments, k becomes evident that only one side is moved, that only one arm or one leg is raised, while tlie other side remains per> [ectly motionless, and after consciousness is fully restored the certainty is lorccd upon us that one side of the body is de- prived of its power, or, as we say, is p:iralyzed. This we call a "str<ikc wiih focal symptoms." At this stage, however, we arc unable to decide whether the focal symptoms are the result of a dcstruclion of nerve paths or centres — in other words, whether they arc direct and therefore incurable — or whether they depend upon indirect action, so that the loss of function is only temporary. It [he latter be the case, wc speak of "indi- rect " focal symptoms.
Again, the ha:m(>rrhage may not cease at all. but conltnue with increasing blood pressure; then the patient remains un- conscious, the breathing becomes irregular and more rapid, and assumes the so-called Chcyne-Stokcs type, the pulse be- comes more rapid and small in volume, the face grows pale and haggard, the saliva getting into the trachea produces the well-known tracheal rattling, the temperature rises gradually but noticeably, and the patient dies without having come to himself, and after a period of unconsciousness which may have lasted many hours or even several days and nights.
If, in the course of a " delayed stroke," the breathing, until now quiet and regular, suddenly gives place to a rapid, irregu- lar, stertorous respiration, and if at the same lime the partial unconsciousness deepens into a profound coma, the rellexes become lost, and tetanic convulsions of the whole body and hemicontracture of the paralyzed side make their appearance, then we can assume that the ha;morrhage has burst through into a ventricle, and give an absolutely unfavorable prognosis, because in a few hours, more rarely in one or two days, death almost invariably follows. The haemorrhage itself in such cases is, as can be demonsinated at the autopsy, generally by no means copious, but the fact that it is found, even if the ependyma of the ventricles be thickened and hardened, speaks most clearly for the high arterial pressure under which the blood escapes (Wernicke). The bursting of the blood into the fourth ventricle is the most rapidly fatal, and it is in these eases that we sometimes observe nystagmus.
The disturbance of consciousness in its many gradations, from the slight vertigo to the deep coma, is the most character- istic, or at least the most important, symptom of an apoplectic
APOi'LBCTlC EQUIfAlBNrS.
221
^
¥
Ic produced by ha;morrhagc.and it ought not to be under- rated, even if it docs not become futly developed, but only ■mounts to a traiinicnt .slight speech disturbance, accompanied br a IccUng of faintncss and weakness. There are patients in Whom such disturbances occur several times before the onset "( a real attack. Such patients complain of transient vertigo, iligbt weakness, and heaviness in one or the other hand or l»»t : they can at times not find the right word, the correct txpression, or lose speech entirely for a short while. All these intiicationg are premonitions, not direct forerunners of the tttack, but symptoms which warn us. indicating that the brain ii subject to alterations in the blood pressure, a condition which may lead to serious consequences if the arterial walls arc dis- eased (" apoplectic equivalents").
Complete absence of all disturbance of consciousness is a rare exception, and can only be found when the blood escapes quilc slowly, so that the increased pressure rises only very );railually. and to no great degree. The patient then is seized with a sudden weakness, purely physical ; he sinks into a chair, uid after a few moments, during which time there is not the ^igtitcst disturbance oE consciousness, he becomes aware of a Kit oi difficulty in moving the extremities of one .side, which, in the most unfavorable instances, in a short time passes into a genuine paralysis of that side (focal symptoms without stroke). Here may also be meniiuned the cases obscr\-ed by Romberg. Grates, Andral, Senator, and others, in which after a hcmf- pkgui DO trace of hasniorrhage was found at the autopsy, but wljra diffuse hypcra;mia of the brain could be demonstrated — "pteudo-aiioplexy."
On the other hand, it is not a %-cry unusual occurrence that ipalieiit awakening in the morning after a quiet night's re«l ^ himself paralyzed on one side : in such cases we are, of cwrie, not able to decide how much bis consciousness would hlTc been impaired bad he been awake.
In every hemiplegia that occurs in the course and as a con- fluence of cerebral hn:morrhage there is a possibility of re- (eienilion to a greater or less extent; but whether this regcn- niiufl will lake place, and when, and, moreover, whether it *^l be complete or not. are questions that can not at once be "^Klded. They all depend on the condition ol the cortico-mus- ^r tract, as we have pointed out before — upon whether this
333
DiS£/ISES Of THE BKAIM PKOrEH.
be actually interrupted, w hcther its fibres in places, (or instance at the internal capsule, be completely deslroyed. or whether their (unction be only leinpurarily ittipaircd in cnriacqiiencc of the increased blood pressure, so that alter the cessation ol the hemorrhage a riititulto in Mtrgrum of the nerve tissue can follow. In the latter case the paralysis disappears after a few hours or days, while after an actual interruption o( the cortico- muscular tract the hemiplegia is incurable, and the patient is deprived of the free uscol the affected limbs, and. even though he may regain after a long time some power of motion, his movements will always remain awkward and restricted.
Sometimes, and this is nut very rare, a patient may have an apoplectic stroke after which the paralysis disappears quickly and entirely, but which is in a few days, on some slight provocation, followed by a second attack, accompanied by a severe permanent hemiplegia, which under certain cir- cumstances can cause death. Such a possibility should always be thought of, and wc would here say that the prognosis, no matter how slight and favorable the apoplexy may seem, should always be very guarded.
Among the "concomitant symptoms" which only excep- tionally persist tor any length of time, and ought therefore to be regarded as indirect focal symptoms, may be mentioned a peculiar deviation of the eyes and Ihc head — the " dH.<ialion eon- jugiUf" ol Provost — generally toward the side of the lesion, so that the eyes "look toward the disca.sc.focus." This has been thought to be associated with a lesion in the upper parietal lobule. PrivosI and T,andouzv gave this rule : •" Le malade regarde son hfimisph&rc alt6r* s'il y a paralysie— il regardc scs membrcs convulses s'il v •* excitation " (the patient looks to- ward the damaged hemisphere if he have a paralysis; if there be irritation he looks toward the convulsed limbs). This is seen, for instance, in the so-called cortical epilepsy, which we have spoken of on page 187. The htad seems forcibly turned to one side, and the eyes arc turned so far over to the canthus that we arc scarcely able to lest the condition of the pupil; along with this symptom there is found almost always a more or less marked dullness of the sensorium. Why this condition is generally transient is explained by the fact that the muscles of the eyes and neck can be innervated from both hemispheres, so that even if one side becomes incapable of working, the other can act vicariously for it. Only in bilateral huimor-
THE CEHEBKAt. HEMIPLEGIA.
22J
I
I
rhages which produce a permanent paralysis uf the eye mus- cles is conjugate deviation found to persist.
Unilateral ocuUvmotor paralysis on the side o{ the hcmi. plegia is very rare: it is supposed to be associated with lesions u( the lower parietal lobule.
Ader 3 severe attack there may be a transient polyuria last* ing lor one or two days; the specific gravity of the urine, which is then (aintly acid, may be 1.003 <^r i-ooi; at times, but not always, albumin or a trace of sugar can be demonstrated (Locb. Prafjermed. Wochenschr., 1892. 50). This some authors, amnng them OUivicr. were inclined to attribute to an action (Ki the centres situated in the floor ol the fourth ventricle, the exUtencc of which Claude Ilcrnard had already demonstrated. This polyuria after an apoplexy does not persist, while this tnay be the case in tumors of the posterior fossa, in local lesions of the pons or the medulla oblongata, where it has to be looked uptin as a focal symptom (Kahler. /eilschr. f. Heilk.. vii. 2, 3,
Id proceeding to the examination of a Ircsh hemiplegia — iku Is to say, one of a few days' or weeks' duration — the foU toaing points nnisr be borne in mind :
The facial and the hypoglossal nerve deserve the most wtcntion (cf. also Koenig. Deutsche Mcd.-Xcitg., 1892. 2$. p. J^V The former is injured in its central course, and shows a gurjlyxis or only a paresis in its lower branches, while the \i\\- per branch is intact; the patient is unable to inflate the para- IjFttd cheek, and can not whistle, while wrinkling of the fore- ieid on the paralyzed side presents no difBculty. Careful uamination shows distinctly that the disturbance on the para- l/Hd side of the lace is much more marked on attempting nioDUry movements of one side alone, whereas those of ex- pnaton — for instance, laughing, crying — arc at least passably Waited. This, again, may be explained by the fact that mus- dfs used involuntarily arc innervated from both hemispheres. Tlie duration of the facial p.iraiysis varies; sometimes the Werencc between the two sides of the face disappears almost oiniplctcly in a (ew days, while in other instances it may be •oiioeablc for weeks or, in rare exceptions, even during the *l<ole lile. In this point it resembles the speech disturlnnce ^ncd by a lesion of the hypoglossus, a disturbance consisting Otntially in faulty articulation, which is noticed by the patient •ore tlian by those who converse with him. It may disappear
224
D/SF.ASES Of-- THE HHAIN PKOt'fUf.
in a few hours, but may persist for months, even years, when improvement in the affected side lias gone on (or a long while, and gratifying progress has already been made. A paralysis of the same nerve, or rather of the genioglossus muscle sup- plied by it, is also responsible if the patient is unable to pro- trude the tongue straight; il is deviated to the paralyzed side because the wl-II genioglossus is stronger than the diseased one, and consequently pushes the tongue over toward the side of the latter.
The condition of the soft palate is not the same in all cases. The velum may be considerably lower on the paralyzed than on the well side, but it may also occupy its normal position. The uvula is at times deviated to the well, at times to the paralyzed side, and again at other times its position may be unchanged. These changes do not give rise to any noticeable disturbance of function.
Examination of sensibility in the first few days reveals de- cided alterations. Sensibility to pnin in most cases is dulled, and sensibility to touch and pressure is decreased, though to a less marked degree. The patient feels a pin prick either not at all on the affected side or, at any rate, with less acuieness.
Of the nerves of special sense, it is especially the optic which takes part in the disturbance. The apoplectic atUick may be followed under certain circumstances by hemianopia of the corresponding side (Gowcrs), often, too, by amblyopia.
Smell and taste, as a rule, do not suffer to any great extent ; but there is a decrease in hearing power, so that the patient is no longer able to understand words spoken in an ordinary tone at a distance of fifteen or twenty feet. Such a decrease is not rare, yet an absolute (unilateral) deafness never seems to follow as a result of an apoplectic attack.
With regard to mobility, examination shows that either the extremities of one side of the body arc completely para- lyzed (hemiplegia) or thai the power of movement in them is impaired (hemiparesis). In the latter case the arm is usually more affected than the leg and the hand more than the arm. Indeed, the movements in the .shoulders and elbow joint may be as good as normal, while those of the fingers are very awk- ward ; in such cases the leg can generally be moved quite well. The muscles of mastication and those of respiration are, for the reasons above mentioned, almost intact, the muscles of the trunk are only slightly implicated, and, if at all, the change is
TItE CBREBKAL ftEAliPlECIA.
225
only apparent in the trapezius, so that the shoulder of the afiected Mile is raised less energetically than its Icllow.
The tendon and skin reflexes arc, in the first few days »(ter ^hc attack, decreased or even lost on the allccied side, a condi< Bion which, as we shall sec shortly, soon becomes materially duinfccd.
The sensorium usually clears up in from one to four days.
specially in light cases. The patient again becomes conscious
his surroundings, and recollects quite well all incidents which
[bppened nearly up to the lime of the attack. Thence on. there
of course, a blank in his mind. On awakening, at first he
Ibu no (dea of what has happened to him. His frame of mind
tttfin according to the degree of his bodily helplessness, but.
u a rule, is better than we might expect, considering the
dunage which has been done. Sleep is for weeks much intcr-
kred with. The patients are extremely restless; they throw
iliemselves about in bed. and are unable to remain in one pnsi-
liimfor any length of time.
The further course depends upon whether the hemiplegia ;>rovcs to be an indirect or a direct focal symptom.
The slighter cases ol indirect hemiplegia, when Ihey have M completely passed off after several weeks, arc at any rate gtacnilly improved The one-sidedness of the face, seen at li« beginning, has disappeared : the tongue is now protruded Xlif^ht. speech is again norm:il. the k'g can be moved almost » (irely as ever, and the only thing which is left as a reminder d the dangers through which the patient has passed is a ccr- Oioawkwardness in the movements of the affected h.ind.
The graver cases of indirect hemipl«gia need fr<im two to U»ttc months for complete recovery. For weeks after Ihc at- t«k the patient presents marked disturbances in motion as well VKosation, and only ]xi)nlully and with the help of a stick can M liobbic about his room, while the arm and hand arc almost "Vflai Vet a constant progressive improvement of the par- ■l*tt(l limbs enables >is to recognize the favorable tendency o( "•ecMe and to predict with certainty a complete recovery.
la cues of direct hemiplegia also the course of the disease ^yissume many varieties. All are char-ictertzed by the per- **>tnice ol the (ocal symptoms. The attack, too, wc should ■tvp in mind, need not be particularly severe, nor need the filial general symptoms have been especially grave ; <mly the QvJBgate deviation of the eyes and head is a symptom which
226 DISEASES OF THE BRAIN PROPER.
preferably occurs in grave hemiplegia. Its presence, therefore, permits a priori of an unfavorable prognosis with regard to complete recovery.
In the first three or four weeks things remain apparently about the same ; the paralyzed side is flaccid and about five ninths to one degree centigrade warmer than its fellow, the slightest motion is impossible, speech remains impaired, and the face is one-sided. It is not until from three to six months have passed that we are able to notice a slight improvement in the power of motion, so that the patient (who is still confined to bed) is able to move with ease some of his toes, perhaps also the lower leg, while in the thigh motion is still incomplete, and in the arm and hand quite impossible. In such cases all the improvement that can be expected is but small and the damage which the stroke leaves very apparent. After from six to twelve months the patient again begins to be able to use the paralyzed leg. which in the meantime, in consequence of the flaccid condition of the ankle, has become longer. The walk is then very characteristic. Flexion in the hip being insufficient, the aflected leg is brought forward by the aid of the pelvis, so that, trailing along the ground, it describes a half circle around the sound one. The centre of gravity of the body then is transferred to the paretic leg, the knee joint passively extended, and the leg thus used as a stilt (Wernicke). If improvement goes on, the movement ol circumduction gradually disappears and the paretic leg is simply dragged behind. The gait is so characteristic that the diagnosis, especially when simultaneous- ly there is a paretic condition of the upper extremity, can be made at a glance.
The upper arm is slightly abducted, the forearm flexed, the hand hangs down, the fingers, which are fixed in a somewhat flexed position, are completely useless, and the patient is un- able to grasp large or small objects. The arm can hardly be raised at all, and the movements of the forearm on the upper arm arc very limited. In the lower leg extensor are more fre- quently developed than flexor contractures, and it is remark- able that in the morning, when the patient awakens after a Ions; sleep, how slight they are and how little they trouble him. whereas in the co.ursc of the day they arc materially increased.
Contractures, which are in old hemiplegias hardly ever ab- sent, arc most likclv to be atlribnlcd to a shortening of the muscles produced by disuse. This idea is suf)ported by the
TUP. CHRERltAL HtiMlPLEGlA.
727
fact that by systematic passive exercise, begun as soon as pos- [sibic, we arc able to prc%-cnt contractures; and if they exist, a [proper galvanic treatment, which takes the place of passive motion, perceptibly diminishes them. It is tnic it remains unexplained why contractures are not tound in all cases, and why in some the paralyzed extremities remain for life flaccid. That anatomical changes, too. especially, as Charcot assumes, the secondary degeneration of the pyramidal tract, arc not without influence, and that, at any rate, the contractures are more marked the farther this secondary degeneration advances can not be denied. H A symptom which accompanies contractures, but which Boften occurs much earlier, is an increase in the tendon reflexes f on the piiralyzed side. Tapping of the triceps and bice]>s tendon of the arm. of the patellar tendon, and the tendo Achillis evokes lively muscular contractions. From the last named — the Icndo Achillis — we can also obtain the so-called nnkle clonus, of which phenomenon we shall speak later. Even tapping of bones is attended by jcrkings, which arc best seen in the leg when the tibia is struck {" periosteal reflex "). Here again we must leave the question open whether this increase in the reflexes is due lo the degeneration in the pyramidal tracts or merely connected with the suspension of certain re- flex-inhibiting influences in the brain. In favor of Ihc latter hypothesis speaks the fact that this increase in the reflexes is occasionally observed as early as a few days after the stroke, at a lime when there can be no question of degeneration in the spinal cord.
With the skin reflexes it is just Ihc reverse ; they arc usual- ly entirely lost on the panily/cd side or are ai least decidedly diminished. This is especially the case (or the abdominal and cremasteric reflexes, which can only in exceptional cases be obtained on Ihc affected side.
Sensation either returns soon after (he initial disturbance or ■is permanently lost. In the latter case — J. e., where besides the hemiplegia there exists also a hemiana^lhesia — the lesion is lo be located in the posterior portion of the posterior limb of the internal capsule. The hemian:csthesia takes in. in pronoimced Leases, the whole half of the body, including the mucous mem- iranes, and extends as far as the median line. Face and trunk ire equally affected ; occasionally we may find that the tri- geminus remains exempt.
228
mSEASES Of THH BRAIN P/tOfEfl.
I
In slight cases the disturbance is confined to the extremities and concerns more the sensibility to touch than the sensibility to pnin, The patient feels the prick of a pin, but is unable to direct his fingers properly if the eyes are closed ; he makes _ mistakes in recognizing objects which are given him to fcel:M he is unable to fasten small buttons, etc. Changes in the mus- cular sense also may exist for a considerable time, the patient being unable with his eyes closed to give any information about the position into which his hand has be*^'n brought.
In examining sensation in hcmiplcgics. Uppcnheim (el. lit.) has noticed that at time^ bilateral impressions are appreciated only on one side; that, for instance, if a patient is pricked simultaneously in the right and left thigh, he only perceives one prick — namely, that on the well side.
One of the rarest of sensory disturbances is the persist- ent hypcrajsthesia of the paraly/ed side, described by M. H. Fischer (Arch, dc phys. norm, ei path.. February i;, 1887, ix.
p. [85)-
The psychical condition is not always the same. In certain cases the patients seem to have regained all their former lacul> lies satisfactorily, so that a careful examination brings to light nothing more than a slight loss of will power and of the capa- city for grasping ideas ; but in other instances the patient be- comes mentally weaker and at (he same time irritable. He » easily made to cry and is liable to sudden changes of temper Such patients are, however, notwithstanding their apparent obstinacy, very manageable and easily guided. Again, there arc cases in which the mental weakness becomes very aji- parent. The patient forgets the commonest things, the nunw bcr and the names of his children, confuses things and placet. does not know what day of the week and what season of the year it is, etc. ; at the same time he may have different Ae- Itisions and hallucinations. Some cases finally go on to com- plete dementia, which takes a course not unlike that of gener>l paralysis. Lcgrand du Saullc has published an interesting study of such disturbances among the apoplectics of the Saliir- trifere (tiaz. des ht>p.. 6871, r88i).
In the further course of severe hemiplegias where regcn- erntion is impossible to any great extent, motor disturbances which we have designated as posthemiplegic (cf. lit. under treatise of tireidenberg) may follow. One of these is the W- called hemichorca, consisting of involuntary irregular move-
I
I
THE CRREBHAt. IIF.MlPLEiUA.
239
»ments in ihc paralysed limbs, which become aggravated by every mental emotion and voluntary movement and which en- tirely cease during sleep. These movements, which are best Hudicd on the upper extremity, occur more ircc)uently after cerebral infantile hemiplegia than in any other aflection. The "hemiataxia " dcscrilwd by Grassct (cf. lit.) is closely related l«» hemichorca. and ought to be regarded as a variety of it. ■According to Charcot, the scat of the lesion in these cases is in Bthe posterior portion of the inlcntat capsule, the posterior part Ho( the optic thalamus, and in the foot of ihc corona radiata. ■The so^allcd hcmiathctosis will be considered in the chapter on the cerebral palsies of children.
A second class of motor disorders is made up of those pc> culiar involuntary movements which have been described as "associated movements." They are observed in the paralyzed extremity when the patient moves the corresponding, unaf- fected, one : thus, lor instance, if a patient uses his right, well vrm. the paralyzed arm makes similar movements, of course being restricted to a lesser or greater extent by any contract- ures which may be present. These movements have nothing in common with the so-called rcfJes movements which are loimd to occur in the paralyzed limb on stimulation of the sound one by the prick of a pin. the faradic current, etc. A peculiar instance of " associated movements" in an old hemi- plegia I had the opportunity of observing for months. It was « follows: Every time the patient yawned the left arm was niscd involuntarily at the shoulder-jfiini, and w.is kept up while the yawning continued ; as soon as it ceased the arm dropped down helplessly. Sometimes one sees the sound Hlinibs make involuntary movements if the patient attempts to Hit^ the aHecled ones, and again and again I have seen patients, Bsirsining to bend the paralyzed leg. become greatly astonished "»t the Hexion which took place in the well leg without any such intention on their part. That in intended movements ol certain muscle groups the antagonists begin to make invoUin- t»ry movement.s — that, lor instance, if an extension ol the flexed lini^rs be attempted, the Hexion at first becomes more forcible before extension begins (Mitzig)^is, according to our experi^ _<i)ce, very exceptional.
^p There arc other as.<iociatcd movements which occur in the
paralyzed hall ol the face when the sound side is moved ; thus,
Jor instance, in laughing, the muscles of the paralyzed side arc
230
V/SEASKS O/-' THE BXAJA' PJfOPEJt.
seen to contract equally, or even more strongly, than those of the well side.
Various theories have been proposed to explain »&sociated movements (Wcslphal, Dcncdikt, Broadbcnt, Ross), but m»nc of lliem can be taken as entirely explaining the facts. It is by no means impossible that all such motor disturbances arc reflex in nature (Charcot and Brissaud ; cf. also Senat<ir. L'fber Mit- und Ersatzbewcgungcn bci Gel^hmtcn. Berliner, klin. Wo- chenschr.. 1892. 1). ■
As a third posthemiplegic phenomenon we have the tremor. ^ It is not rare, and that form especially which occurs on volun- tary movements of the afTccled side is rallicr frequently met with ; on the other hand, wc shall very rarely have the oppor- tunity of observing this tremor while the extremities arc at perfect rest. Relatively, the largest number ol cases who presented tremor, in my experience, showed sensory changes, which consisted of paroxysms of pain in the affected extremi- ties. On a cursory exiimination this tremor may be mistaken for unilateral paralysis agitans (hcmiparalysis agitans), espe- cially as the number of oscillalions is about the same in both afTections, 4>, to ;Vi >'■ ^ second. Pronounced intentional tremor, which wc look upon as a pathognomonic symptom in multiple sclerosis. I never have observed in hemiplegia. Prob- ably the cause of this posthemiplegic tremor has to be sought in the general increase of reflex activity, which, as we may remark here by the way, is observed besides only in a very few cases of tremor of a diflercnt nature. Here it seems to play the most important r^/f.
Of great interest, as well as, at times, o( no small practical importance, is the fact that in cases of incurable hemiplegia the non-paralyzed side, that is, the apparently well extremities undergo certain changes which we are compelled lo regard as pathological. Thus, I'itres has found that the well arm loses somewhat in strength, and that this Es often more marked in the beginning of the hemiplegia than later on. On an aver- age the loss amounted to about 58 or 40 per cent, while no in- crease in the tendon reflexes could be demonstrated at the same lime. The well leg becomes weaker, and indeed in a more marked degree than the arm, the strength being reduced in some cases even by one half. The patient, though able to move that leg with perfect ease while in bed. finds it almost useless to attempt to stand or walk. Pitrcs was also the first
THE CERKISMAL HEMiPUiOtA.
SJI
(0 notice that the patellar rcftcs of the sound side, as well, is abnormally active, an observation which is daily conlirmed. The presence of the ankle clonus is noted by Wcstphal iind Dcjcritie. All authors, however (Haltopeuu, Brissaud, Vtri:}, agree that it is extremely unusual to hnd the later contrac- tures on Ihc non-paralyzed side. On the whole, these changes, which occur on the so-called unaffected side, arc more marked and of greater significance to the patient than we should be led to suppose from a superficial examination.
I-ITERATURF.. Ucbcr l'seiula>A|io|)Jexten im (iehirn.
liuuj[.-DiM«rL, Biciilau,
I
I
I
MKJtm.
iWi.
LoewmfeM. Sluilitn ubrr Aeliologie uiul Palhox«i)c>e <ler xpantanen HirnMut>
iMgen. Winbailcn. 1886.
HnchKauK. Brrlinrr klin Wochenschr,, 1887, t, (Meningilic Hemiplegia. j
■.urwenfrlil. 7.ur l^^hrc von <len Miliiiranvuriitinen dcs Mimt. Wiener med.
WocJicmchT., il«7, 47. _^^^^^
dnidcnhcrg. Arch. f. Pf)-ch.. 18S6. xvii, 1. (Post-hciiiiptc^c Molor Di^iurh-
10cm. I Stqihan, Rrvuc tic mM., iSS?. 3. IPrt- and I'oM-hcnnlplcgic Tremor) Bnsuutl CI M^inc. Prngrtt n\tA.. 1887. %. 7. (The Condilion of the Facial m
Hf&lencal HcmipleKia^) Wcmkkr. Bcilincr klin. Wochctischr. 18891, 4S SduAin'. Ilcitnig lur l.chic v»n dcr !ii;cun<ljlrcn und muliiplcn DcKcneralion.
Viti-h. Arch.. i8</x cMii, 1. 2. Schnbrr. Areh. f, lS)'ch.. 1890. xtii. 1. p. I3i. (" Aihelosis sputi».") Citmi. Vcrauch dnrr F.rklSiunK Tur iUh vrrachicdene Vcrhallen der Sdinen-
rcflnc luch Hlrnbtuiuiij^n. Wiener mcd. Wothenschrifi. 1890. jj, SinuH. Zwcihuaden un<l funfiig Ffflle von rrchi«- und linht-Kiliger Henti-
plejpc - tin Beiirag lur Frage nach der functionellen Venchiedenheil twMler
Hcmbfihltrrn. Inaug.-DiMcn.. Beriin. 1890. VUok. Gu. degli o»p«dali. 189:.
Trophic vasomotor changes are not uncommon in the par- alyzed limbs. While in the beginning of u hemiplegia the »kin ol the afTccted side is warmer and redder than that of the well side, it btxomes cooler as the disease progresses, and fre- quently assumes a somewhat cyanotic color. The trdema often BCen in the afTccted extremities is due to the absence <>( muscular movement and the consequent slowing of the blooil and lymph current. In a palicnt who, two years before, had a pretty severe apoplectic attack with persistent speech disturb- ance. I have repeatedly observed slight repetitions of the orrhage, during which the 5|«.'cch, which had consider-
333
ntSEASKS OF THE BKAIX rjfOPEX.
ably improved, again became entirely unintelligible. Siinul lancously there was developed on each such occasion over the whole body, and not merely over the paralyzed rtf^ht side, an urticarial rash which persisted as long as the cerebral symp- toms lasted. No doubt this was due to a disturbance in the vaso-motnr innervation of the vessels of the skin, which reap- peared wilh ihe transient increase in the intracranial pressure. Charcot describes an acute malignant bed-sore which appears two or three days after the onset of the hemiplegia in the ffluieal region, beginning as a red spot and developing in a few days into a brown, dry eschar six to seven centimetres broad. It always ends fatally, and is. according to Charcot, a purely trophic disturbance, an alteration in the tissue, which we can attribute only to nervous influences.
The nutrition of the muscles which for years have been par- alyzed usually suflcrs but little. We can easily understand that a slight degree of atropliy. due to inactivity, occasionally manifests itself, yet the excitability to both electrical currents remain;^ normal. Only in exceptional cases is there pronounced muscular atrophy in the affected limbs when these, although their motion is impaired, can still be used to a certain extent. In such cases the atrophy can not be referred to inactivity, but we must rather assume a lesion in the trophic centres of the cortex, the seat of which is, however, siill unknown. Since these conditions have received considerable attention of late, wc add here some references.
UTERATURB.
Quinckr. Tlctilschn Arch. t. klin. Med., i$8S. xUt, $.
ItDcichtriiir. t.'eher die fruhztriili;^ Muskclalrophie bci cicr ccrcbriilcn Uihtnung.
Dcutsilics Afch f. klin. Med., Novnnhrr. 1889, xlv, 5. <>i (Atrophy on
llic Third Pay aftrr HrmiplcKiii: ihe Inian was llioughl ii> t>e ifl the
ihaUinu!!.) Ciwiiluhr. Muskclairophic und cleciriKchc ETregbarkeitirerifnderungen lid
llimhenl«n. Ncur. Crotralbl., 1890, 1. Daiksi-Iiewilicli. Zwcl KillU- von fruhxeiiigrr MiiskcUlrophk tm eiiiem Hrmi-
(ilegikcr Neurol. Ccniralbl,. 1891. 10. <D, regards it u « cerebral
amyi>lTO|>hy.) MMiritofT. Arch. tl« Neitr.. 1891. htlH. p. 461. Sli-lner. i;cb<T die Muskdnirophie bd der cerebralen Hemiptc^e. Deutsche
Zcitxchr. f. Ncrwnhk.. 1893, ill, 4. 5.
The simultaneous appearance of a hjemorrhage in each hemisphere is exceptional. It needs hardly to be stated that
DlAGXOSrs OF CEKEBHAL HEMORRHAGE.
3J3
luch an ucciilcnt must necessarily give rise to the gravest symptoms : bilateral hemiplegia — that is, paralysis of all four cxiremiiies — bilateral facial and hypoglossal paralysis, aniauro- tis and total anaesthesia.
Diagnosis. — The diagnosis of cerebral haemorrhage may
^ve rise tu considerable dilhculties. It is easy only when a
suddenly or gradually developing unconsciousness is followed
by a paralysis or paresis of one side in a patient not suffering
Intm any valvular disease of the heart. Under such circum-
H stances the case is absolutely clear, and even the most cautious
H rliagnoulidan, if he can exclude hysteria, may safely assume a
^1 cerebral ba-niorrhage with cuns<H|uent hemiplegia.
H It is a diScrent matter where we have to make a diagnosis
at a time when we are unable to ascertain the presence or
extent of the paralysis, but where wc arc restricted to an in>
Iicrpretatiun of the unconsciousness of the patient. Under these circumstances wc have to be familiar with the conditions which, besides cerebral h:emorrhage, are capable of giviny rise lo unconsciousness, and be acquainted with the characteristic oani testations which each offers.
In the lirst place wc may have to deal with a simple faint- ing fit. The concomitant symptoms — the wax-like pallor of the face, the small, frequent pulse, the cold sweat which covers face and body — are not likely to allow us to mistake the con- H djiion for one of apoplexy, especially as the gravest sytnptom ^ — the loss of consciousness — as a rule, is not of long duration, but vanishes rapidly if the patient is bid down wtlh the head lowr. the face sprinkled with cold water, or if ammonia or eau
»dc Colf^ne, etc., be held to the nose. The success or non- tscocss of these measures will help us to settle the differential diagnosis in a few miruites.
Secondly, we may have before us an epileptiform attack ^without convulsions or the coma which so often follows epilep- tic fits. Mere the loss of consciousness is also complete, and ' *Hc diagnosis can only be made if we can obtain a history of ^ P«"evious epileptic convulsions, or if wc are able to assume this ^•"ota scars on the tongue. In the absence of such evidence '"C cnJor of the lace may sometimes be of value to us ; in some T>llcplic» this is very pale, in cerebral hasmorrhagc of a pur- ?1i)ih color, yet this rule by no means always holds good, and •hiiuld therefore be accepted (um grane salts.
234
MseASES Of-- rue brain pkopkk.
The unconsciousness su often occurring in the course of a meningitis may be rccogni/ed from the temperature and the pulse, the poculiur drawing in ol the abdomen (scuphuid abdo- men), the jactitations, the rigidity of the ncclc. and p'l^sibly from ihe existence of choked disks. The possibility ol an internal pachymeningitis haemorrhagica must be thought of when the development of the condition has been characterized by sudden exacerbations and remissions, and when at the same time a history of alcoholism can be obtained.
In the beginning and iit the course of progressive paraly- sis of the insane (dementia paralytica) apoplectiform attacks occur which resemble those produced by cerebral hemorrhage very closely indeed, and which can be recognized as belonging to the former disease only from the previous history of the patient (and later from the results of the autopsy). If we can get no information from the history the differential diagnosis is impossible.
Intoxication with chloroform and alcohol may be Attended by complete loss of consciousness. An individual in the uncon- sciousness of alcoholic intoxication is just as hard to arouse as one in apoplectic or epileptic coma, and the diagnosis may pre- sent some difficulties under certain circumstances — when, for instance, nothing can be learned about the cause, or what has immediately preceded the loss of consciousness. Usually, h<)W. ever, it is easy enough. Sometimes the smell of the ingested substance puts us on the right track, sometimes prompt reac- tion to energetic stimuli applied to the skin may make i>ur diagnosis clear. As long as we are not sure of our ground, we ought to abstain from all therapeutic measures. Of opium or of morphine poisoning we need only think when the pupils of the patient are conspicuously small. A degree o( myosis as high as we find in opium poisoning has only its parallel, and then but rarely, in haemorrhages into the pons, which arc rapidly fatal.
Uremic coma can easily be escluded. if we arc able to ex. amine the urine, and can detect neither albumin nor tube casts: besides this, with the history, the examination of the heart tor a possible hypertrophy should not be forgotten.
Diabetic coma, finally, is characterized by a peculiar fruity odor which comes from the mouth of the patient. It. of course, only enters into the question i( sugar can be demonstrated (or has previously been repeatedly detected) in the urine.
I
I
O/AGXOS/S OF CEk'EBftAL IIMMORKIIAGE.
235
I
I
and
It is not common to encounter any difficulty in decidiii{; which side is paralyzed; nevertheless 1 have seen instances in which this was the case, Thns it occasionally hapjwns ihal. owing (o the deep coma in which the patient lies, the limbs of both sides fall equally flacctdly when allowed to drop, white ni» (liflerence can be discovered in the two sides o( the face. In such cases it is well to Ihrow some tce-waler over the patient, Dpon which it wilt be observed that he wilt malcc movements of defense only wiih the non-paralyiied side, and the lacial musck-H will contract only on that side.
The anatomical nature of the hemiplegia may remain en- tirely otMcure, and only in certain cases are wc able to ^ive a decided opinion about it.
Whether hemiplegia following a stroke is due to ha;mnr> rbas;e or embolism am only be determined by accompanying circumstances. The existence of valvular lesions and of athe< toma speaks for embolism; nephritis, heart hypertrophy, albu- min uria. for haemorrhage; yet this rule has many exceptions, and we may assume that in about half the cases a correct diag- nosis is impossible (cf. Dana, Med. Record, 1891. p. 30).
The meniuf^ilic hemiplegia has these points in common
h the hemorrhagic— namely, the paralysis on one side and (be " conjugate deviation " ; but, as we have before pointed out. to meningitis we generally have the characteristic rigidity ol the neck and the scaphoid abdomen; where these latter symp- toms are not even suggested, a differential diagnosis, or rather the rect^nilion of a hemiplegia as of meningiiic origin, is im- possible.
The hysterical hemiplegia, finally, if it persist (or a long tiine, and if other hysterical symptoms, as anaesthesias or con- tractures, arc wanting, can never with any certainty be diileren- ibtrd from that depending upon cerebral hwmorrhagc. Bolh may present Ihc same peculiarities, and a decision as to which condition wc are dealing with may be beyond the powers even <A the practiced diagnostician. We are indebted to Charcot for a new symptom, to which he lias drawn attention, and which is said to be characteristic of hysterical hemiplegia — tamely, a paroxysmal spasm of the muscles of the cheek of one side, associated with an excessive deviation of the tongue to the aame side. This " glosso-labial hetnispasm " never exists in orgsnic lesions of the pyramidal tract, and is therefore pathog- nic for hysterical hemiplegia (Urissaud and Marie. c(. lit.).
A
2i0
D/sEMses or the BUMfx r/iorEK.
I( the question of the anatomical scat of the haemorrhage is to be considered in our diagnosis, we mu&t in the first place not forget that the mere exiHtencc nf a hemiplegia is not suf- ficient to give us an answer, for as long as we do not know whether to regard it as a direct or indirect symptom, wc can say nothing positive. If we further add that even an indt> rcct hemiplegia may persist for years, we can easily see with what difliciilties we meet in attempting a topical diagnosis. It may be quite true that in a great many cases where an apo- plectic attack is followed by hemiplegia, the lesion is situated in the internal cnpsnie. and we have become accustomed lo as. sociatc in our minds a certain typical clinical picture — that is, hemiplegia with more or less marked sensory changes — with a lesion in the internal capsule. We must, however, in making a diagnosis of that kind, always keep in mind that an indirect hemiplegia may be produced by lesions in any part of the brain, by lesions in the frontal, in the parietal, the occipital lobe, of the thalamus, of the lenticular nucleus, of the external capsule, and that, as we have also said, the duration of such in- direct hemiplegias is by no means always restricted to a period either of a few days or a few weeks. Hence a certain reser- vation must ever be observed by a prudent diagnostician, and he should speak with some certainty only when he h.is some other direct focal symptom to guide him. Among these, wc have, for instance, sensory aph.-isia for the (left) temporal lobe; (or the occipital lobe, hemianopia ; for the optic thalamus (with a high degree of probability), posthemiplegic chorea ; for the crura, alternating oculo-motor paralysis: (or the pons. alternat- ing facial paralysis. According to Diirck. it is possible at au- topsy to determine approximately the age of the hajmorrhagc from the condition of the red corpuscles (whether tliey are normal, discolored, swollen, shrunken, etc.). and from the ana- tomical and chemical condition of the blood pigment. If these points arc taken into consideration, its age within a period of from one lo seventy-two days may be estimated (ct. Virch. Arch.. iSg2, cxxx. Heft i, p. 89).
Prognosis.— After all that has been said, we hardly need to add anything about the prognosis. Any cerebral haemorrhage is a gnive event, which puts the life nf the patient in danger, or rather it is a symptom which denotes that a grave arterial dis- ease, without which a h;vmorrhage never occurs, has reached a slate dangerous to life. 1( once a haemorrhage has occurred
\
fHOCA'OStS fy CEREBRAL HEMORRHAGE.
237
I
I
I
I
vre are not sure but that it may be repeated at any moment, since the condition which favored it. the briitleness of the ar- lerial walls, means a lastin}; incurable prcdispusilton to a fresh luemorrhage.
In the presence of a recent apoplectic attack, it is impossi< ble for us to give a certain prognosis, or to predict what wilt follow. The severity of Ihe disturbance of consciousness is in a way indicative, and we may say that the severer this is found lo be — in other words, the greater the traumatic effect of ihe hasmorrhage — the less favorable is. actfris /laribus, the out- look with regard to life, as well as with regard to recovery. Yet exceptions occur, and even a very severe coma which has persisted for hours does not only not always produce death, but need not necessarily leave behind it focal symptoms, as hemiplegia or the like, and such patients may then be well for years afterward. Unfortunately, so favorable a result is rarely met with. As a rule, a haemorrhage of any considerable size i» either fatal or is followed by a hemiplegia.
.As to the difference in the prognosi<i for the individual, in*
direct as well as direct (ocal symptoms, most that deserves
mention has already been spoken of. The indirect symptoms,
u a rule, disappear alter a certain time, und a rfstitutio in in'
tfgmm is not impossible : the direct ones are only curable
when vicarious innervation takes place from the unaffected
bnaispherc which assumes the function iif the damaged one.
Thi* can be the case, for instance, in unilateral lacial and hypo>
gkesal paralysis, and in the lateral ilcviation of Ihe eyes {lesion
ot the lower parietal lobule) ; it may also occur in motor
■phasia if the patient is still capable ol learning to speak with
Ut right hemisphere (lesion ol the region of Bnjca). On the
ui^r hand, it docs not occur in cases of direct hemiplegia due
luilnion of the internal capsule : then the paralysis is incur-
*bk,and the improvement which may lake place is always
Wfy imperfect, ahhough a properly conducted treatment may
*Bcei some amelioration, and thus conduce much to the well-
tsioR f»l t he patient.
Treatment. — The primary affection, the disease of the ar- '"w to which cerebral ha:morrhagc is due. is beyond Ihe ^tb of therapeutics. W'e possess no remedy which can ^uie the miliary aneurisms to disappear, and our efforts are wofiacd to combating those symptoms which accompany and I^OK which follow the haemorrhage. Thus we have to deal
238
P/SEASRS OP THR BRAIN PROtEk.
with (ii the apoplectic attack itself; (2) the anatomical changes whicli are produced in the brain by the hemorrhage: (3) the foc:il symptoms, the paralysis (or paresis) of one side ; and. in general, all motor and scnsorj- disturbances rclcrablc to the Attack.
(d) The treatment ot the attack itscU varies according as we have to deal with a suddenly or gradually developing apo- plexy. In the lormcr case wc may assume that Ihe hxmor- rh.ige has already stopped when we first sec the patient, whereas in the second case the presumption that the bleeding is still going on is justifiable, and hence all measures which tend to arrest the hemorrhage arc strenuously indicated nt once. One o( these is venisection, which produces a fall in the blood pressure, and should always be resorted to in cases in which, after (or during or perhaps before) a harmorrhage. the carotids are found throbbing. Ilie action of the heart is tumul- tuous, and the face red and congested. The success is some- times surprising. The patient, who just before was comatose and moitonless, with stertorous breathing, immediately altera free bleeding begins to breathe more quietly, and evidently with greater ease. He stirs, opens his eyes, and becomes cor- scious. in such a case venesection was the only measure indi- cated ; it could not have been replaced by anything else — in short, it has saved Ihe patient's life. The compression o( the carotid artery, which Spencer and Ilorsley recommend as a result o( their experiments upon animals, will probably be re- sorted to only in rare instances (Brit. Med. Joum., March 2. i&Sc)). If the pulse is small, the face pale, and the heart sounds arc weak, no one will ever think of taking away blood, Then the administration of stimulants will be found useful; of course, they have lo be given with great caution, and be selected care. fully. Vinegar enemata. sinapisms, and ether injections may be tried. Changes in the blood pressure of the brain ought lo be avoided most carefully; they may be produced by turning the patient in bed. by shouting at him frequently, and by other attempts to wake him from his coma. The physician will have lo warn the friends against doing this, and do his best to have ihe patient left ijuiet and undisturbed. If ilie face is congested, he will order his head to be placed high and have him kept in one position. Local bleeding from the head is. if not directly harmful, absolutely useless. If bleeding is indicated at all. we shall choose venesection : cupping and leeching are matters of
TREATMENT OF CEHEBRAL HMMORRHAGB.
239
!(0 much detail and arc so slow in their action that they can not be recommended.
Immediately aflcr the attack has passed off and (he patient has regained consciousness the cliici task of the physician is to Bsee that he has absolute rest Even more than any other sud- Bden illneK!. apoplexy produces the greatest excitement and V conftlcrnation in a family, and it can hardly be wondered at that this fnvcs place to the greatest joy when the patient, who has already been given up. is seen to return to life, and that each member uf the (amily is anxious to express his feeling of satisfaction. All such outbursts may be very harmful to the pa- ticnt. and these demonstrations must be crushed by the physi- cian with iron tirmticss in order to avoid any emotion on the part of the patient : besides, he should give directions as tu 8 proper bed which will answer all the therapeutic and hygienic requirements of the case, and, above all. from the very first due precautions against bcd-sore3 ought to be taken. Proper arrangements should be made for the reception of the stools ind the nrinc. The head ought to be covered with thin com. K (iresscs, cooled with ice-water or with a light ice-bag that will eicrt nil pressure. The application of cold must not. however. be carried too far. since by a contraction of the peripheral vessels we run a risk of producing an increase in the intra* cranial blood pressure, which vi-ould be the opposite of what we are attempting to do. Any simple medicine which con-
IUins acids or cream o( tartar or tartar, boraxat. and the like, a sufficient tor the first few days, during which the patient onKht to be fed upon a light, nourishing, but unstinuilating (i) The treatment of the focal lesion in the brain— that is, ol the place where the harmorrhagc has occurred— should not btb^iin until a considerable time has elapsed after the gen- ual symptoms have abated. This will usually be from about tour to six weeks after the attack. Whether it is actually xiy to wait so long we do not know, but, as a matter of )t. we are afraid to undertake any active measures at an Wiicr moment, and certainly if a physician should go contrary •o trxdition, and if accidentally another ha-morrhage should *t«r, he would by himself open to severe censure on the part "* the family.
Ott the other hand, it seems more than doubtful whether •tare able to influence the disease-focus in any way by treat-
h
340
DISEASES OF THE BXAIK PROPEK.
ment or succeed in Imstcning the absorption which we desire. It is, however, supposed that this can be accomplished in two wa^'S : namely, by internal and external remedies, by polassitim iodide and mercury, and by galvanic treatment rcspcctivelv. The iodide treatment is based on the supposed absorbent pro|>- criics of the druR. Whether it possesses such a power to any great degree is doubtful, and the (act that it so frequently fails to give good results seems to speak very much against it. ()n the other hand, there is no question but that iodide, if used for any long period ol time, acts dclctcriously on the stomach, and Spoils the appetite and may lead to symptoms of intoxication. An unprejudiced practitioner who docs not administer medi- cine in a routine way will therefore .ilways first ask himself which of thetwo is the lesser evil — xvhcthcr he should renounce such help as is supposed to be derived from the remedy in the process of absorption and keep the patient's appetite in a good condition, or whether he should depend upon the more than doubtful action of the drug and at the same time ruin the pa- tient's digestion. But if we have once decided to administer iodide of potassium, let it tje done boldly, and let 2.0, 3.0, $.0 (30, 45 to 75 grains) a day in one or two doses be given in hot milk. Given in this way the administration of the drug is less likely to be followed by unpleasant effects than if we order a tablcspoonful three times a day of a solution of iodide, 4.0 to 8jO; water, 200 ( 3 i - 3 i j to 3 vj). The mercurial inunctions to the portion of the skull corresponding to the focus arc not harmful if any symptoms of intoxication arc watched for and salivation is at once treated energetically ; but their success is in no way greater than that obtained with potassium iodide.
With regard to the galvanic treatment, it must first of all be absolutely admitted that it is possible to act upon the brain with the galvanic current. The peculiar phenomena which occur during galvanization of the head — vertigo, seeing of sparks, etc., the cerebral nature of which can not be doubted— speak strongly in favor of such a possibility, and the experi- ments of Loewcnfctd on animals seem to indicate that these are due to an influence on the circulation in the brain. Whether, however, the galvanic current possesses, besides this undoubted action on the vaso-motor nerves, definite catalytic projierties, and. if so, in a measure sufficient to enable us with its help to influence the discascfocus, nobody knows. We will suppose this and hope that it is so, because it is the only weapon upon
TRKATMHNT OF CEftF.BKAL UtiMt/'l.HafA. 24I
hick wc have lo depend. The best and most reliable electro- ;bcr3f>euti$ts, Erb at their head, with his unusually wide cx> n'encc, ndniit the scarcity of positive rcsuUs front such a liratmeni, and acknowledge that in by (ar the greater number of cases tbcy arc negative (Erb. Ilandbuch dcr Electrotbera- *'e, page 320, Leipzig. 1882), .Yet cases may occur where the ysician is forced to resort to galvanization of the head — "the electrical treatment of the brain." He should therefore be familiar with the mode o( application. Only large electrodes ought to be used. Fig. 73 represents the head electrode of Erb. The anode being placed on the forehead, the cathode on the neck, weak currents without make or break should be al-
}
f%. 1^— Tks IjiRot ItSAD CLsnaooB icovRKBn wtiH Sfowos) of Ckii.
Icved 10 pass through the head of the patient for from one tninutc and a half to two minutes. Transverse and oblique oitTots may al»o be tried. (Details are to be found in Hin. Lcbitach, /iv. (-/>., page 165.)
(() The treatment of the hemiplegia and the posthemiplegic Botordiiiurbances demands, if any success is lo be expected, ■Wb perseverance on the part of the patient as well as of the phfiician. If we can not familiarize ourselves with the idea **t far weeks and months the same procedures and manipU' '•tiona have to be gone through in exactly the same way, wc '*i»U not begin the treatment at all nor order it to be under, ^keii. Wc shall then at least spare ourselves the disapp<iinl- "njt oi a failure : yet with patience, and where the ncccssiiry ^^Ans arc not wanting, it should l>e imdert-iken. The cases ■•hicha syMcmatic treatment for a long time has benefited ^W patient very materially arc numerous enough, and ihey
243
DISEASES OP THE RKAl.K PKOtEM.
wuuld undoubtedly be met with more freqiienlty if a (air trial were ^ven it more often than if> unfortunately the case. Oross> \\\i\\\\\ has shown that suggestion plays a prominent part in the results ui this treatment (Die Erlolge dcs Suggcstionsthcrapic bci nicht-hysterischen Uihmungen, Berlin, 1892), Since there can be no question of regenerating destroyed brain tissue, his aim is U) produce an iinproventenl in the general cerebrul energy. To this point wc shall return later.
From internal medicines absolutely no effect on the hemi- plegia is 10 be expected, and even the most sanguine thera- peutists, whose faith in drugs is unbounded, abstain here from fruitless attempts. The same may be said about the posthemi- plegic motor disturbances, and if we here make menti<m of the use of veratrine (0.002 to 0.003 tf- 'U '** '/■] -i ^^y '» P>"*) against the posthemiplegic tremor, it is only to declare the utter futility of this medicament. We have here also to resort chiefly to electrical treatment, but with this difTcrcnce, that the good results observed are much more frequent and much more marked than in treating the disease-focus. Definite rules (or the electrical treatment of the focal lesions as well as the hemi- plegic and the posthemiplegic phenomena can not be given. Every experienced electrotherapeutist follows certain rules and principles which he has found out for himself in the course of years trom personal observation. Thus one claims only to accomplish his end with quite weak, while the other has seen better results from the use of strong currents. The one uses galvanism, the other by preference the faradic current. Every one adduces reasons for his own method, which, as a rule, are strongly combated by other writers who claim to possess in- finitely more experience.
Above all, the wishes of the patient should guide us in de- ciding which mode of electrization should be chosen. One man tvill have a genuine idiosyncrasy against the faradic cur- rent, and more especially a^in.<tt the faradic brush. Another can not stand strong galvanic currents; they excite him, make him nervous, and disturb his sleep. In a very general way we may lay down the rule that in paralytic conditions most is accomplished by the galvanic current, with frequent makes and breaks, so as to produce contractions of the muscles. In conditions of irritation, especially contractures, on the other hand, most is accomplished by local fiiradiiaiion. Wc hardly need to insist that the greatest attention must be given to lire
\
TKEATMENT OF CEKEBRAL HEMIPLEGIA.
243
I
UlC(
^ in
grou|»8 of musck-s most severely aflcctcd — lor instance, in the upper extrt;inities. tu the extensors. The funidic treatment niiiy. e5pccially tl contructurcs arc threatening, be begun earlier thnn is allowed by our rule given above, even twelve to fourteen days after the cessation of the general symptoms, without any danger to the patient.
I'alients in good circumstances expect their physician to (end them to a watering place every year, ns a stay there is a pleasant change from the monotonous electrical treatment, and «i-e can not blame anybody fur putting great failh in it. Un- fortunately, these hopes are not by any means justi6ed. and by a course of treatment at Oeynhausen. Wildbad, Gastcin, ind Kagatz. 'where, by the way, the temperature of the balhs Might not to exceed 93* F„ painfully little is .iccomplished, cer- tainly a great deal less than by electrization or this alternated with massage. The latter ought to be mrricd out only by well-trained masseurs, and only with the greatest care. From the cold-water treatment we also have seen little success on the whole, although it is decidedly to be preferred to the simple bot baths and the like. This also must be administered care- fully, and must be adapted to ihe idiosyncrasies of the )xitient. 1 rule which is unfortunately not always observed. Hydro therapeutics can not be learned in the clinics, where only an occafiitinal remark is made about it. but deserves and demands I practical study in establishments where this treatment is in- telligently and carefully conducted. The reason why it is not esteemed everywhere as highly as it ought to be is because it is frequently not understood. Those who wish to acquire the theory of this treatment thoroughly I would refer, among other works. 10 the excellent text-book of Winternitz.
White we have seen, then, how helpless therapeutics is inst cerebral haemorrhage and its consequences, wc have. (M the other hand, the satisfaction of knowing (hat so much lucccM is promised by a timely and appropriate prophylaxis, that wr must rccf>mmend it most earnestly to all individuals of X Kk-calle<l a|>oplcctic habit, all who are inclined to cerebral CMigcslion, all patients with a heart hypertrophy, and. finally, all thoitc with hereditary tendencies. They should try to avoid putting on too much flesh, and shun everything which would cnnducc to the production of an undue increase in the blood pressure Among the most important rules upon which wc must insist arc moderation in eating, regulation of the bowels.
344 DISEASES OF THE BRAIN PROPER.
frequent exercise in the open air, systematic gymnastics in- doors— for instance, on the "ergostat" of Dr. Gartner, of Vienna, a small apparatus which can easily be kept in the room and on which a large amount of work, measured by kilogramme-metres, can be done (the work can be prescribed in kilogramme-metres). This apparatus I can highly recom- mend, as I have very often seen good results from its use. To avoid increase in the blood pressure, the use of alcohol, coffee, and other stimulants, finally, all excitement, be it sexual or of any other kind, should be interdicted. Unfortunately, these warnings of the physician are not listened to until it is already too late, and men who will protect themselves in time and give up some pet habit — the customary nap after dinner, or the like — in order to avoid a danger that only threatens, are few and far between.
2. Embolism and Thrombosis of the Cerebral Arteries, Eiieephalomaiaeia .
Pathological Anatomjr.^We have already adverted to the fact that the arteries of the cortex anastomose among them- selves, while those of the basal ganglia are what we call ter- minal arteries ; from this it is evident that the embolus has quite a different significance where it plugs up an artery of the former type to that which it possesses when the ob- structed vessel is a terminal artery, and no collateral circula- tion is possible, fn the first case the collateral circulation compensates for the damage, while in the second case we arc bound to have a necrosis in the areas supplied by the ob- structed artery, a '■ focus of softening." It is unnecessary to dwell much upon the important bearing of this fact; suffice it to say that the arteries usually concerned are the main branches and, above all, the middle cerebral. The reason why embolic processes arc more frequent on the left than on the right side has already been explained. Brain emboli origi- nate in the same manner as emboli in other organs; among the causes are diseases of the left heart— chronic endocarditis, mitral disease, and weak heart — aortic aneurisms, more rarely diseases in the pulmonary circulation. Thus in certain cases [Hirulent particles may pass from the lungs into the pulmonary vein (in ulcerative bronchitis, gangrene of the lungs, etc.), and bf carried into the svstcmic circulation. In a case reported by Diihnhardt a doublcd-up cchinococcus vesicle was the cause
SUeOUSM Of TIIH CEREBKAL ARTERIES.
«4S
<A embottsin in the left art. fnssnc Sylvii, the lelt art. prof, cerebri, und thcartcr. basilaris iNcurol. Centralbl., 1890. No, 19). Pilichen (c(. lit.) has also shown that certain poisons, cspc- ci:illy carbon monoxide, ^ippear tu sometimes produce soften- ing of the brain substance. According to him, the CO while circulating in the blood acts injuriously on the nutrition of the vessels, and brings about fatty degeneration and calcihca* lion in them, tience there finally results a necrosis of the liisue. Il is possible that phosphorus acts in a similar way. Age plays a still less important rSk in the aetiology ol embol- ism than in that of h»:morrhagc, whereas the influence of sex not be denied, as it is well known that by far more women '«« attacked by cerebral embolism than tnen : it is possible that this is the case, owing to the greater fretjuency with which we find articular rheumatism with its accompanying heart lesions in the female sex, especially in its younger members. The puerperal state may also have something to do with it.
• Thrombosis ol ihe cerebral arteries is either produced by an atheromatous process which narrows the lumen o( the ves- sel, and by slowing the blood current gives rise to co.igulation, or by an abnormal proncness of the blood to coagulate. The
tfir»t happens frequently in old people, and we can fairly say that atheroma is just as often the cause of senile softening as tniliary aneurisms arc the cause of cerebral ha:morrhaRe. The sttmormal tendency to coagulate (hyperinosis). which the blood presents in the puerperal state, in pneumonia, etc.. is rarely or
»>icvcr the only cause of coagulation. It can not be said to do »n«re than favor it. and hence we need not go further into Ihe cjuesliun. 0>nstdcrable general increase in the intracranial
IT ■ ' e may give rise to thrombosis (compression thrombosis),
. - • the pressure exerted on the vessels which occurs some- times in iMMlar meningitis. If. in addition, the arterial walls are ItseAsed — fur instance, by rubcrculosis or syphilis— Ihe coit- liliun* are still more favorable for Ihe formation of thrombosis. According to Ocrhardt, the hemiplegias which occur in the ruurse ol basilar meningitis are due to thrombosis with second- iry Mtflening.
Finally, we should remember that traumatism— a fall or a alow upon the he:id — may produce a disease in the arteries which long alter may give rise to Ihrombosis,
the necrosis of the brain tissue which follows the cutting i the arterial blood supply is called softening, encephalo-
246*
DiS£ASES Of THE BflAtX PHOrEK.
malacia, and wc speak, according lo the special {etiological lac- tor, of a traumatic, an embolic or tlirombolic. and an atlieroma> tous (senile) sultcning. The process 15 as folloivs {Wernicke): The vessels in the area (rom wliich the blood supply is cut ufl collapse, the Lymph spaces dilate and through aspiration be- come filled with cerebro-spinal fluid, so thai the whole tissue appears soaked, and the recent locus ol softening shows a de- cided increase in volume; the nerve fibres and nerve cells then become macerated in the fluid, and soon undergo destruction. With the microscope we delect varicosities ol the nerve fibres, myelin drops, and the neuroglia and the connective tissue appear irdemntoiis. If many red corpuscles arc present, the coloring matter coming from them gives to the whole locus u yellowish tint ; such a discoloration is especially seen in the cortex (///i^fir/j yi»M«*-j, Charcot) ; the white matter which lies beneath is usually of a lighter tint. I( then no sufficient col- lateral blood supply is established, which, as seems not impos- sible in a recent focus, might produce complete regeneration, there commences lo develop in from thirly-six to loriy-eight hours a fatty retrograde metamorphosis of the necrotic tissue, Polynuclear leucocytes emigrate from the dilated blood-vessels and invade the necrotic tissue: they take up the fatty parti- cles, and some reach the blood current again through the lymph channels as compound granular corpuscles. The latter, which arc invariably present in foci of softening more than two days old, on account of their infiltration with fat granules, are larger than the normal leucocytes. A pari of them seem to undergo fatty degeneration, others seem to be transformed into myelin drops, especially in old foci. A quite gradual absorp- tion of the dead and disintegrated brain tissue takes place, and a so-called cysl is formed, which am not be distinguished from that following a brain hwniorrhagc; more rarely wc find a cicatrix of connective tissue, which becomes as hard as car- tilage, and grates under the knife. Softenings, which from thff onset take a chronic course, have frequently been found I form sclerotic cicatrices, so that the soficniiig can eventually- become a sclerosis (Wernicke).
In softening of the cortex quite considerable areas may be- come deficient, which are partly replaced by serous fluid partly by thickened pia. The convolutions, which sometime! remain, present a yellowish discoloration, appear atrophic, an arc of a firm sclerotic consistence.
CEKEBRAl. EMBOLISM.
■ 24?
H Symptoms and Diagnosis. — Just as in hemorrhage, we H may in embolism haw symptoms which have to be regarded ^1 a» premonitory of ihc regular attack. They resemble very V clfwdly those above described, and chiefly consist ol vertigo, I lieadache, an occasional feeling as of pins and needles in the limbs, etc. The headache may be especially prominent ; it i; may persist (or weeks with undiminished intensity. »i)d ttien H disappear, or be lullowed by a distinct deficiency in memory H or beginning mental decline.
H The attack proper, which occurs at the moment the lumen H of the vessel is completely obstructed by the embolus, may ^ simulate the a|)uplcctic attack so closely that it may be abs<> lutely impossible to distinguish the one from the other. All ihe above-described differences in the nature and degree o( disturbance of consciousness may be met with here also, and though it is true that at times the attack sets in with more vio- lent epileptiform convulsions, that the face is less congested and respiration less disturbed, these points arc by no means sufficient (or a differential diagnosis. It is supposed that com- Hplctc loss o( consciousness speaks more against embolism and Hior haemorrhage, and the early disappearance of the paralytic ^kymptoms present point rather to embolism. Gerhard! con> Hsidcrs (fieri, klin. Wochenschr.. May 2 and 9. 1S77) a welU Vproouunced aphasia to be in favor of embolism in doubtful cases.
In embolism the attack is not evoked by an increase in the blo<Kl pressure, as in apoplexy, but by a " negative pressure." ** Since the vessels lying to the peripheral side of the embolus buddenly collapse, and the blood contained in the capillaries lows into the veins owing to the i-/j a ftrgo exerted by the contraction of the vessels, a vacuum is suddenly formed in
KHe ti5sue, and hence a negative bk«)d pressure is produced" Wernicke, toe, ett., p. 133). In its efforts to fill up the empty »f>acc. the brain parenchyma is bound to be subjected to a r«»<>rc or less considerable tniction from all sides, which may »*"»melimes lead to disintegration. 1( only a very small area is ^fTccled by the embolus, a regular attack may not lake place »«»d consciousness not be lost: it it is very large, various in- *J « rcct symptoms may .tppear, and indeed even the non.afTecled "*^misphcrc be implicated. But even after a severe stroke and *>licr consciousness has been lost (or quite a long time, a favor- ^^Ic event is by no means impossible, because the tissue does
248
I>/S£AS£S Of THE BRAIN rKOPHK,
not necessarily disintegrate, as in lia;morrhagc. but an equaliza- tion o( the blood pressure can take place, which will cause the disappcamncc of all the symptoms.
Cerebriil thrombosis rarely gives rise to a stroke, owing to the slowness with which the process lakes place, and when an apopleciilorm att.ick actually does occur, it must be due to ihe previous obstruction of other, neighboring, vessels. We had » considerable area dependent for its blood supply on a single vessel which before remained open, but has novr gradually become so narrow that the pressure in it becomes too low lo keep up the function (Wernicke).
The necrosis (softening, enccphalomalacia) to which the ob- » siruction of an artery, if lasting sufficiently long, is bound to \ give rise, manifests itself by certain focal symptoms, which may. just as in haemorrhage, be divided into direct and indi- rect. Among the indirect the hemiplegia, often attended with hcmiana;sthesia, which closely resembles that described above, is the most important. Monoplegias also and hemianopia may set in without a definite stroke, and m-iy be produced indirectly from the focus of softening, which lies in close proximity to the pari the functions of which are interfered with, if an cm- bolus obstruct an artery which can communicate by anasto- moses with those of neighboring areas, and thus the dam.ige can be compensated, wc shall meet with transient focal symp- toms (Wernicke), which at the most require eight days (or complete recovery.
To determine the exact seal of the focus of softening, we must go to work with the same caution as in making a topical diagni>sis of a cerebral h;eniorrhage. Here, as there, wc have lo look for direct foail symptoms, and it is to these that most attention should be given in our examination; on the other hand, wc must not forget that a focus of softening, even if i be of considerable cxlenr. may pass through all its phases with- out a single symptom. No one region of the brain seems tu bes more exposed to softening than another. We found that the numbei' of ti.xnmrrhagcs at the base largely preponderated ovc those in the cortex ; in embolism this is not Ihe case. It is only^ because the surface covered by the cortex is much larger than that of the brain stem that we find in the latier numerically (ewer cases of softening than in the cortex (Wernicke)>. The thalamus and pons arc only rarely the seat o( isolated soften tng, while hxmorrliagcs arc lound there much more frequently
PSKUPO-nCl.n^R /'AXALYStS.
249
I
whereas the medulla oblongata is more commonlj- the seat o\ softening (cf. Berlin, klin. Wochenschn, 1S91. 24). To diag- nusitcnte hemorrhage in the medulla oblongata during life iti practicalljr impossible, as in these cases deatJi is almost instnn- laneous.
Prognosis. — The prognosis in embolism is, tateris f^ribus. in general better than that oi haemorrhage. Not only is the OMtlooic for complete ncoytvy more favorable even if the attack has been severe and has lasted for a considerable time, but in most cases the danger to life is far less than in apoplexy. Indirect action upon the medulla oblongata, in consequence which the urine may contain albumin or sugar, is n rare urrence. Kven a softening of considerable extent may ex- ist for a relatively long lime without the manifestation of any ^rave general svinploms. Yet an unfavorable turn is not im- possible, and this should always be feared if a sudden and marked elevation of temperature takes place.
Treatment. — The treatment is very limited; indeed, embo- lism as such, and the necrosis produced by it. arc entirely out o( its reach. It can only be directed against the attack or cxmsisl of the prophylactic measures by which we may hope to prevent the occurrence or repetition of the accident. The latter un- doubtedly is the more important, and much can be accomplished by repealed local bleeding from the head (I^bordc). a proce- dure which is also indicated in the treatment of the attack itself, i*5 the cerebral circulation is possibly favorably influenced by it. That absolute rest is strongly indicated in cases where heart disease exists, needs hardly to be mentioned. Where there is » reasonable suspicion of syphilis, potassium iodide. 2X> to 5.0 <^^. xxx-lxxv)/»ffl die, ought to be exhibited.
WScrc there are multiple foci of softening the symptoms lurally depend on their seat. At the autopsy a number of uch foci may be found which could not be diagnosticated uring life because they were too small and were situated in lied imiifferent places. If several portions of the brain are » fleeted, c-ich of which gives rise to a focal symptom, there may t>g a complication of the most varied clinical manifestations.
0( great practical interest is the observation to which of ^4kte years attention has repeatedly been called, namely, that '^»ci of softening may occur in that cerebral portion of the muscular tract which contains the fibres destined to
350
DlSRASes OF THF. ItltAIN moPEK.
supply the muscles used in spenking and swallowing. These fibres pass from the lower third ol the central convolutions, where the supjioscd centres for the hypoglossiis and facial arc situated, and end in the nuclear region of the medulla ob- longata. Such foci have again and again been found. Some- times they were bilateral and situated in the basal ganglia, especially the lenticular nucleus, sometimes on one side only — e. g., in the right corpus striatum — and it has been observed that they sometimes give rise to a complication ul symptoms which simulate most closely those of Duchcniic's bulbar paral- ysis. The fact, however, should be especially emphasized that the occurrence of such a focus on one side is sufficient by itself to produce all these symptoms (Lupine and Kirchhoff, cf. lit.).
The disturbances which go to make up the clinical picture arc at times exclusively, always chiefly, referable to speech and deglutition. They resemble at first sight so much those of bulbar paralysis that the name pseudo-bulbar paralysis, or paralysis glosso-Iabio-pharyngea cerebralis. seems justifiable. Still, there arc some points which should help us to avoid mis> takes. Thus, while the beginning ol the true bulbar ]>aralysi8 is slow and gradual, the cerebral form often sets in quite sud- denly with apoplecttfortn symptoms ; in the pseudo-bulbar paralysis there is a manifestation of other cerebral disturbances which do nut occur in I)uchenne*s disease. Again, the latter runs an uninterrupted progressive course, while in the cerebral paralysis long remissions are frequently met with. A certain asymmetry of the paralysis, which is especially noticeable in the orbicularis oris(Berger), favors the diagnosis of the cerebral as opposed to the bulbar alTcction. Far more important than all these points is the condition of the paralysed muscles, which show no atrophy (Lercchc, cf. lit.), and of the tongue, which also does not become atrophied in the pseudo.b»lbar paralysis, and hence does not assume the appearance so eminently char- acteristic of the true bulbar form. Consequently there are no changes to be made out in the electrical cxcilabilily. whereas in Duchennc's disease reaction of degeneration is the rule. 11. finally, we add that in the cerebral form the laryngeal muscles seem lo be not at all or only slightly adecied, we have sufficient data to solve the question of dilTcrcntial diagnosis in most cases satisfactorily (cf. the excellent article by Oppenheim and Sie- mcrling).
The prognosis with regard to life is just as unfavorable in
PSBUIH>-HULffAi! rAttAt-YSiS.
251
L ihe o ■ itiat i
I
ihc one as in the oilier form, only this should be borne in mind, itiat in the pscudo-bulbar paralysis remissions may occur ; that
therefore can with a clear conscience give the patient good s of improvement. The duration ol the disease may be much longer than is ever the case in the genuine bulbar paral- ysis.
The treatment is not so hopeless as in Uuchenne's disease. The galvanic current intelligently applied, and careful galvan- iialiun of the brain and peripheral faradization of the paretic rauM^lcs, frequent excitation of the muscles of deglutition, as was described on page 149. all may be tried with the justifiable eipcclation of effecting at least a transient, sometimes indeed a quite gratifying, improvement.
LITERATt'WB.
^tcr. L«ltrbuvh (im allgcm. itod spccicllcn palhol. Annlomie. Eiil. ii. /rail,
188s. mcben. Zur AelwIoKJe (l«f tlinwnvricl^ung nnch Kotilcndunslvcrgiflunt;,
nchtl dnigcn Benierkunf^ 4ur Himqueltchung. Viirhow'v Arch., Btl-
ci». Hrh 1. i8S«. WKhwiL Zur PathulufiH! rlcr Encrph.ilomnt.icic. Innug.-DiKi^, Breslmi, 18S7. ^lotbv Bdtrai; 4ur ]>Aiholug:le dcr (idtimrrwckhunK- InuuK.-Diss.. Bresliui,
l«87. Guchholc L'cbcr V<:fiindcruiii;rn *n den Cetilam tier (lirnl)4n«. XIV. Wniulrf>
tcrummlunK dei suditcu lichen Ncuruloj^cn. Arcli. f. I'^ycli,. 1889, %%i, i.
p.448- UilumL Ein I'lll von srcunclXrer ErkrAnfcung des Sehhu|{e1> uml dcr Regia
wtnhaljniica. Arcl» f P*>Th„ 1S93, wr, j. Mwlmwi, Zur Kmninisi ikr I^mholie und Thrombo^p dcr t'lrhimanrruti,
«c BrtL klin. Wochenschi.. 1S94. 1.
>Ua. l/ebrr I'KtidobulbArp.ualyM. Inaug.-lM&am.. Unsliiu. iSBa
Voakke. ht. tit., pp. w8 tt itf.. 1881.
KWllMa; Arch. f. I>»>ch. und NtrrvcnkniTikh.. p. 131, 1881.
Km BnHn.Julr. 1881.
B>|n. <> Paralysis ^liMso-lal>ii>-pKir>'nK(Ni ctrcbnilis {Psrudo-tnillMr paraly-
*). OnsJ. Kr/il. Zduchr.. 3 // «v.. 1884. "ifufaiiii and Sic-mcrling, Ulc aciiic ItullidriMnilyir und die Psruiln-hulMlr-
fvalpr. CluM^-Anniikn, 1887. xii. p. jji. iktaifte. Dniucbp innL WocltciuctiT.. 1888. jj. (•"Kfcr. £t(Hlc Mir la panilysie {[louo-lnbiie cirf brak A TArmr pMudo-bunwire.
Tiirik. 1890. WnnwT, Zur t^hr« von dw tVudo-hutbKrpamlysc. Pragrr mrd. Wochcn-
Khnfl. 1890, ig, JO. (•Uttirllc. Dcs paralysks |)wudo-bu1bain:s d'origiiic cir^br.dc. MunijicIlicT,
idgj.
,252
D/S£ASSS OF TUB HRAI.S' PKOPhR.
3. Etidarlcriitii (Sjfphilitua).
This process, first accurately described by Mciibnerin 1874? nfTects more especially the vessels at the base of ihe brain. The walls become opaque, show grayish translucent or whitish J thickenings, and the vessels may tinally be converted into firm, grayish-while cords. The new (issue which ciicroiichcs upon the lumen ol the vessel either originates in the intitna by an jn> ■ crease of the endothelial cells, which become transformed into connective tissue (Heubner). or is derived from the nutrient ves- scls ol the media and advcntitia, and consists therefore ol emi' ■ grated cells ftiaumgarten). On account of this tendency 1<) thickening and corisetiucnt obliteration of Ilie vessels. C. Fricd- lUnder has proposed for the process the name endarteriitis ob- ■ litcrans. While not denying that lleubncr, who has studictl ihe question most carefully, has arrived at important results, we must at the same time affirm that the arterial disease, which he describes as specific in nature, is not peculiar to syphilis, but that wc find the same changes wherever we have a chronic inflammatory process with Ihe formation of granulation tissue, as, for instance, as a consequence ol alcoholism (C. Fricd- lUnder). This one fact remains of the greatest practical impor-. tance, that in the course of syphilis the cerebral arteries arc very frequently diseased, and that as the outcome ol this dis- eased stale the most diverse cerebral symptoms may arise. Chorioretinitis, for example, has been observed by Oswald (Deutsche Mcd.-Ztg.. 1888, 86). That under certain circum> stances a hemianopia can be the result of such disease is proved by the inlcrcsting case reported by Treitel and Daum- gartcn (Virch. .^rcb.. Bd. cxi, Hefl 2. 1S88), where, as a conse- quence of gummatous arteriitis obliterans of the arleriu cor- poris callosi dextra, although the optic nerves were intact, a unilateral temporal hemianopia had developed. Furthermore, it is to be remembered that often enough an autochthonous thrombosis due lo this arterial disease gives rise loan attack which can not be distinguished from the abovc'dcscribcd true apoplectic stroke with consequent hemiplegia. If recovery takes place in these cases the same thing may be repealed sev- eral times, and it is especially in syphilitic diseases of the ar- leries that this is relatively frequent. The patient suffers from I intense p.iroxysmal headaches, occasionally loses his conscious- ness, and presents a transient hemiplegia, but again recovers
\
DILATATION OF TUB ARTERIES OF THE BRAIN.
253
I
'ly well, until finally he succumbs lo a graver stroke. This, then, is the usual course which the disease takes. It can, of course, only be diagnosticated where the history of syphilis is clear.
The recognition may sometimes he diHicult if other cerebral sy>n|>lnms arc present, such as speech disturbance;^, intention tremor, decrease in memory, and the like, when we arc liable to think of multiple sclerosis, or progressive paralysis of the in- «ive. and it may only be the amenability of the disease to spe- citic ircatmcni which will clear up all doubts. This consists in the use of bold doses of potassium iodide, 4.0-6.0 (3 j~ 3 jss.) a ^y in hot milk until sixteen ounces are taken, and an ener.
\c course of inunctions — thirty to (ilty inunctions of 2.0-2.5 ();r. xxx-xl) ung. hydrarg. It should be begun as soon as pos- Mble. as the patient is in no way injured by this procedure, while the benefit may be most conspicuous.
4. Dilatalian of Ike Arltrifs 0/ tht Brain.
Aneurisms of the cerebral arteries may be of traumatic origin or, what is more common, may depend upon endarteri>
Iiiis, and in this latter case syphilis again deserves special men- lion, a» among fifty cases of brain syphilis there were found ux instances with aneurisms (Heubner). Spillman reports Utcen cases in which following syphilis aneurisms of the iMllar artery were found (Ann. de Dermal, et de Sypli., 1S86, ' rii. p. 641). Further, there is the embolic origin of aneurisms, which must not be forgotten (Ponhck).
Dilatations have been noted in the basilar artery, in the middle cerebral, and, though but rarely, in the vertebrals. Three cases of basilar aneurism have been reported by Noth- I'Aagcl (Topischc Diagnostik. p. 526) ; others by Watson (Lancet, (October 13, 1888. p. 719). The symptoms presented nothing mctcristic, but varied much, and even symptoms referable to the pons were not in all cases present. Vertebral aneurisms, described by Cruvcilhier. I-cbcrt. and others, have ncca- kion.itly been found to be attended with occipital neunilgia. I^ibtalion of the vertebrals produced by atheromatous degen.
■W'T-aiiiin may affect the surrounding pansand. as a consequence •»l Uructuml ch.inges produced in the neighborhood of the 'v>{ru». lemd to attacks of tt^itching in the velum palati and to ^tave respiratory disturbances (Oppenhcim and Sicmerling). Aneurisms of the ophthalmic or internal carotid in the
«S4
DKSKASSS OF THE BRAtX PXOPBlt.
cavernous sinus may give rise to a pulsating exophltinlmus. wbich can by appropriate manipulation be temporarily pressed back into ihc urbit. The pulsation of the eyeball, which mav bc propagated to tlie forehead and temple, is a source of grcul annoyance to the patient. In connection with multiple aneu- risms, such as have been observed by Patilicki. for instance, fvisting simultaneously in the basilar, the anterior communi- cating, and the middle cerebral artery, epileptiform convul- sions and psychoses have been noted. Definite p.ithognomon- ic signs do not, however, exist, and the diagnosis intrp '.■ilam is only exceptionally made with certainty. According to Oer- hnrdt. there can at limes be heard between the mastoid process and the thick cords o( the muscles of the neck a murmur refer- able to the cerebral arteries; it is systolic or continuous, and is heard on one or both sides if the patient refrains from breathing or swallowing. Nevertheless, it is rather cjcccji- tional that a (small) .-iiicurism of the cerebral arteries is diag- nosticatcd correctly during life. In larger arteurisms. which produce characteristic focal symptoms, this will at times be easier, especially when etiological data — e. g., traumatism — are present.
5. The Neurosfs of the Arttrits of thi Brain {Anatnia and Hyperamia 0/ lh<- firatn).
The vaso-motor nerves of the cerebral and meningeal arter- ies arise partly from the cervical sympathetic (Dondcrs and Callenfels), partly from certain cranial nerves (Nothnagel), They may be excited or paralyzed idiopathically. or re8exly. especially from the stomach, and the resulting conditions, although as yet only imperfectly understood, are of great practical importance. Both stimulation and paralysis are, of course, usually only temporary, while in the intervals and in the normal state the vasn-motor nerves as well as their centres are in a state ot moderate tonus. If the stimulation should frorp any cause be more than is necessary to maintain this normal tonus, a spasmodic contraction of the smaller arteries takes place, the absolute amount of blood in the brain becomes diminished, the patient gels pale, complains of dizziness, and loses consciousncss^in other words, " faints " (acute nervous cerebral an;emia). At the same tinTe the heart's action is weak- ened, the pulse is small, the face and body are covered with cold perspiration, and if this irritation is frequently repeated a
XEUHOSES OF THE CERBliRAl. ARTBRIES.
ass
certain predisposition to slight changes in the blood pressure becomes gradually established, a condition oi things which is lavored by the mobility of the ccrcbro-spinal fluid. The at- tacks now occur on the slightest provocation, and in the in- tervals between them the |>atienl complains of dnil headache, vertigo, etc., the face at the same time usually being of a pale, w-ax-likc color. Certain general diseases, especially chlorosis and pernicious anaemia, greatly predispose to these paroxys- mal vascular spasms : in fact, cerebral anivmia is not infre- quently one of the symptoms of general anxmia, as ir is ob- served, for instance, after frequent and profuse bleeding from
iiorrhoids.
Among the (etiological factors, certain occupations play an important Hlc. Working in lead especially may give rise to a chronic vascular spasm, and thus to a cerebral anaemia, which is associated with almost constant headache (cnccphalopathia mumina).
Tanqucrel des Planches, the best modem authority on saturnine affections, has described this condition, and il ha& again and again been made the subject of the most careful in- quiries. It would be beyond the scope of our present work to t'pcak nf these in detail : those interested in the subject will find references at the end of the chapter; suffice it only to say here that this saturnine anxmia, if the obnoxious action of the metal is continued and the disease is once established, may pro- duce in the workers severe cerebral attacks, epileptiform con- Tulsiuns, and the like.
The treatment of acute cerebral anaemia consists primarily
ui placing the patient in an appropriate position — that is, with
the head low or at about the same level as the feel, so as to
aid the blood flow to the brain ; the use of stimulants (wtne,
brandy, coflec), occasionally a subcutaneous injection of ether,
(nay be indicated. Those who are familiar with the procedure
inflate the Kustachian tubes, as Kessel recommends : this
r4ouche" is said to be an excellent method of producing jiidly an increased flow of blood to the anaemic brain (Laker, ^Vicn. mcd. Presse, 1891, 25).
Kur chronic cerebral ana'niia galvanization of the brain or
**t the cerebral sympathetic may be tried. As u matter of
coune, attention must also be paid to a possible primary cause,
and "rvcry pernicious atiological factor removed (change of
"ccujxiliim, etc.).
2S6
P/SE^SHS Of TUP. nUAIN PKOPER.
The opposite condition, a paralysis o[ the vaso-motor nerves. produces u dilatation of the cerebral vessels, and thus an im- mediate overlilling o( the same. This can be deniunst rated by ophthalmoscoiiic examination. Often, but not always, the vcs. sels of the face share in the disturbance ; the countenance uf the patient assumes a piirplish-red color, he complains of throb- bing in his temporals and carotids, of headache, ol buzzing in the cars (acute nervous hyperemia) — in general, of about the same symptoms as we have described in the vascular spasm, the only diflcrencc lying in the color of the face. It is ob- served in certain individuals regularly after the use of quite moderate quantities of alcoholic beverages (wine, beer), or, just as the ana'mia, after emotions, stning bodily or menial exer- tions, too much study, etc : the abuse of tobacco may also give rise to it.
On account of the very varied manifestations of the aSec- lion different forms of cerebral hypcraimia have been distin- guished (Andral. Eichhorst). Thus, a ccphalalgic, a psychical, a convulsive, and an apoplectic form have been described, according as cither headache or psychical excitement, with in- somnia or epileptiform attacks or periods of unconscioustiei^ (which latter arc not rarely followed by cerebral hemorrhage), are the most prominent symptoms. The transition between these ■■ forms " is, however, so gradual, and so seldom are they sharply defined, that for practical purposes it docs not seem worth while to make the distinction. We have repeatedly ob- served marked contraction of the pupils, while in ana-mia they are more frequently dilated and react sluggishly. As we have pointed out above, simple cerebral hyperarmia may produce hemiplegia, which can easily be confounded with the apoplectic form (pseudo-apoplexy).
The treatment is rather unsatisfactory ; it is true wc may in acute attacks of cerebral hyper:tmi,a give early relief io a patient by placing him in an appropriate— that is, nearly sil- ling— posture, by applying ice-bags to his head, or, finally, by free venesection ; but these atucks are so frequently rcpCJitcd in individuals predi-sposcd to them that the question of such treatment is not of so much importance as of the adoption for months and years of a careful dietetic regime. Besides keeping the bowels well open — a thing which should never be omitted — the patient must be advised to take enough exercise, even practice gymnastics ; he should be cautioned against indul-
DISEASES OF TUB C£ff£fiJfAl VELVS.
257
rnce in heavy, indigestible foods, and, above all, in alcoholic averages. A yearly visit to places liltc Marietibad. followed Pby a stay in a pure mniinlain air, moderate but daily cxcur- [sions on foot, the occisioiiul um: of Carl^^bad water under the direction of the physician— all these may be prescribed with [advantage. Much caution should, however, be used with the [fk^alled cold-water treatment, which, like scu-balhs, may only [hcn-asc the hyperiemia. This applies equally to the massage rlrcaimcnl, which, unless carried out in accordance with cer- 'lain indications and fixed rules, and under the supervision o( a
rompclcnt medical man, often is productive of more harm
than good in this disease.
I LITERATURE.
Tuiqurrcl d« IHanchn. Lrad [>iiicasi-s : wSih Noics and Additions on ihe Usr of ihr LeA«l I'ipe ami in SututiluiM. By Sxmuel L. Danji, Lon«ll. 184S, ■Dd BiMion. i8ja
Rtittloat. Gat. dcK hAp.. 6S-71, 1873.
Iln)[n', O. BnlmcT Iclin. WochenKhr., n, 14. p. tS3, 1874.
JI^AiMT/. Cu. dc PaiH. I. i. 187,^
Bmchtai. Cm. dcs hA|x, 14. 1875.
lipinc U31. <k Pjiris. 47. 187S-
II>n. Kinnkhdtcn drr Arlwiict. iii. 49, 187$.
HweiKti. Wim^Rili. Con^f). H).. li. y>, iSKt.
Ilibbli. 2ur i:n<:r|>halo|Miliia saturiims. Allg. ZeilschT. 1 P«>'<:h., uxtx, 1. 3,
I«t3.
CUilltr. Contriliuiiun & I'Mude |»tho;,'6nique du salurnbme cer^bro>«pina).
lYmc ik fJin^. No, 101. 18S]. p|> 45 rf iff. kkili. I*iiul. Uclirr F.iii.'«'j>halo|M(hi.» und Arihnilgia t^aiumiaa. Inaug.-Uira.
VrjiiiLiv. 1H8;. fimtf. New Vurit M«li<-;ik Record. Novrnibcr 13. 1886 iMgwiid. Hypcrhimic chionii|ue du cervcau ct dc la iikh'IIc ^pinirrt, I'rogr.
nhU 9<. 1887. Wai|luL Alrx. Ucbrr Encrphalop.-iihu saturnin.-i. Arcli. f. l'i)«K., xix, 3.
R Diseases of the Cerebral Veins and Sinuses.— The blood f"™ ihe htJiM and meninges j§ earned hack toward the heart by the ""nnal jugular vein. This vessel emerges from the jugular (orn- "Ml and after its junction with the external jugular becomes Ihe wnwon jufiilar. which, after it ha« in turn received the stibtlaviiin, ■^ciUcdthc innominate vein. The lu-o innominate^ together fwrro "It Mi{icnor vena cava.
Uctwecii ilie two layers of the dura mater there exist spaces "web CDnTe)r venous blood but arc without valves. These are ^kA «nii!te». The vein* of the Cnrlex cmi>!y themselves into the iMKttiidinal stnus (sni. faldf, ma) ), which terminates behind in the
IT
258
P/SSASSS or THE BRAlff PROPER.
lorcular Herophili (connueiii »iiiiium}. The mode in which the veins empty into the stnu&— namely, in the direction opposite to that of the blood current in the latter — produces a slowing of the circuta- lioR, and thus explains the frequent occurrence uf coagula in the veins of the cortex and the sinus. The deep cerebral veins are col- lected into two trunks, winch are known as the veins of Galen, The^ again unite into one, the vena magna Oaleni. They convey the blood from the ventricles to the sinus rectus (pcrpendicularisi), which in its turn empties itself into the torcutar Herophili. The blood from the inner ear goes into the cavernous sinus which is situ- ated at the Mde of the sella turcica; that from the mastoid cells into the lateral sinus, which at the jugular foramen pahttet into the ao-called bulb of the interna) jugular vein. The veins, ihems^elves anastomose but little with each other, nhile the sinuses do m> freely. It is important to note the cotnmunications between the mtracranial and the extracranial veins — for instance, of ihc nasal with the ante- rior end of Ihc longitudinal sinus, the ophthalmics with the sinus cavemosus and the facial veins, etc. — and the communications made by the venu: diploiiiicK, for only then can wc understand how patho- logical proccMes can extend from the outside of the skull to the in- side, and how occasionally we find an external swelling in affections of the sinuses.
Here it is more especially thrombosis with which we have to deal, which may occur in the veins as well as in Ihc sinuses. The di>>tinction is not always easy in li(c nor even after death, because alter death the venou;^ thrombosis may extend into the sinus and be taken lor a sinus thrombosis.
If only one vein isaSected the mischief may be but slight. Usually, however, it takes in one or two ol the larger veins, which become obstructed during the course of exhausting, acute, especially infectious diseases or after an injury, lor in- stance, a blow on the head. The preponderating number o( the patients are children, and at times, especially during the hot season, quite young children, in which cases a special aetiologi- cal datum can not be found. The symptonns are the follow, ing: Hemiplegia, ushered in by convulsions and lasting only a few weeks, is followed by a permanent weakness, not infre- , quentty by occasional spasms in the arm. The development ■ of the child is then usually faulty, for apart from the occasional atrophy in one arm or in one leg or of the whole side, epilepli- form convulsions may persist (or years, which not rarely have ■ an injurious influence on the menial developmcnlof the patient, hi such cases at the autopsy often thrombosis of the longilu
1
1
DISF.ASF.S OF THF. CF.RF.BRAL VF.tUS.
2S9
I
dinit sinus and o( the veins empt^'ing into it is demonstrable. In adults, such a thing as a thrombosis ol the cortical %'cins is extremely rare.
Sinus thrombosis may have one of two causes. Either we have a general disease which favors the coagulation of \\w blood — as in children profuse diarrhtra, acuic infectious dis- eases, in old people, tuberculous and carcinomatous processes — or neighboring parts, as, for instance, the skull bones or the skin of the scalp are diseased (erysipelas), an extension of the process becoming possible on account of the communications between the extracranial and intracranial vessels above de- scribed. \Vc distinguish the true inflammatory thrombosis, which afTccts the later:il, the petrosal, and the cavernous sinus, Irom the soollcd marantic thrombosis, which often occurs in the superior longitudinal isinus. In both cases the secondary symptoms of engorgement, which are especially marked in thrombosis of the longitudinal &inus and which manifest them, wives in so-called meningeal ha;morrhngcs. are of the greatest importance- Such meningeal hieniurrliages are found in chil> drcn (post mortem) as thick congula distributed over ihc cor- tical motor centres, where they have in life given rise to a curious combination of paraly^^ and spaKm, the power of spon- Uncous movements, however, being retained{Gowers). Choreic movements complete the picture which congenital chorea, bilateral athetosis, and double spastic hemiplegia present, cases which arc difficult to interpret and still more diflicult to diag- imticate. In these patients, too, the mental development rcmiins imperfect, and their irregular movements and cnnlrac- lurci (often most marked in the calf muscles) give them the appearance of helpless cripples.
The diagnosis of sinus thrombosis can only be made with 4>| certainty if to the general symptoms (headache, somno- wet, paralyses in the distributions of the cranial nerves) signs "i added which point to circulatory disturbances peculiar to linits thrombosis. Thus, for instance, symptoms of engorge- 1^1 in tbe ophthalmic veins, manifesting itself by prominence "I (he eyeball, (rdcma of the lids, congestion of the retina, etc., point to obstruction of the cavernous sinus; (edematous swell, wgs behind the ear to affections of the lateral sinus, and finally tynptoms of p.issivc hyper;emia in the nose — epistaxis, marked ■iwen in the veins of the tcmpund region, in small children lalhen ol the anterior (.acial veins situated bctwcn the large
36o
DtSEASF..'! OP THE RHAllf PROPER.
fontnnellc and tlie temples (Gerliardt)— to implication of the tungitudinal sinus. Fain and swelling of the corresponding side of tlie neck may be signiricant of a jugular thrombosis, etc. All these conditions arc, however, but rarely met wiih. and they arc more easily found in the books than demonstrable in the patient. The duration ol a sttius thrombosis varies be- tween several days and three to at most lour weeks. The prognosis is usually unfavorable and the treatment unsatisfac- tory and purely symptomatic.
l.ITKKATt^RK.
Powell. Ca«e of Idiupaihic I'hronihoxJs i>r Ccretiral Sinus and Veins o( Calcn in « Young Woman. Lancci. lJiM.-«inlicr, 1888. ij, 13. |>. 1134.
Uonley. A Cane of Thrombosis of ihc Lnngiiurtin.i) Sinus, together with the Aiilcrior froiilal Vein, musing Localiicil Foci of H*m(irth,ifre. which prodiicect Remarkably Lomli^fd Conical Epilcp&y. Itrmn. Ajiril. 1K88.
MilicMtwcif;. Subilunlc llliitiing .iiis abnorm vcrUud'Dilrn CtchimvenetL Neurol. CMitralbl. 1889. 7.
Fcirnri. Oblitfritiion cxpidiocnialr (1» »inus (I« la <lurc-ni4re, ric. Arch. ital. debiol., 1889, xi, p. 171.
Zaufitl. 2tir Otithlclite der operallven Uehandlung der Sinusihroinboic in Folge von Olliis media. Pf.ij;cr med. Wochenschr,, 1891, 3. (Ligation of the Internal JtigiiUr Win .ind OpFiiiiij; iif the Thrombosed Sinus.)
I'arkur (Liverpool). Itcrliner kli". Wochcnschr, 1891. xni*. la
Zitm. Wiener klin, Wochentchr., 1893. v, 36-3S. (Sinus ihrnmbosis xfA Exophihalmus.)
Elirentlorfcr Wiener med. I'rcsse. 1893, xtxiij, 19^ aa (Sinus ihrombosis dur- ing ihc Puerperal .Si.ntc.)
BJickletx. Arch. I. Pttych. u. Nen-enhh.. 1893. xxv. t.
INFLAMMATORY PROCESSES IN THE BKAIN SUUSTANCK.
/. PuruUnt Encf^phalitis — BraiH Abictss.
Pathological Anatomy. — Circumscribed pus formations in the substance of the brain, which anatomically differ in no war from pus form;ilions in oilier orjrans. are called brain abscesses, and wc speak of ihcm as encapsulated and non-encapsulaicd, accordtnfi ;is to whether or nt>I Ihry are definitely .separalcd from the surrounding tissues by sclerotic thickening. In the former, n membrane of connective tissue incloses the abscess, which contains a thick pus ; in the latter, disintegrated nerve tissue and crystals of cholestcrin are found in conjunciion with the frequently very ftttid pus, and the abscess walls arc formed by a soft layer of brain tissue intilirated with pus. and sur- rounded by areas of yellowish softening and oedema. In the
BKAIS ABSCESS.
361
^ ^
to
icned Areas compound granular corpuscles are found in t numbers. The size of the abscess may vary from that of thai of ai) apple, and it may even take in nearly (lie hemisphere. The larger the abscess the more marked arc the signs of increased iutracranial pressure, the more flat- tened and Indistinct ihe con vol 11 lions on ihe surface of the brain, and the <lrii:r and more aclhcrciu becomes the pia mater. Should the abscess break through into one of the ventricles, pus may eventually be found in all of them, and Ihe cpcndyma (hen appear cvdematous. If it reaches the surface ul the brain il may give rise toa diffuse purulent meningitis (VVernickc).
Etiology. — .-Etiologically. injury is of the greatest impor- tance. though it need not necessarily have aflectcd the skull itself, but may produce an abscess just as well if contined to the »oft parts ; in such a case, the inHammutiim extends through the bone, and the infectious material penetrates into the brain from the flesh wound. If we have no open wound, no break of continuity in the soft parts, then even extensive destructions of the brain sul>stancc often do not lead to an abscess formation, just US in the fractures of the skull healing occurs without sup- puration provided that the external air is excluded from the injured parts of the brain.
Besides traumatism, suppuration occurring in the neigh- borhood of the brain may cause a bniin abscess; thus, in rare instances, it is a purulent parotitis or suppuration in the nasal cavity, or, more frequently, caries of the petrous portion ol the tetnporal bone or suppuration in the middle ear. which becomes the starting point. For years an otitis media may persist and be attended with a purulent discharge front the external ear without any brain symptoms, but suddenly this running may slop, the pus is retained, and probably gives rise to the caries of the bone, on account of which the petrous por- tion may become so soft that it can be cut with the knife: a brain abscess then develops either In the temporal lobe ur in one of the hemispheres o( the cerebellum.
Suppuration in the bronchi, putrid bronchitis, bronchiecta> sis f Bicrmer). lurthermore, ulcerative endocarditis and pyemia, may a's't give rise lo bnun abscesses, which are then dcsig. tiatcd as "metastatic" abscesses. Idiopathic abscesses — that fs, thove In which no setiotogical factor could be discovered — have been observed by Strlimpcll in some cases ol epidemic cercbro-bpiual meningitis.
362
DISEASES OP THE BJtAtX P/tOPER.
Symptoms. — The symptoms of a brain abscess are divided into general and local. There may, however — and this is ol much practical imp^trtance — be no si(;ii of brain mi^htef at all. A man may not complain of anything worth mentioning, save. perhaps, of an occasional headache, and nt the autopsy a brain abiwc&s be discovered. Quite a number of these cases arc well authenticated, and there can be no doubt as lo their existence ; to be sure, we ought not lo forget to add that the place in which such an abscess is developed must be in a si»-called in- different region.
.Among the general symptoms the one most constant and the most distressing to the patient is headache; it can by no means always be localised, but more frequently affects the whole head, and may last with greater or less severity for weeks or even months. Occasionally the torture is such that the patient, incapable of doing anything, is forced to remain quietly in bed. although no other symptoms may be present. Very often, it is true, disturbances of the scnsorium may ap- pear after the headache has lasted for a long time; a strange apathy takes possession of the patient, his sleep is disturbed, and his general condition is aggravated if. as is common, febrile movements set in, which may be attended with convul- sions, which arc mostly unilateral. Attacks of vertigo. some> times severe enough to cause great anxiety, and sometimes only transient, occur, and not rarely there are spells of vomit* ing. sometimes lasting (or days, and acting very delcleriously on the patient. The ophthalmoscopic examination, as a rule, does not reveal any fundus changes ; choked disks are only ex- ceptionally found, certainly much more rarely than in brain tumors. The focal symptoms of cerebral abscess are almost exclusively direct. This is a (act which is easily understood if we consider their mode of origin; Ihey are produced either by a direct destruction of the brain substance or by the pre- ceding cedema and the attendant " preparatory softening " (Wernicke), both of which processes arc strictly local. At the same time we must not lose sight of the fact that the pan affected by this " preparatory softening " is still capable o( regeneration. Indirect focal symptoms have only been ob- served in cerebellar abscesses ; in such, paralyses of the abdu- cens .ind other nerves have been noted (Wernicke).
How different local symptoms show themselves, and which are characteristic of lesions of the different parts of the brain,
BftAtN ABSCESS.
263
discussed iibove (page 162 et ttq.")'. suffice it here to
Tadd that abscesses of the so-called motor region produce hemi-
jileijias, which appear in a very characteristic manner— namely,
Mcp by step. In abiice&ses o( the uccipital lobe hemianopia is
iihe direct local symptom which, il properly used, may settle the diagnosis. The direct local symptom of the temporal lobe — Ihc crossed deafness — can only rarely be accurately deter- mined, as the suppuration of the middle ear. which we have shown often to be a:tiolugjcally connected with brain abscess. h mostly bilateral, and as tcsling of the hearing in palicnts, whose menial activity is somewhat dulled, is very difficult. »ince Ihcy are usually unable lo appreciate any decrease in hearing on one side. In general, we must confess that tcx) little attention has been paid to the testing of the hearing, and thai _ the examinations have not been made with sufficient care. H In no one of the few reported cases of abscess of the pons, V Ihc medulla oblongata, and the cerebellum have direct local Ktymptoms been observed, ur at least noted with any certainly ; ^Ihe general symptoms, which arc mentioned in connection with the abscesses of the cerebellum, must be attributed to ^ pressure produced by the growing abscess, f Course. — The disease may pursue its course in one of three diRerent ways:
(t) It assumes from the onset a tumultuous character, whether it originate from a traumatism or disease of the mid- dle car. Violent pains^at first local. later spreading over ihc » whole head, and lasting fiom two to four days — together with marked elev.itionof temperature and paroxysms of convulsions. are followed by grave disturbances of consciousness. These may last lor three, four, even eight days, when the patient, without regaining consciousness, dies in a restless delirium, presenting the picture of one sufTcring from severe organic dueasc. •
■ (s) These paroxysmal symptoms lose, after a few weeks. their acute character, and become less and less marked ; the p.itient seems to feel better, and he may. indeed, be free from ail ln>uble for several months. Even the headache seems — at KJeast at certain times — to have vanished. This stale of absnlule V(or retative) latency may be of variable duration, and may by ihe inexperienced diagnostician be mistaken for complete re< covery. bul it is doubtful whether this latter ever occurs. It certainly happens much more frequently that after this period
2&4
DtSEAS^lS Of THF. BRAIN PROPER.
o[ latency the initial symptoms again make their appearance, this time to continue without iiitcrinission until death. The duration of the whole disease comprises then three to six months or more ; it is extremely rare that lhe[>eriod of latency lasts for years.
(3) The onset of the disease is insidious and chronic. The patient, who presents slight fever and general symptoms, grad- ually becomes emaciated. He complains of headache and dis- turbed sleep, and from time to time, apparently without rcjson, is taken with chills; he begins to have a cachectic appearance, and bears on his lace the imprint of a grave disease. In such, withal very rare, cases our patient is suffering from phthisis and the brain abscess is of a tubercular nature. The dura- tion of this form, as a rule, does not exceed three or fotir mtmths.
Diagnosis.— In the diagnosis »vc may have to differentiate between brain abscess, purulent meningitis, meningeal haemor- rhage, and brain tumor. If the course of the abscess is very acute, as has been described above (eight to ten days), then it is often impossible to distinguish it from an acute purulent meningitis, an error which is the more excusable when all direct focat symptoms which often accompany an abscess arc wanting. Remissions point rather to the existence of a brain abscess.
From meningeal haimorrhage, which just as abscess may be the consequence of traumatism, it is also distinguished by its course. Traumatic meningeal haemorrhages usually give rise to epileptiform attacks, which arc to be referred to the effect of the entrance of the blood between the dura and the skull on the motor centres. They arc immediately followed by a coma, which lasts until death. In abscesses the insensi- bility usually lasts onl}* a few hours, and only after a marked improvement has again taken place do alarming symptoms make their appearance.
A brain tumor can be differentiated from an abscess by the fact that id the former febrile symptoms arc absent, while on the other hand, in the latter, choked disks, which arc a fre- quent sign in brain tumor, are only exceptionally noted. The course — more especially as regards the remissions, which arc well marked and often of long duration— Li characteristic of abscess: a tumor usually is steadily progressive. Finally, we are justified in diagnosticating an abscess if alter a protracted and varying course the disease suddenly terminates with ccr-
BRAIN ABSCESS.
26s
^
^
tain severe symploms ol collapse and dealli. When this occurs it is probable that an abscess existed which has perforated either into the veiitriclcrs or to the surface. In aises of trauma- lism or in cases in which the cerebral symptoms were preceded bjan otitis media we should always think first of brain abscess.
The seal of the abscess can only be determined with any certainly if characteristic (ocal symploms — lor instance, hemi- Mopta or sensory aphasia — arc present. Incases of hemiplis gia we can, from the order in which the compnncnt monoplegias occur, draw a conclusion as to (he point of origin uf the ab- scess. Thus, if at first a paralysis of the leg, together with marked sensory disturbances, arc the prevailing symptoms, and only later the arcn and facio-lingual region become nftecicd, we (nay conclude that the abscess is proceeding from behind forward, while if the symptoms occur in the reverse order, then the frontal lobe may have been the starting point and the abscess be extending backward. In cases of traumatism the abscess is to be located in very close proximity to the injury. Where there is a history of otitis media it usually establishes itself in the temporal lobe or the ccrcbelUim. The white mat- icr is, in the cerebrum as well as in the cerebellum, by far the most common sent. In the brain stem it occurs only very rarely, while in this situation, as we have seen, hxmorrhagc and softening are more common.
Prognosis. — The prognosis is ahsoUitdy bad with regard to recovery and doubtful with regard to life. We can sec from what has been said that spontaneous cures, most probably never, theraivculic cures quite rarely, take place. It is well to be very guarded In giving an opinion as to the duration of life, and we should never forget that even during a seemingly excellent ite of health suddenly grave symptoms m-iy develop which lead to a r.ipid termination.
Treatment — Of an effectual treatment we can only speak in (hose cases in which an operation is feasible. Since this — 'tiephining of the skull, splitting of the dura, opening of the ■itwcess with the knile — must always, however, even if con- ducted with the strictest antiseptic precautions, be regarded a»a grave undertaking, we shonhl only resort to it when the location of the abscess has been established with some cer. taiaty. If this has been done, operative measures are at once indicated, and should be carried out without delay, provided, o( course, that the abscess be in a part accessible to the knife,
266
JttSBASES OP THE BRAIN PXOPf.K.
which. \vc need not say, is hardly the case in the basal ganglia, the pons, the medulla oblongata, and the cerebellum.
But, unfortunately, an operation is in (he greater number o[ cases not (enKible on account of the uncertainty in the top- ical di^i^HOsis. Then our treatment can only be symptomatic, and wc arc coiihncd to local bleeding, hypnotics, bromides, etc., which ellect but little. For that matter the results of a so-called succes.5ful operation are not always lasting cither, and repeatedly one. two. or lour weeks after the pus has been evacuated an untavorable outcome has taken place— c. g., in the case ol Wernicke-Hahn (cf. lit.).
LlTEkATtmE.
Wernicke und Hahn. Idiopalhischcr AhscMS t!** OcclpilAltappcns ittttch Tw-
(uniiltun cnilecM. Virchaw's Arch.. Ilii. Uxtvii. i8Si. GrecHlielil. K«inarlu on a Case of Cerehral Absceu with Otili*. succnafully
irc-iicd by Oprraiion. Brit. Med, Journ,. ii, W, 1887. FiAnkFl, A. Uebcr den lubrrcutoitcii Him.-ibicniX. DcuUclie metl. Wochen-
whr. 18. 1887. Sommcnille. Analyvls of tlic Urine in Two Cbm» of Cerebral AlM«e»». L411-
cci. ii. II. 1887. (Incfcaw of iIk- wnhy phospliaies.) t.lnk. TrnuniAt. Gelm niibsccss. Wiener ninl. Wcichenschr.. No. ja 1887. Roma. New York Med. Kerord. xnij, July $. 1887. (Brain abtceu following
a puruli'nl oiiiis inedi.*.! LAcher. Muncliener ined. Wochenwhr.. ixiiv. 33, 1887. Barr, Glisgnw Med. Joum.. Kxviii. SciHemlier 3, 1887. <VCTy protr.icieil
cou pte — luiij; iniermiMions,) V. Berifmann. Die chinirKi^che Ilehnndlurii; von Himknuikheilen. (Brain ab- scess, etc.) Arch. f. klin. Clnrurjjie, liU. 36, 4. 1887. V. BcrKmiinn. Ueui«lie Med.-2iy.. 1888. 100. (Recover)' fromi h™n abscest ) Mahr. Wiener med. HlJiUcr, 1R88. 23. (Ree-overy from brain abice**.) Crawford- Renton. Cerebral Abiceu uHer Orbital IVrioHlitis. Ophthalm. Ko
view. 1888. V. ]>o6-l>0&
3. NoN-su/fpurathv Encfpltalilis and its ConsrqHences {"At/ir/asis").
A. IN ADULTS.
There is no question but that inflammatory processes, acute as well as chronic, occur in the brain which show no tendency to suppuration, although our knowledge of their pathogenesis and iheir symptomatology is very imperfect. These processes take place preferably in quite early childhood, or even during intra-uteriiie life ; only exceptionally may they occur in adults, as a consequence o( the abuse of alcohol. They arc then cir- cumscribed inflammatory processes, occurring partly in ihc
DIFFUSE CEKEB/tAl SCLEMOSIS.
367
I
cortex, partly in the white matter, which admit of regeneration. 11 brgcr areas are affected, the tissue becomes shrunken and o( a distinctly firmer consisleacc, so that it cuts almost Mkc leather. Just how these changes are brought about, in what way the nerve tibrcs of the white matter waste and the coti- oecti%-c tissue increases, which of the two processes is the pri- mary and which the secondary, can not as yet be determined with any certainty. Peculiar disturbances in nutrition in cer- tain areas of arterial distribution may give rise to delects which cause a distinct sinking in of the surlacc of the brain (Kundratj, •■ porencephaly " (l-'ig. 74). At times we find a true
dcitricial tissue, which chanictcrizcs ihc terminal process of the diSuio cerebral sclerosis. The n)acroscopic appearance of the biia is similar to that in the "induration cartilagineuse " of Cnntllhicr ; microscopically, the same histological elements as 'rcscenlnall degenerative processes of Ihc gray and white "Wtfrol the brain, spider cells, .tiuI compound granular cor. fuscles. arc noted (Kasi). Marie and Jcndrassik (cl. lit.) see •"I perivascular changes the chief factor which under certain anriiauunces brings about a lobar atrophy. At limes we have ^iVal undoubtedly with the consequences of a uniform arrest "^••i tltTcIopment which especially takes in one hemisphere, and '■'e iiatumical cause for which is not understood. The cir- "tmicribed inflammatory foci m.ny also be found in both hcmi- S*HM. in which case wc speak o( a double lobar sclerosis-
368
J>/S£^SES OF THE B ft A IX PftOr£R.
The clinical course of the disease is practically unlcnown. Probnbly there dues not exist any well-detincd cuitslatit clinical picture, btit the symptoms vary according to the analomicul scat of the process. They are symptoms ot paraljMS or of irri- tation, and arc partly " cortical symptoms " and partly to be referred to disease of the cerebral vessels (cf. Fiiedmann. Arch, f. Psych,. 18S9. xxi, 2. page 4,f>i). In the few cases in which a diagnosis could be made during life, apoplecitlurm attacks, rhythmical choreic movements. longer or shorter spells of un- consciousness, were observed. The difficulty of grouping and correctly interpreting the symptoms is chicfiy owing 10 the impossibility of an early diagnosis. Mencc it will be the chief task oHuturc observers to direct Iheir attention to the initial stage, for only after wc have once become familiar with the development and the anatomicil changes in this hrst stage can we hope to elaborate an efficient mode of treatment, which, we need not say. at present is absolutely wanting. The irra. tional trials with potassium iodide we can certainly not regard as such.
B. IN CHIIJJKKK.
Cerebral Patsy of Children — PoUo-encfphalilis {Slriimpell').
Pathological Anatomy. — In view of the comparatively fre- quent occurrence of cerebral palsies in children, it is rather to be wondered at that so extremely little is known about their pathogenesis and their initial stage, more especially with reference to the anatomical changes that occur. This may perhaps be accounted fur by the difliculty, and sometimes even itiipossibility, of making an caily diagnosis. At a time when we are able to recognize the disease wc usually have to deal with a process which has already passed through all, or almost all, of iis dilTcrcnl stages. It is the same with the le- Rions which we find : they in no wise explain the exact nature of the disease, but only give us an idea uf the many various wavs in which the brain with its meninges may be altered in early childhood as a consequence ol the disease, which was most prnb:ihly intra-ulcrine. General cachexias ol the parents — e.g., svpliilis — may be the cause when ihe adectlun begins during inlra-ulcrinc lile ; in Ibis case marc than one child may have the disease. During the act of birth iraumniisms roar I produce unilateral or bilateral conical hasmorrhnge. After birth, infectious diseases (pertussis, scarlatina, tuberculosis.
CEHEfiHAt. PALSY OF CHllDXEV.
369
^diohthcria. syphilis) pUy the most important rdU in the causa- The case which is briefly described on page 377 (Fig.
"^^S) shows thai injuries— from a fall, for example — may also precede the aflfcclion. We do ncit, however, know of what aature this process is. whether it is a sinus thrombosis, as rers claims, or an inflammation leading to alrnphy, as in tingo- myelitis chronica. Neither can we tell wliL-ther the iacrense in the connective tissue which has been noted by many authors is a primary one. and what part the disease of the ves- scli, the thickeiiinji of their walls (Hayem, and others), plays in the pnKess : but one thing is certain, that the disease is not confined to the gray cortex alone (as Siriimpell has assumed, and tor which reason he has proposed the name polio-encepha- litis, analogous to polio-mycliiis, cf. lit.), but that the white mat- ter as well may be implicated. This is shown by ihc case pub- lished by Kast (cl. lit.), and also by the following observation, which was made in my wards, and which I propose to relate here in brief, as autopsies in cases of this class arc rare :
Magdalcna St., iwcnty-onc years old, coming from a healthy fam-
f, WHS taken sick in her second year with violent fever. Aocord-
ng tu her mother's aecoiinl, she hud convulsions for four days and
'iiur nights. When she wanted to get out of bed after thi« her left
ude was found lu be paralyzed. In^de of three months her condi-
(in was so far improved thai she coutd walk, although with a limp.
Tiradoally the left lower leg became smaller and somewhat curved,
knil (khc cnmplntned of pain tn the whole limb. The upper cxtreni-
iiy did not at Tif*! take part in the atrophy ; it was, however, almost
■plctely powerless. For two years the convulsions did not re-
kpi>ear; but for the last four years the patient had had. on an avcr-
k^c, about one epileptiform attack every three weeks, in which she
riiet ber tongue and passes her urine involuntarily. The following
t ftn extract of the note made on October 15. 18^5 :
Head : Kight parietal region painful to percussion ; in the region
I f the left glabella and the hairy part of the scalp, on the same side,
«'( ate Ncvcral areajt of anaesthesia. I'upillary reactions and move-
► «it9 of the eye muscles normal. Nothing abnormal in ihc distribu-
><iaof the facial and hypoglossal nerves. On the right side hearing
■Bich below normal, on the left there is complete deafness. On
: *»( anicnor third "f the left half of the tongue taste is lost. Uvula
^ct«)ghl and movements of the soft palate normal.
TtttQk : On the left half of the chest touch and the prick of pu are not perceived; temperature sense seems decidedly sub- l«>oniul.
a7o
DiSSASES OF THE BKAIN PMOPEK.
Upper Kstrcmitieg: The whole left upper exlreinity, including the hand, is shorter and smaller than the rijctit ; motion of the wrist, especially extension, i& impaired. The hand is flexed on the fore- arm, and only with force cAn the Rcxion be overcome. The thuml) is drawn into llie hollow of (he hand, the zciX of the fingers urc slightly Hexed. Motion in the shoulder joint normal ; in ihe elbow joint extension is slightly impaired. There is a general decrease in the sensibility. Electrical reactions arc found to be normal for lioth currents, on direct as well as on indirect stimulation. The right upper extremity docs not show abnormity with regard to development, size. mobtliiy, or sensibility.
The left lower extremity is considerably smaller and shorter than the right : sensibility is the same a^ in the corresponding upper ex- tremity ; the same holds for the electrical condition. Tendon and skin rcdexes are retained on both sides.
■J'he epileptic attacks continued, and occurred about every sixth or eighth day; the intelligence became more and more impaired. A tuberculous process in the left lung was superadded to the already existing trouble, and. in <;onse<|iicncc of general (atture of strength, the patient died on March ii, 18K6.
Autopsy: Eighteen hours after death. Extract from the post- mortem record : After opening the skull the pia is seen to be con- siderably thickened at different places, especially over the right hemisphere. In volume the right hemisphere is not much smaller than the left ; the anterior and posterior central convolutions on the right side, especially in their lower half, arc markedly atrophic, the gyri are shrunken to about a third of their natural Mxe; the mar- ginal and the angular gyrus present jhe same atrophic condition. The upper right parietal lobule is less atrophic, nevertheless the gyri are here also remarkably narrow. I'he portions of Ihe first and sec- ond frontal convolutions bordering on the central convolution appear also atrophic. On section the gray matter is hcen to be considerably diminished.
The ventricles appear markedly enlarged. On frontal sections, after Pitres' method, no important changes, with the exception of the shrinking, either in the centrum ovale, or in the basal ganglia, can be observed macroscopically ; on microscopical examination K]>ider- cclls and fat-granules arc found in considerable numbers nut only in the gray cortex, but also in the white matter.
This observation determines us in m:iinlaining with Kast the old dcsi{;naiion, "cerebral palsy of children." a n.imc by which nn definite pathological change h implifd, .ind in aban- doning the term polio-encephalitis, to which the pathologic.it changes do certainly not always correspond, especially as (he
CEREBRAL PALSY OF CUtLDREN.
ri\
latter name has already been proposed by Wernicke for the disease uf the gray matter around the third and fourth vcn> t rides.
Symptoms. — The symptoms of this disease-group diUer according as the pathological process is conhncd to one hemi> sphere ur attacks both.
In the former case the symptoms and the course are so characteristic that a correct diagnosis can almost always -be made during lite. The disease usually sets in brusquely, the symptoms are violent and can not be overlooked. The child is seized with a high fever; soon, sometimes only a few hours later, twitchings — at first only in one extremity, later in the whole side — appear; at times the whole body may be con. vulscd : this may last, with but slight interruptions. lor from oiie to three or even four days, and be accompanied by per- sistently high tempcraiurc. The symptoms now abate, the convulsions become less frequent, but after their disappearance the child is found to ha\»: lust the use of the limbs of one side —hemiplegia infantilis spastica (Benediki). II an early and careful examination be made, a moderate facial paralysis is noted, the condition of the extremities being very nearly the same as has been described on page 226. The condition of the facial nerve in this affection has recently been studied by W. Koenig (Deutsche mcd. Wochcnschr., i!)93, 42). Itcrc.as in the common cerebral hemiplegia, the arm is pressed against the thorax, ihc forearm flexed at right angles with the upper arm, the hand flexed and adductcd. the fingers bent. The leg is dightly flexed at the knee joint, the foot extended ; not un- commonly (he big toe is in marked dorsal flexion. The sensi- bility is, as a rule. m>t much altered. After several weeks the little patient regains enough power to perform the coarser movements with the leg, while lor a considerably longer lime the arm does not lake part in the improvement. If the child was able to walk before the onset of the disease, it will gener- ally regain this (acuity after a lime, but its gait will always be haltuig.
The further course of the disease is not the same in nil cases, and it has been our experience that it differs according as the initial convulsions contituie or cease. This, therefore, is an Important point to consider in the prognosis for the relative recovery. It will also decide the question whether the child, while bodily more or less a cripple, is in addition to be mcn<
272
D/SIiAS£S Of THE HHAtff fKOrE/t.
tally defective and totally useless to the community. What conditions determine the conliniiaiicc ol the convulsions, whether this is inOucnccd more by the nature ol the lesions or more by lljeir scat, we are unable to say.
As a rule, the attacks, even if they should have a tendency to continue, (to not recur for months, for one, two, or even lour years, after the acute period of the disease has passed ofT. Then, however, they may return on any provocation — alter a fright, maltreatment, sometimes during the second den- Ittion — at first ni long intervals ol months, then more Ircqucnllv. At firsl they may be slight and of short duration, then more severe, until 5n»lly they resemble in every point the classical - attacks of epilepsy — in other words, the hemiplcgic or hemi- \ paretic patient has now become an epileptic. As has been stated, the influence which these attacks have upon the nnental development of the child is very detrimental. Much more often than is the case in idiop-ithic epilepsy docs the patient become weak-minded. The condition of speech found in this disease is interesting. II the patient had fully acquired speech previous to the attack, it is only affected il the lesion is on ihc left side of the brain, in which case the symptoms do not diller from those which we have described under left-sided cerebrdl hemorrhage. If. on the other hand, the patient has not yet learned to speak, he will, in case the hts continue, either not learn at all or only ver)' itnpcrfectly. and his talk will, even if ■ his mind is only slightly impaired, be quite unintelligible; but olten Ihc attacks do not recur, so that the mental development, progresses normnlly. In such cases speech likewise reaches &,■ gratifying degree of development even if it had not yel been fully acquired or had been lost. The healthy hemisphere takes on vicariously the work of the injured one (cf. page 1S2, remarks on aphasia of children). j
Independently of the epileptiform attacks, there may occu4 changes in the extremities which are in a way analogous to those described above. An especially characteristic symptom is the pronounced spastic condition which manifests itself i" an increase ol the reflexes, rigidity and spasm of the muscJfs — hemiplegia inlanlilis spastic.1. This rigidity is especiaf'v well marked in the muscles of the hand and the calves, a"*' leads, prelei^bly in the former location, to contractures, whk^ however, differ from others, inasmuch .is they cease durinj rest and sleep and only appear on voluntary motion. Bew-
CEREBRAL PALSY OF CHILPRE.V.
373
"dikt. above others, has pointed out thai at one lime one. at another time another, f;roiip o[ muscles may be affected : that, e.g., in walking, the loot may be held normally, while ag-ain in the same (out we may see a talipes calcaneus, or at another time a talipes cquinus. Similar conditions arc observed in the hands : thus the fingers, which appear to be in a state of immo- bile flexor contraction, may at other limes present a remarkable degree o( mobility. We shall shortly discuss carefully the entirely involuntary movements of the affected hand which are noted in the course of this disease. E, Kemuk has shown that such a spastic paralysis with contracture may lead toa luxation ; in the case which he reports a retroglenoid subacromionlux^
Ition developed (Berlin, klin. Wochenschr.. 1S93. 52). In almost all cases ol infantile cerebral paralysis an arrest in development or growth becomes apparent in the affected ctircmiiics. Thb may be only instgniticant.su as to be hardly appreciable. On the other hand, the limbs may in all their dinrnsions be considerably smaller than the corresponding OKS of the sound side. Occasionally the tvhole half ol the body, trunk and head as well, share in this arrest, and we have "hat is called u general hemiatrophy. Borgherini has ob-
Ivned this to occur a few day<i after the onset of the disease (Deutsch. Arch. (. klin. Med., xl, 5. 6). The following illustralions of cases from my clinic rcprc **nt (liflcreni tyjMrs of the cerebral pamlyses of children : Rgs. 75 and 76: Hemiatrophy of the whole left side of the 'X'clt. E|tilepti(orm attacks. Dementia.
Figs, 77 and 78; tlemialrophy of the whole left side o( 'he body. Cause: Traumatism. No fits. Intelligence nor- n»al
Fig. 79: Atrophy of the left upper and lower extremity ^'''^sectiun of the knee joint). Epileptiform attacks, with a mod- kte degree ol dementia.
Fig*. 81 1084: Atrophy of the paralyxed side, very slight.
't perceptible. All three patients sufler from epileptiform
kttacks and arc demented. All three present contractures on
^c affected side, either in the wrist (Fig. 81, and also Fig. 75)
U) the ankle joint (Figs. K3 and 84).
All these eight cases, which came under my obscrvatfon, °«T"'i>i!cd upon disease of the right hemisphere. Whether thi« 'i- i< ali»>geihcr more fre<]uenily attacked, and. if so, how the be explained. 1 dare not at present decide.
274
DISEASES OE THE BftAllf PROPEH.
If both hemispheres are affected, the symptoms are very diflercnt, and the diagnosis is much more difTicuk. Freud has classified all these affections as instances of cerebral diplegia, a term which may be accepted without reserve, as it is purely
descriptive, and is noncommittal so far as regards the pattio- logical process. He divides the cases into four groups : i. The general cerebral spasticity tirsl described by Little and called by the Bnglish authors Little's disease. 2. The paraplegic spas- ticity (so-called spastic paralysis). 3. The bilateral hemiplegia. 4. The bilateral chorea and athetosis. The latter will be referred to again (page 384). Little's disease and spastic paralysis arc frequently congenital; in the latter affection especially predis- posing and hereditary influences play some pari, and several members in the same family may develop the disease (N'cwraark,
I I
CEKKfigAf. PALSY OF CtllLDREX.
V%
A Contribution to ihc Study of the Family Form of Spastic
Paraplegia. Aracr. Journ. Med. Sci., April. 1893). (Cf. Fig. 80.)
Diagnosis. — The diagnosis of thr tinilatcral affection is, as a
rule, easy. AS the acute onset with Ihc consequent hemiplegia
fit. jc
Thp patient, vrho is now ihirl>'4ix yean oUi. wu talten ill incnrlrchiidhood
^ith in Bculc vioteni frvrr and canvtilstons ; ihc iauer lailcii for icrcral days.
*^l aftrr ilut dikappcnrcil, Ftf>m ihni lime ihr left Hdr did not develop M well
"** Xhr nj-hi. ftothai now ilvr tcft upjwr eiiremiiy. whith on bt moied. with
'*'1kuliy tmly. in the ihoulilrr and dhow joiciis, is scvtn centimetres shonff
"-*n the rlfht, whik tlw left lower cxlrcniity is three ceniimeircs shorter than
"^ fiUtiw. The whole hatr of the body hu shared in the uiro|tliy, which is also
^«II marked i« the natn. The circumference of ihc left upjier arm m^'atum
I ^***'t' ceMimeircs aitd a half.tkttof the left teg three centimetres Icm than thai of
I **^ cormponding ntremtty. When the paiicnt wa.i fourteen yc;>rs old the con-
I "^Uigna reappeared, and he hu util one or two epik|i(irom) aiiacks a week.
276
DISEASES OF TUB BRAIN PROPER.
is characteristic enough ; but if the patient come from a phlhi»> icalfamilyand is himseH tuberculous, some doubt may arise. \Vc may have a case of tuberculosis of the brain to deal wilh, which sometimes resembles in its onset the cerebral palsy of children. High fe%-er and convulsions are not absent, and se-'
verc motor disturbances occur also. The fact, however, thai la , cerebral tuberculosis generally Ihc base of the brain with i"tj nerves, especially I'le oculo-moior and abducens, arc implicilcd, and, further, ihal it runs a rapid and fatal course, will cnah'c us to inake a correct diagnosis.
Spinal and cerebral infantile paralyses can not be con- founded with each other if wc keep in mind th.il. in the Uttci", one whole side of the body is affected; that the musclci -vc rigid, the reflexes increased ; that convulsions occur not only
CEUBBRAL PALSY OP ClIILDftElf,
277
at the onset, but also in the further course of the disease ; that (he mind becomes impaired, etc. In the spinal form, either one limb alone — arm or leg — is affected or both arms or both le^, and the reflexes in the paralyzed extremities are lost — signs enough to enable us to differentiate between the two
Tbr puieni. mm- Ihiny-four yenn old. ML nl th« age of ihicc, IVo<n a hif[ti tttet-ttool «ad injuroil ihe ri^i »idc of his l>c;ul. He lost a conMikrablc nmaunt «f tilood, and wu unciMixcmi^ for quite a long time. Six monih^ nftcr ihe in- jury the airopby of Ihe Icfi side of the tiody became apparent. fir»1 in the u|)p*T. then in ihe lower cxircmity. With ihe cxccpiion of ibis utrophy. whirh h» mow takpn in the wb(4c half of the liody. DK-ludini; ihe thonx (coTn]>arc the left »Hh the n)(hl mamina). the |Kiticnt is peffrcily healthy. He has T\r\rt h.icl epi- Irpurnnn aiudu, Uwtb are no hemuiihctoid movementt, and no (Htxhical allcr- Uiona what«vir.
278
mSEASES OF THE BRA IX PROPER.
nffeclions. A hemiplegia due to cerebral haemorrhage can ia most case!) be excluded, owing to its rarity in childhood. Such, moreover, would usually not be associated with any muscular
The I
He. rt-
years ol age, had. when six months i plrclic tlruJic." and never learned how to walk properly, since the left half of ih^^ ' body waa paralysed up to her second year. The powrci of mocion ha& ioipewec:^ la A cenain ntent : the left leg, howet-er. and the left arm have remained be— ^ liind in dcvelnpmenl. so much so that the ami is eiKbl centimcires, the le@^F iwenty'fit-e ttniiiiietres, shorter than the corresponding limb of the right «i(fc "^ The shonenitig of the leg i* partly iliie to a reaeclion of the knee joint per- "■ formed ihirtceri jeiirs ago (the re*son for which procedure could not be mad^ ' out). Patient suffers from cpilepiifonn at lacks, occurring once a month : \hty^^ laat from a quarter to ihrec qunttcrs of an hour, and comiil of more or less »io— ^ lent convulsions. Durinj; the<ie. consciousness is sometimes completely tamed. Thi:rc is nu imcc ul dementia.
CSKEBKAL PALSY OF CHILDREN.
279
I
atropby. In the diagnosis of the bilateral affection wc must take into consideration the possibility of a nuiltiple sclerosis, Friedreich's disease, brain tumor (especially tubercles), menin. gitis, and cerebral syphilis. In many cases it is impossible to cumc to a satisfactory conclusion.
Prognosis. — The prognosis qumd vaUtudxHfm is absolutely, ifuoad viiam relatively, unfavorable. Complete recovery is im- possible, and has never been observed. 11 the patient does not succumb during the first days of the disease, he will remain a cripple all his life, his mental condition being good only in the most favorable cases. Under unfavorable conditions he may be epileptic and wealc-minded, and to a greater or lesser extent deprived of the use of his limbs. The utmost we can expect is that the diseased side may atrophy only to a moderate degree,
The bmlly fonn •■■a jiamptqiU: <i. fourteen ye-ini old: i. lixUen
loM: r. ihineen )'«ar>tiM. lii ilie lint tlw diieuc bc-g^in sA the age of I and A tulf, in ihe socond ai one and a half, in the third at nine. The
*ncHbcr h^ cleren chiklren, ci^hi nf whom are living (among ihcm the tliree
^«tkiil»J. (Abcr Ncvmurk. San Francisco.)
zto
DISEASES OF THE BKAIS PROPER.
that the patient may be sound enough in other respects, bodily and menially, and thus be capable ol making his own living (Fins. 77 a»d 78).
Treatment — The treatment is, on the whole, entirely un- satisfactory. Even by the light uf an early diagnosis, we are
Fiir. 8..
The pniirnl in now fony-four yean o1<l. The ilate ofomcl oftlte iliwue C4I1 nui lie (leliniiely dclcrmincii. She uiOi^red rrom epll^irortn vodvuImoiis from e^rly chiklhood up to hrr Irnih year: ihne hjtve now rniirdy diMppeared. Al limes, however, a " /tV t-om'tf/t'/ " <in t lie distribution of (be lefl faciAt) tt nolcd. The devdo{irMcnt of tlic kl't half of ihe body h;is been retarded, the upper cjiirctnity hrine iwo centimetres, the lower ihrw ceniimeirM, shorter than the conespondinK Umb uf tbe riglit side. There is alM a dffercBCC of from four 10 five centimetres tii ihc circtinirercnce of the linil» of the two sides. The Khouldrr. elbow, nnd wriii j<nnls are cotitracled, the firu being in a pou. tlon of adduction, the second in one of Acxion, and the third in exicnsiun. Marked degree of dementia.
I
CEREBHAL PALSY OF CUILDKEN,
281
The patient, who i« now twenty-two j-tara or ngt, wax taken ill with con- vulUons In catly childhood. Th«>- ceased, but after an interval of ten yiars rc- ajipcarcd In his foiiriccnih yv»'c, and have conilntjcil up 10 the jirctrnl lime, ttcinic qtiite severe and reeuiririK frequently. From childhood he has Hif- ferrd from a severe mulor speech disturbance, and is only ahle to utter a few unintelliKiMe Kyllnbla, and thnt with k'c-ii effort : at such timet Almost all the niwcles of the Iwily are dITecied with a«!tcx:iaie(l mowment*. Atrophy of the Itft tide i» to be noicfl. The circumfrrence of the left upper arm measures three centimetres, llut of the left forearm two cenlimelrcs. that of the Ihigh four centimetres, aitd that of the leg two centimetres lew than the eonrtjiontU ing meuurcmenit on the nghl nde. The left arm is one centimetre, the left Vg ooe centimetre and a half, shorter than tJie right arm ami richt leg respecl- W^. The tefi hand and lingers aic in llexor contraction, faticnt is modcr- Utly demented.
282
I>/S£JSES OF THE BRAIN PROPER.
not in a posilion citlier to prevent the continuance of the epi- leptiform attacks or to wurd oQ the changes in the afiecied extremities, the symptoms of irritation, the atrophy, etc, Tlic symptomatic treatment of the epileptitorm attacks by the dif- Icrent bromides and the galvanization of the atrophic parts is alt that lies in our power, and. unfortunately, little enough is accomplished by these means.
While we do not attempt to give a detailed account of the patholt^y of cerebral diplegias (Freud, Leipzig und Wien,
Fit. M-
1S93), two questions must be discussed, namely, (1) under what conditions do contractures. (2) under what conditions do cer- tain movements, which are independent ol the will of the pa- tient, develop? Unfortunately, we arc not able to answer these
CEREBRAL PALSY OF CHILDREN.
383
questions satisfactorily. With regard to the iirst, the idea de- serves to be mentioned that the extent of the cerebral lesion the secondary degeneration depending upon it arc of some litioincc.
The same uncerl^iinty exists in regard to the second qucs- tion. We are not acquainted with the immediate conditions uch, in the course of the cerebral palsies of children, give
Tbc onset of lh« <li»uue can not delinitcly be ^%t-A. vince ihe mother of the patient dors noi rrmcmbcr ii. and t)i« paiiciil herself, who is now dghtoen )e>n aid, U demenied and coraplcicly dt-privcd of the power of itpeech. The bn, hiiwrtrr. thai the illneu becan in early chiklhoud with convulsions i* un- quntloiM^ ; il u. himercr, not known how long ihcy Luted nor what followed tlMnt. When the i^lrl wu five yean old >he wu not yet ab)e to walk, because tin left leg wM moved only with (tifficuliy. and (he foot frradually uMininl in aqniao^raruk pathlim, whkh can Kiill hr noted. Patient now M-alks on the MIer edge of her foM. and the Icfc b Kiuxely mot ed at tlie knee joinl. The bh opper exirvniilf can tic moved voluntinly in the sbuuMcr and etbow jdnts; rhe Anicm and titc bnnd present athrtoid miivenieriii. while in llie facial mu«- clrtof thr left side a mnrked •• lit eeavultif" is noted. M.iihed dril>t>Iin]{ of ulivK. Pitkeni no tonger siiflrni from epiiteptic attacks, but has from time to time pertodn <>f cidlentent. during which she becomes agi^mslvc.
384
D/S/CASeS Of THE Bit A IK PROPER.
rise to peculiar (unilateral or bilateral) motions in the affected extremities, which present the roUowing^ characteristics:
The patients arc absolutely unable to keep the fingers and the toes o( the affected side still : they arc in constant motion day and night, during waking and sleeping, without inlcmip- tion. If wc observe these movements more closely, %vc find ihem to be relatively slow, rhythmical, and monotonous. The fingers seem to be directed with a definite aim. as if they were attempting to seize something, and it is easily remarked that the normal limits of the movements are exceeded — the fingers arc hyper-extended, the toes are elevated almost at right angles or fasten themselves to the floor like cUws, etc. (cf. Fig. 85). AH this is only possible in consequence of an unusual stretch- ing of the ligaments, which also admits of positions of distinct subluxation. The will of the patient has hardly any influence over these movements, and only in light cases, and then but temponirily. may the patient succeed, by firm pressure of the affected hand upon the body, or by fixing the fingers with the unaffected hand, in restricting a little the abnormal excursions : as soon as the mechanical impediment is removed, they will, however, begin again with increased vigor,
The muscles of the forearm present a firmer consistence, a certain degree of hypertrophy. The arm feels hard, and the surface temperature is 0,5" to t" C. (0.9* to t.S* F.) higher than on the opposite, sound, side ; not but what the muscular strength is materially lessened and sometimes so much diminished that the examination with Duchcnne's dynamometer yields aston- ishing results. With the affected arm the patient can hardly lift five kilogrammes, notwithstanding the apparently good de- velopment of the muscles, while with the well arm five to eight times as much work can easily be done. In the muscles of the lower extremity a similar condition may be noted ; not infre- quently the ankle joint takes part in these movements of the toes, and, in exceptional cases, the knee joint as weU. Other muscles than those of the extremities are not affected.
The first who studied these movements carefully was Ham- mond, of Nexv York, in tS/i. He gave them ihc special name atfiftosis ia-Ti0tifu) and raised them thus to the dignity of a sepa- rate disease, which, in our opiaion, they never deserve. Athe- tosis— and by this we mean the athetoid spasms— does not con- stitute a disease, but merely a symptom. It is the expression ol cerebral affections, the anatomical basis of which is variable.
t
i
4
THE ATHETOID MOVEMENTS.
285
Only in the rarest instances, one could almost sajr never, do athetoid movements occur alone without any other symptoms, tmost always they are associated with other disturbances.
Tlw (wltimt. now twenty-nine ]»r!t old. tras Ukcn at thf wge of six monihs Mhui '*a|nf>lcctic Mrokr" fitltownl by convuUions. which nl hnt ncmnvd *l long Inivmb, l;>lvr (nor* r(v<(urnilj', tn,,. ahoiil once every Iwo weeks ; ihcy piT*niied nil the ehancierisiica of F|)ilcpiiform jci/ures. ^uitc curly, peculiar Inralunt^rv tiMWrmenlt npfienred In the Iffl ruiicmilies, more panifulnrly In < tie Ir ft arm. which musr hi- ontilikrrfl n» nll>elui<l. At resiilar Imcnrjl^the Aofrn an' rxtmiled jiid ji){iiin ilr.iwn inlti the hulUm' of the h«inl. this licing re« pulnl 4l»iut tiliy iiriici * minute. In the left (not hlmibr, althixigh, of course, bs* prDcumiKt:*] inovrnMrnis.. o<cutnnK rsfwialli- in the .inkk Joint, nrr noted. At atMMil iti« aic i^r live (he comuUiMif rrappcorcil. although iK^-uniii); vnih dimxiiihrd frequency, t e.. from ihrre to five limes n )mir, The |>aiicnl is cii- tUblc. iraKtble, and ai times even violent. Inieltigeitoc is normal.
286
J>/S£AS£S OF TUB BRAIX PHOPEK.
cither psychical (the patients arc mentaily undeveloped, de- mented, sometimes of a chanfj^eable, irrtlnble disposition) or somatic, such as para1y!<cs or spasms in the distribution of difTereiit nerves — for instance, the (aci;il — contractures, etc. Again, the patient may be subject to epileptiform attacks which recur at intervals of various lengths.
If we thus affirm that every athctosis^be it the much rarer bilateral form (see above), be it unilateral, the " hemiathctosis " — is only to be regarded as a symptom, wc are. on the other hand, willing to admit that there are individual cases where the athetoid movements arc such a prominent and dominating feature of the case that wc may overlook others, or at least not be inclined to attribute any importance to them. So it is in an instance reported by Gnauck. who speaks of a primary — that is, idiopathic — athetosis, but who has noted a simultaneous jMiresis of the facial and a hemiana;sthesia of the affected side. Wc can hardly call this an idiopalhic affection, but must rather look upon it as a prehcmiplcgic phenomenon (cf. page 218); and, similarly, some explanation can be fotmd for the few re- maining cases published as "idiopathic" athetoses, some of which were congenital. These movements arc always a symp- tom of cerebral disease. That they are occasionally met with in the course of other diseases— e. g., spinal affections, cspe. cially tabes — there can be no doubt. The pathological changes observed in cases which had presented athetoid movements during life, in addition to those found in cases of cerebral pal- sies of children, consisled in small foci ol softening in the b.isal ganglia, the thalamus (Lauenstein), the corpus striatum (Schuiz). and in the temporal lobes (Kwald). although wc can in none of these instances be certain that the lesions found were actually the cause of the movements. After cerebral harmorrhage whci-c we have a lesion of the internal capsule, in old hemiple- gias therefore, bemiatheloid movements are occisionally seen, yet, in comparison with the frequency of cerebral hemlplegiis in aduils. these arc very rare, certainly much rarer than in the S(>callcd infantile hemiplegias. We see, therefore, that cortical lesions and lesions of the cortico-muscular tract as well as of the basal ganglia may give rise to athetoid movements, al- though we do not understand the ttexus ctusa/ii, if indeed such exist. In our opinion, disease of the cOrlex undoubtedly plays the principal part in the causation of athetosis, and wc can all the more reckon upon the occurrence of athetoid movements
THE ATltETOtD MOVEMENTS.
a87
If ihe conical disease has appeared in early childhood and has been cllhcr entirely confined to or has affected more particu* Iwly Ibe motor region, the central convolutions, and the adja- cent portions. In lesions of the other parts of the brain, espe- cially ul the basal ganglia, the thalamus, the lenticular nucleus, and the caudate nucleus, alhcCuid movements are only excep- tionally developed, the conditions which favor iheir occurrence being then wholly unknown. That there is a cerebral lesion which produces no other symptom, whether psychical or so- matic, than these movements is unlikely, and consequently, as we said, the name " athetosis," as indicating a separate disease, can not be held to be justifiable.
Keeping well in mind. then, the characteristics of the move- ments which have just been described, and especially after having had occasion to study their peculiarities, one can hardly mistake them lor anything else. A good point to remember is that they continue during sleep, so that the patients have to Mop or at least impede them by mechanical applianccs-
We shall give up the ide.t of chorea or hcmichorea which we might entertain should the athctoid movements be accom- panied by facial spasm, if after observation of the patient we have been convinced that the movements persist when he is asleep. Furthermore, the duration ol the disease and the fact that it resists all therapeutic measures, more especially the pro- tracted use of arsenic, are facts not reconcilable with the diag- H nusis of chorea. Other points of dtlTcrcncc will be found in H Ihe chapter on the latter disease.
H We possess no specific which will put a stop to these athe.
H mid movements; their treatment is that of the primary dis-
^^^asc, and, as this is usually beyond our reach, the outlook in
Hi^thetosEs is necessarily very gloomy. If Hammond chiims to
linve efTccted a cure by stretching the median nerve, we may
t>c pardoned for asking how long this cure lasted : and if
^nauck has seen the movements disappear after the use of the
j^lvanic current and the intcrn.il administration of potassium
^^liromidc. we are justified in assuming that in his case the aflcc-
^■tion was due to a functional disturbance of the motor area.
^^ '^Vhal lasting good results can be accomplished by hvoscinc. a
drug which has been used by I^ib, 1 have not as yet been able
to establish with the material at my disposal.
I
288 DISEASES OF THE BRAIH PROPER.
LITERATURE.
Strumpell. Uebcr di? acute Encephalitis der Kinder. Polioencephalitis acuta,
cerebrale Kinderlahmung. Vortrag gchatten auf der S7ten deutschen
Naturforscher-Versammlung zu Magdeburg. Jendrassik et Marie. Conlribution i I'^tude de l'h£miatrophie cMbrale par
sclerose lobaire. Arch, de Physiol., i, 1885. Richardi6re, £iude sur Ics scleroses encdphaliques primitives de I'enfancc.
Havre, 1SS5. Marie. Himiplegie c^rfbrale infantile et maladies infectieuses. Progr. ni£d.,
xiii, 2me s£r., No. 36, i88j. Bernhardt, M. Ueber die spastische Cerebral paralyse im Kindesalter. Vir-
chow's Arch., I)d. cii. 1885. Bernhardt. Jahrbuch f. Kinder heilk., N. F.. ixiv, p. 384, 1886. Kasl. Zur Analomiedercerehrnlen KinderlShmung. Arch. f. Psych.,xviii. 2, 1887. Mathicu. Progr. med., 2, p. 29, 1888. {Cerebral Infantile Paralysis as a Con- sequence of Traumatism.) Wallenberg. Verfinderungen der ner\'oser» Centralorgane in dnein Fallc von
cerebraler KinderlShmung. Arch. f. I'sych., xix, 2, 1888. Benedikt. Berliner klin. Wochenschr., 1888, 51. Hoven. Arch. f. Psych.. 1888, xix, 3. Audry. I.es Porencephalies. Revue de m*d.. 1888. 6, 7. Schmaus. Zur Kenninissderdiffusen Himsbterose. Virchow's Archiv, 1888. cxiv. Pilliel. Arch, de Neurol., September, 1889. 53. Slriimpell. L'eber primare acute Encephalitis, Leipzig, 1890. Sibol. Arch. de. Nfuroi,. 1890, xix, 57. Sachs and I'tterson. A Study of Cerebral Palsies of Eariy Life, based upon an
An.iiysis of One HundrL-d und Pi irty Cases. Journal of Ncrv. and Mcnt.
Discasrs. May, iSi/a. Freud und Kit. Klinischt Stu<iie ul)er die halbscilige Cere brail ah mung der
Kinder. Mono^jraph, Wi^'il, r8gi, Chaslin. Contribuiinn A I'tiude de la Sclerose cerehrale. Arch, de m^d. ex-
pcrim. vX il'.inat. p.ith., iKiji, 2. Sachs. H. (Ni-w York), Cimtribiiiicms to the Palholo^y of Infantile Cerebral
P.ilsies. New Yr)rk Mrd. Jiiurii.. May 2, 1891, Sachs (New Vi>rki. Die HirnliihmunEcn der Kinder. Samml. klin. Vortr,
N. F, 1K92, 46. 47. .Michailonslii. I^-tude ilinique sur I'alheiose double. Th^sc de Paris, 1891. Freud. Zur Kcnntnisi. der cerebntlen Diplegien ini Kindesalter. Leipzig u.
Wieii. 1893,
Bidim. l-'ss.ii sur I'hi'niichori'c syniplonialique des maladies de I'encephale.
Kevue ile lued.. iH.^fi. Bourni'ville ei I'illiel, Deux cis d'athclose double avec imbecillile. Arch, de
Ni'uriil,. xiv, Ni), 4;, 18M7. C.erlint,'. Teber Allielosis. bLiui;.- Miss., Kiel, 1887. Kuhiiiii. Crinirihii/iiine 1 liiiir ,1 alio siiidui dell' atetusi e del paramiocluno molte-
plii-e. KiriirtiiJ rin-clii"i. ly'^. I1SH7. {Cf, also ihi; texl-hoiik,'. i.l Sirunipell, Scfliguniller, Eichhorsl.)
attAt/f TUMOHS.
389
IIRAIN TUMORS.
Pathological Anatomy. — Brain tumors may be cither sharp- ly circumscribed or ditluse, iii llie latler otsc Ukiii^ the pl:icc, as it were, of (he brain substance proper. The most common — e. g., the gliomata, the curciiiumata, and the surcomata — occur in bolt) varieties. The clinical manifestations ol brain tumors depend upon the nipidity of their growth ; ihis, again. u[Hm their anatomical nature. Among the most important and the most Ircqucnt (orms ol tumors must be mentioned :
['he glioma. a form which is peculiar to the central nervous system, but is found much mure fretiuently in the cerebrum than in the brain stem or the spinal cord. It is formed by an increase in the cells of the neuroglia, the axis cylinders in
Flf. aSi— CUOKA TKLAiTOiicTAricUH. (Afut ZiiuL.KK,) hmoiAl HCiion ibroueh the !«•». d, tijchi Mrninim wmlonle. t, sUoma Id the lefi bcntephcrc.
the involved region first becoming swollen, and the nerve fibers then destroyed. If the newly formed cells are small and com ])3ra lively few in number, and if their fibril-like processes Jorm a tiensc network, ihen the tissue of the growth is firm and solid ; if the cells arc numerous the tissue is softer. On section, the glioma looks gray, grayish-red. or yellowish, some- times variegated, and if, as is m)t uncommonly the case, it contain areas of haemorrhagic softening, the tumor may be filled with opaque more or less fluid masses. The diameter of a glioma may measure from three to eight centimetres. The
»9
tgo
U/SBASES Ofi THE BRAIN PROPER.
transition into the adjoining substance of the brain may be graduitl or abrupt, and the tumor appear macroscopically sharply dehncd. The aHectcd part of the brain is enlarged, but keeps its normal configuralion while the ventricles are often dilated (Fig. 86). I
The tumor nearest related in texture to the glioma is the ' sarcoma; it occurti in soft nodes, which, on section, present a marrowy, grayish-white appearance. It is seen much more frequently at the base than at the convexity of the brain, and not uncomnioiily is found to originate from the dura, from the periosteum of the skull bones, or from the skull itself (osteo- sarcoma). According to the character of the cells, we distin- guish a round-cell sarcoma, a spindle-cell sarcomu, a 5bro- sarcoma. etc. In size they may vary from that of a walnut to that of a man's fisL. and may be solitary or multiple.
The carcinoma, which appears usually in the brain or in the dura as fungus durxmatris secondarily to carcinoma of the breast, lung, or pleura, is found especially in the ventricles as a soft tumor (cf. Fig. 87), displacing the neighboring brain sub- stance, and giving rise to hydrops ventricutoruni.
Clinically of great importance are the tubercles and the syphilomata (gummala), which, although they show macro- scopically as well as histologically much similarity, can with certainty be distinguished by the presence or absence of the tubercle bacilli. They also may be cither sharply defined or may intiltr-ite the tissue ; they appear on section as yellowish, cheesy tumors consisting in pan of granulation tissue. The "solitary tubercles," which may reach the size of a bazelnul. ■ are single or multiple: they occur by preference in the pons. In the cerebellum, and in the cortex. Syphilomata more fre- quently originate in the dum mater, and thence invade the brain subslancc.
The psammomata. which, coming also from the dura, arc characterized by calcareous concretions imbedded in them : the cholesteiilomala. which on section have a lustre like that of mother-of.prarl : the lipomala. often found in the corpus callo- Sam ; the enchondromata, which originate especially from the bones of the base — all these are clinically of little importance. as they produce, owing to their relatively small size, either only insignificant or no symptoms at all. Hence we may well omit them in our description.
At the autopsy we can often demonstrate the consecutive
BRAt.V TUMORS.
291
changes produced by a general compression of the brain. The skull bones themselves in young people may appear perforated ,Wtd riddled with holes, there may be gaps in the dura or signs of in(l;i(im)alory irril.ttiun. cerlaii) areas may be rough and tliickcncd. presenting a velvety appearance, the convolutions, flattened and presM^d against each other, have lost their dis- tinctness, the pia looks dry and anivmic. Ccrtaiii alleralioiis o( shape seem always to occur if the pressure reaches a con-
^
lt#r.— PAnLLAxvCAniiwoHA IN IKK TKI«n VtHTKictj:. (Afier ZiccLKM.) Prnaul MCMaa tlimii^ Uu licaln. •!. tumor wiib c]«k 4, rishi iluljuiuu>. r. teaUoiiu nucJoHL 4, fclltnwl opmlt. /. TMnUleuuclnu. /, led UuUmiu. ; , lenllcuUt nudeiu. 4, iMcT' Ml tB>Willi t, dlUic4 bttnl ««nukic.
liderable degree : thus a pressure in one hemisphere exerting ftsclf from above downward changes more especially the shape of the insula and the portions of the temjioral and parietal lobes which cover it in (Wernicke). This eltect must be attributed not unly to the increase in volume of the tumor, but also to the increased amount of the lUiid in the ventricles, the hydrops vcntriculorum (internal hydrocephalus) which almost con- ftaatjy accompanies tumors. No doubt this internal hydro- cephalus itself is due to pressure on the venous trunks in the brain, and it occurs, therefore, earlier, and is more marked if the large venous trunks coming from the tela choroidca are preSKd upon by the tumor (Wernicke).
On the cranial nerves signs of pressure have also been
29Z
ffiSEASeS OF THE BKAIN PftOPEt!.
noted. The optic tract, the oculo-motorius. the abducens (Tiirck) have been found compressed by lightly stretched vessels, and an exudation into tlic sticath of the optic nerve has been observed (Leber). In some cases we find a more or less widely spread softening in the parts surrounding the tumur. in others ll»is may be entirely absent: i( the softening is of a ha:inorrhagic character, this must be attributed lo a cutting ofF of the arterial blood supply produced by the cere- bral compression and lo venous stasis. Sometimes, in the neighboring vessels, there develops an arteriitis obliterans with its sequelae (C. Fried lender}. Cranial nerves in the immediate neighborhood of carcinomata and syphilomata arc found to be iutiltrated with the tumor elements (Wernicke).
Etiology. — The aetiology of brain tumors is entirely ob- scure : we do not know in the least whether certain external influences increase the predisposition to tumors in ihc brain or not, just as we are entirely ignorant of the a*tiology of tumors in general. Although the common idea exists that traumatism may be the starting point for a new growth, it is dilTicult to understand the connection : certainty, however, this factor plays an infinitely smaller part in tumor than in brain abscess, and the occurrence of a brain tumor fallowing an injury is probably for the most part accidental. No doubt, in some kinds, hereditary predisposition must not be disregarded, as in carcinomata and tubercles, but even this loses some of its significance, because malignant brain tumors, especially car- cinomata. are usually secondary, as we have said. Nothing remains, then, but to inquire how far age and sex influence their occurrence. With reference to the former, it is supposed that some brain tumors, such as tubercles, predominate in the young, while carcinomata and sarcomata are chiefly found ia older people ; othcrs^e. g.. myxomata and sometimes glioniala — are congenital (Virchow). As to sex, older and more recent authors (Lebcrt. Friedreich, Hasse) agree that males are more Hnble to brain tumors than females, and Wernicke has calcu- lated that the proportion is about three to two.
Symptoms. — The symptoms we are wont to observe in brain tumors arc due to the mechanical influence which the tumor exerts by general or local compression of the skull con- tents, and, further, to destructive or irritative actions which depend upon certain vital peculiarities of the growth, the irri- tation mostly accompanying the infective neoplasms. Oneur
mtAtiV TfAfOffS.
i9S
\
f
the other of these just-mci»tionecl factors will influence the clinical picture of the disease in a mure or less characteristic manner, and as one or the other is more prominent the whole aspect of the disc:ise will vary.
With reference to the former, tlie increased intracranial
pressure, il it appears acutely, we have first a displacement,
then an increase of tension, in the ccrcbro-spinal fluid. In
chronic processes the latter docs not necessarily occur, but us
the skull cavity gradually becomes encroached upon, some of
ibe fluid may be absorbed or the brain become atrophic. As
the intracranial pressure becomes higher the circulation ia the
brain and its membranes is retarded, What ts the cause of
this retardation, wlielher the diminution in the lone of the
vessel walls produces such an increase in the tension of the
cerebro-spinal fluid that by compression a narrowinj* in the
capillaries is produced, or whether ffuxionary hypcricmias come
■ into play, we are not able to decide definitely. At any rate, it
m the IiIo<k1 current in the interior of the skull frequently undcr-
I goes II slowing, there is a tendency to increased transudation
H«nd lymph formation, and with it a danger of oedema of the
H brain (c(. von Ber^mann, Die Lehre der Kopfverlelzungen,
^Stuttgart, 1880, pp. 3i^3(h)-
H The symptoms to which this increase of the intracranial lension gives rise, and which one h.is frequently the oppor- tunity of studying in (he course of brain tumors, may be di- vided into general and focal. The former, fur the knowledge of which we have to thank especially I-eyden, Munz. and Durct, usually appear in a regular sequence and are always tlte name for the same degree of pressure.
The most conspicuous and earliest to appear is the head- ache. The patient complains of nothing but his head, which feels heavy and dull. Every movement causes p.tin, and this B becomes at limes so violent that the patient feels as if he were B losing his reason. The pain seems diffuse and can not be locaU W ized. It is in front on the forehead, behind over the occiput, ft to the right, to the left : il torments him evcrvwherc, and the f lightest lap with the finger anywhere upon his head is intensely disagreeable. Sometimes there comes an hour or two of relief. allbough the patient feels by no moans well and is never with- out pain even in sleep. The scat of this pain which is due to the general increase of the inlracrani:)l pressure produceil by ihe tumor, is not known. It is, however, not likclv to be in
394
DJXRM.IKS OF TIfH /tftA/N PKOP/iS,
I
the substance o( llie brain iisell, unless it be perhaps in the corpora quntlrtj^emlna and the thalami. We should rather look for its position in the (iura. wiiich derives its nerve supply from the trigeminus (cf. page 61). II the fibres of this nerve are compressed by the tumor in the posterior fossa, then there I is not the vague pain taking in the whole head, but another welUdelined headache relerred by the patient to the back nl the head and neck only, a trigeminal or occipital neuralgia ■ which is not a general but a focal symptom. This double sig- nificance of the headache may become a very valuable point in the topical diagnosis. Entire absence of headache is rare, and wc fail In find this symptom only when the growth o( the neoplasm is slow. Its occurrence with unwonted vehe- mence has repeatedly been noted in aneurisms situated near the dura. Occasionally it disappears when definite focal symp- toms become established, and it naturally is more obscured in the later stages of the disease, when the patient becomes som- nolent, lis existence is then only apparent from the fact that the hall-unconscious sufferer frequently puts his hand to his head and moans.
A second general symptom is afforded by the epileptiform convulsions, which cither aflcct the whole body or are confined to one side and during which consc'ousncss may or may not be completely lost. They arc by no means so frequently asso- ciated with brain tumors as headache, still their occurrence is common eiioiigli to he. of diagnostic value (rl. IJremcr and Car- son, Amer. Journ. Med. Sci.. September. 1S90). They, too, may constitute a focal symptom, as is, for instance, not rarely the case in cortical tumors ul the frontal or p;>rietal lobes, which partly exert local pressure, partly irritate the cortex. We must not suppose that these two symptoms, although they are both of an irrtlalive nature, always go hand in hand. Hither one or both may be present, sometimes the one as a general, the other as a focal symptom- Convulsions occur in about fifty per cent of all cases of brain tumors. WcU-marked hys- tcroid convulsions have been observed by SchJinthal in a case of tumor in the corona radiata of the fronl-il lobe (Berlin, kh'n. Wochcnschr., 1S91, 10).
The psychical changes constitute a third general symptom, which, however, disturbs less the patient himself than his friends. A certain slowness in thinking is occasionally noticed in the patient, at first temporary, but later more constant
BRAIN TUMORS.
395
fnabiltly to apprcciulc properly the commonest details uf daily
Ililr which had never been* before remarked in him. At the s.inie time the (caitires become dull and lose their animated ex- |iri'ssi()ti. hi^ niuvcmenis slow and awkward, he grows careless tn all his doings, and this listlcs<)nc»s about everything going on around him may be carri<.'d to such an extent that he lets \\\t, tirtne and (kccs pass (rom him without showing any con- cern or attcmpiin<; to satisfy his needs in a proper maimer. ■ Onidually he begins to show occasional signs of bewilderment. Tilings thai he meets with every day he no longer recognizes. Hi» own house seems strange (o him. he (orgcis the way to his (lining- rot tm or bed-room, and has to be shown there, etc. Me even forgets how to read and to wriic. how to solve the sim- H [)lest mathematical problems which would not give the slight- " c»t diflicully to an eight-year-old child, and gmdnally he becomes more and more demented, until lids condition ]);isscs into one of deep coma and death. In other cases the intclli-
tgence seems to remain intact for a long while, and only the weakness of memory strikes one. The friends of the patient Iwcorac alarmed on noticing that he forgets things which he has said or done only one or two days or even a (cw hours be- fore, that he does not remember the visits of the physician who comes daily, but complains of not having seen him for a long lime. Vet although he may be troubled with bodily pain. the patient may seem at the same time cheerful, inclined to I, and to look ai things from the humorous side, and it is not tit later thai the other mental defects also begin to show themselves, and not infrequently the physician is not consulted until the friends discover that the patient is no longer capable
Iol conducting bis own aRairs. Actual speech disturbnnccs do not usually occur. Certain peculiarities ol speech which do come on and make it different from that in health are due lo the cslcnsive loss of memory ol the patient, owing to which he fcas ilifTtcully in finding the right expressions, and often mixes them up, etc. This makes hJm uncertain in speaking, lie talks »li»wly. and his deliberation becomes quite noticeable. In consequence of the increased intracranial pressure, not Tirrly disturbances in ihc sensorium occur. The patient is in a da/ed cimdition. has a constant desire to sleep, and is drowsy. H The pulte U often slow at first (lortyfivc 1o lilty*tive beats per minute) and irregular, similar to that which we may ob. icrve in apoplexy. This retardation is finally folh^wrd by an
296 DISEASES OF THE BRA IK PSOfEtf.
increase in the frequency in the number of beats. In other words, the primary irritation Ikis given way tu paralysis of the vagus.
Tttgelher Willi llie action of the heart, respiration is aflcctctl. During cotna it Is deep, slow, and often stertorous; with the continued increase o( the cerebral compression it becomes irregular and shallow. IVcp inspirations arc interrupted by long pauses, in one o( which the patient dies.
Slight vertigo, sometimes attended with vomiting, is not uncommon. The latter, whicli is cerebral in origin, has certain peculiar characteristics. It usually occurs on the slightest provocation. It iii.ty be provoked by a simple change in the position of the body, and often comes on in the early morning and without the existence uf any stomach trouble. Without any retching large amounts of watery clear stomach contents are repeatedly thrown up. and .-ifter a short while the patient (eels perfectly well. Sometimes the vomiting is the forerunner of apoplectiform attacks, in which the patient may be uncon- scious for hours. Such attacks are due to a sudden increase in the intracranial pressure, either from hiemorrhage into the sub- stance of the tumor or from sudden hydrocephalic exudations (Wernicke),
That papillitis is extremely common in brain tumor wc have said before. We may add here that it may exist without headache, for the increase in the intracranial pressure sufficient to produce papillitis does not necessarily produce an appre- ciable irritation of the dura, and. on the other hand, if head- ache exists witluiut papillitis, it is not referable to the cere- bral compression but to irritation of the dura. We should never forget that papillitis may exist without any visual dis- turbance, and hence never omit the ophthalmoscopic cxamina- tion in suspicious cases, no matter whether the patient com- plains of trouble with his eyesight or not. Again, the patient may only complain of one eye. while the other seems to per- form its function normally, and yet profound changes be found in either fundus.
If in the course of a brain tumor the patient develops in addition to papillitis an early blindness, then the amaurosis has to be interpreted as a focal symptom, and the tumor located in the cerebellum, as neoplasms in this situation are usually at- tended with verv marked internal hydrocephalus, especially of tthe third ventricle, the floor of which becomes distended and
HKAttf rtwoxx.
297
presses upon Ihe chiasm situated under it (Turck). Moreover, early amaurosis may be produced by tumors in ihc region of ihe corponi qiiadrigcmiriii. especially those of the pineal fjland, by basal neoplasms, which, jusl a» those of the pituitary body, press on the chiasm and the beginning of the optic tract, or which raise the base of the brain from the ha»e of the !it;ull, so thai the artery of (he curpiis callosum is made tense and compresses the optic nerve (TUrck).
The visual disorders which occur in the course of brain tumors ha%-e been group<"d in the following manner by Hirsch- berg (Neurol. Ccntralbtatt. iSgi, )$):
(I) Attacks of blindness— epileptiform amaurosis, (z) Per- manent visual disorders :
A. Produced by changes in the brain : a Homonymous brmianopia (destruction of one or both visual centres in the occipital lobe). 0 Crossc<l hemianopia (tumors in the region of the anterior or jiostcrior angle of the chiasm. 7 Bilateral hemianopia — total amaurosis.
B. Produced by changes in the eye-ground : a Enlarge- ment of the blind spot {not noticed by the paticntj. ff Nar. rowing of the field of vision. 7 Diminution of the central acutencss of vision, due either to anatomical changes in the retina or to interruption of the nerve-fibres leading to the retina.
In considering ihe (ocal symptoms produced by brain tumors wc must first of all slate that these may be entirely absent, just as we have seen is sometimes Ihe case in brain abacess. Instances of this kind have repeatedly come under observation, and it was on this very account found impossible to make a certain diagnosis during life. Absence of both gen. eral and local symptoms is very rare, and only possible when the new growth is very limited, and situated at an inditlerent place. Further, there are symptoms which we are justified in taking for focal symptoms, but which are in reality due to the general compression. The most important one of this nature is hctniplcgia. \Vc may in a case of brain tumor find a well- marked hemiplegia, which persists without any amelioration, and be induced to call it a focal symptom, and yet, to our sur> prise, at the autopsy a tumor may be found in an entirely in- different area — for inslancr, in Ihc white matter of the frontal ibes — a connection which we could not reckon upon. An in-
agg DISEASES OF THE BRAIN PROPER.
stance of this nature t had published in an inaugural disserta- tion. This was the case of a man fifty years of age who suffered from mitral insufficiency, and who was seized with a grave right-sided hemiplegia which persisted unchanged for months, associated with speech disturbances. Papillitis could never be demonstrated. The case was then supposed to be one of em> holism in the left middle cerebral artery, but at the autopsy a round-cell sarcoma the size of a walnut was found in the white matter of the frontal lobe, in the pars frontalis media of the left hemisphere (Steinberg, Beitrag zur Localisation der Himtu< moren, Inaugural Dissertation, Breslau, 1886). For the hemi- plegia to be uncrossed — that is, to be situated on the same side as the tumor — is certainly very exceptional ; in our case it was crossed. If focal symptoms make their appearance compara- tively early, we mostly have to do with basal tumors which produce fatty degeneration and gray atrophy of the involved cranial nerves, notwithstanding the no inconsiderable power of resistance which such nerves possess. Besides the optic (unilateral papillitis) and the oculo-motor (ptosis), the fifth, the facial, the abducens, and the hypoglossus are then relatively frequently affected. Of the fifth, usually only the sensory por- tion is implicated; sensory disturbances in the face, tic dou- loureux, later ancesthesia in its area of distribution, occur much more frequently than paralysis of the muscles of masti- cation. The facial is, on the contrary, affected in its whole dis- tribution— a fact which, in conjunction with the reaction of degeneration in the paralyzed muscles which also exists, is characteristic of the peripheral origin of the paralysis (cf. page 89). The whole hypoglossus is involved, which causes not only the tongue to be protruded to one side, but also leads to atrophy in the affected muscles; swallowing, mastication, and speech are necessarily affected. The hypoglossus paral- ysis, however, is much rarer than that of the facial. Com- bined affections are found :
(rt) 0{ the oKactory, the optic, the oculo-motor, and the first branch of the fifth in tumors of the anterior fossa.
ib) Of the chiasm, the oculo-motor, the first branch of the fifth, and the abducens in tumors of the pituitary body.
(r) Of the oculo-motor, the patheticus, the chiasm, in tumors of the middle fossa, if situated above the dura, of the three ocular nerves and the fifth, if situated below the dura: and, finally,
BRAIN TUMORS.
299
the auditory, the glc
I I
(1/) Of the (acial. ihc trigcmini pharyngeal, the v»g(is. the accessorius. and the abducens in tumors of the posterior fossa.
Diagnosis. — It is the object uf our diagnosis in a given case
'to determine first the presence, then the position, and finally the nature of a tumor. The tirst question inn, as is apparent Irntn what has been said, by no means always be answered
[with certainty ; especially is this difficult if cither only general or only local symptoms are present. Among the former, head- ache, we have said, plays the most important rSU. It may last
I for years without any other signs to lead us lo suspect a tumor, and il is in such instances thai wc- can easily understand how this tnay be inislaken for simple habitual headache or hemi> crania, where the pain may also attain an almost unbearable intensity. Yet in hemicr.mia and its allied alTecttons there occur remissions, and there are cimsiderable periods of time
I during which the patient is perfectly free from pain; whereas in the course of a brain tumor this never hapiicns. Here wc find no intervals of relief, but the patient's sufferings arc unin- terrupted. Moreover, a headache, no matter how severe it be, whtcl) is materially improved by the exhibition ol salicylates, bromide, or caffeine, etc., wc can hardly refer to a serious organic brain disease. If, however, it persists uninHuenced by all the ordinary therapeutic measures, this ought lo put us on our guard, and make us look further for focal symptom;^ — unilateral papillitis, lor instance — which may he present: yet we should, on the other hand, nut lose sight of the fact that there arc quite a considerable number of cases of pure migraine which do not yield to remedies, and which have to be regarded as incurable.
Convulsions, although less often than headache, may be the only striking symptom. If they last lor months, appearing at moderately long intervals, wc may. in the absence of any other symptoms pointing to a tumor, think o( idiopathic epilei>sy. Here, also, the therapeutic test may throw light upon the subject. Large doses of bromide usually diminish the fre- quency as well as the severity of epileptic atUicks. at least (or a lime, and the favorable intlncnce of the drug is often, indeed, quite striking: while if the seizures are due lo an organic cere- bnil lesion, bromides, even il they be continued for a cncd pcrifxl, have but iitlle effect. Such fruitless trials p' direct our attention again to the possible existence ol a
398
DISEASES OF THE BRAtX PKOPRK.
Stance of this nature I had published in an inaugural dis&crta' tion. This wa!i the case of a man fifty years of age who .suHered from mitral insulTicicncy. and wlii> was seized with a grave right-sided hemiplegia which persisted unchanged fur mnnihs, associated with speech distil rhances. Papillitis could never be demonstrated. The case was then supposed to be one of em- bolism in the left middle cerchral artery, but at the autopsy a round-cell sarcoma the size o( a walnut was found in the white matter ol the frontal lobe, in ihe pars Irontalis media of the left hemisphere (Steinberg, Beitrag zur Localisation dcr Hirntti- moren, Inaugural Dissertation, Brcslau, 1886). For the hemi- plegia to be uncrossed — that is, to be situated on the same side as the tumor — is certainly very exceptional ; in our case it was crossed. If local symptoms make their appearance comi>ara- tively early, we mostly have to do with basal tumors which produce fatty degeneration and gray atrophy of the involved cranial nerves, notwithstanding the no inconsiderable power of resistance which such nerves i)ossess. Besides the optic (unilateral papillitis) and the oculo-molor (ptosis), the fifth, the facial, the abdticens, and the hypoglossus arc then relatively frequently affected- Ol the fifth, usually only the sensory por- lion is implicated: sensory disturbances in the face, tic dou- loureux, later ansesthesia in its area of distribution, occur much more frequently than paralysis of the muscles of masti- cation. The facial is. on the contrary, affected in its whole dis- tribution— a (act which, in conjunction with the reaction of degeneration in the paralyzed muscles which also exists, is characteristic of the peripheral origin ol the paralysis (c(. page 89), The whole hyptiglnssus is involved, which causes not only the tongue lo be protruded to one side, but also leads to atrophy in the affected muscles; swallowing, mastication, and speech arc necessarily affected. The hypoglussus paral- ysis, however, is much rarer than that of the facial. Com- bined affections arc found :
(<i) Of the olfactory, the optic, the oculo-motor. and ilie first branch ol the fifth in tumors of the anterior fossa.
(*) Of the chiasm, the oculo-motor, the first branch of the fifth, and the ahduccns in tumors of the pituitary body.
(r) Of the oculomotor, the patheticus. the chiasm, in tumors of the middle fossa, if situated above the dura, of the three ocular nerves and the fifth, if situated below the dura: and, finally,
HKAIN TtfMORS.
299
iJ) Of the facinl. the trigeminus. Ihe auditory, the glosso- ptiaryngcal. the vagus, the uccc»soriu$, and the abduccns in tumors ol the posterior fossa.
Diagnosis. — It is the object of our diagnosis in a given case to determine first the presence, then the position, and linally the nature of a tumor. The hrst qtic>itioii can, as is apjtarent from what has been said, by no means always be answered tvilh certainty : especially is this difficult if cither only general or only focal symptoms arc present. Among the former, head- ache, we have Siiid. plays the most important r^if. It may last (or years without any other signs to lead us to suspect a tumor, and it is in such in!«t.inccs (hal wc can easily understand how this may be mistaken lor simple habitual headache or hemt- crania, where the [uiin ntiiy also attain an almost unbearable intensity. Yet in hemicrania and its allied affections there occur remissions, an<i there are considerable periods of lime daring which the paiient is perfectly free from pain ; whereas in the course ol a brain tumor this upvct happens. Here we iind no intervals of relief, but the patient's sufferings are unin- terrupted. Moreover, a headache, no matter how severe it be. which is materially improved by the exhibition of salicylates, bromide, or cafleine. etc., we can hardly refer to a serious nrganic brain disease. If, however, it persists uninfluenced by all the ordinary ihcrapeulic me.isiires, this ought to put us on ■>ur guard, and make us lo<)k further for focal symptoms — unilateral papillitis, (or instance — which may be present; yet wc should, un the other hand, not lose sight of the fact that there are quite a considerable number of cases of pure migraine which do nut yield to remedies, and which have to be regarded U incurable.
Convulsions, although less often than hcad.-iche, may be the ly Klriking symptom. If they last for months, appearing at
:len)tely long intervals, we may. in the absence of any other symptoms pointing lo a tumor, think of idio)>athic epilepsy. Here, also, the therapeutic test may throw light upon the subfect. Large doses of bromide usually diminish the fre- quency as well as the severity ol epileptic attacks, at least for a time, and the favorable inlluence of the drug is often, indeed. v|uite striking : while il the seizures arc due to an organic cere- bral )e!ii<m, bromides, even if they be continued for a length- coed |h:m<m), have but litilc cITect. Such fruitless trials should ^rcct uur attention again lo the |>ossiblc existence of a tumor.
■* til
300
DISEASES OF THE BRAIN PROPEK.
\
and lead us to search for further symptoms which may help the distg-nosEs.
If the patient complains of nothing further than attacks ot vt-Ttigo and vomiting, if psyclilcal changes, headache, and con- vulsions are absent, then the diagnosis remains uncertain, because vertigo can be produced by m;my different causes, and cerebral vomiting i» met with in affections so different from one another that it is simply impossible to diagnosticate a brain tumor Irom these two symptoms alone. They even do not necessarily indicate a bniin disease, as we may have to deal with M^nifere's complication of symptoms, with a stomach- neurosis, or a spinal disease — e. g.. tabes. The gastric crises of the tabetics may resemble very closely the attacks of vomit- ing in the course of a brain tumor.
Among the organic diseases ol the brain which may be mis- taken for a new growth are brain abM;ess and meningitis. The former — the abscess — is almost always associated with febrile movements, and rarely with papillitis ; moreover, there are the characteristic remissions, so that the patient's general condition may be excellent for years. If we keep these points in mind, and if we make it a rule never to diagnosticate a brain abscess unless wc can obtain in the history some a:tiological datum, such as an otitis media, traumatism, etc., the differential diag- nosis will usually present little difficulty. In meningitis, lever , is the most important symptom. Papillitis is more frequent "I here than in abscess, and hence ol less value in the differential diagnosis between tumor and meningitis, yet the early delirium _ and the jactitations are sufficiently characteristic symptoms to I be of diagnostic value.
Other diseases to be considered are chronic cerebral sclero- sis associated with arterial disease, and lobar sclerosis. The absence of grave general symptoms, the usually much slower course, the appearance of multiple sclerotic foci, the absence of papillitis, are often points enough on which to base a diagnosis.
Finally, the possibility of contusing brain tumor with pro- gressive paralysis »\ the insane (dementia paralytica) and with chronic alcoholism ought to be spoken of. This can, of course, only happen in those cases of brain tumor where apoplectiform att:icks occur, where headache is either absent or only slight, where, however, the mental disturbances are marked, and where, owing to the defective memory, the altenitiuns in ^eech become a prominent feature of the case. The course
BKAftV rUMORX.
301
will clear up all doubtful cases. If we are dealing witli a dementia paralytica wc shall not have to wait long for the , |pp(';ir:iiicc of the chariiclcristtc delusions of grandeur, and ihc |«ti(-'nt will bcc<imc bewildered and have transitory periods ol cxcitemeni, whereas, with the tumor, stupor and somnolence »re developed. In chronic alcoholism tremor and the occur- rence of slotnacli and liver atlections are usual. Above all, a conscientious use of the history will guard us fnim an error in the diagnosis.
The seat of the tumor wc can only attempt to determine when we have reliable focal symptoms to aid us. but. as we have observed, such may be abi>cnt. and. as it seems, this is n»re especially the case in soil tumors occurring in the ventri- cles and sometimes in the frontal lobes, which give rise to nj-mptoms of general compression only ; even tumors of the lounh ventricle arc by no means necessarily associated with well-marked and ch'-iracteristic symptoms, so that often only a probable diagnosis is possible (Josef. Zeitscbrift f. klin. Med., 18S9. xvi, 3, 4). It is furthermore perfectly certain that a great (art of the basal ganglia, the lenticular and the caudate nu> deuK. also the anterior portion of the thalamus, the corpus oil- tosum, the fornix, the choroid plexus, and finally the cerebellum, urith the exception of the vermiform process, may be the seat of neoplasms with a complete absence of all local symptoms. On the other hand, tumors of the motor area, of the occipital and temporal lobes, ol the pulvinar. of the crus, the pons, the medulla oblongata, and of the vermiform process of the cere- bellum, often manliest themselves clinically by characteristic focal symptoms, which we here need not describe, as they have been considered above in detail. Wood (Univcrs. Med. Maga- ^ne. 1889, April. No, 7) reports a case of tumor in the lempoml iobe running its course without giving rise to symptoms. Suf-
»*icc it only to add that destruction of the pulvinur, no less than ^dcitruclion of the occipital loljc, ni.ty give rise to hemianopia, ^h.-tt an early oculo-molor paralysis points to the existence of a ^uraor in the cms. while severe general syni|>tom8— tonic coi>- '^fulsjons. without the loss of consciousness, staggering gait — i (idirate a neoplasm in the vermis of the cerebellum. Tumors • »l the medulla oblongata may. if general symptoms arc absent, simulate bulb.ir paralysis in llieir course. Vertigo has often been noted in connection with such tumors. Other symptoms %e changeable and uncertain ; somclimcSt indeed, there are no
^
303
DiSEASKS OF THE «KA/X fiXOPE/t.
symptoms at sll. Paralysis uf the abducens points to the pos- terior fossa as the scat of the neoplasm. The affections of other nerves, which are important in this connection, have been men- tioned above.
Where we have amaurosis, the pupillary reaction to light Ougfht to be carefully examined. Its presence denotes thai the optic nerve and trad arc intact, and the new growth can only be situated in the central optic fibres, while il it is absent or much diminished we have to deal with a lesion of the optic nerve or tract. Even with the existence of papillitis the pupil- lary reaction may be present. Then the occurrence of the former with the central lesion must be considered as an acci- dental coincidence. If we think il possible that the amaurosis is due to double hcmianopia. we may examine for the so-called hemianopic pupillary reaction (described on page .J5) to throw light upon the question.
The existence of focal symptoms, however.'does not always facilitate the dtagnosiii as much as wc might suppose. This is especially true if the general symptoms are very grave and pronounced. As wc have remarked, a hemiplegia must not always be taken for a focal symptom, and we must again insist that its presence is of no value for the topical diagnosis. Wc need not mention that various disturbances may be produced by indirect action which baffle all altcropis at a topical diag- nosis (cf. the lecture of Jastrowilat. the reference to which is given at the end of the chapter).
The nature of the tumor can in some cases not be deter- mined, while at other times it may be very apparent. The course of (lie disease is o( less value in this question than, for example, the history of the patient's previous diseases: and the fact th.-it certain tumors show preference for certain portions <A the brain, sometimes also the age of a patient, are likely to a0ord us valu.ible hints.
Where syphilis has existed, we have to think of gtimmala. If the family history he one of tuberculosis or carcinoma, brain tubercles or secondary carcinoma uughl to be considered. .A chronic cerebral affection in a child, attended with headache and convulsions, is strongly suggestive of solitary or of multi- ple cerebral tubercles. Tumors of the cortex are more likely to be of a syphilitic or tuberculous nature, while those o\ the b.ase are preferably sarcomata; those of the while maltcr. the centrum ovale, gliomata.
I
I
HKAtN rujaoxs.
30i
I
!
Prognosis.— The prognosis in brain tumor is generally un* bvorablc. and death within one or two years after the appear- ance i>( the first symptoms may be predicted. Spontaneous rcc(»vcry is unheard ol. and improvement as a consequence of treatment is very rare and has only been observetl in cases o( gummatous or tuberculous neoplasms. Here it occurs beyond (question. conse()ucnll>' the prognosis is much less gloomy in these than in other tumors. In general, the course is, in spile o( all treiilment, steadily progressive. Tlie patient's sufferings increase in severity, and the agony is only blunted by the dull- ing of the scnsoriiim. Death occasiotially sets in suddenly, as a nile only after a protracted state of marasmus in consequence of cxhiiusiion.
Treatment. — The treatment is in the vast majority of cases of no avail. Only in rare instances can we by a systematic administration of potassium iodide (5,0 to 8,0 [grs. Ixxv to 3ij| (Uily in hot milk for one and a. half to two monllis) effect a Mticcablu improvement. Whether this is due to iJie direct Kiion of the ii^lide on the tumor, or whether only (he second- uy changes, the softening, the cx^dema, the accumulation ol luid in the ventricles are influenced thereby, we do not know. A« a matter of fact, however, the improvement docs occasion- ally occur, and. \yc it explicitly stated, not only in cases of gum- aaln, but also in other, malignant, neoplasms, tlcsides iodide «i potassium, arsenic seems at limes to have a beneficial action, JctKutficicnt positive observations arc wanting on this point.
The (lueslion of operative inlcrferenee, if such appear indi- atcd, involves the same ])rinciples which we have set forth in ooaiKction with operation for abscess, and which ought to tvAt us here also. Symptoms pointing unmistakably to an cmUtion into the ventricles justify trephining and tapping of the btenil ventricles (or the purpose nf lowering the intra- tnnial presS'Ure. The posterior fossa is always a sort of a ntfli ^ tiugrrr (Wernicke), lieadache, vertigo, and vomiting are •O be treated symptr)malically. Instructive cases of brain lu- •ors, in which an operation was performed, have recently been IHiWshcd bv I£rb(Deutsclie Zeiischr. fllr Ner^-enheilk., ii'(t892>.
1.ITERATURR. mr Svmplom.iiulof^ uiul
tihwutur IWrlin. Hirscliw.iW. 188.. "Wiiw. Drri Fllle nxn Tu)>rrt:clffrwliwii1sicn im Miiicl A»(h. r. Psych, u. Ncfvenkr. «ii. 3. 1881.
DiagniMiili rier HimBC- und Nachhitn.
304
/)/S£AS/!S OF THK BHAIN PROPER.
SinimpcIL Kin Fall i-om Grtiirnlumor roil centralw clnMltigtr TaubhciL Neu- rol. Cenlnlbl.. No. 16. 1881. Aiulry, J. LcKiumcun [Ir;^ plexus choriciidcs. Rrvuedero^d., vi. 11, p. 897, 1886. Sldiilwrg. Ikitraj; lur Localisation <Ict tlimtuinotvn lnaug.-t>iM.. Ureslau,
1886. Hcuiwr. Virchow'j Arvhiv. Bd. 1 10, p, 9, 1887, (On Tumors of the Pilultary
Itodv.) Tuubncr. Iliid.. Dil. 1 10. p. 9;, 1687. (On Lipoma of tlie Brain.) U<il). Bum. xxuvili. fi, 334. 1887. (Tumor or \\v: I'inea) tiljnd.i ^|
lluichin^nn. Ibid., p, 323. 1SS7, (Ncopla<m» in both Corp. Sinat.i.) ^1
Briegcr. Berliner klin, Wochcnsclir,. No. 47, 1887. (Case of Sarcoma of ihcPla.) Birdsall, Phil^d, Mcil. an<l Surg. RepoHcr. Ivi. April 18. 1887. ChurMm. Brit. Mi-d. journ.. May 28. 18S7.
L«clcrc. Trois cas ilc lumcurs intracr.iniennn. Keviie ik tnkA.. tt. 1887, Sokolc-IT. CUiiim lips Crnir.ilncncnsj-stems, Dmlschcs ArcK. f, klin. Mrd,. IW.
45- Hell 4. 5. p. 443. 1887. Jaisirowitf. Ileitriigc tat Lucalinaiion \m Grosslilm und dcrcn praktisclie Vcf-
wefihung. ElcrUncr klin. Wochcnschr.. kkIv. 49, sa 1887. Schmidt- KimplcT. Arch. (. .Augcnhcilk., xviii, i. 1887. (Glioma of (he Pons.
The au(hor speaks of paralysis of (he ocular muiclet and ihc origin <i(
choked disks .J Schwdniu. Philarf. Mrd, and .Surg. Rep., Ivij. October, 1887. (Tumor of the
I'ituiiary liudy.) Osier. Juutn. of Nervous and Mcnla! Disease). 1887. II, 13. (Choleslcatoma
of thr Third VrnirJrle.) Siemens. Tunioren m dcr moiorischen Region. Berliner ktln. WorhcnschnK.
1888. 15, Moppr. Fall von Tumor dcr VierhuKi-l. Inaug.-Disun., Ilalle. 18S8. Kaufnunn. A. Vierteljalirschr. fur gcrichll. Med.. Januar, 1888. {Accident
rollowcd by Brain Tumor) R.-ith. Arch. f. Ophihalm.. 1SS8. wxvi. 4. (Tumon of the Hypophysis.) Dudley*, nrain, Jiiniury. 1889. (SymiXoms of Tumor appearing Thrcr I>>yfi
after Injury.) Hafncr, ISrrlincr klin, Wociim«hr.. 1889. 31. (Hymploms oJ Brain Tubkii-'
appearing Kive Yenriufler Tmumalism.) P*an, Ballel el G^lineau. Acail, de mtd. dc Pari*. F^vr. 19. 1889^ Noihnagcl Wiener mcd, Prruc, 1889, xxn. 3. (Diagnosis of I'unMW in ibca
Corpora Quadrigeniina-) Oppenheim. Arch. f. Psych, und Ncrvenkr.inkh,, 1B89. «i. J, p. 560. (O
irilmtlon [o ihe Paihobg)' of Tumors in (he Cerebrum.) Chri^l Dcuisclies Arcli. t. klin. Med.. 1890, >i!vl. 5, fi. ICvrald. Itcrltnc-r klin. U'ochrn<ichr.. 1S91, ta (Forced Movements in C
of Tubercles of ihe Brain.) V. Hippel, Virchow's Arck. 1891. c»xv(, 1. (Tumors of the flypophysis.) Kutlnrr. ZurCaxulsiik der Himtumorcn. Berliner klin. Wochenschr,. 1S93. J?-" Giesc. Zur Caiuislik der Balkcntumoren. Areh. f. Psych, u, Ncrvcnkr.. 1891
miil, J, Ackennann. Ucultche mcd, WochcntKhr.. 1893. 31. V. Bramaxn. Arch. f. klin. Cliir.. 1893, xlv, a. (Extirpation of Brain Ttunut^)
PAMASITKS OP THE BJfA/.V.
JOS
*
I
APPENDIX.— I'ARASITES OK THE BRAIN.
Among the parasites luttiid in llic brnin the cyslicerct nnd the cchinococci are the must iniportant.
The former — the cysticcrci — are found quite frequently it the autopsy when ihcir existence during life was not diagnas- ticatcd or eveti suspected — a prool thai they may be present vtthout giving rise to any symptoms, or that they may pro- duce a clinical picture such as is often due to other causes. The cysLs. which arc rarely single, but mostly multiple, uDounling as they may to one hundred or more in number, have their seat, some in the meninges, sonic in the substance oi the brain, in the gray as well as in the white matter: some- times they arc Ircc in the ventricles. They may be so nuiner< (ms that the whole surface of the brain is studded with iheni. Their sue may vary from that of a bean to that ol u walnut,
iftd but rarely exceeds that ol the latter. They contain a
KKHis fluid. At a place where the cyst wall is somewhat
thickened are situated the neck and head, the latter often
dnply pigmented, and to be recognized on closer examlna-
^n by a crown of houklets
»«! Slickers. The parts sur-
rouwling the cyst are either
periectly normal or in a statt-
^ isAammatory softening.
Thii biicr is found as a rule
*l)r when the cysticercus
u dead and has undergone-
■Usages. If the cyst sends
"oitfiTcnicula it assumes the
'ft* nf a bunch of grapes.
""1 hence is called cysti-
^*fcia raccmosus(\^irchow,
*'«chand). It is estimated
'**« the [Kirasites live from
'*> recto MX years. After their death they are changed into cal-
^ftous concretions, surrounded by a connective-tissue inem-
'^nc. which in their interior contain cholesterine and fat.
It is impossible to sketch a clinical picture produced bv
^>«if«rci in the brain, because this varies, of course, with the
^^1 of the cysts. I had oi:casion in the past few years to ob-
**rre lour cases in my clinic, and ol these only one was diag-
^i^^
■* ^ '
Fl(. KS.-Clniiiti,k. I.- KuKH<ni;s (Afwr Uari'iiahii.)
3o6 DISEASES OF THE BRAIH PSOPBJt.
nosticated during life, and this one not because it presented characteristic symptoms, but owing to the history of the pa- tient, from which we learned that he was in the habit of fre- quently eating raw pork. In all four cases the patients suffered from epileptiform attacks with convulsions, sometimes with, sometimes without, loss of consciousness. Two of them were in the intervals between the attacks temporarily completely bewildered, and were sometimes for hours not able to fioA their way in the ward where they were staying, did not recog- nize their fellow-patients — in short, presented conditions which, considering the attacks which they were subject to, were looked upon as epileptic equivalents. Motor disturbances were not observed in any of the cases ; all of them, however, complained at times of headache and vertigo. In one case three cysts the size of a pea were found imbedded in the left lenticular and caudate nucleus, the internal capsule being spared, so that the patient had had perfect use of the right extremities. Id another case there was found a focus of soften- ing the size of a pea, in which the calcified remains of a cysti- cercus could be demonstrated, in the left half of the middle segment of the pons immediately below the middle line, with- out there having been during life any noticeable symptoms of destruction. A third case showed, besides numerous vesicles imbedded in the gray cortex, cysticerci swimming free in the fluid of the ventricles, the amount of which was considerably increased. The high grade of hydrocephalus was probably responsible for the mental enfeeblement of the patient, a con- dition for which during life the epileptic attacks had been held accountable; these, in their turn, were doubtless connected with the parasites in the cortex. Cases presenting a course which resembles that of the progressive paralysis of the insane I have myself not had occasion to observe. According to Wernicke, such instances are not rare (/if. cit., in, 373). Michael has described a case in which the presence of a free cysticercus in the fourth ventricle gave rise for a considerable period of time to a picture simulating diabetes mellitus (Deutsch. Arch. fUr klin. Med., 1889, xliv, 5, 6).
Hence it is evident that a diagnosis of cysticerci and echi- nococci in the brain can only be made if we know that the patient has had a tapeworm, or if we have been able to demon- strate cysticerci in the muscles, the eyes, etc. H in such cases epileptiform attacks set in, which alternate with conditions of
fA/lAStTES Of TUB BKA/.V.
307
I
I
and if we are able to exclude syphilis and tuberculosis, we arc justified in suspecting the presence of parasites, espe- dally of cysiicTrci.
The R;tiulogy of cysliccrci in the brain is that of cysticerci in any other part of the body : th<iy will develop in persons who often give tlie parasites a chance to invade their body, as is, for instance, the case with butchers, and hence they occur relatively fretjuently in such individuals. Therapeutics in this case is powerless : \vc have no menus of destrnying the parasite.
Echinocucci are usually found in single solitary vesicles on the tree surface of the brain or the ventricles. Their ycl- towish mucoid contents, surrounded by a cyst-wall and a connective-tissue capj-ule, can break through to the outside, and be evacuated through the nose, the ears, etc., and a sort ol spontaneous recovery take pLicc.
Echinucucci of the brain often do not present any peculiar symptoms which could be used for diagnosis. The clinical picture by which they manifest themselves is usually that of a tumor, but when they have perforated lo the outside we may be able to <lcmonsirale on the protruding tumor lluclualion and pulsation. II ihcy perforate into the orbit they give rise In a-dema ol the lids and csophthalmus. Westphal has ob- served a case in which over ninety cysts were evacuated lo the outside.
Thai actinomycosis may occur in the human brain is shown by the publication of Bollinger (cl. lit.), where a tumor in the third ventricle is described which contained numerous charac- lertstic granules. Often the diagnosis remains obscure, as hap- pens sometimes also in actinomycotic affections of the lungs; the process in the brain may remain latent (Orlow, cf. lit.).
LITERATURE.
Vtrchow's Anh.. Dd. 7$. Brrsl. ami. Zciiuhr.. 1881. Urbcr ffcn Cyst, rac«nt. 6r.% Gchirns. ErlAnera. rSfti,
C]r*tic«n:uR ccrabh multiplex Im einem ijUhr. Kinilc. [li»l. Sntl. Zciuchr.. No. m 1881.
' CyslicCTkrn Im vienen X'enirikcl. Inaufr.^DJtH . Iktlin. 1886. Ffrier Cy«(iccmi» Im Clchini, t^cuuclio Arch. f. kliii. Mcil,, B7. (Ni> convulskmi.) BnlDii|[rT. tVbrr pnmSrr A<-lliKHnyc>i>«n im Uchim <la Men»chen. Munch.
mnl, Wochcnschr. |>. 7S9, 1887, , Cagd. Fin Tall ron C)>iic«i:us l>Fim Menschcn aIk Bcitrag lur thiigno«tik dri Cyaiicrrcus crrrbn. Prij^rr idfi}. Wochrnichr.. xiii. 1, 1888. ■mf. Cyk1kcn)ue ilu ccrvnu. Kncfphair, viii, 1, 1888.
3o8 DISEASES OF THE BKAIN PROPER.
Manasse. Ein Fall vun Cyst. Thalami optici. NeuroL Centralbl., 1888, J3. Hanimcr. Zur Casuisiik der sogenannlen freien Cysticerken in den Himven-
trikeln. Prager med. VVochensehr.. 1889, xiv. 21. Bitot et Sabraz^s (Uordeaux). £tude sur les cysiicerques en giappe de I'en-
ciphale el de la moSlle chez rhoinme. Gaz. mfd. de Paris, 1890, Ui, 27-30,
32-34- Wiesmann. Correspond en z hi. f. Schweiier Aerzte. 1890, xx, 11. <Cysticercus
between the Crura Cerebri ; Paralysis of all Four Extremities.) Bostrbm (Giessen). Untersuchungen uber die Aciinamykose des Menschen.
BeiirSge zur path. Anat. u. all^. Paih. von Ziegler u. Nauwerck. 1890,
ix, I. Orlow. Zur Fr.ige von der aclinomykorischen Erkrankung des Hims und
seiner HSule. Deulsche med. Wochenschr., 1890, 16,
CONGENITAL UISKASES — KVIIROCF.PHAI.US — MENINGOCELE — POREN- CEI'HALV — ABSENCE ItK CERTAIN PARTS OF THE 8RAtN.
Our knowledge of the collections of fluid in the brain, which are described under the general term of hydrocephalus, is, on the whole, very defective, and this is even more true of the causes which bring about the abnormal increase. We know that the fluid is either contained between the meninges or within the ventricles, and speak accordingly of a hydro- cephalus externus and internus. We know further that it may collect very rapidly or very slowly. In the former case we have a hydrocephalus acutus, and in the latter a hydrocephalus chronicus. Finally, we know that the conditions under which ii develops may sometimes exist during intra-utcrine life, or, again, may appear much later, and we consequently distinguish the congenital from the acquired form. But, after all, the dis- tinction which we gain by this is only superficial. About the exact manner of development of any of these forms there pre- vails a great difference of opinion, and the question under what circumstances hydrocephalus may develop as an independent idiopatliic disease can not be satisfactorily answered. There is no doubt but (hat in bv far the greater majority of cases we have to do with a congenital disease, and, as a matter of fact, this form plavs in praetice ihe most important rSU.
The congenital hydrocephalus is very rarely external, but is much more often internal. It may be well developed at birth, so thai Ihe diciimference of the skull measures sixty or seventy cenlimctrcs or more. The skull bones then are usually so thin thai their thickness scarcely amounts to that of a sheet of paper. The fonlanellcs and sutures arc separated by wide gaps. The distention of the ventricles may be so enormous
/lYD*lOC/ir//ALVS.
309
'Ihat they form a large cavity which is surroundcfl by brain substance one and a half to two cenlimelrcs thick. The lat- eral ventricles are usually dilated to a much greater extent than the third and luurth : still, these latter may also be mud- crslely distended. The whole brain, more particularly the bisal structures, presents the signs of an increased intracranial pressure; they are flattened out, the corpus callosum may suf- ffcr considerably from pressure (Schroder. Allgem. Zeitschrifl \\. i^ychialrie, 1888. xliv, 4, 5), the commissures are stretched,
->■
the loramen o( Miinroe is very large, the walls of the ventricles are often covered with gmnulatiuns, the ependyma inflamed and in pbccs slightly thickened. The colorless serous fluid, the amount ol which may be as much as one and a hall litres, contains 99 per cent, of water, 0.3 per cent, albumin, traces of ults. and so forth, and the sp. gr. is 1.004 to '-006 (cf- Anton, ^ur Anatomic dcii l-Ivdroccphalus u. s. w., Med. Jahrb. 84, . Jahrg. 188S, N. V. iii, I left 4. p. 135, from Mcynert's clinic).
3IO D/SEASES OF THE BttAIN PROPER.
The most conspicuous symptom of hydrocephalus is the pe- culiar enlargement of the head. This is, however, not always apparent in the first weeks. Sometimes one and a half or two months may pass before the increase in size begins to be notice* aUe. The circumference of the head, which at birth meas- ures forty centimetres, and a year later forty-four centimetres, rapidly becomes greater, and every week a half or one centi* metre is added to it, so that after a certain time, often only after a few months, the head has reached in circumference a size which it does not generally attain to before the age of puberty — viz., fifty centimetres. If the distention of the skull is equal on all sides it becomes spherical, and forms a striking contrast to the smallness of the face, which, of courw, does not take part in the enlargement. If, however, this is more marked in the sagittal diameter, the skull assumes a dolicho- cephalic form, and its appearance is no less bizarre. This is still more accentuated by the enormously enlarged veins which as blue cords run over the skull. The eyes are frequently di- rected downward. This may depend upon an insufficient in- nervation of the eye muscles. The appearance of a child with a well-developed hydrocephalus, the enormous head, which, if the child is held erect, rolls from side to side, the small trunk which with its shrunken limbs looks as if it was only an append- age of the head, the idiotic facial expression, are together characteristic enough to warrant the diagnosis without any further examination, which would reveal various motor dis- turbances, spasms of the muscles, and sometimes increased re- flexes. It need hardly be stated that the intelligence develops only in a very imperfect manner or practically not at all. Most of the children never learn to speak or at least only imper- fectly. They are not able to play like others, their conduct is silly and senseless, their habits are dirty, and they require much painst.iking care and nursing. In exceptional cases their mental development reaches a somewhat higher stage and they are able to comprehend certain things, so that under particu- larly favorable circumstances, as in a well-conducted home for feeble-minded children, it m.iv be possible to give such children an amount of knon'led<^c and skill which is quite remarkable. The appearance of epileptiform attacks, which are always to be anticipated, often greatly interferes with such attempts.
The course is either chronic or acute. The issue is always unfavorable. The children either die during or soon after
// VI>ftOC£P//A l. US.
%M
I I I
I
I
birth, or they attain an age uf a few nionths, or finally they may
lire (our or five years, while it is very exceptional fur thcni
t» live longer and to reach the age of puberty. If, however,
this happens, the head ceases to gruw and remains of the same
iize or becomes even a little smaller, and the skull ossifies. If
death occurs fn an earlier stage, this happens cither during a
convulsion or comes on gradually as a consequence of general
marasmus. There is no question but that in (ace of this affec-
lion therapeutics is powerless. We may well omit the usual
inunctions of the skull with mercurial ointment or the painting
with tincture of iodine, as well as the internal administration
■'{ iodide o( potassium, without any feeling uf self-repruach, fur.
often as these measures have been used, rarely has any good
result from them been seen. Good general nursing of the
child, later a well-conducted simple instruction as far as this is
feasible, finally, symptuniatic treatment, more especially of the
more dominating symptoms, as the epileptiform seizures, which
are best met with bromides, is more rational than any other
more or less futile measures, not excluding puncture of the
head .ind other surgical interference. That we are ignorant ol
the a:tiology we have said above, and would only add here
that the statement that syphilis and alcoholism in the parents
nre predisposing causes, is without foundation.
The idiopathic hydrocephalus which appears later in life may be connected with atheromatous processes and focal dis- eases in the brain. Owing to the rarity of its occurrence. how< ever, it has been hut little studied, and the pos.sibility that even ID such cases we have in reality to deal with the secondary, deuteropalhic. hydrocephalus is by no means excluded.
The secondary hydrocephalus has at times to be attributed Id disturbances of the circulation, at times to general disorders (if nutrition. Among the former may be mentioned active hy- peremias of the brain, occurring in consequence of the abuse ol alcohol, and venous stasis, as it is seen in valvular diseases of the heart and emphysema. There arc. besides, the circulatory disturbances caused by circumscribed mcningitidcs, tumors, and abscesses, by which, (or example, obstruction of the aque- duct of Sylvius may be brought about {Seel igm 111 Icr). .Among the disturbances in nutrition there arc certain forms ol anic- mia. general dropsy, phthisis pulmonalis (Callender), The aflection may run a very acute course and prove fatal in a few days. On the other hand, it may be eminently chronic, and
312
DISHASKS OF TUP. BKAIN PROPKIf.
then the symptoms need nut by any me:tns be characteristic, and it may he the more difficult to make a diaj^nosis. as the tn- crcabc in the size ul tiic head h wont not to lake place. Some- times the symptoms are those ol brain tumor ; again, those o( a spastic spinal p:ir;ilysis may predominate.
The so-called hydroccphaUis ex vacuo, a (orm which devel- ops in old people under the influence of a general atrophy o( the brain, must also be looked upon as a secondary hydroccph- ulus. It is associated with mure or less pronounced dementia. About etiology and treatment nothing need be added to what has been said on congenital hydrocephalus.
Under certain circumstances there are found defects in the bony skull cap which allow the contents to protrude. By this the dura and galea as well as the skin are raised hemispheric- ally, constituting what is called a brain hernia or ccphaloccle. and wc speak ot an cnccphalocele if the brain substance and the pia are both contained in the dural sac, while if only the dropsical soft meninges arc to be found in it, it is called a me- ningticelc. Whether a local decrease of resistance of the mcnn- branuiis skull and defects ot ossification, or perhaps abnormal adhesions of the meninges with the amnion, are the cause of such anomalies has as yet to be decided. Clinically they pos- sess no significance.
The above-mentioned defects (page 367), which we call por- encephaly (Hcschl), may also be congenital. Some gyri may be entirely or partly absent, so that clefts or (unntUsliapcd openings or pits are formed. The defective areas, unless there be a communication with the ventricles, arc covered with pial tissue, and the empty space is filled up with fluid which col- lects in the subarachnoidal tissue ; or, again, the neighboring convolutions are pressed together over the gap, and instead of a hollow we only find a deep cleft (cf. Zicglcr, Pathol. Anat., ii. 636).
Very remarkable is the fact that certain parts of the brain may be entirely absent. This has been observed for the corpus callosum. the fornix, the corpora albicantia. the gray commis- sure, and others. With reference to the absence ot the corpus callosum %*arious hypotheses have been put forward. It has been thought to be connected with the development of the base ot the skull and to depend upon the angle which the petrous portions of the two temporal bones form with each
AftSf.NCB Of CmtTAl.V PASTS OP THE fittAf.V.
3IJ
N ^
k
Other (Kictiter, Virchow's Archtv, 106, 1886). Kuufmann has described a case where the corpus callosum was completely absent ami where its formation had never even begun, so thai the commencement of the disturbance in dcvch>pmcnc hid to be referred to a time between the third and fourth months. In this case the high grade of internal hydroceph- alus which was present had to be looked upon as the cause (Arch. (. Psych, und Ncrvcnkrank., 1887, xix, Dd. iii, page 769). This, in all probability, is more frequently than is generally supposed the immediate cause of congenital malformations due to arrest of development which is principally the result of traumatism during birth, protracted labor, asphyxia in consc. qucncc ul compression, etc. Deficiency in the region of both fissures of Rolando are especially of interest because they may simulate in their clinical manifestations spastic spinal paralysis, although the resemblance is somewhat obscured by the simul- taneous presence of cerebral symptoms ; and there is. of course. «very possible gradation, from the pure picture of a sp3.stic spinal paralysis in which only the lower extremities are affected, to that in which the arms are implicated and cerebral symp- toms are well marked. Schultzc (Deutsche mcdicinischc Wo. «henschrilt, !■;, 1889) has observed the spastic rigidity in the lower extremities in more than one member of the same family <cf. Kig. 80).
Sometimes certain parts o( the brain are only imperfectly developed. Such a condition has been found in certain gyri, the opiic ihalamf, the corpora qundngemina. the corpora stri- ata, and others. Schrtitcr, among other writers, has described Such a delect in the corpus cullosum, which in his case was abnormally short (Allgem. Zcitschr. f. Psych., 1888, xliv, 4, 5). "The cerebellum may also remain very much behind in devel- •^jpnirni. so that under certain circumstances il scarcely attains the size of a walnut. The causes ol such local malformations 4rc usually as obscure as their clinical manifestations during lite.
DISEASES OF THE SPINAL CORD.
What we have said above about the diseases of the brain holds good, with certain limitations, also for those of the spinal cord. The anatomy of the cord certainly offers less difficulty than that of the brain, and, especially as regards the finer structure of the organ, has been more minutely examined into and is better understood ; but in the physiology there exist still so many points, some obscure, some still under discussion, that the pathology remains here also very incomplete. To give a description of the diseases of the spinal cord, especially when questions of its physiology and pathological anatomy are to be discussed, is an extremely difficult undertaking, and were it accomplished far better than I have been able to do it, would still stand in need of a lenient judgment. We shall adopt the same arrangement as in our account of the cerebral diseases, and divide the subject into three parts. The first will contain the diseases of the membranes of the spinal cord, the second those of the spinal or peripheral nerves, the third those of the white and gray matter of the cord.
3'4
PART I. l}/S/i^SES OF THE SPINAL AfF.N/NGES.
The spinal meninges arc, on the whole, not frequently dis- nsed atone ; more often the inflammation spreads from the (soft) membranes of the brain to the piu of the cord, or from the surrounding structures to the dura spinalis. The one of (neatest practical interest among iht- afTeciionsiif the meninges ul the cord is the pachymeningitis cervicalis hypcrtrophica, which wc shall shortly describe.
Of the anatnmy but little needs to be added to what has been Slid on page j. The spinal portion uf the du» is iliinncr than the cerebral; it widens into a large cylindricid sac, which i» by no meant Ailed up by the spinal cord. This dural xac extends beyond ibe lower en<l of the spinal cord (conus medullaris), and tcfmirtatcs is a cone-shaped point at the level of ihe second sacral vertebra; all these are points too well known to be dwelt upon here at length. The conus tncdullaris ends in the liliim lerminatc, a filiform process which is ac4'ompunicd by ilic longitudinal nerve bundles coining from the luinhai and sacral portion of the cord, which conMitute the <3iada etjuina. The ao-called ligamentum denticutatum is a Hat band which by its inner edge is connected with Uie pia and externally by ft Inollied edge to the dura matef ; the arachnoid lies in such close coniact with the dura that the subdural space is only a capillary »fMce, whcrcUK the subarachnoid space, situated between the arach- iwid and the pia, is of considerable width. The denticulate li|;ament divides it, lhouf(h incompletely, into an anterior and a jMisIerior half. In contradistineiion to tlic pia raalcr of the brain, that of the >pin«l cord presents two ditlcrcnt layers of connccitvc tissue, the atiter one of which, very well developed in man, passes into the sub- arachnoideal irabccul», while the inner is made up of a single layer of circular bundtcd of fibrillac (Schwalbe) {viJt Fig. 90).
3i6
DISEASES OP Tt/£ SPINAL MEXINCES.
CHAPTER I.
INFLAMMATIOK» OF TKK DURA UATRK. PACHVMKSINUITIS Sl'lNALIS.
While in the cerebral purtiuii of the dura ilie inner surface is the usual scat of the inflammation, wc find that the spinal dura mater may be diseased on its outer as well as on its inner surface: yot the clinical recognition and separation of these two forms is very often impossible.
The inflammation of the outer surface of (he dura, the ■pachymeningitis spinalis externa, or the inflammation of the
^^"m
Lit.
jur.
r.*.
Id.*.
FiR. 9a> — CKon^ecTtoiii thkolcii tjh Vhutcdhai. Columw akd -nut SnsiAL Coi® (DlADIUNHAnL-AL). ff^. L.tpidattA ipocs. n/. I , lubdufal ipuzr. nr.i., tutttn^ ■Kiidtpaoc. (./., Innet periDaileum u( vertebra. ■/. h. . dura mater. iii/..jir>chiicild. /. r., poMarinr upliial root. /. 4., denticulate ll£«ineiit. *. r., onieilor iplnol (oM. lAIMr
ClCllKOKtlT,)
connective tissue between the dura and the vertebral column, peripachymeningitis, is a very rare disease, and probably only occurs secondarily. The inflammatory changes, which at times are most marked on the posterior surface, consist of a thick- ening and cellular inliliration of the dura; sometimes, also. the membrane may be found covered with dense cicatricial deposits (Eichhorst). The chief causes are caries or tuber- culosis ol the vertebra*, piciiritis. psoas abscess, syphilis, puer- peral pyiemia. suppuration in the peritonea! cavity, and In exceptional cases the disease may have its origin in a neuritis
tNFlAMMA riO.VS Of THE DUKA MA Tf.ft.
3'7
migrans. The clinical picture depends largely upon the impli- catton of the nerve roots and of the spinal cord. If the cord )s compressed by the ihitkcning. the symptoms of a pressure paralysis, lo which wc shall have occasion to rclcr later, make their appearance. I( the nerve roots are implicated, there are violent paroxysmal pains which run along the vertebral col- umn and radiate inio the extremities. Rigidity of the neck and tenderness on pressure over the spinous processes of the vertebrae are rarely absent, but are not sufficient to warrant a diagnosis, as they may be found just as well in an inflammation of the pia. To make a definite diagnosis will in any case only be possible if accompanying signs are taken into consideration, more especially those of any primary disease. It is always a difficult, sometimes even an impossible, task.
The inflammation o( the internal surface of the dura mater usually develops in the cervical portion of the cord : follow. i&^ Charcot, who first described the anatomical and clinical
tk.4.
V-*
*.r.
h
Tx, 91.— CWOW ttCTlOW THMOit'OII Tilt UlDDLK OT TMC CCIirrCAI. KSTtAMOUmTT IK
PAOiVKENiMtrriS CKBviCALt* KrPKKiKopHiLA. /tv.. Uikkwwl dun. <*./.<-.. \y lonnacl cavMtts. m.r., ncmMOola. (Aftn CKAjicnr.)
tMTcs of the disease, il has been called pachymeningitis cer- vicalis hypertrophies ; the inflammatory new formation and thickening of the connective tissue, which are most marked on the posteriur inner surface of the dura, exist in circumscribed areas (Fig. gi); this compresses the ner\'e roots, which pass thnkugh the membrane at these places, and finally even the curd, and may give rise to the formation of channel-like cavi'
318
DISEASES OF THF. SPINAL NHX/XGRS.
ties (i». /. e. ill Fig. 91). If the compression continues for a considerable time it leads to secondary degeneration of the pyramidal tracts in ihe spinal cord, as well as of the motor nerves originating in the jKirts diseased, and to atrophy of the muscles supplied by rhem.
Symptoms. — The symptoms of the disease arc mostly the outcome of the participation of the nerve roots ami the spinal cord. The disease may well be divided into two stages, each having its characteristic symptoms. To the first belong the pains, to the second the paralyses (Charcot). The pains vary exlremely in intensity and exlenl; as a rule they are confined to the region of the neck, whence, occurring in paroxysms of increasing severity, they radiate into the upper extremities and arc accompanied by paraislhcsias in the arms, tingling and formication in the finger tips. The grip is u-sualty markedly diminished, and a test with the dynamometer shows (hat the palit'nl is able to lift only tun to fifteen kitognimmes. Not rarely trophic disturbances, in the form of vesicular eruptions. roughness and desquamation of the epidermis, arc noted. The sensation of stiffness in the neck and of difficulty in moving the head troubles the patient a great deal, and gives to him a siili. quite characteristic appearance. He carefully avoids tuniing his head in any direction, and tries to make up for this rigidity of his neck by turning the whole body, which he docs slowly and in a somewhat awkward way. The most careful examina. tion of the cervical region, percussion of the spinous processes, hot sponges applied to the skin over them, and the like, dties (tot always reveal an increased sensitiveness.
Gradually, that is to say, in the course of two or three months or more, the patient gets accustomed to his pains, mi much the more so as they become less severe in the further course of the disease. On the other hand, he discovers to his great distress that the motor power of his upper extremities is becoming more and more impaired. The stage of paralysis, as a rule, is 'immediately preceded by a peculiar heaviness and sitflness in the shoulder and elbow joints. The patients notice that they arc unable to raise their arms as high as before ; if they arc females, that they can not arrange Iheir hair them- selves any more, owing to the impairment in the upward and Uickward motion of the arms, movements which finally become totally impossible.
The elbow joint, too. becomes stiffened, and the motions
/XFl^MMATIoys OP THE DURA MATER.
319
t
I
t
o( the wrist and finger joints become visibly impaired. The disability is not, however, usually equal in both arms and hands, as one hand may be ahnost useless, while the (unction ol the other is not much interfered with. Still, in .some in- stances, the trouble may progress in both arms /ari passu. Curiously enough, not all the muscles ol the (orearms become affected, but more especiully those supplied by the ulnar and median nerves, while the extensors, which are supplied by the musculo-spinil, remain more or less intitct. The afTectiun ol the muscles maniiests itself by an increasing atrophy and weak- B Bcss, which allows an ovcraction of the healthy antagonists — ^^ the extensors — so that the hand, although by no means in all, but only in the well-marked cases, assumes a very character- istic position. It is dorsally Hexed, and the hngcrs, which arc tbent in the second and third joints, give to it the appearance o( a claw <rig. 92). About the development ol this position
^ 9L— PdHnoM or THi IIako in pArNVNF.VTxaiTis CnvKAi.ia KrpKRnioipHiCA.
(Charcot.)
wc shall have more to say when speaking of the ulnar paraly- sis. The dilhculties arising from this diminished molar power *re considerably aggravated by the parresthcsias in the finger tips. The patients are unahle tn lake hold <if small objects — piiu, stcri pens, etc^they are unable to attend to their own titilet because they can not feel small buttons, and so forth. They become more and more helpless, and, what is of the greatest significance for- patients belonging to the working classes, they become incapacitated lor work and unable to earn Uicir living. This may indeed be the case at quite an early period, when the patient is otherwise in a comparatively fair
320
OtSEASES OF TUB SP/XAl MBN/A'GES.
condition, especially in Icmalc patients who do fine hand-woric (sewing, knilling, embroidering). The whole condition be- comes worse and worse, Anns and hands become stiver and slilTer. nniil finally, although not in all instances, a complete paraplegia of the upper extremities develops. Whether or not lo these symptoms a paresis or paralysis of the lower exireml- lics or bladder disturbances are added will de]>end entirely upon the extent to which the spinal cord takes part in the pro- cess. It can in no case cither be predicted or excluded with certainly.
Course. — The course of the disease is always chronic and extends over years. Alter the period of pains has passed the patients are, as a rule, free from them forever, and only suHer Irom the helplessness which results from the motor disturb- ances. Owing to this they reciuirc scrupulous care, have lo be dressed, undressed, fed. etc.. by an attendant. Recovery or even an improvement is an extremely raic outcome. To he sure. I have seen a cured patient in the clinic of Charcot, but from the minuteness with which this case was described, from the feeling of justifiable |>ride which accompanied ' the demon- stration, one could well see how extremely rare a cure must be. Remak. too. speaks of the curability of the disease (Deutsch. med. Wochensclir.. 1887, No. 2(5). I myself am unable to pre- sent such a case. The patients in my wards, after unsuccess- ful trials of all proposed modes of treniment, have long given up ail hopes of any marked improvement.
Diagnosis. — The disease may. especially in its onset, possibly be confounded with either spinal leptomeningitis or, as we shall later show, with syringomyelia. It is nalural that tumors of the vertebral column, if they be situated m the region of the cervical enlargement, should produce in the initial stage the same symptoms as a paclivmcningilis. The further course, however, will soon settle the diagnosis. Besides (liesc there are two more diseases which may in the mind of the beginner give rise to some diflficulties with regard lo the differential diagii()sis--namcly, progressive muscular atrophy and amyo- trophic lateral sclerosis. It is true th.tt a patient with .1 ]>achy. meningitis may sometimes jtresent the appearance of a roan suflcring from progressive muscular atrophy ; but the two dis- eases should never be confounded, inasmuch as in the latter affection the initial stage is not accompanied by jxiin. and the stiff neck has never been known to occur in il. The idea of
IKFLAMMATIOSS OF TItK DURA .VATF.fl.
3"
^^ amyotrophic lateral sclerosis will prob;ibly also be discarded,
^■fts in this disease the lower exircmilic<t .ire implicated, and as
^^uMlculty in swallowing, a si^n which indir^tt-s <^xtonsiuii uf the
^^^RKcss to the medulla oblongata, will usually not be very late
in appearing. Wc may say that the diagnosis of cervical
IMchynieningilis can, if the case is carcltilly examined and U
the course o< the affection is taken into consideration, almost
ulways be correctly and definitely made out.
k Etiology.— \\'c are wholly ignorant of the aetiology of the disease. Sume maintain that ihc abnsc of alcohol is ul some importance in this connection, others the living in damp houses. Whether syphilis has any such inllucnce, and, il so, what is its mode o( action, is not as yet established. There is no doubt that the aflection is more common among the working classes and
■ Ihc lower grades of society, but what are the conditions and in- fluences which .icl as direct causes, if such there be, we arc not able to say.
Treatiaent. — The treatment comprises local as well as gen- eral therapeutic measures. The former consist in the applica- tion qI strong counter-irritants — c. g., the painting twice daily with tincture of iodine, in the use of irritative ointmcnis or ffloxs. The application of Paqucltn's cautery, with which punclilorm scars on the skin are produced (the so-called fwittts df frtt of the French), only deserves preference because it is less painful than the others. Any lasting result can not be ex- pccie<i (rom il. No more is effected by general or internal ireaiment. and It Is impossible to give the Indications for any Itanicular remedy. Iodide of potassium has l>cen used in order that iomrthing might be done, without, however, producing anything else than disorders of digestion. If the patient in- sifcU on taking medicine, a placebo ought to be given — acids, hitters, etc. In no case were we able to sec any beneficial cflectft from warm baths and hydrotherapy in general. The only measure which at least modified the symptoms somewhat, in that it gave the patients for a time more freedom of motion i^in their paretic extremities, was electricity, more especially the ^kutaneous faradization with the brush on the neck as well as ^nip and ihiwn the limbs. If the constant current is used it Bought CA|K:cially to be applied to the muscles innervated by the nlnar and mc<)f»n nerves. By repeated closing and opening o( the current muscular contractions should be elicited.
chapter ii.
the inflammations of the soft spinal meninges.
Leptomeningitis Spinalis.
The soft membranes are rarely ever by themselves the seat of inflammation, whether of an acute or a chronic type. Such, however, may exceptionally occur as the result of traumatism, of overexertion, carrying heavy loads, or as a consequence of exposure to cold after sleeping on the damp ground in camping out, etc. (Braun, of, lit.). But in the greater number of cases we have to do with the extension of an inflammatory process of an infectious nature, as in epidemic cerebro-spinal menin- gitis, or in tubercular meningitis, both diseases which affect the membranes of the brain as well as those of the spinal cord. That there are instances of meningitis secondary to other dis- eases, and under what circumstances they occur, we have already stated above. Here we only wish to draw attention to its connection with acute articular rheumatism, of which Krabbel (Inaugural Dissertation, Bonn, 1887) has reported an instance.
Pathological Anatomy. — Pathologically the acute spinal meningilis is divided into three stages. The first is character- izcd by a diffuse reddening and swelling of the meninges, more especially of the pia; the second by the appearance of a puru- lent or fibri no-purulent exudation upon this membrane. This may occur gradually, and may vary considerably in extent : it may be found over the whole length of the pia (always more on the posterior surface), or may be confined to circumscribed areas. In the third stage the pus becomes reabsorbed and thickening of the pia vvith therformation of adhesions between it and the dura takes place.
That the nerve roots also participate in the inflammation is evident from the hyperjemia of their blood-vessels, the infiltra- tion of the interstitial connective tissue, and the eventual de- 331
mf-'LAMMATIONS Of THE SOFT SPINAL MKNINGES.
323
)
i
generation ol the mwlullatcd nerve fibres. If we remennbcr the many processes by which the pia is united with (he spina) c'ird itself, it is nut suqmsing that the latter is implicated. On cross-sect iun il looks in places injected, u'denialous, and it seen to bulge : on the other hand, there arc undoubtedly instances In which the cord does not take part In the tnflam- maiion.
The chronic (orm, which seems very rarely to occur pri- marily, and then only after the protracted abuse o( alcohol, is usually preceded by the :icute disease or is secondary to difier> cnl spinal lesions or various alTcctions of the vertebra:. The [Mlholo^ical changes occurring here can well be compared wiih those ol ihc acute form. In this condition we find thick- cniog and opacity of the tissue, masses of newly formed con- acclive tissue, and adhesions to the. dura. There is turbidity ul the sjiinat Muid, which is abnormally increased, and somr- limcs abnormal formation ol pigment. The brownish-red and black specks often seen are to be looked upon as the remains u( previous hicmorrhugcs. in which the coloring matter of the blcNtd has undergone changes (liichhorsl). In consequence of the extraordinary development of the processes of the pia. this membrane adheres very tirmly to the cord, so that it can not be stripped off without loss of substance of the cord. Here, again, the nerve roots arc implicated, as is evident from their cbange<i appearance. They look flattened and atrophic.
Symptoms.- In the acute form pain undoubtedly plays the princi|>al part. Even in the initial stage, which docs not diflcr bom that of other acute diseases in most of the symptoms (chill, general malaise, loss of appetite, disturbed sleep, ele- vation of temperature), the pain along the spinal column is very marked. The patients are constantly troubled with it in whatever position ihcy may lie. although it is especially sharp on any attempt to move or to sit up in bed. At the same time they IccI an unwonted stiffness in the muscles of the back, and have difficulty on motion. On careful examination o( the back wr find that, althou-;h Ihc spinous processes ol the vertebra: arc tender on pressure, and by the slightest lap or by the touch of a hoi sponge p;iin is evoked, this is in no way com- {tarablc to thai felt by the patient without any extraneous in- terference. This persists obstinately, and usually in the further course of the disease may radiate into the anns and legs, owing, o( course, to the implication of the nerve roots. The
324
DISEASES OF Tll£ SPINAL MENINGES.
same (actor also accounts for (lie differcni hypcncsthcsias ot the skin, the girdle sensation, the muscular p^iins. etc. Rigid- ity of t'lc neck is only observed if ihe process has attacked the cervical portion, If the spinal cord itstdf becomes implicated, spinal symptoms, bladder disturbances, increased reflexes, and extensive sensory disturbances make their appccirance. AH these symptoms may persist unchanged for weeks, the patienl feeling very badly and complaining of constant violent pain. H the disease take a favorable turn the pains gradually abale and the patient gets relief ; but, on the other hand, tht- sym[>- toms of irritation may give place to those of paralysis, and as anatomical changes go on in the nerve roots (degeneration, atrophy), we have analgesias and anaesthesias, the muscles be- come more and more incapable of performing their functions, they undergo marked atrophy, and on electrical examinAtinn distinct reaction of degeneration is found. There is direct danger to life (i) if the process extends upward to the medulla oblongata; in that case death may occur in a few days: (2) il owing to an extensive myelitis, bed-sores develop which lead to the utter exhaustion of the patient. Recovery may be com- plete or incomplete: in the latter case pareses. parxsthesias. and bladder disturbances arc left behind as the result of irrepa- rable anatomical changes.
The symptoms of the chronic do not differ much from those of the acute form. The pains, however, are occasionally less, pronounced. They vary with regard lo their violence and scat ; sometimes they are most marked high up between the shoulder blades, sometimes lower down in the back, so as lo interfere more or less completely with stooping; not rarely they arc found to radiate toward the front of the thorax, sometimes on one, sometimes on both sides. Even slighter degrees of pain are sufficient lo seriously interfere with the occupation of the pntient, especially, of course, if the arms or legs, or what is, however, rather rare, all four extremities are implicated. Sen- sory changes are found in both the acute and Ilir chronic form ; an implication of the cord itself leads to the same symptoms of irritation or paralysis which we have before mentioned. The disease may drag out its course through a numl>cr of years and still there may follow a relative recovery ; complete recovery I have never seen.
DiagnosE8.~To make a correct diagnosis of this disease much cx|)cricnce and carefulness is nec<rssary. Acute spi
INFLAMMATIONS OF THE SOFT SPINAL MENINGES.
325
menin^tis tn»y be mistaken for muscular rheumatism and lum- bagti, the chronic form tor what was formerly called spinal irrilation and cord diseases. A differentiation from the former may be facilitated by an examination of the spinous processes lor tenderness on tapping or touching with a hoi sponge. In simple muscular rheumatism the spinous processes are not sen- sitive, whereas the different muscles are found to be tender it pressed or kneaded. loimbago pains are recognized by their greater severity, their frequent change in locality, and their lesser persistency. Spinal irritation iihould only be diagnos- ticated in ver>- ana*mic hysterical individuals: and the further course and linal outcome of the disease will guard us against the assumption of the existence of a cord disease, for, if this be present, the issue is always unfavorable.
Treatment. — With reference to treatment, little is to be added tu what has been said on page 321. Here, too, local measures — counter-irritation, etc. — must first be tried, and in case they should be found uf no avail, prolonged tepid baths {93° Fahr. for from half an hour to an hour and a half) should be substituted. Electricity should also be used in the form of the faradic brush applied over the painful muscles. Ocnlle massage, if practiced by a competent person, is strongly to be recommended, and ought to be continued (or a long time. The administration of iodide of potassium, (or which no indi- cation whatever exists, is to t>c condemned.
CHAPTER III,
HEMORRHAGE INTO THF. SPINAL MEMBRANES MENINGEAL APOPLEXY
— PACHYMENINGITIS INTERNA HiCMORRHAGICA.
The vessels nourishing the spinal meninges are the anterior and posterior spinal arteries, arising from the vertebral artery, which in its turn comes off from the subclavian. They join with a succession of small branches which enter the spinal canal through the interver- tebral foramina and form median vessels, which run in front and behind the cord along the longitudinal fissure, having numerous hori- zontal anastomoses. Both of these arteries send constantly fine horizontal twigs into the substance of the cord, while others are dis- tributed to the pia. The capillary network is decidedly denser in the gray than in the white matter.
The occurrence of a haemorrhage between the membranes of the spinal cord (" intrameningeal"), or between the dura and the bony vertebral canal (" extrameningeal "), is, on the whole, very rare. If one of these two forms occurs more fre- quently than the other, it is the latter, the extrameningea!, the so-called apoplexia epiduralis, so named because the blood es- capes into the epidural space. The haemorrhages between the dura and the arachnoid — apoplexia subduralis — and those be- tween the arachnoid and the pia^apoplexia subarachnoidalis — which break into the space filled with the cerebrospinal fluid, are much more uncommon. If we find on the inside of the dura encapsulated foci of variable size which contain products nf decomposition, ha:matoidin crystals, detritus, etc.. then we speak of a pachymeningitis interna hasmorrhagica. The loose blood coagula may be found of such a size that they compress the cord and the nerve roots. On the other hand, there may be nothing more than punctiform extravasations of blood, in the neighborhood of which the vessels of the dura appear more than usuatlv full. That these coagula are to a certain extent
I
I
MEX/A'GEAl. ArOfLUXY. 327
cipidle of being absorbed, and that ihcy do not necessarily irreparably damage thpcord and the nerve roots, is proved by the cases which take a favorable course.
Etiology. — With reference to the ietiulogy, it may be said that such hicmorrhagcs may be evoked by overexertion. They occur by preference in men, and more especially in laborers who do hard work, such as carrying heavy loads and who drink a great deal of alcohol. They may also follow tranmalic influences, either direct injury to the bodies of ihc vertebra; or severe concussions affecting (he whole body, such as one might receive, for instance, in a collision between two railroiid trains, in which case sympUtms arise which simulate very much the clinical appearances o( railway spine, which wc shall describe later. Secondary meningeal apoplexies occur in the course of infectious diseases — scarlet fever, small-pox, typhoid fever, etc. Also in epileptics they are not rare, and, according lo Hasse, are often associated with heart hyperlropliy.
Symptoms. — The symptoms very closely resemble those of ipinal meningitis, only that the onset is always very sudden — "apoplectiform." A person in perfect health may feel sud- iply a violent circumscribed pain in the back which differs in ee and extent in dilTcrcnt cases, and which if the hxmor- rliage is extensive may in a few hours give place to complete' pinilysis of the legs (more rarely of the arms). In milder cases, while the pains gradually abate, sensory disturbances, [Anesthesias and anesthesias, gradually develop, also slight motor disorders, weakness in the muscles of the extremiltcs, MHQclimes also signs of motor irritation — trembling, twitching. etc. The main characteristic of a meningeal hiemorrhagc which is purely spinal is the complete freedom from disturb- ances of consciousness. The course and the duration of the disease depend uptm the extent of the harmorrhage and ils capability of being absorbed. It is necessary to have seen, carefully studied, and analyzed several cases of this nature in order to properly understand and correctly recognize a new insUincc. The implication of the spinal cord itself necessarily gives rise to what are known as " spinal symptoms " (increased reflexes, bladder disturbances, persistent paralyses), as wc have rejM-aic<lly stated,
Diagnosis. — The diagnosis is easy in the cases with charac* icriMic onset if we are satislicd with ihe diagnosis of ■• menin- geal apoplexy," whereas it is very ditficult, nay. often impossi*
3l8 i>/StAS£S OF TUB SPINAL ME.VINCES. ^|
blc, to determine the exact kind, whether it is epidural or sub- dural Again, lo determine its situation is cumparativcly easy if we remember that in alTcctions ol the lumbar cord the legs, bladder, and I he rectum mainly suffer, whereas aflecUons of the dorsal region give rise to symptoms ol irritation in the dis- tribution of the intercostal nerves, and those of the ccr\'ical portion lo motor and sensory disturbances in the upper ex- tremities. If the scat be still higher up — in the medulla ob- iongaui— bultxir symptoms, disorders of respiration and deglu- tition, will not be .ibsciit. and the case will be fatal in a short time.
Progfnosis.— The prognosis depends upon the extent of the haemorrhage. Cases with a favorable outcome have repeatedly been observed. Implication of the cord and the neiTrc roots makes the prognosis more unfavorable.
Treatment.— In the treatment, our first duty in a recent case should be to procure alisolutc rest in bed and apply tee over the supposed seat ol the trouble, to arrest the haemor- rhage, if possible, or to prevent the return of it. If the irrita- tion seems to be localiired. local bleeding may be indicated. The further treatment is the same as in acute meningitis.
Tumors of the spinal meninges are of no practical impor- tance, because they can never be diagnosticated with certainty. Although we know well from the report of autopsies that just as in the cerebral we may in the spinal meninges find psam- momata. sarcomata, myxomata, gummata. carcinomata, etc., and that their seat may be epidural, subdural, and subarachnoidal, we arc never able to recognize definitely from the symptoms observed during life cither the nature or the seat ol a tumor in the meninges of the cord. The reason is ver>' simple. The tumors, as long as they are very small, produce no symptoms, and. i( they grow, give rise to symptoms which depend upon the compression of the cord and the nerve roots and can not be distinguished from those produced by pachymeningitis and leptomeningitis spinalis. They consist, therefore, of signs of motor and sensory irritation and later of paralysis, which vary according to the scat of the tumor. If. for instance, only one half of ihc cord is compressed, we may have a clinical picture which resembles that of a unilateral lesion of the spinal cord, viz., paralysis and hypcrpcsthesia on the side of the compression, ana;sthesia on the intact side. A case of this kind has been re-
TUMOKS OF rUE SPINAL MENINGES.
329
»
ponctl by Charcot (cf. Ut.). Innumerable variations are pos- lible. according to the size and scat of the tumor, and the less we are able to fully diagnosticate tlie case during life the more taiportant and instructive it will be to examine and describe as carefully as possible wliat is found at the autopsy.
UTERATURE.
Bmin. Bcmcikungrn uber die Mcningiiis spinalis, baonilcrs aach FclcliUgcn,
M Oflkieren. OeulMrhe mililSrirtil. i^eiiachr.. 1871, 1, 3. 4. p. 116. Uyitrit. Klinik dn Ruckcnntukskntnkheiicn. DcTlki. 1874, 1. pp. 44] tt itf. Ouicoi. Klinitchc VonrMge ubcr Kranlthcilcn des Ncrvcnsysienw. German
by VriiKt. Siuiifan, 187S. it, 83 tt se^. Unubach. Arch, f, Psych, und Ncn-vnkr.. 18S4. xv, ^ 4S9. {Lipoma of ihr
Spinal Meiunxet.) Hint. Vie U pach]rineninKflc ccrvicalc hypcnrophlquQ cunttlc Arch. g<n<r..
Juifi. ittSA, p. 641. KaTfnoni). Da difKrcntes rormes de Icplo-inytiim tuberculeusev Kcvue dc
cnM.. March. 1886. vi. j, Senator. U'ebcr cinigc FUle von epulcmischrr Cei«bnMi>inalTnenin);iUt. cic.
Chahit-Aniulen. 1886. xi. p. a88. finuich. Zur Pathologic dcr CrtcbrosplnaUncningtlis. Ibid.. 1886. p. S>S> WorhieltMiim. Fonschrillc Her Med., 1887. v. 19. Ekhbont Kandbuch dcr spceitllen Pathologic und ThcTii|itc, y Atifla^c.
Wim und Lripttg. 1887. iii. 166 rt t^. GolilKhmidL Ccniralbl. f. U»clcri6lotne und PaiaaUenknnde, 1S87. ii, 31. p.
6491 (The Dlplococctis InlracenulaHs Meningitidis.) Hagnire. A Case cf Idiopaihic S«ippuraiion of the Spinal Dura Maler. Lancrt,
Hr 7. 1S87, p. 9. Oamtt. Uchrr multiple Angioaarcomc der Pia maler spinalis mit hyalinrr Dr-
gmeralion. I naug.- Dissert.. Marburg, 1S89. Vogt. Ucber Meiungiti^ i^tualiv Ueutschc mcd. Wochctuchr., 18S9, 38.
(From Jurgcnscn's Clinic.)
PART II. DISEASES OF THE SPINAL NERVES.
The nerves of the spinal cord, which are called spinal or periph- eral nerves, arise, as is we!l known, by an anterior smaller, and a posterior larger root. These are flat bundles of fibres, loosely sur- rounded by the arachnoid, which pass into the intervertebral foram- ina, where the posterior roots form a swelling, the ganglion inter- vertebrate, and emerge from the spinal canal, the two roots having united to form a common round trunk. This again divides after its exit from the canal into two branches, an anterior and a posterior. The anterior, usually the larger, forms numerous anastomoses with the branches above and below it, the so-called ansse, which are col- lectively called plexuses. The posterior, smaller nerves, pass back- ward between the transverse processes of the vertebrae, and are distributed to the muscles and the skin of the back.
Of the thirty-one pairs of spinal nerves, there are eight cervical, twelve dorsal, five lumbar, five sacral, and one coccygeal. The pos- terior as well as the anterior branches contain fibres from both roots. The anterior roots are motor (Charles Bell, 1811). They supply, besides all the muscles of the trunk and extremities, the unstriped muscles of the iiUernal organs and the unstriped muscles of the ves- sels. The posterior roots are sensory, but we should keep in mind that the anterior most probably contain, besides the motor, also tro- phic and secretory, and the posterior roots, besides the sensory, also fibres for the reflexes (cf. also Sass, Deutsche Med.-Ztg., 1890, 12).
The peripheral nerves, just as the cranial, may be affected independently or secondarily, and as the result of some pri- mary disease in other parts. In cases of the first class over- strain plays an important rSle, often also, as we have seen to be the case in diseases of the cranial nerves, exposure to cold and traumatism, while in those of the second class a great many factors come in, more especially infections, intoxications, and general cachesiae: of these we shall speak when we treat of the individual nerves. 330
DISRASF..S OF TUB PF.ttrPltKRAL NERVES.
331
II wc inquire into the anatomical character of the disease wc shall in many instances have to admit thai wc arc unable tt) find any anatomical chanjrcs whatever in the affected nerves. This is true in many cases o( mild neuralgias, but also in some o( ihc severe, even ol the severest, types. The examination ol pieces of the irigeminus, (or instance, which were cut out where a resection had been made un account of intolerable ptin has by no means always revealed appreciable changes in the nerve; on the contrary, this has on microscopical, as well as on macroscopical, examination repeatedly hccn found to be abwlutcly normal. In other instances, however, an inllamma- \v\n — i. «.. a neuritis — could be demonstrated as having been Ihe cause ol the trouble. In such cases there is seen in the scute stage an exudation in the interslitial tissue and an abun- dant infiltration of the same with round cells, a condition which gives rise to a swollen and o-dematous appearance of the nerve ("purulent neuritis "). If this inDnmmalion continues fur some time the process goes <m to degeneration, under the influence ol which a part of the myelinc sheath is destroyed and com- pound granular corpuscles are formed. The axis cylinders l^encrally remain for some time intact. In some bundles there nay be found nerve fibres completely atrophied, while the ih^th is somewhat thickened and irregularly contracted, pre- senting a wavy outline. This increase and condensation of the connective tissue makes the nerve look more and more like a cord of connective tissue, which is thinner or thicker than normal according to the amount of the newlv former] tissue: s^imetimes. also, it is in places irregularly thickened (neuritis nodosa). The pigment deposits found have to be looked upon as the remains of previous hemorrhages. Even after extensive destruction of the nerve fibres by the connect- ive tissue, regeneration is to a certain degree possible, as the peripheral nerves possess this power to a considerable extent, a point which is ol importance for the prognosis. According » Ihe advance of Ihe process is centrifugal or centripetal we •peak of a descending or an ascending neuritis. A neuritis migrans has also been described. If the process occur simuU taneously at different places, we sjwak of a multiple or a di-S- Bcniinaled neuritis tl^yden. Roth). From Ihe researches of Schcube we should be led to regard the so-called beri-beri, or kak-ke. a disease ivhich occurs epidemically in Jnpan. as a multiple neuritis. In very chronic cases the inflammatory'
3J2
0/SEAS£S Of Tim SPINAL NER%'ES.
\
cbangcs in the connective tissue are so slight in comparison to the degenerative process in the nerve fibres that it is prefcra. ble to speak in those cases (as Sirilmpcll has proposed) of a "primary ciironic degenerative atrophy of the ncn.'CS." instead of a neuritis.
The symptoms of neuritis, of course, vary according to the position and the (unction of the affected nerve, as we snail show in the following pages. The symplomatolog>' of the primary multiple neuritis ^r f.x<elUnce we shall describe later.
The periptienil nerves may also be the seat of neoplasms, which, when developing in them, usually start from the connect. ive tissue. Only rarely do they consist of newly formed nerve fibres, and deserve properly to be called neuromata; much more frequently they arc fibromata, which may be found as ■ solitary or as multiple new growths, and which not uncom- monly may give rise to thickenings and nodular swellings, which can be easily demonstrated and felt on the nerves. Ex- tensive tumors, where numerous nerve trunks are united by connective tissue into a compact mass, the so-called plexiform neuro-libromata, are rare. Malignant neoplasms, carcinomata, and sarcomata of the peripheral nerves are sometimes met with. That here, also, the symptoms depend on the seal ol the new growth is self-evident (c(, Kniuse on Malignant Ncuro- J mata and the Occurrence of Nerve Fibres in them. Volk- * mann'sche Sammltmg klin. VortrUge. 293. 294, 1887, Deutsche Med..Zcitung. 1888, No. 15).
We shall first speak of the affections of the motor and the sensory nerves which innervate the muscles of the extremities and the trunk, and certain internal organs which arc not con- nected with the cranial nerves, and after that we shall turn our attention to the trophic, the vaso-motor, and the secretory fibres as far as our scanty knowledge on these points will allow. An appendix will be devoted to the primary aSections of the muscles supplied by the spinal nerves.
A. DtSEASKS OF THE MOTOR KHm SENSORY NERVES. /. Diseasts of the CervUai Ntnvs.
Of the four upper (smaller) cervical nerves, the first, which is called the suboccipital, emerges between the occipital bone and the atlas. The anterior branches of these four form the plexus known u the plexus cervicaliti, which is situateil opjiosite the correspond-
THE CERVICAL PLEXUS.
333
la{ renebne. From this plexus coric. besides (he muscuUr branchM to the scalenus, the tongas colli, etc., the phrenic, which is formed clucily by llie fourth cervical nerve, and which for the most part is
'. n-— DUoaUtMATIC 0UTt.l9CI OF THK CUVICAL AMO BlUCHIkl, PLKXVMS. (AfUT
ScirWAUH*.; tV-F///, root* of the owlud novo, ll/ttl. rnnu o( Oie finrt llire« ifitHl Bcno. /If, pmcrlot brMictt*-/, ot (be mcddJ, f^. •' ilw ihlrd nrrKal Mnc I, Miliriar branch orf the ftnl oerrful nem and loop i>f uiiiiin wUh ItM «cand. )> mhU fMdptla) noTtL j, great auricular narva. j,. twporfclal arvical nenc .)n, liMwlllltialhH tMiichca to tha ifaacmidnia nnni from th* ncond and ihinl. jX fonl- ■Mri(Mll(lothaBeca»iw1iu from Ibslhlnl and liiunh ncmea. 4, (upnKlaiinilAi nrms. if pkMMk mtwn. Brachial |>laiu: i'-V/lI. anij /) . tba file raoti lit U"' htacMal A"*- 5, rbe»hBlcl nam. j,, uipnaopular. s„. pcMerim tboncic. 6, ntm lu iha mUitIiu mwKla. ;, 7 . inner and mjt« anterior thoracic nnva, \ B,. R„. (ufatcapa- hr amv,. JTC. niMcakMniUMODii. JV. mediai)^ 6*. ulnar. US. muKuln^filial. it, H', nvrvr tik Wrutere. r, timmAn. f . ■; InMeotal oovta. lA,
* aMor nerve, the superficial cervical, (he auricularis magnus, (he °ccifiit«lb minor, anil several commnnicating branches to the tipper Wtiral |{angli(in and (he ganelifnttn plexus of the vagus f I-'ig. 9.1), The anterior branches uf the four lower (the stouter) cervical
334
i>/SSAS£S OF THE SPINAL liBRVES.
nerves, after they have |iaK»cd between the anterior and mtddte scalenus and have reached the aupractavicutar fnssa, form, in ccmi- junctiod wiih the anterior bratich of the first dorsal nerve, the so- called brachial or subclavian plexus, which may be divided into a smaller or supraclavicular portion situated above, and a larger infra- clavicular portion situated below, the clavicle. From the former are given off, besides the suprascapular, only the three subscapular nerves, the anterior and posterior thoracics, and the rhomboid nerve. The larger portion, which has also been ciiUcil the axillary plexu», furnishes tlic large nerves which supply the entire upper extremity, the circLimtlex (axillaris), the median, the ulnar, ihc musculo-spiral {radial) and cutaneous branches, namely, the nerve of Wrisbcrg. the iniernal, and the {longest) external or musculo-cutancous nerve, which has also been called pcrforans Gasscri {cf. Knic, lieilrag xur Frage der Localisation der motonschen Fasern im Plexus brachia- tiK, Inlemat. kiln. Kiind^chau. 1889, 14).
Just as wc have seen in speaking of ihe cranial motor nerves— c. g., the oculo-molorius, the abduccns, and the facial — the motor disturbances of the spinal nerves may be of a I paralytii; or of an irritative character. In the former case the mobility of the muscles supplied by the aflccled »crvc is di- minishcd (paresis) or completely lost (paralysis). In the latter I we have symptoms of motor irritation which arc not under the control of the will, the so-called spasms. These consist cither of transient muscular contractions or of a lasting state of spas- modic contractinn nf one or of several muscles. The former we call clonic, the latter tonic, spasm.
On the whole, paralytic symptoms arc much more common in the distribution of these plexuses than symptoms of irritation.
In Ihe sensory disturbances wc can equally distinguish paralytic from irritative conditions, the former giving rise to anxsthesia, the latter to hyperesthesia. The anaesthesia is characlerij-ed by the fact that external (mechanical, chemical, or thermic) stimuli arc cither not perceived .it all or with di> minishcd acuteness, whereas in hyperesthesia, on the contrary, even very weak stimuli are felt to be abnormally strong and unpl&isant. The latter condition is usually attended with symptoms of sensory irritation, manifested by pronounced pains or by parxslhesias — that is, abnormal sensations of prick- ing, formication, numbness, or a " furry feeling."
The affections of the sensory fibres of the spinal ncrs*es manifest themselves chiefly by symptoms of iirilalion. They
THE BRACHIAL PLEXUS.
335
are always associated with more or less pain and are called neuralgias. That these also occur in the cranial nerves has already been stated, and the trigeminal neuralgia (cf. page 68) may be taken as a type of them. The neuralgic pains are usually very violent, but are rarely or never constant. They appear periodically and follow fairly accurately the distribu- tion of the afiected nerve. The diagnosis is rarely difRcult. Peripheral anaesthesias — that is, such as are only due to affec- tions of the peripheral nerves or their end organs — are, as we said, rare.
CHAPTKR 1.
LRillONS OP THE CERVICAL PLRXUS.
Thk cervical plexus is. on the whole, much less frequently aflccted wilh motor disturbances than the brachial. Among the nerves belonging to it, it is the phrenic more especially which may present symptoms ol paralysis or ot irritation : yet neither paralysis nor spasm of the diaphragm due to disease ol the phrenic is of any great practical importance, since such an aflection scarcely ever occurs by itself, but is much more often met with only when associated wilh other diseases, Paralysis, for instance, is observed in the course of progressive muscuKir atrophy, in hysteria, probably also in lead poisoning. Trauma- tism or mechanical compression produced by tumors or ab- scesses in the neck may be tht- cause. Recently it has also been observed in tabes (Berliner klin. Wochenschr., 1893, xvi). Among the signs of paralysis of the diaphnigm there is one which is very conspicuous, n-imcly, the faulty expansion in the epigastric region during inspiration. Instead of becom. ing prominent, as is the case in the normal condition, the cpi- guslriutii is drawn in. and when we lay our hand on it we can feel that the diaphragm does not descend. If only one of the phrenic nerves is thus allccied this phenomenon is present only on one side, while the other half of the diaphragm performs its function prupcrly. Besides this, hardly any other symp- toms arc observed in uncomplicated cases if the patient remains at rest, whereas if he exerts himself a distinct dyspnnea and an increase in the frequency of the respirations become tipparent. The obstinate constipation which such patients compl.'^in of can well be understood if we remember the part which the diaphragm takes in the abdominal pressure.
8p.ism of the diaphrnj^m. at least the tonic form of it. is not more common than paralysis. Patients aflccted with this suffer from great shortness of breath and quickly become cyunoscd. 330
LSS/OJVS Of THE CERi'lCAL PLEXUS.
n?
Bcoti
The markedly prominent epi^slrium remains with the dia- phragm immobile and is tender to the touch, and only the upper part of the thorax shows shallow rcspimlory movements, 1(1 some cases of tetanus, tonic spasm of the diaphragm seems to be the cause of death. It occurs almost never by itself with- out some accompanying or underlying alTcclion. except in hys- terical persons. On the other hand, the clonic form of the spasm, the so-called hiccough (singultus), is extremely common. Everybody is familiar with the short clonic movements of the diaphragm, which are accompanied by inspiratory sounds and hich vary in frequency and severity, occurring sometimes in ch rapid succession that eighty or even a hundred may be tinted in one minute. Severe protracted hiccough may be- come very troublesome, indeed, even dangerous, if sleep is for a long time seriously interfered with. This is, however, only the case if singultus occurs as a symptom in the course of other diseases — e. g., in apoplexy, in peritonitis, in chronic gas- tric catarrh, etc. Even when it appears as a reflex neurosis— e. g., in the course of a chronic gastro-ententis — it may cause a great deal of trouble to the piiticnt (Dcbio, Berliner klin. Wochenschrift, 1889, 33). As a rule it is arrested without any interference on the part of the physician by popular methods, &uch as holding the breath, closing the glottis and then at- tempting an expiration.
Therapeutics is almost powerless in the f.tce of affections of the motor hbrcs of the phrenic. In paralysis, electrical itimulation of the nerve, in the (tonic) spasm, chloroform and morphine, have been recommended : yet these measures are by no means reliable.
The sensory fibres which the phrenic takes up in its course, and which arc distributed to the pleura, the pericardium. and the pcritonfcum, may also be affected. Neuralgia of the phrenic is rare, or perhaps we had better say is undoubtedly but rarely recognized. The pains, starting at the base of the thoTVi at the puinis corresponding to the insertions of the diaphragm and radiating in all directions, arc taken for rheu- matism of the chest muscles or intercostal neuralgia, and it i» odIv in cases 10 which the pain is felt directly over the scalenus I Mticus and corresponds to the course of the nerve that the ^B liiagQosis is made correctly. Valleix's painful points can occa- ^m tionally be demonstrated on the spinous processes of the ^^jiiuuer cervical vertcbrse and at the points of insertion of the
J38 DtSe.ASBS OF Tlie SPISAl. HERVES, ^
dupliragm. Respiration is interfered wilh only witen the mo- biliiy ol the diaphragm is at the same time impaired.
The JCliology o( the disease is obscure ; more especially are wc ignorant of the conditions under which it may occur in- dependently. It seems not to be a rare accompaniment of Graves' disease, of angina pectoris, and of sclerosis of the coronary arteries.
Another apparently more important neuralgia in the region of the cervical plexus is the occipital or cervico-occipilai neu- ralgia, which alt.icks by preference the occipitalis major, but also the minor, further the auricularis miignus, the subcutancus colli and the tympanic nerve or plexus, which belong to the glosso-pharyngeal nerve (Jacobson's anastomosis). The pa- tients complain of pain in the whole occipital region, in the neck, often, too. in the cars. Much more rarely the pain radi- ates in a forward direction to the cheek and the lower jaw. The so-called otalgia nervosa may give rise to such cxcruciat- ting pains that the patient's consciousness may become clouded (Gompcrtz, Centralbiatt (. d, ges. Therap., 1890, Hcfi 5), and very severe pains may also be produced by an affection of the tympanic plexus. In such cases it is important to examine for ulceration around a tooth or in the tarynx. Such patients dread every motion of the head, and carefully avoid every cause for laughing, as this, as well as sneezing, chewing, and so forth, is liable to bring on an attack. The consequent rigid position of the neck is quite characteristic for this form of neu- ralgia. Painful points can sometimes be found at the exit of the occipitalis major — that is, about halfway between the mas- toid process and the spinous processes o( the cervical vertcbrec. Where they are absent the disease may be conlounded with torticollis rheumatica: yet such a mistake may be avoided by remembering that the neuralgia is not constant, but char.icter- ized by intervals of perfect ease.
The course of an occipital neuralgia is often tedious, but on the whole it is not unfavorable, and complete cures are not rare. The prognosis is bad only when there exists some organic lesion of the nerve, caused, for instance, by disease of the cervical venebrjc. If, as is usually the case, no definite cause can he found, cncrgciic countt-rirrilation to the skin. local bleeding, galvanisation, the application of moist or dry heal, or the use of nnlipyrin or phenacetin, will usually effect a cure or at least an improvement. Subcutaneous injections
I *
I I
I
I
I
LESIONS OF THE CERVICAL PLEXUS.
339
of morphine we shall probably in most cases be able to dis< pense with. The removal of every deleterious cause should, of course, be insisted upon. Under certain circumstances the occupation has something to do with it. Thus, I have found that the stevedores of the London docks, who carry extremely heavy weights on their backs which press upon the neck and the occiput, arc frequently subject to occipital neuralgia (cf. Hirt, Krankheiten der Arbeiter, iv, 91).
CHAPTER 11.
LESIONS OF TKE SKACMIAL PLCXOS.
The brachial plexus may be diseased in its supra- or infra- clavicular portion. Tbe affections of the latter, undoubtedly the more frequent, are of greater practical importance than those of the former.
Here, too, the motor disturbances are more prevalent, sen- sory disturbances in the region of the brachial plexus, espe- cially neuralgias, being decidedly exceptional. In a case re- ported by Stern (Berliner klin. Wochenschr., 1S91, 46). the compression exerted by a bandage had produced an affection of the whole brachial plexus, with consequent arrest in growth and extensive atrophic paralysis.
In the supraclavicular portion, the posterior thoracic — which, coming from the fifth and sixth cervical nerves, supplies the serratus magnus — is affected in an interesting and very striking manner.
The so-called serratus paralysis is quite frequently due to the calling of the patient, as certain occupations seem particu- larly to predispose to it. If prolonged pressure is frequently exerted on the nerve — as, for instance, is the case in people who carry heavy loads on their shoulders, or if the shoulder muscles, especially the serratus, are overexerted, as happens, for instance, in mowing, in certain manipulations of tailors, shoemakers, etc. — the paralysis has been known to develop rapidly. Occasionally such a:tiological factors are alssent, and we are forced to fall back upon the still obscure influence of what is called " catching cold."
The condition is quite characteristic whether the arm be in a state of motion or at rest. In the latter position the scapula appears elevated and approaches with its lower angle the ver- tebral column more than normally, the inner median margin having an oblique upward and outward direction. The cause 340
LESfOXS Of THH HKAaHAL PLEXUS.
341
ol this deformity is to be sought in the overaction of the an- tagonists— the rhomboids, the levator anguli scapula:, and the trapezius (Fig. 94>. On moving the arm, the palienl, we imd. can raise tt only to the horizontal position, owing to the ab- sence of the action ot the serratus. which pushes the scapula lor< ward. As soon as we produce artificially the action of this
Flc.9^^C*M or Rraitr-nDtK Sekhitvs I'akalvsu ik a Mam TiiiitTV-rtvc Vmu iw Aac Pertka n(ihcKaf«U»lili the jumlianipiii; down. >Afi«r tlKiiiKimr.)
muscle by fixing the shoulder blade and pushing it forward, complete elevation o( the arm is possible. If the patient al- Icmpts this s.imc motion himst-U the scapula is approached to the spinal column. If the arm is raised in front of the chest the inner ed^c o( ihe scapula is elevated and stands ofl from Ihc thorax in a wiiiglike fashion, so that wc arc able to touch the inner surface o( llie bone (Fig. 9i). Besides a moderate
34J
DISEASES OF THE SPIXAL KRKVES.
impairment in adduction, which sumewhat interferes with ihc folding of the arms across the chest, there are no other abnortni< ties to be mentioned. Espcciully is it to be noted that there are no decided sensory changes lo be perceived in a pure scr- ratus paralysis. As this affection is not rarely met with in the course of progressive miisciikir atrophy — sometimes this dis-
Fie. «s-— Thb mhk Cue WITH T«e Amu habbo.
ease begins with a serratus paralysis — it is not to be wondered at that the muscle at fault is suiiietimes found to l>e wasted. In the traumatic paralysis the atrophy comes on very late — many years after the traumatism. The muscle remains intact, elec- trical reactions arc normal— reaction of degeneration being by no means always demonstrable — and yet there is no improve, ment. The prognosis, on the whole, is bad ; the disease even
l£S/0/ifS OF THE BRACHIAL tLEXVS.
343
I
ja Lhc most favorable cases is of very long duration, and may lor weeks, months, or years. Often it is not curable at all, Uid the patient is, :is it were, maimed (or the rest ol hi& days.
Not too much hope m\%\\\ lo be placed in the electrical treatment, no matter in what form electricity be etnploycd : in grave cases, at least, such hopes :ire doomed to disappointment.
The paralyses o( the pcctoralis miijor and minor (^interior thoracic nerves), of the rhomboidci and the levator anguli scapula? (muscular branches from the third, fourth, and fifth cervical nerves), of the liiti^simus dorsi. subscapularis, and
ne- «fik— PMmoti or tui Hkau in Spaui or tmk Sruwivti Catitis oh tkb
Rkiit Si DC.
teres major (subscapular nerves), finally, those ol the siipra- »p(natus and infraspinatus (suprascapular nerve), have by them- selves no practical im|K)rtance, alrhoiigh isolated aScctions of the last nerve have, of late especially, been repeatedly ob- ■enred. Thus Bernhardt has reported an instance ocairrinf^ .after coniusiun of the shoulder joint (Krlcnmcycr's Cent ralbl. li. Nervenhcilk.. 18R9. 7): F. Sohulze. 11 case in which ilic atTec- rtion was produced during birth (Arch. f. GynUc, 1SS8, 3): [.Sperling, one in which, after neuritis of the whole brachial lus, an improvement took place in all branches except the
344
D/S£AS£S OF TUB SFINAL NE/fVES.
suprascapular (Neurol. Ccntralblatt, 1890, 10): finally, Hcuzler has reported a case in which he fourd atrophy of the muscles supplied by this nerve ([)cut!U:he mcd. Wochciischrift, 1890. 51).
Spasms ot the muscles cuncenicd here are also unusual. A characteristic position of the head is evoked by a unilateral spasm of the spleiiius capitis (Fig. 96). Bilateral spasm of the deep muscles of the neck produces a strong retraction of the head, while spasm of the rhomboids alters the position of the shoulder blades, etc.
Of the ner^'es belonging to the infraclavicular portion o( the brachial plexus none is so frequently the seat of disease as the continuation of the posterior irunlc of the plexus, which becomes the musculo-spiral or rndial nerve, and supplies the skin and the muscles of the extensor surface of the arm.
Fie- 97-— Ml)*CVUO-«PIBAL PAKALVnS.
The musculo-spiral paralysis can better than any other form be recognized at a glance. A patient with paralysis of the extensors is unable on stretching out the arm to raise the hand, while lateral motion is diflicult. Dorsal flexion, which is per- formed by the extensor carpi radialis and the extensor carpi iilnarts. is impossible, abduction and adduction difficult, the hand hangs down flaccidly (" wrist-drop." cf. Fig, 97). and when rested upon the table can not be raised. On a more careful examination it is noticed that the first phalanx of the fiexi^d (iiigers can not be extended without assistance, but that if this phalanx is passively extended the patient cart straighten out the others himself. The first condition is due to ihc paraly- sis of the extensors, which, as is well known, on the dor
%
LESIOMS OF TUB BRACHIAL PLEXUS.
34S
I
surlaccof ttie first phalanx pass into an aponeurosis: the sec- ond to the preservation of the function of the interossei, which arc Mipplicd by ihc ulnar nerve. Since its extensors arc »Iso implicated, ihe thumb, of course, can not be actively extended. Dcilhcr can it be abducted, because the muscles concerned are alfto paralyzfd. Some intercslint; conditions will be found on examination of the forearm in extension and flexion. If, for instance, the forearm is extended and pronated, supination is impossible, because the supinator brcvis is paralyzed. During Bexion of the forearm, however, the biceps, which is intact, can perform supination without difficulty. If the forearm is in A position of supination it is easily flexed by the intact muscles, the biceps and the brachialis anticus, while if it is half pronated flexion is imperfect, owing to the paralysis of Ihc supinator longus. The characteristic prominence formed by the belly of this muscle when the forearm is Hexed is abso* lutely wanting. Any participation of the triceps in the paral- ysis is only observed if the lesion js high up {" crutch palsy "). . Usually the injury is situated where the nerve turns over the humerus or lower down, in which case naturally the normal lunctinn of the triceps is not interfered with. Isolated paral- ^^is of the triceps is very rare : a case of this kind has been published by Oppenheim (Rerlin. klin. Wochcnschr., 1S89. 44). The patient was a weaver, and the aflection was regarded as having been due to his occupation. Permanent trophic dis- turbances, shown by pronounced wasting of the affected mus- cles, are rare in ca.ses of pressure paralysis, while they arc fre- quent in the paralysis developed as n consequence and in the course of lead poisoning.
The flexors, otherwise perfectly healthy, also become weak- ened, because ihcir points of insertion arc approximated to Ihc points of origin more closely than under normal conditions, on account of the constant drooping of the hand, and hence Ihe interference with motion is ag^ra\Tited. The patient can hardly use the hand at all ; he is unable to lake hold of any- thing, the finer manipulations necessary for writing, drawing, etc. arc impossible, and in the majority of cases he is unfit for work or for making a living during the whole course of the disease.
Sensory changes are rarely sufliciently marked lo add much to his troubles. Sometimes parivsllirsi.i.s may be complained of — a feeling of cold, numbness, furmicatioD, and the like;
346 DISEASES OF THE SPINAL NERVE&.
sometimes, also, there is a distinct decrease of sensibility, so that zones of anaesthesia can be made out. Pagenstecher has published the results of his study of these conditions in an article (Arch. f. Psych., 1892, xxiii, 3, p. 838), in which will also be found a careful collection of references to the literature. On the other hand, a source of great annoyance is found in the peculiar painless swellings of the extensor tendons on the back of the hand. These node-like swellings have been de- scribed by Gubler as tenosynovitis hypertrophica, and are to be attributed to mechanical influences acting injuriously on the tendon.
The duration and course of a musculo-spiral paralysis may vary greatly, and it is often hard to give an opinion on these points at the very onset of the affection. An electrical exami- nation, which reveals the reactions of the muscles and nerves to the faradic and galvanic current, is the only means by which we can arrive at an opinion as to the duration of the disease. . The conditions are the same as those we described as existing in facial paralysis, and it suffices, therefore, to refer the reader to that chapter. But here again be it stated, a prognosis should never be given without a previous electrical examination of nerves and muscles.
The aetiology of musculo-spiral paralysis is interesting from the fact that it is fairly well understood. While, as all con- fess, the cause of most nervous diseases is absolutely unknown, and we therefore are forced to fall back on uncertain explana- tions, such as exposure to cold, it seems, according to our present knowledge, that musculo-spiral paralysis always can be traced back to one or two kinds of causes, viz., mechanical or chemical. There are quite a number of lesions due to mechanical or traumatic causes. Frequently a man, when greatly fatigued, drunk, or exhausted, goes to sleep, using his arm, usually the left, as a support for his head ; the latter, pressing on the nerve in the lower third of the humerus, gives rise to an injury in a relatively short time, or the arm support- ing the head of the sleeper may press with its outer side against a chair or the like and a paralysis be the result. This is the so-called " sleep palsy." Next we have compression happening to the patient as a consequence of his daily occu- pation, due to pressure from ropes, handles o( water-jars (as in the water- carriers' paralysis of Rennes), etc.; sometimes in infants this paralysis occurs from too much compression
ISS/OXS OF TUB BKACHIAL PLEXUS.
347
»
on the arms by loo tight swathing-clmhcs: iiomclimcs too tight plastcr-ol-Paris l^ndagcs have been the cause: and, fiiutlty, ^11 clirccl injuries to the nerve — stab wounds, blows, gunshot wniiiids, anil coiiipressioii ol the nerve b)' iibnurmu) callus formation alter fracture of Ihc humerus — must also be mentioned.
The lesions due to chemical causes may be the result of the action of certain poisons, among which lead deserves to be mentioned first. It is a fact no less remarkable than well au- ihenlicated, to which we shall again refer when speaking of
tiead poisoning in general, that this agent acts by preference :
li. mUnaar t*fpi r«^atit inriar It. atifti^t 4ifitoram Mmmmw Jf. nUnaar miitimt Jif/iti M. olMwr nutisii
tl. ttttntor irrvu yoUieU M. ralntwr ttuwiit l>al>M»
.V<rnu BiiunAi-ftitrvni il. wMuw lai^
y\f. gK-HOTOtl PMim or TKL UiKULO-aniUt. Nrmvx anu tiu Mutcuu >ui-i-tut> mr (T.
on the muscle!) which arc supplied by the musculo-spiral nerve. This muscuIo-«piral paralysis, however, unlike the form which is produced by mechanical action, is not an inde|K-ndent dis> caM. but merely a symptom of a general intoxication. Accord* iog to (he commonly received opinion (Leyden and others), the (jaralvMs de|}ends upon a degenerative atrophy of the motor peripheral nerve fibres, to which is often superadded a spinal affection. It differs in its clinical aspect from the mechanical legion, inasmuch as the supinator longus and the triceps remain intact. Of late years several cases have been published where, after subcutaneous injections of ether into the extensor surface of the forearm (or tlierapetiric purposes, a musculo-spiral pa- ralytta appeared (Kalkenheini. Aruoxan. Kcniak, 1 1. Ncuniaim,
348
DISEASES OF THE SPINAL NERVES.
cf. lit.). In using the drug in this way this possibility ought to be thought o/.
In contradistinction to the frequency with which paralysis is found, signs of irritation in the distribution of the musculo-
\-riH
lOtM
Fig. 1)9. Fig. loa
The Distribution of the Cutaneous Nerves or the Arm and Hand. (After ErctiHORST. ) Fi^. 99, volar suj-far^ of the u^^wr extremity, ijf , supradavicular ntrve. ■iax, circumflu nerve, ymd, internal cutaneous Derve. 4^/, eitemaJ culajieous nerve, Si-m. cutaneous medius. (mr, median nerve. 7h, ulnar nerve. Fig. 100. ise. supra- clavicular nerve, xax. ciicuraflex nerve, yps. superior posterior cutaneous nerve. ScP', inferior posterior cutaneous nerve, *riiid, inlemaJ cutaneous nerve. 6i-*i, median cutaneous nerve. 7c/, eitemal cutaneous nerve, Sii, ulnar nerve, gra, musculo^piial nerve, lante, median nerve.
Spiral nerve — that is, spasms — are extremely rare. They have been observed most often after manual overexertion — gymnas- tics, etc. (Hochhaus, Deutsches med. Wochenschr,, 1886,4;: Laqueur, xiv. Wanderversammlung der siidwestdeutschen Neu- rologen, Arch, f. Psych., 1889, xxi, 2, p. 660).
In the treatment, electricity not only plays the chief, but the only r^/e. From the motor points (Fig, 98) the muscles ought to be stimulated with the constant current, and, besides this,
/.£S/OyS OF THE HRACHIAL FLEXVS.
J49
i
frequent extensive applications ol the laradic brush tu the skin nl ihe afTecicd arm ought to be practiced. That the cause, il such should be present — (or instance, pressure o( crutches, o( dislocated bones, etc, — ought to be removed, is self-evident. Hcusner( Barmen) demonstrated before the Association of Nntu- ralists in Halle |i.S<)t) an apparatus by means of which the ftction of the extensors is replaced by rubber cords; this appa- ratus has proved to be satisfactorj^. The sensory disturbances which may be found in the distribution of the musculo-spiral we shall mention when considering ccrvico-brachiul neuralgia. The mode of distribution of the cu- taneous nerves of the upper extrem- ity is illustrated in Figs. 99. 100, 101.
The median and ulnar nerves supply lofEcthcr the innervation of the museleft and the skin of the inside of the fore- arm and the hand, the former innervating alno*t at) the ITcxorb of the forearm, the pronator radn teres, and the pronittor quadraius, the ftexor carpi radiali», the Dcxor sublimis digilorum, and a part uf Ihe profundus, leaving the Hcior carpi alnarit to the ulnar. Amung the thenar muiiclcit the median nupplics the abduc- tor brevis, the opponent, the outer head of ih« flexor brevis, further, the first three lumbncalcs. while it again leaves
to the ulnar, besides the one flexor mentioned, the antichcnar, the adductor brevis pollicis. the deeper head of the Hcxur brevis pollicis, the fourth tumhrtcatis, and all the interos^ci.
Both nerves have this in common: that they only rarely become a0ectcd by thetnsclves. much more rarely than the musculo-Kpiral, and that they arc, unlike the latter nerve, liable 10 disturbances not only in their motor but also in their sensory fibrc». We shall have to speak, therefore, not only of paral- yses, but also ot neuralgias. With regard 10 the sciiology. we may cotuider it as the rule, just as in musculo-spiral paralysis, thai motor disturbances only occur as a consequence of me- chanical injury, provided there be no other disease present — e. g.. progressive muscular atrophy and the like ; while neural- pas may appear under other circumstances — e. g., after acute dtaeaaes, after exposure to cold, sometimes also without any
FfK- Kii.— DHraiRnHKn or thk SBmoHT NCHVUoit Tiir. UtcK
or TKK KlHOaiU iKHAL'MII.
r. nnuculi>«pir>l iwrvc. m, ul* Dar ntrvc m, locdiui iwrrc
350
I>/SEASES Of TtiS Sl'INAL NEKl'ES.
demonstrable cause. The ulnar paralysis may be caused bjr certain occupations, as Duchcnne has already observed re. peatcdiy in workingmen who arc obliged to press the elbow
Pig. (Oa. HVTOK PCIIKTS or TKr MeUIAK NSHVE and THt: Ml-^CLEt •UI'TIJSD kV IT.
firmly upon a hard surface. It is not a rare occurrence in Those who have to use the ulnar side ol the hand— hypothcnar eminence — a great deal to strike certain instruments (cabi- net-makers, dyers, cobblers, etc.). •v.
jir.iiiiHini
ilJUtormryi •^•muU
rig, i«3.
.Vnrof
RJ}.. Ittt It
M ■uUwrfnr mi-iiti MfM W Btlmtftttmit
A pure median paralysis is chiefly characterized by the in- ability to pronalc the forearm and to flex the hand, as wc can easily understand from the anatomy of the parts. A very slight flexion of the hand toward the ulnar side is, however.
LESIOXS OF THE liftACIIlAL PLEXUS.
35'
k
rendered possible by the action of the intact flcxur carpi ul. oaris. The tcrntinal phalanges can not be bent, but in the first phulangcs, which arc under the control of the intcrussci. this mutiuti is nut impaired. The part of the flexor profundus digi- tonini which is supplied by the ulnar makes it possible for the patient tu seixe some objects with the third, fourth, and fifth fingers. The extended and adductcd thumb, which tics in close apposition to the index finger, is almost useless.
On the other hand, wc find in ulnar paralysis that the thumb can not be pressed against the index finger on account of the paralysis of the adductor pollicis, that the terminal phalanges of the fingers can not be straightened, the first ones nut flexed (paralysis of the intcrossci), and that the little finger
.■ A/I*
IT, oUbslpr rnWun HgUi FIc. ia4.-)loTO«i ISHitn or thi Vu(*ii Nmvi:,
is almost wholly useless. With the median paralysis the ulnar lorm has this in common, that flexion at the wrist joint is greatly impaired. In the latter cs|)ccially lateral movement toward the ulnar side is interfered with owing to the paralysis of the flexor ulnaris. lastly, the difficulty which is experienced by the patient tn spreading his fing<.-r<i apart and bringing them together again, movements which arc indeed almost impos- sible, greatly facilitate the diagnosis of ulnar panilysis, which, however, lor that matter, is always simple.
Muscular ;iirophics not uncommonly develop in both o( these paralyses, but more frequently in the ulnar form. The intcfXKseal spaces on the back of the hand become sunken in. and, if the wasting affects chiefly the iiiterossei and the lumbri-
353
D/SSj4S£S Of rUH SPtNAL KEMX-RS.
cales, the hand assumes a peculiar appearance. Il becomes not unlike a claw, since the healthy antagonists — the extensor digitorum communis and the flexor digitonim — produce a dor-
sal Rexion of the Brst phalanges and a complete palmar flexion o( the second and third (cf. Fig. 105). This is called the " claw hand." the " main m griffe" of the French.
Atrophy confined to the anlithenur eminence I have repeat- edly observed in cabinet-makers. They themselves attribute it to the continued use of the plane.
The allections of the sensory fibres of the median and ulnar nerves may cither occur alone or be found associated with those of the motor fibres. In the latter case wc have to con- tend with disturbances of sensibility, parxslhesias. numbness,
A' miiinrij-twIaMM
M, (pmAm'm iHrinii
Fig;, n'i " " i.'iMs i>F tHK UvscL'UKiVTJkHEovs NKJtvK ASft nir HL-mj»
ll/PPUBD W» IT.
anaesthesia, and pains, sometimes cjuitc well pronounced, which arc most marked in the initial stage of the paralysis. In the tormer there arc genuine ncuratg;ias. acute, spontaneous, tanci-
LESIOXS OF THE BRACHIAL PLEXUS.
3S3
i
BHig pains which follow the course of the nerve and winch are inlensified by pressure upon it. Such pains are more frc> quently observed in the distribution of the median than in that ol the ulnar, but they are nut common iti cither of these rc- fftons. 1 have known them to occur occasionally after acute diseases, especially adcr typhoid fever. In their course they differ in no way from other neuralgias. The only fact remark- able is that atrophy of the interossei and the "claw hand" may develop in their course even when there are no motor <li^tu^t>ances present. A rt-lapse in a case of ulnar neuralgia in.-iy occur after an interval of years, but no satisfactory expla* bation for this has been discovered.
lastly, wc have to consider in ihe upper arm the musculo- cutaneous and the circumflex nerves (Fig. 106), cither of which may he affected by itself or in connection with other nerves of the plexus. The former supplies the coraco-brachialis, the brachialis anttcus, and biceps : the latter, the deltoid.
Lesions of the motor fibres of the muscu to-cutaneous, which are only met with independently after injury due to surgical operations, impair and completely prevent flexion of the fore- arm on the upper arm. In lesions of the circumflex, motion of the arm away from the trunk is diflicult, and even rendered impossible, if, as often happens in the course of the disease, the deltoid atrophies. This atrophy is readily rect^nized by the fLittening of the shoulder, and is often associated with reaction ol degeneration (cf. Windscheid, Neurol. Centralblatt, 1892, 7). OccaMonally the participation of the sensory fibres of the cir- cumflex is more prominent; the patients then complain of violent neuralgic pains (llemi, cf. lit.), which are aggravated if any attempt is made to move the arm. It is important in such caaes to make a careful examination of the shoulder joint, and Ircquenily we shall find a chronic inflammation here to be the luu of the neuritis. Keccntly. F. Scimltzc h.-is carefully udied the so-called acrop:ira;sthcsia (Deutsche Zcitschrift f. crvenheitk., 1893, iii, p. 300).
In other cases, again, we can not make out any organic hanges in the joint, and we have to think of a joint neurosis, or information on this point the reader is referred to the haptcr on Hysteria. A severe concussion, a fall upon the Ider, which at first produces hardly any symptoms, may rtw to disease, Listing for years, in which both the joint ^the nerves of the plexus take part.
3S4
J>/S£AS£S OF THE SPIS'AL HERl'ES.
In any one of these affections of the nerves of the arm we should in the treatment, besides aiming ut the removal of the cause if such be found, make use as soon ns possible ol the gnl- vaoic current. It is a mistake lo lose time with other meas- ures, such as bathing, massage, rubbing, and the like. Where the electrodes arc to be applied may be learned from the illus. iRitions, in which the motor points arc accurately given. We need hardly say that, besides the electricity, various placebos, rubbing and passive motion, may be used to quiet the patient's mind.
Not uncommonly several nerves of the brachial plexus arc paralyzed at the same time. Duchennc was the first to de- scribe such instances in children in cntiscquence of obstetrical (ipenitions, such as version and subsequent extraction, the Prague method of extraction, etc., and designated this form as " puralysie obst<Stricalc infantile du mcmbrc supirieur," or birth palsies. Independently of the French investigator, Erb has given us an excellent well-defined picture of such a paraU ysis. The lesion which affects the plexus f^ives rise to a simul- taneous paralysis of the deltoid, the biceps, the brachialis anticus. and the supinator longus, and the patient can neither move his upper arm away from the body, nor approach the forearm to the upper arm. The whole extremity hangs down daccid, while the fingers and hand retain their mobility. The lesion in such cases must be situated at a point where the cir- cumflex and the musculo-culaiieous and the mu&culo-spiral are still close together — i. e., at about the exit of the sixth cervical nerve — between the scaleni. and it is from this so-called ■' Hrb's" or "supraclavicular" point (cf. Fig. 107) that we are able to stimulate simultaneously all these four above-mentioned muscles. If the infraspinatus is also taken in, the arm is in a position of internal rotation, and can nut be turned out- ward.
This paralysis, which Erb has aptly termed "combined shoulder-arm palsy," is often a very tedious and troublesome affection. The longer it lasts the more the nutrition o( the muscles suffers, and the most varied degrees of atrophy, which is often especially marked in the deltoid, arc seen. On elec- trical examination we find that the faradic and galvanic excita- bility of the nerves, although not completely lost, is diminished, as is also the laradic excitability ol the muscles, while the gal-
I I
LESIONS OF THE BRACHIAL PLEXUS.
35S
vanic excitability of the same has undergone qualitative as well as quantitative changes, a coiiditkiti which Erb has dcsig- iTiitcd as partial reaction ol degeneration. Someliineg, also, there is present complete reaction of defeneration (cl. page 91). If ihe sympathetic is also implicated (SecligmU)ler). the ensuing paralytic symptoms, contraction of the pupil, narrow- liig of (he palpebral fissure, and retraction of the bulb on the aflcctcd side, arc further sources of annoyance to the patieitt.
MTK \it. pittn.)
Br<ttlkiitl lirtra
KrVt r^^mrlmimhr point Fie. 1*7.
How the participation of the sympathetic is to be explained. whether, as Klumplce (cf. lit.) holds, by a lesion of the commu- nicating branch of the first dorsal, wc can not decide. If the wnsory fibres arc also implicated, the patient comphiins. in ftddiiion 10 the motor, also of sensory disturbances, not only of great difficulty in moving the arm. but also of pains, numbness, and forroiuition.
The Ircaiment. ol course, consists in the use nf etectricily. galvanic stimulation from Erb's point, and the application of
356
DISEASES OF THE SPtXAL NERVES.
ihc laradic brush, which, acting rcfleitly, oflen give very good results.
Peculiar and very curious motor phenomena in the upper extrcmiticii arc observed in conncctiun with and us a direct consequence of certain callings. Such occur in cases where no particular exertion of the muscles might lead us to think of a peripheral lesion of the plexus as the result of overstrain, but in persons whose occupations bring into play complex, co-ordi- nated movements. Since in many cases — hut by no means in all — a faulty cn-nrdinatinn nf the movements is the cauM: of the afleciion, we may for the present accept the name of •' co-ordi- nation occupation neurosis," which was proposed by Benedilct, at the same lime insisting upon the fact that il only fits a cer- tain small number of cases.
Anions the occupations which relatively frequently give rise to the disturbance in question the most important certainly is writing, and writer's cramp — mnfrigraphia, graphospasmus — is one of the nervous diseases to which most careful study has been devoted. Nevertheless, our knowledge is extremely lim- ited, and we must confess that we have not as yet got be- yond the description of the symptbms. The pathogenesis and tlierapeutics are ttrra imogniltt.
In ilie tirst place, we ought to state that only in a fractional number of cases have we to deal wilh a cramp or spasm : more often the conditions are the following : The patient, after having for weeks, perhaps months, noticed that while writing the hand becomes tired more easily than before, finds one day that he is utterly unable to write another line without great strain; as soon as the pen is taken into the hand the sensation of fatigue comes on; hand and arm drop as lE paralyzed, while at the same time the patient may complain of mnrc or less intense pain in the forearm, upper arm. and possibly in the shoulder. The writer's cninip in such cases is iii reality a writer's paral- ysis. In other instances, as soon as the penholder is clasped the hand bi-gins to tremble and the handwriting becomes un- certain and tremulous, which is all the more striking because on examination the patient's hand, especially the right, proves to be quite steady if it is not used in writing. Sometimes there is an actual spasm when the penholder is seized, which attacks the muscles of the hand as well as those of the forearm, so that hand and arm make involuntary movements or they become stifT and immobile (clonic and tonic spasm). The pen is either
/JSS/OXS OF TUF. BKACHIAL FLKXUS,
357
irregularly jerked to and fro or firmly pressed a^ninst Ihe paper : in both cases writing is absolutely impossible. On furlher examination nothing else is discovered, and. what is more especially interesting, the patient is able to do anything else with his hands, even the finest work. He is able to draw (with a pencil!, play the piano, etc.; moreover, the electrical eiaininatiun of the apparently seriously affected muscles scl- diim reveals anything abnormal worthy of mention. Dubois (Schweiz. Corrcspondenzbl., 1887, 5) found the excitability (or both currents, especially in the thenar muscles, increased. Sensibility is, on the whole, normal. Pains only occur un forced attempts to write : in short, the patient can do anything demamled of him except write.
Analogous lo the affections just described are Ihe condi- tions of falii;tte in the muscles of people, cliicfly professionals, who play the piano a great deal. In them not only tbc light hand, but, especially in female patients, the left also is affected. Pain and weakness m.ny become so marked in both hands that piano-play in); has to be given up completely. This becomes the more necessary when the symptoms persist during rest as well, and not only when the patient is playing. Such disturb^ anccs are also noted in telegraph operators, cigar-makers, and in milkers of cows; also, but rarely, in tailors it is pro- duced by the frequent handling of the heavy shears, etc. In all cases it is evident that the occupation is the sole cause, although we do not know how and upon what organs it acts injuriously. It is very unlikely that the disturbance is of a peripheral nature, the negative result of the examination of muscles .ind nerves and the uselessness of any treatment sccm< ing lo indicate this. We can not accept either the theory which altempis to explain the symptoms by a primary weak- ness o( certiiin muscles and a secondary spasm of the antago- nists (Zur.ulelli). or that which assumes the spasm to be of a reflex nature, starling from the sensory nerves of the skin (Fritz): or, finally, the explanation that we have to deal with a disturbance in conduction of the nerve muscle apparatus used in writing ; but we arc rather of opinion that the weakness and the motor disturbances of the upper extremity arising in con- sequence of Ihe occupation are of a central nature and are to be referred lo the brain cortex. The situation of the centres ODflcerned in writing and in other movements which depend upon a co-ordinated action of the muscles of the bands is un-
358
DISEASES OP TltE SPtXAL NERVES.
known. These centres in consequence of overexertion, but also often without any appreciable cause, arc thrown into a state ol paralysis or irritation which jjives rise to corresponding dis- Itirhanccs in the extremities. I'crhaps this may at times arise simply as the result of a general increased nervousness which may have a hereditary origin. It is evident that besides those alleclions which are due to a functiuiial disturbance of the cor- tex there arc those in which anatomical lesions, whether ol the central organs or of the peripheral nerves may be the cause of the same symptoms as those now under cofisideration. Thus we may sometimes meet with cases of old almost cured hemi- plegias in which as the only remaining disturbance a slight difficulty in writing or similar occupations may be present. The same may happen in slight disseminated scleroses of certain collections of fibres in the spinal cord, or, finally, as I have had occasion lo observe repeatedly, in the initial stage o( tabes, and the disturbance at the first glance may suggest to us writer's cramp. Hence we should, first of all, endeavor to decide whether the trouble is an independent affection or wliclher it is to be regarded merely as a symptom of an underlying disease.
The prognosis is usually unfavorable. Only in the rarest instances are we able to afford the patients any decided last- ing relief, a fact of which we should inform the friends before taking churgc ol the case. Only when we arc able to gel hold of the patient in the earliest stages of the trouble and can in- sure him perfect rest and the removal of the exciting cause, such as writing, piano-playing, telegraphing, etc., lor weeks and months, is it sometimes possible to effect an absolute cure. If this can not be done, and if the rest is not complete, the success of all our attempts becomes very uncertain and the result will usually be disappointing. W'c may try massage, as has been done also by some non-professional specialists with transient success. Galvanism, faradism, rubbing with different external applications, hydrotherapy, gymnastics, may be advised. The result is usually the same as if strychnine or atropine is in- jected hypodcrmically ori( ihediflerent nervines be given inter- nally for months. Writing may be facilitated by using a pen. holder passed through a potato or through a wooden ball fitted to the hollow of the hand, or by using Xussbaum's bracelet. The advice to educate the left hand to write is always good because it gives the right hand a rest. Yet the value is by no
l£SfOXS OF THE nitACHlAL PLEXUS,
3S9
means lasting, because the motor disturbance, as a rule, shows itseU soon in that hand also, a fact which is an additional argii- tDcnt in favor of the central nature of the disease.
The simultaneous aReclion of several sensory nerves of the brachial plexus, analogous to the motor disturbance in the sbouldcr-arm palsy, is not common. When it does occur the pains arc very violent and deprive the patient of the use of ttie csclrcmity. The ccrvico-brachlal neuralgia may affect all the sensory branches of the brachial plexus, so that the whole upper arm, forearm, and hand arc painful ; but it may also be confined to the area of distribution of one nerve, often the musculo-spiral or median (cf. Nourric. De la n^vratgie brachiale double. Thfrsc de Paris, 1889).
Painful points can sometimes be demonstrated in the region vi the circumflex nerve over the scapula, of the median in the bend of the elbow, of the musculo-spiral in the lower third of the humerus, and of the ulnar at the internal condyle. Vaso- motor and trophic changes may be entirely absent, yet the skin of the fingers not rarely looks glossy and atrophic (" glossy fingers"). Here, again, traumatism, mechanical pressure— by tumors, aneurisms, etc. — arc the most prevalent causes of the neuialgia. It may occur reflexly after amputation of the fingers or the forearm. A bilateral neuralgia of this kind is suggestive of a spinal disease, more especially of pachymenin. gitis ccrvicalis hypcrtrophica.
The treatment is in the main the same as in other neural- gias. Besides narcotics the electrical treatment should be be- gun as soon as possible. Descending currents through the diseased nerve, as well as the application of the anode over the aOcctcd plexus, are to be recommended. The faradic brush is usually borne well and is of use, although the manipulation itvcll may nut be very agreeable to the patient. In rare in* stances wc must have recourse to energetic counter-irritants t<i the skin. We have repeatedly made very successful use of \\ic fvinis lir /tH with Paquclin's cautery.
Para;slhestas and ana;sthesias arc quite common in the dis- tribution of the brachial plexus. They are not always con. hned to one nerve. Tpper arm and forearm, the hands also, are frequently affected, particularly when the occupation ne- cessitates overexcrtiim ol them— e. g., in brick-makcrs. Again they are caused by the action of cold and hot water, olteti
360
J>/SEAS£S OF THE SPINAL NERVES,
also by wftter containing lye (anfesthesiaLivntricum.nnd tlie mat dts bassins of the women engaged in unwinding the silk from the cocoons in the silk>spinning mills, etc.). Tor such patients the only remedy lies in •ibsteiilion from this kind of wurk.
I.ITKRATURE. Uiiant <•/ ikt CfFvitat Pbsm.
Peter, M. Neumif^ia phrvnica. Arch. gti-\iT., 1871. 6me s£t.. xvii, p. 303. Ert>. Hflndbgch dcr Kraiikhdlcn dcs NcrvcnByiicniB. 3. AuD.. 1876b A. pp.
114. 135- Sirilmpell. Lix.iii., 1887. p. 31.
y.nr. <il., 1S87. pp. 47. 79. 8;.
C3M \A I'enislcnl Hiccough ; Nenopsf ; Remnrlui. Lancet. 188}.
Eichhoret. Stei'eniion. i. 1043
L/ileiu ■>/ Iki Brukial PItsmt. I. Paralysis of ihe Serratus.
Bergrr. O. Die LHlimung do Thonicicua longu^ Hatnliutioniscbriri. Dre»-
lau. 1873. Brack. Eit\ Fall von ScrraitislShmunf nach aculer Krankhdt (T)phci((T). In
aug.-DJKMTt., VfsiW.. 1873. Lewinski. Ufbcr Uic L3hrnuiig des Srrraiiu amicus majw. Vitchow's Arcltiv
1878, Ixiiv. 4. p, 473. Lewinski. 'Iw Uiugnoae tier Scrra.(u»liilimun|;. Vircliow's Archiv. 1881. luxtv,
I. p. 7i. nfiumli-r. Isolirtc I.ahmunf; <lft Serrat. ant. ra^j. Arch, f. Psydt. und Ncrvcn
kninkhcitcn. 1882, xiv, 3. p, 7»i. Dixoci Mann. Srrr,i(u« l^nnilysis. Lancet, February. 1884, ). \. 6. NofTin.inn. Uolirit periphery LHhmiini; iIck Nerv. supnucapul. aninlr. Neurol
Ccntr.-ilbl.. 1888, 9, (Pains aiitl Alfupliy of llie Muscles suppbed by ilu
Nerve.) Bunlinn. K<i&« K. l'ar.ilyM« of (he Scmtus Magniu> Joumul of Nerv.
Mcnl, l)i«catn, 189a, sv, p. 67.
I. Mujculo.spinil I'aralyMs (not including the Saturnine Foem).
Fischer, Ziii I-chrr von dcr Ulhniurig dcs N. radialls. Dculsches Arch. f. klin.
Med., 1876. xMi, 4. 5. 39*. Onimus, Gnj. Iicliitom.. 1871, 2me s6r., xv, 15. \Vhit!ic)n. Mu%culo.%|)ir7il Paralysis in Consequence of Pressuir cxened li)* a
Piece of U'jiic. Edinb. Med. Journ., 1881. xitvii. p. 724. Doycr. He In pamlysie du ncrf radial par compression icnijioraire. Th^K dc
Pari*. i8$3. Joffroy. Du rAle de la compression dans In production (te U paralytic radlale.
Compt. rend, gtnfr., May 14. 1884, p. 184. Arnoian. (,lax. liebd.. i88j, ixxii. z, 3, — tl. Remuk, Oerliner klin. Worhrn»chr.,
1885. «"'■ S-^-H, Neumann. Neurol, Ceniralbl,, 1885. iv. 4.— l-'.ilkcniicim.
Miitbeilungen nus tier mcci, Klfnik ru Konigslwrg, 18GS. (Muscuto-splnl
Par^lyti^ afler Subcuianeous Injection of Elber.J
I
LSS/O/fS OF THE BRAClllAl. PLEXUS.
36.
^
I «t Dcjcrinr. Rechrrches cliniqucs ct np^rimentalcs sat la puilyiie
ntdiale. Compt. rrnd. hclHl. Ac \a Soc. Ac DhiL, 1886. 1 ;. p. 1S7. ScKribcr. M. Kin Va.\\ van ^chwcrcr cumpliclitcr SchlkflahtnunK am linken
Arme. Neurol. Ccntriilhl.. 1886. v, ij. Kolmer, H. Em Fall von Kldchiciligcr mumatlscher (Druck) Lahmung der
Setvi raili.il.. uln. uiid mcdUn. tmistr. Deutsche mrd. Wocliciudir., 18M.
10.
r Chicle. Sllning Atr Berlinn G««t1sch4fl T. P*)-ch. a. Ncivenkrankhciltrn VDin g Juli. 1H88. (Tniunuiic ^tu»culo- spiral P«al)-Hs cured by Sec- nndary Nerve Suture.) TiW Mrl l-oa Leu Ha BaU l-hil
I
3. Median niul Ulnar Paralpis. llcrnKanll. Uehet den Bereich der ScnsilKlilSls-Siorung nn Hand uml Fifi|;cr
M Llhmung dcs Medianuft. sowie lur I'aihulogie der Kaduih»p«raJ]iMn.
Arch. f. l'*>Th. uml Ncricnkr. 187s. v. 3, TiWen. Tfi>phoncur>b»« after Itijurj* t» ihe Median Nerve. New York Med.
Record, Sejiientber 11. 18B6. \x\. p. 30, 4. MrN'auifhi. L'In.ir Nfuralgia. Brit, Med. Jouia, April 30. 1887. p. 93J. I'oore. Lancet, Seplembei. 18S3. ii. 10. 13. Leudtl {de Rouen). Gai. m<d. dc I'^ns. September 1 ^ 1 88 j. lieu, Juliu*. Ueber Tempcr^iturcn und derm Mcuting bci UlnaruUhmungen.
Itcrtinet klin. WochcnKhr., 18S6, xxlii, y>. BaUet (>■ AcddeniB constcutifs k la compressimt hahltuellc du cubital chci un
OovTieremployi AauvtafTM Ic vvire. Kcvuede mM..6, iSSj. ItiihoTii. I>e la nivnte p^riphjrique du cubital consecutive ^ la A^-re typhotde.
Tlt^M' lie ^Mit. 188^. No. 1 19. ENkfiburg, Ueber Lilhmuni; (lurch poliicilichc Fessetung (ArrestantenUhm-
unc) der Hand. Neurol. Ccniralbl.. 1889. 4. Rir«Ser. Medianus- Neurit i*. hlUnch, incd. Wochentchr., la. 1889. SientPl DeiitMhe nteil. Wucheiudir.. iltiS, xiv. 31. (Four Ca^n of Trauma-
lism o( llie Ulnar Nenf.J
4. MusculivCutaneuu* and Circumflex rnralyiis.
Hcon. [>e la itivri1){tc circoiiltexe ou anilbirc ThiM de raris. 1883. No. 17;. FauveL Drs paralyHU tiautnaiiques d'origine pfrtphiriquc. 'these <k Vmm,
1885. No. 37 1. I>anu1ris. Zuf Dia^rnoM uimI Prof|;noM dcr Axillaridlhmung. Munch. ownL
\V»chciuchr.. 1S88, 21. 12. Ilruns. Isuliric Laliniunj: der linken Flex. poll. long, dunh Ueberanstrvnguni;
( I}ruinn>cr'« Paralysis). Neurol, Ccnirjlbl , 1890. 11. vnn Zander. Trammlerlahmuri);. Jnaujc.-UiMCrt., Uerliii. 1&91.
S- Plexus Paralysis— Combined Shoulder-arm Palsy.
Ba«luKtl. Ueitnff t\a Lehre von ilcn LShnMtigen tm Ikrciche d« Plexus
biwhldis. Zeiischf. liir klin. Med,. 188a. Iv. 3. p. 41 S- I'tmntll. Zwei Kalle iwi der Form der " combinfrten SchuUcrarmlahmung."
Neurol. Ceniullil.. 1881, 13. Klumi>ke. Cnniiihutlon it l'6tude des p.-imlysics radicubires du plexus brachiaL
KniN du mtd.. Juitlct-Scpi.. 1885.
363
DISEASES OP THE SFINAt SERVES.
Vinajr. Taralyaies nidiculaitcs tu^ifricurcs tin plexus brachial, d'onginc profes-
sitiiMielle. Lyrtn iiicd . ;3. 18G&. tSemhardt. Neurol, Ccniralbl., 1SS6, 6, p. 141, Riiiii-. Utuiiclie Zdlschr. f. Chiiurg.. 1886. xxiv. 3, 4. Murult. Einigc. xum Thcil chirurgischc Uiihciiungcn im Itercichc d«9 V\kk.
brachiali». Schweii. Cancsiponitentbl., 18SS. xvhi, t%. Mi(l<lcli)(»rpr. Wiener incd. Woiheiisclir., 1888. 14- (Pressure Pais)- of ihe
Musi:u1i>-spifal and Ulnar Niivcs.) Jolly. On Uirlh PabJcM. Briii»!i Med. Journ.. 18S9. 6. Arcns. Uciirag rur I'xthuloglc ilcr Eiitbimlun^'iljfhnmngen. Insug.-Di&Mn.,
Goitin^en. 1B89. Lesiyn^ky. W. A Cuntflbuiiun lo the Clinical Study of Kpontnneous Dcgen-
er.itive Ncuriii« of the Itrachial Hlcius. Jouni.of Ncrv. and Ment, Discabcs,
January 1. 1890, iv. Schacfcr (Owiosh). UeberArbeitaparesen. FrvmMenders Pulyclinic. Inaug.-
Dissert., Drrlin, 1B90L rfeilTeT. ZwfI FBIIe vein IJIhtnunErler unlcren Wuncin (let I'lexus brachlalis
(Klunipke'a I'ar.ilysiO. Deuisclie Zeruchr, f. Nervcnhb.. 1891. i. 5, & OriaiiolT. C.is [Ic pnr.itysie raiJiculairc, brachiale toule. Arch, de Ncur.,
Novrmhrc, iSyr, 66. Ucrnliarili. L'elm eincn Fall von doppelseiti),'cr tr^numatisclicr LS.)imuni; im
Bereiche dcs Plexus brachialis. Neurol. CenimM, 1891, 9. (Prudoecd
durins ^n oper.-ition by exceaive ttilduclion of both Mboulijcn.) He^it Ein fall von dopiielsci tiger Neuritis de» I'lcxus hraehialis (»bere Wuriel.
neuriiis) bei Plithitii pulmonum. Berliner klin Wochensrhr.. 189J. 51. d'Antros. Lfon. l.'.ivcnir dcs purul>-Hii.-n i>bii£ I tickles dti metnbre xup^rieur.
Ket-uc mens, des mal.idies de I'enfaiicc. Octobre. 1891. Rirdcr. Die SirinttfigrrlUhmiing. Munch, mcil Wochenfchr., 1893. 7. Bniun, H. Die Urueklilhmungen lr» Oebiele dcs Plexus broch, Deutsche meil.
VVuchenichr.. 1894. 3.
d. Co-ordination Occupation NeuroKS.
N3pi;L«. Pboiographer's Cramp. Revue d'Hygiine, Noiemlwr. 1879^ MObiuB. Berliner klin. Wochcnschr.. 1880, xvii, st. (Cramp from rtaying the
Zither.) Dally. Joiirn, de Thirapem,. 1882. 3, 4. Kobinson. Casct tA Telegrapher's Cramp. Brit. Med. Joum.. Navemlicr.
1883. Poore. Brain. T883. p. 23). f Sawyer's Cramp.) Vigoumiix. Progr. mid., 1882. x. 3. Nussli.ium. B.iyer. ;lnll. Inielligenxbl., i88>. Rxix, 39. (Dcsctiplion »f the
Bracelet.) Viltcmin. Arch. d. mM, el de pharm. milil,. 1S83. pp. 91-95. Poure. A Ci«e of Hammerman'* Cramp. Lancet. AuKUSt ii. 18S6, 8. L.ttlenianil. De U cntnpe ilea icrivains et son traiicment. Tliise de i'aris,
1887. iViore. The Lancet. 1887. 3311. fWriier's Cramp.) C.-iborian. Coinritiution A I'itude des spasmes profcssionncls. Thbc de Parift,
1887.
O/SEASES OF THE DORSAL A'SXVES.
363
I
hMre. On Ceruin Condiltimi of (he Hand and Arm which Interfere with the
I'crfurmance of I'TofessJonal Acts, ctpecj^lly I'lano-playing. Unii&h Med.
Joum., Fctmur>' 36, 18S7. Zenner. Berliner klin. Wochenschn, 1887. 17. Chambafit. Coninbutiun \ rfiiulogk el i la ^'mptomatologie des bnpMenco
fonctionelks. Rcruc dc rnW.. 1887. vii. 6, pi. 464. (Occupation Neurosct.) Henschen. Writer's Cramp, l'|«alfl lackaic forrnmgs. Forhandlinf;. 1888. Ktcltcl. Contributionti uuv |>araly>i» el aux anfMhisics rfflexcf. Arch. dc.
fhysiol. norm, el Paihiil.. 18S3, 7. Tnrlieft. Contribution i Ifiudc dcs n^^ntlgics du tnctnbrc sup^rieur. Thise
Inaugur.. Paris, 1884. Cosier. ZumCapilddct Artwitspnrcscn. Berliner Itlln.Wochensrhr.. 1884.83& S(|uirc, J. Edward Some Caitei uf Local NumbncM of ihe F.xi remit irti, with a
CompafiiMjfi between Local Syncope and Ni|thi I'alijr. Lancet. December,
iSSs. U. 33. Bernhardt. Ueber eine weni)[er bekannle NeuroM dcr EdFcmitaieo betonden
dcf obrren. Ceiitrolbl. f. Kenenhic, 1886, Ix. 2. Kctnalc. Ziir F^tlhntoglc des Meikcrkramprcs. Deutsche nicd. WochenichT.,
1889. I J. p. I i8. Weiss. M. (Wfen}. Die Elelctn>lheTJpie cler pcripheren ([raphiiiclven Slorungen,
CcnlralU, t «1. ges. Therajnc. 1891. it. 4. p. 19J.
//. Diifasis of Ihe Dorsal Ncr^Yt.
Th« anterior (ventral) divisions of the twelve dorsal nerves are called the intercoKliil ncrve», since ihcy nm in Ihe intercostal spaces. They supply the iiiteTCtuial niii*,cle>. ihe levaiores costartim, the scTTAti p<>&tici, and the three broad abdominal muacles. To the in* tceucnent of the chest and abdomen tliey supply ciilaneous branches. The posieiior divisions of the dor»al nerves are divided into internal and external branches. The former are dislribulcd to the deep mtiscles of the back, sending nerves to the rhomboidci and the latis- ftimtiN dorsi ; the latter, passing between the longissimus dorsi and the ucrulumbalis, also furnish numerous muscular branches., and, to- gether with the internal, supply the skin of the back as far down as the crest of the ilium.
The sensory as well ns the motor fibres of the dorsal nerves may become the scat of disease, but. and this is practically ol much importance, the anttrior, the intercostal nerves, arc more subject to sensory disturbances, while the diseases of the pos^ tenor brunches are almost exclusively motor affections.
The disease of the anterior brannhes, the so-called intercos- tal neuralgia, is found with relative frequency in the female sex, especially in those of middle age. ./f^tiologically, oc> CDiKition .ind hard work in general are of some importance- Servant i;irls and women o( the poorer classes suffer more
3^4
P/S£AS£S OF THF. SPIXAL NF.KVP.Sl
{rcquently than others. I have seen many such instances, and have found it besides in the cniinie of phthisis pulmonatis when associated with peripheral neuritis. Traumalism, aortic aneu. rism, and spinul affections, may also give rise to intercostal neuralgia.
The pain appears in paroxysms and attacks more frequently the left than tlie right side, and almost exclusively the anterior or lateral, rarely the posterior, portion of the nerve trunks. It often follows the course of the nerve and at times reaches a degree of intensity most distressing to the patient. The re- spiratory movements, more especially coughing and sneezing, cause great agony. Three tender points can usually be demon- strated— one close to the vertebral column, one in the middle of the course of the nerve, and one close to the sternum — called respectively the vertebral, lateral, and sternal points. The fact that frccjiiently after cessation of the p.Tin a herpes zoster appears is of great interest, although the question whether we have to regard the latter as a genuine trophic dis- « turbancc or simply as an extension of the iriH;innuatit)n from | the nerve endings to the skin, as Gubler thinks, is still unset- tled. For the prognosis it is without significance. In all cases of intercostal neuralgia the prospect for complete recovery is slight. Although we may succeed sometimes in cuttinfi; short the individual attacks, we can never be certain tiiat they will not recur, and there are persons who all their life long arc condemned to suffer from this disease.
The diagnosis is not always simple. Rheumatism of the chest muscles can easily be taken for inlercoslal neuralgia, and vice vt-Tsd. In such cases wc shall find it useful to observe %vhcther motion has any influence on the pain or whether this _ exists independently. If there is a history of traumatism, neu- I ritis is always to be thought of. only wc must beware of being deceived by malingerers, and to avoid this the condition of the _ abdominal reflex and the pupil should be examined into. The I former in the case of neuritis is increased, the latter often di- lated on the side of the pain. This fact was first established by SeeligniiJIlcr, and shows that the sympathetic is often im- plicated here just as in the affections of the brachial plexus (Deutsch. med, \Vochenschr., 1887. 45).
In the treatment morphine plays the most important rSU, and. as a matter of fact, it is of much more value than the much- lauded subcutaneous injections of osmiumlne (one syringeful of
D/SEAS£S OF THE DORSAL NERVE&.
36s
^
¥
loe-pcr-cent soliilion at a dose), for this not only frequently disappoints us. but also produces I0c.1l troubles, small ubscesses, etc.. so tliat llic patient is left almost in a worse condilion than t»c/ore. The (anidic brush, the " points de feu" with Paquclin's cautery, blisters applied to the painful points, may be tried ; but, on the whole, these means effect but little,
Among the intercostal neuralgias, the so-called mastodynia (the irritable breast of Cooper), a neuralgia of the mamma, is to be included. This is a not very frequent affection of the female after puberty, and may be connected with lactation. It is a very painful and distressing trouble, against which u&ually all remedies are tried in vain, so that in desperate cases the patient herself suggests ampulaiioti of the breast to get rid of the dreadful suffering. Thca*tiology is obscure. Traumatism is rarely the cause. Ill-fitting corsets may have some influence, but women with well-devclopcd and those with small breasts arc equally liable to the affection. The byperassthesia of the skin often binders a careful examination by palpation. With the lEps of the fingers we should endeavor to determine whether there arc hard nodules in the li&sue. which to the inexperienced often suggest beginning carcinoma. In some cases my patients have derived some transient bcnefil from suspension of the breast and the application o( hot cloths. Here aKo morphine is indispensable (cf. Tcrrillon, Des iieu- ralgicsdu scin; Progr. m<Sd., 1886, xiv, 10).
The motor disturbances affecting the muscles of the back supplied by the posterior branches of the dorsal nerves arc generally paralyses. We arc far from being familiar with the symptoms uf the affections of every one of these muscles, and must content ourselves for the present with mentioning the p.iralysis of the erector sjtina;, the sacro-lum balls, and the Ion- gissimus dorsi. which lUiiv be affected in the lumbar, dorsal. orcerrical portion of the vcrtcbnil column. Bilateral paraly. sis causes curvature of the spine b.Tclcward (kyphosis), unilat- eral paralysis lateral curvature (scoliosis). Pandysis or ]>arc- sts of the erectors in the lumbar region gives rise to a charac- teristic walk and a characteristic position of the body. The upper part of the body is bent strongly backward, so that the lumbar part of the vertebral column is markedly curved for- ward. If by any movement the upper part of the body is brought forward so that its centre of gravity is no longer be-
j66 DISEASES OF THE SPINAL SERVES.
hind ttiat of the whtjle body, the patient falls fonvard. or, ff the patient sits on the floor, he has the greatest difficulty in getting up. The manner in which he raises himseU is so characteristic of paralysis of the erector muscles that wc have represented it in Figs. Io8 to 1 1 1. The patient first gels upon all fours, and then climbs, as it were, with his hands up his own legs, con.
Fis- «*.
Fig. io»
Rl*. iiQ. KiE- III.
Flp. loB-i 1 1 flliutraie Uie mtnnct Id which a child whow ckciors tpiiut «n (MntjrMd 1,-M up (rom Ibt fcround. 'Afler Gowktts.)
stantly endeavoring to bring the upper part of the body as far back Ds possible by inuvem(;nts in the shoulders and the arms so that the abdominal muscles may resume the duly of balanc- ing the body. This mode of getting up can best be studied in pseudo-hypertrophic paralysis.
///. Diseases of the Lumbar Nenvs.
The posterior lumbar nerves are. like the doreal, divided into outer and inner branches, which are distributed to same of the mus- cles of the b.ick and the skin of the lumbar and jflutcal region. The anteriijr. by far the stouter, are connected each with the c<irre»pond- ing ganglion lumbale of the sympathetic. They form the lumbar plexus which lici behind and in ihc pso,ns muscle. Its branches arr ( Fig, III): ( I ) The ilto-hypogastric nerve, for the transvcrsalis and the internal oblique; (i) the ilio-ingninal, for the skin of the p<ibc« and the genitals (N. scrotales et labialrs anieriores) ; (.;) the genitu- crural, which divides into the external spcimaiic or genital branch
/JiS/O.VS OF THE LUMBAR NERVE&.
367
and the lumbo-ini;uinaI or crural bmnch, the former Kiip|)lying the ipcrniattc cord, ilie creinatitcr muiicle, and the te»tts, the latter the
I1|. ■».— niAoKtuHjuK Oim-rxK or the Lvmbak aha S*ciul PiBxt**!* DXll, ttk dcowl nam. L/ t'.tkt Ave lumbar nema. S/ I' thr Aw ncnl iwnti. C /. Uh OonyC**) Bmr 1, llir>hjpoeu*rk nerve. ■', Ulo-lD|[Ulnal iiem. 1, i:*i>ila-<ni- nl Mn«. a", (Uternal cnaueoiu nemol the Ihlcti. r'lir, uileriurtniral nttvr. ^A/, •UMHOr oarvc 3, Mperimr cliUeol atm, it, gnU tcUIic Dem. 4, small geiMic . , 4*1 Infickir elHleal nene. 5. Inferior pudend*! nerie. %'. postnior cuunrnw tol llil|[fc and Ici;. (1,6, brueh 10 rititurktoc Inttraui uid cemetliw aaperkir. 6'. 6'. kNMch to Ik* ir«iMl)ui Mfecl-w. iiiuitrriiiu fcoorli, «itd hip )u<nl. ]. twli^ In the pjrl- InnitL S, pulii' mm. g. vlKrial iinDtbM. 9*, twis lo Itie lentor «ai to, perfoiai- \at tMianm —nn. ii. oxqicHibruidiM.
368
DISEASES OF THE SPINAL NERVES.
skin in the inguinal region; (4) the external cutaneous, for the skin down to the knee; (5) the obturator, which gives off a posterior branch to the obturator ext. and adductor magnus and an anterior branch to the skin of the inner side of the thigh ; and (6) the anterior
V
\
V^
cp
\!
\pet.tmjj
tW^V
Uitij
iSi
1 'if.
I \ ts \\\
i
cti
tOi
Fig. 113. Fig. 114.
Areas of Distklbutwn of the Cutaneous Nehves of the Lower Extremcty. (After Henle.) ¥\e. iij, anterior surface, i, middle cuUneous mrve. a. exiirnal cutaneous nerve. 3, i!io- inguinal nerve. 4, genito-cniial nerve. 5. eilernal spermatic. 6. posterior cutaneous nerve. 7, ol>turator nerve. S, intenval saphenous ner\'e, 9. citm- municatiiig peroneal. 10, supetficial peroneal. 11, deep peroneal. 12, conimunicaiing tibial. Fig. 114, posterior surface, i. posterior cutaneous nerve. 3, eitemal cutaneous nerve, .j, obturator nerve. 4, median posterior femoral cutaneous. 5, communkating peroneal, b. saphenous nerve. 7. communicating tibial. S, plantar cuUneuus. 9, me- dian plantar nerve. 10, lateral plantar nerve.
crural (five miliimetres in width), giving muscular branches to the anterior periphery of the thigh and having also cutaneous 'branches — middle cutaneous, internal cutaneous, and the long or internal saphenous nerve (cf. Figs. 113 and 114).
LBSIOKS Ofi Tits LUMBAR NERVES.
369
All the nerves of this plexus contain sensory as well as motor iibrcs. and hence may be aflcctcd in both ways. However, these afleclions do not often appear independently, whereas ihey are frequently observed as symptoms of central, more espe- cially of spinal, diseases, and. above all, of tubes. Our dcscrEp. tion of them, therefore, will here be very brief.
Among the sensory disturbances we have First to mention the lumtxvabdominal neuralgia, in which the hip joint is alTected in much the same way as the shoulder joint in cervico-brachial neuralgia, so that the whole lumbar tcgion down to the but- tock is intensely painful. Of greater practical imporunce is what Cooper has described as " irritable testicle," neuralgia •permatica or neuralgia of the testicle, which either only forms a part of the lura bo-abdominal neuralgia, or, as Rulcnbcrg and others assume, is a neuralgia of the sympathetic nerve. The sjKintaneous pain and the tenderness m.iy attain such a degree as to lead to temporary psychical disturbances. Genenilly only one testicle is alTectcd, and most of the instances are found in young people. Uenda has cured a case of this neuraU gia by the application of a bandage which exercised a continuous pressure upon the inguinal region; it is impossible to explain the modus operandi of this measure (Berlin, klin. Wochen- schr.. 1890. 38). Further, we would mention the crural nciiraUi gb, and (he obturator neuralgia, afleclions which manifest themselves by jxain following exaclty the course of the respect- ive nerves. The existence of tender points is not constant and Ibcir scat varies.
The treatment must be cirried out according to the prin* dples which we shall describe later in our account of sciatica.
Even less frequently than the sensory do the motor disturb- ances occur by themselves. If present, they are mostly of spinal, nirely of peripheral, origin. Paralyses in the distribu- tion of Ihe crural nerve, which interfere with the ftmction of the illo-psnas and the quadriceps, make it impossible (or the palient to l>cnd the thigh at the hip joint and to extend the leg alter it has been flexed on the thigh. Paralyses of the obtura- tor ticrve interfere with the adduction of the thigh and the patient is no longer able to cross the affected leg over the other. On the other hand, a contracture of these muscles fol- lowing myelitis may necessitate the resection of the nerve, an operation which may be followed by immediate relief (Lauen- stein. Centralbl. f. Chir., 1S92. Ii). F6r6 and Perruchct have
370
Dixy.ASES OF rue spiral jveares.
published an exhaustive study upon the traumatic origin of neuralgia of the obturator nerve (Kcviic dc Chir., 18S9. ix, 7, p. J74). Disorders in the nerves of the {gluteus, the tensor vajn- nx femoris, and the pyrifortnis impair rotation of the ihigh inward and outward. Abduction is also hindered, while the actions of walking, standing, and more especially climbing stairs, are performed awkwardly. For details the reader is referred to DuchcnncAVcrnicke, pages 261 and following, where the normat and pathological physiiology of these muscles is carefully discussed.
IF. Diseases of the Sacral and Cotcygca! Ntrvts.
The posterior small branches of the sacral nerves, four of which leave the vertebral canal throujfh the posterior sacral foramtna and llie fifth tliruu^h the foramen between the sacrum and coccyx, form numerous anastomoses, and thus constitute what ts known as the posterior sacral plexus. The anterior, much larger, branches pass into the pelvis, where the first three and a part of the fourth, to- gether with the lumbo-sacral cord (resulting from the junction of the fifth and a part of the fourth lumbar nerves), go to form the (anle- riar) sacral plexus. The plexus is triangular in form and rests upon the pyridirinis muscle. The several nerves unite without much in- terlacement into an upper, large, and a lower, small, cord or band. The upper is formed by the union of the lumbo-sacral cord with the first and second and the greater part of the third sacral nerves and Is continued into the great sciatic nerve. The lower becomes the pudic nerve. The plexus gives origin to a number of collateral branches — the superior and inferior gluteal, the small sciatic, and perforating cutaneous nerves and branches to the pyriformis, obtura> lor iniernus, gcmelli, and quadratus femoris. The great sciatic nerve, the largest nerve of the body, divides into the internal pophleal and external popliteal or peroneal, the latter again dividing into the anterior tibial and musculo-cutancous, the former, which becomes the posterior tibial, terminating in the inlernat and external plantar nerves. The pudic nerve divides into the inferior hxmorrhuidal, the perineal nerve, and the dorsal nerve of the penis or clitoris.
The anterior branch of the coccygeal nerve is distributed to the integument over the back part and the side of the coccyx. It is joined by a branch from the fifth sacral nerve, while the posterior division is lost in the fibrous structures on the back o( the coccyx.
The affections of the sacral plexus, which appear independ- ently of any other disease, are chiefly sensory in nature. Mo- tor disturbances, although they arc perhaps numerically as
L£S10A'S OP THE SACKAL PLBXUS.
37'
common as the former, are in the great majoHly of instances ivmptomalic of spinal disea&e. Careful stndies upon the lesions of Ihe scleral and lumbar plexus have been published by paries K. Mills, in the Medical News. June 15, 189I.
Sciatica.
Among the sensory disturbances there is especially one disease which, owing to its relative frequency and obstinate resistance to treatment, has attained to much practical impor- tance — namely, the aiTcclion of the sensory fibres of the sciatic nerve, the sciatic neuralgia or sciatica, malum Cotunnij (Co- tugno. 1764). This may, as autopsies have shown, be due (o an organic disease of the nerve, a genuine neuritis, or to a func- tional neurosis. In Ihe former there exist varicose dilatations of the blood-vessels ol the nerve, swelling, increase in volume, alterations in consistency, and a collection of serous exudation in the nerve sheath (Cotugno, Jasset). In the Jailer no anatom- ical changes can be detected. The neuritis may be due to dis- ease of the neighboring structures, to a tenosynovitis in the tower leg (Erb), to affections ol the vcrtcbrx (spondylitis, car- cinoma), or may nppcar independently, in which case, leaving cold out of consideration for a moment, we have usually to deal with mechanical injuries, either as the consequence of wounds, fractures, or as the result ol protracted pressure (tu- mors of the pelvis, aneurisms, hernia, uterus gravidus. engorge- ment of the venous plexus of the pelvis, habitual constipation, etc.). The occupation must, moreover, be taken into consid- eration in the artioiogy uf sciatica. It may exert an injurious influence in one of two w,iys. either through the overexertion which it entails or through the exposure to frequent sudden changes of temperature. Of the former we have instances In those who work with the sewing machine for weeks and months for several hours a day. and in those who are always lifting heavy weights (stevedores, blacksmiths, etc.). To this class is thought to belong " U Umbxigo da /iwgrroHs" de- fcribed by Maisonneuvc (llirt, Krnnkheiten der Arbeiler, iv, 90). Of the latter we have instances in puddlers and those who work at smelting furnaces, etc. Sciatica is frequently seen among such people, and seems to affect more cummonly he left leg, probably because in throwing the coal into the urnacc it has to be extended more forcibly (Chicne, of Edin> h, and Hirl).
372
DISeASSS OF THE SPINAL JVEX^ES.
As a symptom sciatica is often seen in spinal allcctions (myelilis, spinal meningitis), in diseases of the general nervous system, especially in tabes, where it often appears bilaterally, also in diabetes. As a sequela it has been described us follow- ing typhoid (ever. Whether malarial intoxication can ever be the cause of it is uncertain. It ts sometimes seen in the course of syphilis. In lead and mercury poisoning it plays an entirely secondary rii/f.
Symptoms. — Among the symptoms of sciatica pain is the most imporiaiit. The motor disturbances which sometimes occur in the course of the disease — tremor, clonic spasmtidic movements, the difficulty and awkwardness in moving which interfere to a greater or less extent will) standing and walking —have to be looked upon simply as the result ul the pain. This varies greatly. At first it may be dull and quite bearable, but later boring in character, extending over the whole lower extremity and persisting without intermission, so that it con. stantly occupies the attention of the patient and forces him to a frequent change of position ; or, again, it may appear in at- tacks, with intervals of comparative case, so that the patient (eels fairly comfortable and is able to follow his occupation. During the seizures it may be of such excruciating intensity that it can only be compared with Fothergill's faceache or the lancinating pains of tabes.
The patient suffers usually more intensely at night after going to bed, or at least he complains more at that time, often because he can not bear the extension of the leg, often perhaps because his attention is then less liable lo be distracted. Yet even in the daytime the pain may reach a considei-ablc pitch, especially when the patient has been making attempts to walk or has been standing too much. He may have perfect ease for hours when lying quietly, and yet a few moments a( flexion and extension of the affected extremity arc sullicicnt to throw him hack into the most distressing condition. The extent of (he pain also varies ; generally it is felt over the whole posterior surface of the thigh and the distribution of the external poplit- eal nerve. It may radiate into the region of the healthy sciatic and the lumbar plexus o( the affected side. The posterior tibial nerve usually remains intact. Examination almost always discloses the existence of tender points, one, for instance, at the exit of the nerve from the pelvis, one at the lower margin of the gluteus, one in the popliteal space, one on the capitulum
LESIOS'S OF THE SACRAL PtJiXVS.
373
I
I
I
ila:. There may be uthcrs. but their occurrence is uncer- tain and their position changeable.
Sometimes patients with sciatica are seen to put all their weight upon the healthy leg in order to diminish the pain in the aflcctcd extremity. This causes the trunk to be bent to- ward the healthy side and the costal margin to approach the ilium, a position which may become so habitual that a genuine scoliosis may be developed, the convexity ol which is directed toward the healthy side ; in exceptional cases the reverse is the case — namely, the convexity of the curvature is directed toward the affected side. Rcmak (cf. liu) is of opinion that the patient is able to convert the "normal" into the "abnormal" scoliosis as his comfort may demand, while Bri.s!>aud regards the abnormal position as the result of a reflex spasm. I have known several cases in which this secondary scoliosis per- sisted after considerable improvement of the primary aflection, whereas in other instances 1 have seen it disappear when the cure of the sciatica was complete.
If we have to deal with a genuine neuritis trophic changes will be found to develop, especially more or less marked atro- phy of the muscles in various regions supplied by the sciatic nerve (Uuinon et Parrnentier and others), with reaction of de- generation (Konne). The patellar reflex seems in such cases to be considerably diminished. An exaggerated knee jerkin the course of a peripheral neuritis has. un the whole, to be looked upon as exceptional (StrUmpell, MObius). In sciatica I have never seen it. If the trouble is purely functional the muscles and reflexes remain, even after years of sulTering, unaltered. Other sensory changes — diminution of the sensi- bility, anesthesias, pantsihesias — occur, but lake a very sec- itndnry position to the donunaling feature of the disease, which is pain.
Course.— The course as well a<i the duration varies greatly, but we may state as an undeniable fact that it is excepticmal to find cases which last but a .<;horl time and end with com- plete recovery. Mostly it is a question of months and years before any decided lasting improvement is brought about. On the other hand, remissions arc not rare. They may last lor months, and the condition of the patient may be such that he begins to be confident of a permanent cure, when suddenly, often without any appreciable cause, sometimes in consequence ol a long walk, the pain again makes its appearance with un-
374
D/SEASES OP THE SPINAL NERVES.
diminished intensity and the treatment has to be started all over again. The more frequent such relapses, the more gloDiny becomes llic outlook tor complete recovery.
Diagnosis. — Great care should be exercised in the diagno- sis, and wc should tirst endeavor to decide whether the trouble has to be regarded as an idiopathic aGfection or as a symptom ol anullier malady, and more especially Itt bilateral sciatica should wu be nn the lookout for a spinal disease or a disease of the general nervous system, such as tabes. The examination of the ttrinc lor sugar should never be omitted. H this ]>rovcs negative, and if wc can exclude general nervous diseases with certainty, wc should proceed to analyze the pain, to examine into its nature, the time of its occurrence, its seat and extent, and should keep in mind that there are other than nervous af- fections that are associated with violent pain in the lower ex- tremities; for instance, acute rheumatism of the lumbar muscles, lumbago, also inflammations in the hip joint, chronic hip dis- ease, malum cox»; senile, as well as gouty alfections and psoas abscesses. In all such instances the immobility of the extrem- ity, which also exists in a pure sciatica, makes the examination difficult, and only after persistent repetitions shall wc be able to obtain a clear idea as to the true nature of the trouble. Al- though it may be going too far to say with Hutchinson that out of twenty cases diagnosticated as sciatica in nineteen there exists no trouble whatever in the nerve {Medical Times and Gazette, 1883, vol. i. No. J648, page 35), there can be no ques- tion but that here many diagnostic sins are committed and that there arc many cases called sciatica alter a superficial ex- ploration whicli later prove to be something entirely dilTerent,
Treatment. — The treatment ol sciatica should vary accord- ing as the neuralgic pains constitute merely a symptom or result from an independent affection of the nerve itsell. In the former case our therapeutic measures, of course, must be di- rected against the underlying disease (diabetes, tabes, syphilis, etc.). If we have to deal with sciatica as an affection by itself our treatment should be systematic and carried out on dcfi- nile lines. Our first rule should be never, or at any rale only in exceptional instances, to withdraw blood. If there are old scybalous masses in the bowel which press upon the nerve and thus cause the pain, considerable and lasting improvement may be brought about by the removal of these, and a course at Carlsbad or Maricnbad may cure sciatica in such cases
1
I
I 1 I
ISS/O.VS OF THE SACRAL PLEXUS.
375
I
I I
I
more quickly and surely than the most careful use of electrici- ty. Next, especially when we have grounds for suspecting in inflammatory condition of the nerve, we should try the ap- plication of counter-irritants to the skin, fly.blistcrs or the so^alled /w/«/* dt feu (witK Paquclin's thermo-cauiery). The former more particularly, which have been used by Cotugno and Valleix, deserve to be recotit mended, as they prove gen- erally very effectual if used early in the disease; they may be applied alonfi the course of the nerve on the thigh or in the sacral region (Anslie). Loss benefit is usually derived from irritating inunctions and plasters, which may, however, be given a trial ; (or instance, we may employ one ol Betz's plas- ter*—empl. oxycroc. i5.o(5ss.): arg. nitr. pulv., i.o(grs. xv) — allowing i( to remain on the skin until it drops off of its own accord. Among other drugs for inunctions besides vcratrine [0.1 : 10 tardj the narcotics (preparations of opium. bclladonDa. hyoscyamus) may be useful. Finally, the chloridc-of-raclhyt spray may be recommended. This, however, should be used with great care ; otherwise it may be followed by a cellulitis, erysiijclas. or even gangrene. The desired effect does not al- ways follow (cf. Steincr. Deutsche Med.-Ztg., 189I, I02, p. 1158).
From internal medicines I have never seen any lasting good results; besides antipyrin and antitebrinc, iodide ol potassium has been used Irom time immemorial, also quinine and all the nervines. Krccntly solaninc has been recommended, fifteen to twenty centigrammes (grs. ijss,-iijss.) a day. In my own expe- rience this drug docs not possess much value; neither docs the oil of turpentine given iniemally in capsules containing fifteen raininis ten or twelve limes a day. In short, I consider all in. temal medicines, unless the case be one of syphilis, as useless and inadvisable, for, owing to the long duration of the trouble, they would have to be taken for months with great detriment 10 the stomach and to the digestion. More is accomplished by external measures — massage and electricity. Both have the disadvantage, however, that they act very slowly and that their application causes more or less violent pain, a remark which applies more particularly to a systematic and an energetic use r>f massage (Schreibcr and others). The faradic brush and the combined current used by De Waiteville are also very painful, but both can be recommended wiih a clear conscience. With regard to the best manner in which the electricity should be
376
J3/SSAS£S Of TUB SPIXAl. Nf.RVES.
given, as we have said before, we now repeal thai every one lias his own method, in which he has most confidence because he is most familiar with it.
If we are forced to send our patients to the springs, we may first of all recommend non-medicated hot springs or hot brine spring:s. Among the former may be mentioned Gustein, Her- kulcsbad, Johannisbad, Tcplitz-Schiinau, and Wildbad ; among the latter, Wiesbaden. Nauheim, Rchme. and Baden-Baden. At hot sulphur springs, (or instance. Landeck. Teplilz-Trenc- sin, and I'istydn in Hungary, such patients do very well, but it is advisable not to raise their expectations too high, as often the results of a stay at the springs arc not very striking. Sea- bathing is not always borne welt by patients with neuralgia. At any rate, it is well to begin with places on the Ilaliic and to select first those where warm sea- water baths can. if necessary, be also obtained— c. g.. Colberg, Misdroy, Zoppot. and others. In severe cases, particularly if there occur transient attacks of intense pain, morphine can not be dispensed with. Subcuta- neous injections in proper amounts and at the proper time will do the patient no harm, but will afTord him unspeakable relief, such as can be expected from no other drug.
I.1TKRATURE.
Albert. Eine eigenlhumlicbe Arl der TinaUkoliose. Wiener med, Prfs«,
}A%\t. i8S6, xxvi. Nicobiliini. Urt>M cine Art dc« J^usammcnhtingcs iwi«chcn Itchus und Skoliosc.
Ibid.. 1886. 16. 27. Vinay. P«rAl)'&tc rudiculaire du ncrf >itiati(iuc par coinpreMion k c«ase <lc roc- couch cm em. Rcvuc dc m^d,. 1887. 7. Babinski. Sur unc iljfonnutiun pnrticuliire du Ironc catiafe par la tcutiqiic.
Arch. d<- Neurol.. 18SS, 1.1. 43. 1, Bernlunlt. Ueber Pcrttneu.ilahmunKcn. Original bericht der CcMUschftfl f.
Psych, u. NiTvcnkb. xu Uerbn aw November 11, 1888. Neiiroi Centralbl.,
1888, 33. Seliudcl. (Jcber Istbias scoliotica. Arch. f. Win. Chii.. iSftS, 38. 1. Weiss. Zur Thcnpk- dcr Ischias. Cmtralbl. f. d, g«. TTierap.. 1889. vii. t, Texier. U^furinalion pacliculibe du trunc causae par la sciaiique. Thisc de
I-aib. 1888, Brissatid. Des scolioses dans les nJvralg^es sclallques. Arch- de NcuroL, Ju)..
1S90. Gorlun. Wiener kliri. Wocherwchr., 1890, ;4.
V. BonsdorlT. Finska ISkarevallsk, h.indl.. 1S90. xixli. J. (Ischlaa Scoliolica.) Guinon ct P.inncnlicr. Arch, de NcuroL, 1890, S9-
Juinski. PnCKlad Ickankl., 1S90, %\\\. 7. 8. (Skoliosis fo)lo»-in|[ Sciatica.) Cussenbaucr. Pragcr mcd. Wocbcnscbr., 1890, xv, 17, 18.
W.S/OKS OP THE SACRAL PLEXUS.
377
^B Popper. Ueulxlve meil. Wochcnuchr,, 1890. 4}. (PcroncAl Pnlty produced by ^V Mechanickl Cuuics.i
V Renuk. Altcmircnde Skoliose bci IscKias. Dcultchc m«l. WochcBSchr, 1891. 7.
• Charcot. J. O., « MeifTc, Un cas de sciailque avec (uraly^ie amyoirophique dint le domninr du poplilt. detcrmin^c par I'usagr cxag£r£ <k la niatlunc A coudre. I'liifiri'i m^d.. 1891. No. 14. Lamy. Deux t»,s ilc KiBt\qu« &|iiL&inudiijue. I'rogrh in^d., 1891, 3. Remalc Ucbrr lochias scoliotics. Deutsche m«l. Wochcnschr, 1891. 17. Higicr. Fiinf Kiillc von Iichias xcalioticA. Ueuixchc med. Wochcnschr. 189a. 37-
»OtMm, Otcar. Fll FatI ar ischial scoliotica. lly-gjca. 1891. 1, Iv. p. 334. Klamroih. Berliner kliit. Wocheiischr., i8</3. 38. pag. 960L Iluncmunn. Arch. i. Gyn., 1891. xlii, j. pag. 489. (Panty&is in ihe distribution
of the Scuilie Nerrc as a Conscijuenix of Ch>kl1>inh.) Sachs. W. Kin lleitrag lur Frage der Ischias scoliotica. Arch. i. klin. Cbir, 1893. xlvi. He ft 4.
Far less (requeiitly — vre might say, only exceptionally— are the individual branches of the sciatic nerve the scat o( neural- gia; tbtis we may have an affection o( the plantar nerves, and sometimes the hyperesthesia in their distribution may be so marked that the patient is absolutely prevented from standing or walking. Barbillon (cf. lit.) has itevuted a careful study lo this sccalled plantar hypern;sthcsia without, however, being able to decide whether the disorder is of spinal origin, or whether it has to be regarded as a so-called dermatalgia, or again as a disturbance in the nutrition of the fitie nerve end- ings. The first explanation is supported by the fact that usually both feet arc affected : the last that it often occurs in people who have to stand a good deal. It has often been known to occur as a sequela of typhoid fever. Cures are said lo have been effected by blisters, or by the application of a spnty of methyl chloride ; bathing the feet fur some lime in hot salt solution has also been recommended. The neuralgia of the external plantar nerve which S. K. Morion has described u mctalarsalgia (Annals of Surgery, June. 1A93). manifests itself in [>an«ysms of p.iin in an area extending from the ihirti to the fifth metatarso-plialangeal joint; during these paroxysms the patient is unable to walk and is forced tu take off his shoe. Badly fitting shoes and Iraumalisin seem lo be ihe causes of the affection. Sometimes it may be neccssar)* to resect the head of the fourth metatarsal bone.
The pudic nerve, which supplies the bladder, the rectum, the perimcum, and the external gciiilals. is often the scat of neu-
378
DtSEASeS OF THE SPhVAI. yERVES.
ralgias which are sometimes purely cutaneous and show them- selves by an extreme tenderness u( the skin of the penis, the scrotum, the region of the anus, and the mons Veneris. In many instances the testicle is affected and, as we have pointed out above, becomes very tender and the seat of violent paroxys- mal pains. Although there may be intervals in which the neu- ralgia disappears, the tenderness and irritability remain as long as the disease of the nerves is present.
Other nervous affections of the male urinary apparatus have been studied by OberlUnder (cf, lit.), who has called attention to the fact that varicocele, chronic gonnrrhcca, hydrocele mul- lilocularis. tuberculosis, carcinoma, etc., frccjuenlly give rise to such disorders, and indeed not only do the just mentioned cuta- neous forms occur, but also a peculiar neuralgia of the urethra, which becomes particularly distressing during coitus and mic- turition, is frequently known to develop under the influence of such alTcctions. The remains of a gonorrhcca together wilh chronic dyspepsia may produce a chronic hyperarsthesia o( the mucous membrane of the bla<ldcr, to which little attention has been paid as yet. The pain appears periodically, affects the whole bladder region, and radiates into the urethra and the ureters. Slight errors of diet may evoke violent exacerbations of the trouble. Neuralgia of the bladder is found in neurasthe- nia, but also at times in the initial stage of tabes ; hence it would be necessary to decide, if wc have diagnosticated a neuralgia of the bladder, whether it is due to a cystitis or a spinal disease, or whether, on the other hand, it constitutes an a0ection by itself.
The neuralgia of the prostatic gland has recently been studied by Preyer of Ziirich ; he distinguishes a hypcrjcst hesia of the organ proper from a hyperaesthesiaof the prostatic por- tion of the urethra, and thirdly describes an irritability of the muscular portion of the gland. Paroxysmal pains and spasms of the sphincter vesica; are the most prominent symptoms of the affection. The treatment consists partly in attending lo the general health, partly in surgical measures, the passing of sounds etc. (Berlin, Fischer, 1891).
Anaisthcsia of the raucous membrane of the bladder and of the urethra as well as loss of [he muscular sense ol the bladder make it impossible for the patient to say with the eyes closed whether he is voiding urine or not. It may happen to tabetics, in whom the condition is not infrequently met with, that, hav-
\
lESJOXS OF THE SACKAL PLEXUS.
m
vag given up all attempts to micturate after unsuccessful strain- ing, tfaey pass their urine involuntarily and become only con- scious of the fact when Ihcy feci ihc dampness oi their clothes. This anaesthesia does nut seem, however, to occur as an inde- pendent disease, but would appear to be always of central origin.
The motor disturbances affecting the muscles which expel the urine and those wtiicli close the bladder may be of an irri- tative or a paralytic nature, the former constituting what is known as slranjjury : the latter arc by the laily comprehen<Icd under the name of " weakness of the bhddcr." Both may be . ^mptoms of chronic inllammaliun of the urethra or of certain ' ^inal diseases, and may also occur independently, as purely nervous affections. The desire to urinate every few minutes. a desire which is increased after drinking alcoholic beverages, (s not infrequently alternated by spastic conditions of the mus- cles of the bulb which give rise during micturition to spas- modic excruciating pains in the perinicum which radiate to the thighs and the buttocks.
In nil cases of this kind the treatment is generally begun with the usual ami. neuralgic remedies, of Lite years also with co- caine. However, the result is often very unsatisfactory. We should always carefully search for possible underlying abnor- mities, such as an elongated adherent prcpulium, insuflicientiy dilated or light strictures, flexion or version of the uterus, or pathological changes in the rectum. If such be found the neu- ralgia is to be regarded as a reflex neurosis, and we have to direct our therapeutic efforts to the primary cause, by which procedure wc may be able to improve and eventually cure the neundgia. To the same class of reflex neuroses belongs the enuresis nocturna, which is rather common among children. The trouble can usually be traced to irritation in the urethra or at the orifice, such as inflammatory conditions, slight adhe- sions of the mucous membraite far back in the urethra, too nar- row an orifice of the urethra, and the like. It has been claimed that the urine sometimes contains an irritating substance which produces reflexly the enuresis, which can be controlled by the wimini>(ratinn of mild narcotics. (Aqua Amygdal., amar.. etc. — Rohde, Berl. klin. Wochenschr., 1893, 42). Here, of course, attention to such primary disorders is the first step in our treatment, and dilatation of the posterior portions of the ure- thra with diLttors made for the purpose will often be followed
38o
DISEASES OP T/fE SPINAL NERVES.
by striking results (OberliUider, Uerliner klinische Wochen- schrilt, i8S8, 31).
By coccygodttiia we mean a neitralgin which is character- ized by pain over the region of the coccyx. The affeclion is more frequently met with in women than in men, and the pain, which shows paroxysmal exacerbations and comes on more par- ttcularly during the iicl of defecation, may attain to a (rightful pitch. The causes of the affection arc obscure, yet we arc probably not far from being correct in assuming that in many cases it is of reflex origin, as in men especially treatment of the genitals — a diminution of an abnormal sensitiveness of the pars prostatica ureth., etc. — may be followed by surprising results. In some cases the pains appear during sleep without any ap- preciable cause, in others they have been known to occur after traumatism. I have repeatedly observed them in neurasthenic and hysterical patients. The excision uf the coccyx, an opera- tion which in desperate cases has been undertaken for relief o( the pnin, should, of course, not be resorted to until all other means, particularly energetic application of the fara^ic brush, have been thoroughly tried.
LITERATURE.
Hammond. Neiiralgi.i of ihc Trsiicle. Neurol. Conlribul,, 1S81. L 3.
Sultoii. Crural Neunilgia in Dcntisis, Lsncct. 1881, ii. 4.
Engtrlhardl. Zur Grnc«e ilcr ncrvoM>ii Symplomcncomplexc bei •uiAlomischen
VcTJiti(leriin){«Tn in den Scxu^lur^^jncn. SlutlKari, Enk& Englisch. Ucber (-iiie besundcrt.' Fonii dcr HSmcirrhRgjc an den UiitcrcxirODi-
iSlcn (Hx-mnrrh.igia ncunlgica). Wicn. rar<l. ItlSltcr, 188;. 24--16. Barbillun. llypcnt^ihesu pluntw bilatcnliii. I'mgr. in6d.. i88j. %m, 19. Sirunnpdl iind Multius. Uebcr Slcignung <!or Schncnirllric bci ErkranktuiK
periphercT N'erven. MDnch. mc<l. Wochcntchr, 1886. ixxiii, 14. S. Laachc. Norsk Maguz. f. LUdTvidensk., 1886, 4 K., i, 19. {Hyperiraih.
plani.-ir,) Obcrlttndi^r. Zur Kennlnbs dcr nervuMrn ICikrankunKcn am Hamapfuraie des
Mannrs. Volkmann'srhc Sfliiiniluiig klin. VorlT., 1886. 275. Adamkiewicit. Ein Mtltcncr Fall von Nctiralj;ic im N. pudrndu conimunls mil
^lucklichcm Au^gange. Breal. KtiiI. Z^ftschr., 1886, 8, Poihrral. N*vralgic visiealc. ProgrJsmW.. 1887. 17. NiMine. Berliner ktin. Wochcn.ichr., 1887, 45. HugliM (St. Louis), Weekly Met). Rev.. March tJ. 1887- (Plantar Hn»era»-
thcsia. Neuritis N. PInntaris Intcmi, in Consequence of Overexertion.) I'eyer. Zwei FiiUe vimi Neuralgic de* Sleitrabdns b« MSnncm. Cenlralbl. f.
klin. Med.. 1888. ix. 37. Bemh.irdl, Klin. Hearst; ^nr I.rhrevonder Inncn'-iIionderDIasedesMastdarmi
und dcr GescbleclilsfuncUun. Berliner klia. Wocbcn§chr., 1888. ixv, 31.
lESWyS OF TUB SACRAL PLEXUS,
381
I
\
I
V. .Swicrkki. Zur opcnitlven l)eh:ii)(Ilung der Cuccjrgodynk. Wien. mcd.
IfUM, 18S8, xxix, 31. OrillV. M. Zcilsdir. f. Gcburtili. und Gynacologic, 18S8, xr, 3, p. 344. Mills, Lttions of Die Sacra) and Lurnlur PIciuses. Mol. News. June 1 \. iSS^.
As 10 llie motor disturbances — and of these wc will take up fir^t the paralyses which occur in the diMribution ol the sacral plexus— here, loo, those of the sciuiic nen'c arc the most im- portant. Stich lc!»iun<i may affect the nerve high tip in the pelvis, or soon after its exit from it. or still lower down in its branches. The 6rst arc almost always caused by ir.iuni:)iism «r pressure exerted for a comparatively long time — e. g., by a pr^nant uterus, the child's head during labor (Vinay). tumors, etc. The others often constitute a symptom of some other disease.
External popliteal (peroneal) paralysis, in which the mus< cles of the anterior surface of the leg are a fleeted (the exlen- sors of the toes, the tibialis amicus, and the pcronci). is easily recognized. The foot hangs down tiaccidly, it can not be dorsally flexed, abducted, nor adducted. As a result, walking \% very much impaired, since the point of the foot often trips over prominences on the floor, but by raising the thigii higher than usual the patient somewhat overcomes the difficulty. As the point of the foot or the outer margin is first put to the ground in an awkward manner, the g:iil is very peculiar and highly characteristic of this form o( paralysis. Contractures of the calf muscles, which may later develop secondarily, give rise to a permanent position of talipes cquinus or talipes cquino- x-arus. External popliteal paralysis may be brought on by the iKcupation of the patient. It has been seen as the result of pressure in those who, from the nature of their work, have to be constantly in a kneeling position, as. for instance, asphalt pavers (Bernhardt).
Internal popliteal paralysis, which implicates the muscles of the back of the lower leg (the Hcxors. the tibialis posticus) and the muscles of the soles of the foot (adductor and abductor hallucis and the intcrossei). interferes with the plantar flexion uf the foot and with flexion and lateral motion ol the toes. As a result the patients are unable to stand on tiptoe, II the in- tcrossei take part, a condition is developed similar to that which is seen in the hand and which we have described on page 352, The toes assume a claw-likc position owing to the iact that the first phalanx is dorsally Hexed while the second
382
msSASSS OF THE SPINAL NEKf'ES.
and tliird are iu plnnt.nr flexion. Here also secondary con- tractures may appear (uf the tibialis amicus, triceps sura:), wliicl) give rise to a paralytic clubfoot (pes planus, pcsequinus, pes calcaneus).
Paralysis of the whole sciatic makes it impossible for the patient to lU-x the lower leg on the thigh, to approach the
A'. ohlnrMrr — M.jHttiatiU
3f. odAtrloT temgM
H. popliltaltt KTlimut if. liUnlU imrirtu M. f/lmnor hingtu
if. peronrut lonrfiu if. prronna Arviia
At. rjimior hrttu poUicit
31. autaitr irrmii
A', eniralu
if. Ittuar mjini*
if. ^adnapi friuitrit 31. rttha ftunn-il M. «tiirrtu if. raaut fttrmmt
if. vo^w Mfntw
JT, jToifrMiHnjiii if.-jlna
31, fttm lontpit
M. oMiMjr mMmi digUi
-^ if. imltf^inl dfrt^n F](, IIS.— MoTOH I*i>ixTS FOR T1IR NiRvn unt Muk-lb* or thk Avmitioa Sukfack
OF TKc Leo.
heel to the buttock, and to rotate the thigh (M. obturator in- lernus), Paralysis o( one sciatic alone does not make walking absolutely impoMiiblc, becauw the leg fixed in the knee joint is moved forward by the muscles of the thigh, and so is used as a stilt (cl. page 226, gait of the hcmiplcgic). Alter a certain time muscular atrophies begin to be noticeable, and later become
LSSIOXS OF THE SACRAL PUiXUS,
383
ry marked. The afTcclion o[ the hip joint, which sometimes develops in the course of the paralysis, but which also at times has to be looked upon as the forerunner or immediate cause of the paralysis, produces more or less marked shortening, so that the patient with his affected lower extremity presents a picture like one of those shown in Figs. 117 and 118. This peripheral alTection of the sciatic, which is to be regarded as a neurilis in the sense described above on page 331, can hardly be mis-
mrn
Uriatie ntrre
AiUttttof niapima
SttitisttuKmuta
StinimimhrtinotMa
iHiritl /ri/itileal
liiileiita/ iraJ) Bolimt
Flour ftinmimit
It. jittvr lanymt poUttit l\>ttrrior tibial i
FIk- I1I1.-1I0TOH Poi9<Ts FOK TMB ScuTK Nekvb A»i>-nie lluscLEB surrucp dt rr.
taken for anything else. The dilTiculiy in moving one leg. which may amount to an actual paralysis, may, il is true, also be the consequence of a central cortical affection — a mono* plegla or monoparesis. In this case, however, the pains are by no means a prominent symptom, nor do we find — and this is the most important point of distinction — either atrophy or •hortcning. The differential diagnosis between cortical and peripheral paralysis has been spoken of on page 18;. The
3*4
DISEASES OF T/fP. SPtffAl. XSKI^es.
treatment of the aQcctinn is to be conducted according to the principles which we have discussed in speaking o( other periph- eral paralyses.
Tie- 1)7.— Case or PcairanHAL S>i »ti:-
AKII ATKOPIiy tiy THE A>"< I.I
<■> IM. S<:uil>. Ncai-E WITH SMORTKniM
I XIBUtlTY (panoMi OtMTVMlOMJ.
The observations which some yean ago were published by Wesl- phal about a periodically recurrinft paralysis of all four extremities have as yet no practical imporlance, since we do not know anything about it« nature. The same may be said about the peculiar parent of the lower lej; and Toot which Zenker has described (Berliner klin* ischcr Wochenschtift, October 8, 1883), and which has to be regarded as an occupation neurosis. It occurs not rarely in persons who have to remain a long time in a kneeling or squatting position, and such inMnnces have been known to occur in potato pickers. It manifests Ititelf in a more or less pronounced seniuiry or motor paralysis of the lower part of one or both lower extrciniiies.
L£S/OfffS Of TIIR SAVRAI. PLRXUS.
385
isms in these musclus arc rure and aru therefore of but
little practical importance; n case of tic convulsif in the ilio>
; psoas has been described by Klempcrcr (Deutscbc Med.-Zig.,
1890, 86). Bernhardt has described a case in which there
were spasms in tJie region of the N. peron. dext. supcrfic, with
I
nc- (*>>—'
SEVRiriit or -niK SaATtc N>:iw .ini Siwwixkino
■Hu Ai*iOi>HV OF IIIK AfrxcTKD ExTKUUTT ipTTViiii ufcafrrUiooV
clonic twltchings in the peroneiis longus ami I i> (Bcrl, kiln. Wdchenschr., 1S93. 17). Schultze has describtJ spastic cot>- «lilions ici the tensor fasci?c lata; (Deutsche Zcitschr. i, Nerven- heilk,. 1893. iii). Spasmodic Ionic contraction of the hip mus- cles has been described by Stromcver as spastic contraction of the hip. A case of spasm confined to the qundratus lumbonim has come under my notice in an hysterical woman. It is illus- trated tu Figs. 119 and 120. Tonic spasm of the quadriceps
"5
386
D/S£jtSES Of THE SPINAL KRK¥E&.
gives rise to extension of the leg in the knee joint : it is some* limes known to occur in neuralifias of tiiv joint. The vcrj- painliil cninip in the call muscles, wliicit sometimes occiit> after great cserlion. sometimes also in the course of certain grave general diseases — lor example, cliolera — is well known.
Plpi. ((9, tia— COKTIUCTUM IN THK QUMIBATUa LUMKIKUH (pOMBal obMnUioKi.
Clonic spasms of the muscles of the lower extremities may be observed in iiyslericiil patients. The so-called "saltatory spasm " (Bjinjberger, Wiener medicinische Wochenschrift, May 4. 18591. which forces the patients whenever their feel touch the ground lo jump, is not an independent aflection, but only a symptom ol central disease. The increase ol the reflexes. which is generally present, is in favor of this view. Of the li'calnieni we shall speak in the chapter on Hysteria.
MUlTiPlB .V£t/ff/r/&
387
UTERATLKE.
[CtltlfiMnn. Fall vtm MgcD.inntcn ultaiodfchcn KrSmpfcn. Ucrtincf kiln,
Wochoiiclmfi. i){67. iv. ly [Ffry. Ueb«r ultaiuriKhcn Kellcxknnipf. Arch. I. INjvlt. u. Ncrvcnlik.. i87(.
rt. I.
Ktu. UebcTUIUturiiictien Kcllevkrarnpf. Nruti^. C«nU^bl., 1683. ij, 14. Kiillmaim. Dnitschc mctl, WiH-hmschr. 1883. ix. 40.
V, Nfuriris imvli'iti/^ Snvra/ S/n'na/ Nerves at flu Same Time — Multiple XfM rilis — PolyiUHril is.
Just as we have seen that several of the cranial nerves can be affected at the same time, so none tlie less is this Hue of the sifinal nerves. It is. however, not many years since it has been shown that such mulljplc nerve affections may occur primarily, thai Ihey arc often o( an inflammatory nature, that they give rise to numerous symptoms which may. under certain circum- stances, be misinterpreted, inasmuch as they may simulate those of central lesions. The affection is known as multiple 'neuritis, and. as we said, our knowledge of it is of quite recent date (Dum^nil, Eisenlohr, Leyden. StrUnij>ell. Vierordt, and I others). We may confidently expect that in the near future Iwe shall obtain further information upon certain points in con- [nection with this disease which have not as yet been cleared up. As we have above, on page 331. devoted some time to the [description of the anatomical features of the disease, it remains xir us here to speak first of the symptoms of multiple neuritis. Mt i;^ remarkable to note that the onset frequently resembles I that of an acute infectious disease : there are fever, general malaise, dull headache, apathy, etc.; soon pains make their ap^tcarancc. first in the liimbiir region and the back, then in the c«>urse of the large nerve trunks. These are followed by an impairment of mobility, especially in the lower extremities, which makes the patient very anxious; the legs arc heavy, they are moved only by a strong effort, and not without pain. ■ and the patient is easily fatigued. The reflexes are diminished or lust, electrical excitability is dccre.ised, but the pains — and thift should be emphasized — usually soon abate and other .sensory disturbances. p:ir;vslhesias .ind anxsthesias. are only [exceptionally met with (IJ;irrs, Amer. Journ. Med. Sc, Fcbnu rr. 1889), the disorder chiefly affecting the mt>tor apparatus, "peatcdljf case* have been <)l«frve<l in which the motor turbanccs made their appearance quite suddenly, an onset
2S&
D/SEASES OF TUB SPfXAL .VKXt^ES.
which we cuuld almost cnll ajjoplectUurm. Wtihout any prc- mttnitor)' symptoms there come on violent rndi'iliii^ pains, with motor paralysis. Sometimes tre I'md atrophy in certain groups of muscles ; reactiun uf dcgcncrulion can soon alter be demonstrated : sometimes thickening and a considerable in- crease in the subcutaneous tissue develop. If this lakes place in the palm of the hand wc have the " flat-hand," in which the normal hotlow is absent, a cunditiun analogous to that of "tlat- foot " (Liiwciifcld, 2 Faile neuriiischcr " Fl^tt-hand." MUnchcncr mcd. Wochenschr.. 1S89, 24). Besides muscular atrophy we may tind ataxia, and this symptom may indeed be very marked, so that it dominates the whole picture and makes it resemble that o( tabes. In such cases the term pseudo-tabes pcripherica, instead of simply multiple neuritis or polyneuritis, is very ap- propriate.
If the pains are very intense, and if we hnd more or less well marked swellings, while other sensory disorders are only slight, the case may be one of acute primary polymyositis, a condition which has been well described by StrUmpcll. This is especially likely to be the case if the pains arc localized in certain muscles ( Deutsche Zeilschr. f . Ncrvcnhk., i, 5, 6). Lewy has also furnished some important practical contributions to our knowledge of this disease (Berlin, kliii. Wochenschr., 1893, 18).
No description of the course of the disease which would fit all cases is possible, because this varies and presents pecul- iarities according to the pathogenesis. Dejerinc has described a case of hiemorrhage in the region of the brachial plexus which was followed immediately by paralysis of the arm <Compt. rend, hcbdom. dcs stances de la Soc. de Biol., 185(0. No. 27); but such a sudden onset is exceptional. If a multiple neuritis occurs in the course of another disease, its manifestations are not the same as when it is a primary afTeclion, which has de- veloped under the influence uf some special cause. Among the conditions in which polyneuritis may develop wc would mention phthisis pulmnnalis, diabetes (Charcot, Arch, de Neu- rologie, Mai. 1890. xix. 57). tabes, articular and muscular rheu- matism, polyarthritis, and finally the puerperal state (Desnos, Pinard, et Jofiroy. TUnion mijd.. 1889, 14). It has repeatedly been described as a sequela of typhoid fever, of smallpox, of scarlet fever, of diphtheria, of carcinoma (.-\uchi. Revue de mid.. 1890, X. 10), and ol leprosy (Arning und Nonne. Virch- Arch,. 1893, cxxxiv. Melt 2) — "infectious form" of Leyden.
MULTIPi.E NEumrts.
589
As an independent disease it may be caused by overexertion. Tw<i cases which we have described were due to prolonged work with the reiving machine (cf. lit.). It in:>y also appciir, and this is unciucsiiunably much more common, as a conse- ({uence of the action of certain poisons, more es]>ccially alco- hoi, nitrobcnzine, auiiinc (f<oss and Uury), carbon monoxide, bisulphide of carbon, lead, arsenic, and mercury — the "toxic (orro " of I-cyden. Besides these two there is, according to Leyden, a third variety, the so-called atrophic (ana:mic, ca- chectic) lomi, which develops after a lonf; and severe sickness, somewhat in the manner recently described by Oppcnhcim and Sienierling.
Fit. iH.'AntDPMT nr TiiK llt'Hri.Eii or tk« Kmitr t'mH Arm in CctxsKgVKNcn or A FKurrvRK or nts IIumkkv* S«vu< Ykaju tvxVKKSvt {pcnoul obwnMkui).
Sometimes sensory, sometimes motor disturbances are the predominating symptoms. In the nctirilis of phthisical pa- tients both arc marked to about the same extent. Occasionally certain nerves seem to be more liable to sufler — (or instance,
. according to Mitbius. during the puerperal state, the median imd ulnar, the terminal branches of which are affected either in
I both hands or only in the one which is used more extensively,
3go
DISEASES OP TJIE Sf/JVAt. KKKl'ES.
u;> a rule the right. In tabes, on the other hand, no region seems to be cscropt, and, us Oppenhcim, Siemerliiig. Piirc», Vuillard. and others have observed, not only ihe |>cri[)heral spinal, but also the cranial nerves may be attacked by the neuritis — for example, the vagus and its laryngeal branches, and the ocular nerves. Korsakow and Serbski have described
Fig. in.— PAHiBTHl.
.-l.il ;...'.':. .t~4i.; J^.i..;i'L£ NEUftlTtt.
the mental symptoms which may be associated with multiple neuritis (.Arch. t. Psycti und Nervcnk.. iSgi, xxiii, i, p. 112).
The neuritis which occurs in the course o( joint afTections often leads to considcnible atrophy in those muscles which arc supplied by the affected nerve twigs. Chronic inflammation <>( the synovial membranes caused by sprains, chronic inflamma- tions of joints, articular rheumatism, frequent attacks of gout,
jaVLTIPLE S-HVKITIS.
39»
raumalism, fractures which give rise to some impediment in the circulalion — all these causes may bring about extensive mus- cular aimphics. A case to the point is illusirated in Fig. 121 ; the paiieni was a boy, tiliecn years old, who had sustained a fracture of the upper arm when he was eight years old. The fracture healed slowly, and was (oUowcd by atrophy of the
Fie. i»3.— l''--'i-'i.iit.i.i-. 1.11:1 M..,^■.^J-l^;l ll!.LruT.B Nn/MTlit
right upper arm and the muscles of the chesL References bearing on these atTcclions and upon " reflex atrophies," which we shall soon mentioti. will be found on page 396. The case which wc have illustrated in Figs. 122 and 123 was that of a young man who suflcred from a panarthritis, and who in con- sequence of his joint aiTcclion dt-veiopcd muscular atrophy in all four extremities, more especially in the upper arms and
393
DISEASES OE TUE SPINAL NERVES.
thighs. The hip and shoulder joints, as well as the knee and elbow joints, had been swollen and painful for years. That this atrophy, which may be due to an inflammation of the fine end twigs of the nerves, may also be caused reflezly by the joint aflection has been shown by Charcot. If the hip joint is attacked, the flattening of the buttock, the abnormally high position of the gluteal fold, the marked prominence of the tro- chanter on that side, are striking features. If the upper ex- tremities, especially the hands, are the seat of the disturbance, the atrophy gives rise to deformities which are either of the extensor or the flexor type (Charcot).
Peculiar and manifold are the manifestations of that variety of neuritis \vhich is produced by the abuse of alcohol. For the sake of simplicity we may distinguish two cardinal forms of this aflection, although the clinical pictures of the two can often not be well separated from each other. In the first the motor disturbances and the atrophies, in the second the sensory disorders, are the prominent symptoms. In the former case the patients complain of violent tearing and drawing pains in the lower, more rarely in the upper extremities, which are rela- tively rapidly followed by a marked difficulty in walking. The gait of the patient is distinctly ataxic and resembles most closely that of a tabetic, with the exception that in the latter no diminution in the strength of the muscles can be noted, while in alcoholic neuritis it can undoubtedly be demonstrated and is to be explained by the muscular atrophy which occurs comparatively early and which is particularly seen in the ex- tensors. The degree to which walking in particular and mo- tion in general is interfered with is very variable. Sometimes the patient can hardly raise himself in bed without assistance, sometimes he may for months be able to get about fairly well without help. It is interesting to note that the patellar reflex is lost very early and completely, a circumstance which may lure not the inexperienced alone into making a diagnosis of tabes dorsalis. This is still more likely to occur, and the mis- take is more excusable, if the action of the alcohol has also manifested itself on the ocular nerves, so that, e. g., we may, in addition to the symptoms mentioned, encounter a paralysis of the abducens, which 1 have myself seen several times in alcoholic neuritis, and which Suckling {cf. lit.) and others have described ; or, again, the oculo-motor may be affected and the patient may complain of diplopia. Pierson, Eisenlohr,
Afvir/pi./i A'RV/ftr/s.
393
^
Stfiimpell, and others have reported cases in which the facial nerve was implicated. Vagus neuroses have been reported in this connection, especially tachycardia, l>y Dejerine. I( we iidd to this the frequency with which Romberg's sign (swaying while standing with the heels and toes together and eyes closed, in consequence of the disturbance of the muscular sense) is found in the disease, if we remember that stomach symptoms occur in both affections — in alcoholism as vomitus matutiims in consequence of a chronic g:isiriits. in tabes as gas- tric crises in consequence of disease of the vagus nucleus — we can not be surprised at the frequency with which alcoholic paniljsis is taken for tabes. Nevcribclcss, it is nut so difficult to avoid such a mistake, more especially if we have a chance to examine the patient repeatedly and do it carefully enough. We should particularly note the condition of the pupils. The absence of the Argyll- Robertson sign and the absence of bladder symptoms, both ol which are very common in tabes, will be si<;ntficant features. In alcoholic neuritis, further, the nerve trunks are usually painful and the c<jursc of the disease differs in the two maladies. In tabes, as wc know, the outcome is very unfavorable, while in alcoholic neuritis, if the causo is removed, it is usually good. Rvcn the individual symptoms may. If analyzed carefully, give us some valuable diagnostic hints. For example, it will hardly be very difficult for the care- ful examiner to distinguish the morning vomiting of alcoholics from the paroxysmal spontaneous vomiting of tabes, which appears now and ag:iin and may not reappear for months.
The second form of alcoholic neuritis may run its course without giving rise to any decided motor disturbances. The patient then only complains of pains which sometimes run along ihe nerve trunks, becoming very violent, and may resemble the lancinating pains of tabes. He may complain of localized hy- pera'St hcsias and anaesthesias, of formication and numbness, all o( which symptoms are especially marked iu the lower extremi- ties. Various vasomotor and trophic disturbances are not uncommon. ClMlema may occur and disappear again, skin eruptions, perforating ulcers (Mclbing. Beitr^ge zur klin. Chi- rurgic, iHSq. v. 3). circumscril>ed areas of an hyperidrosis. and ichlhyolic changes nf the epidermis (Kulcnburg) may be noted. Brissaud has published studies upon the influence ol the trophic centres, especially in toxic neuritis (Arch, de Neur.. 1891. xxi. 63).
394
DISEASES OF THE SPINAL NERVES.
In all cases the psychical condition ou^ht to be carefully considered. It may present changes very early in the disease. Thus Oppenheim has reported instances in which the alcoholic neuritis occurred simultaneously with delirium tremens.
It has long been known that neuritis may be produced arti. ficially, and that it, for example, often occurs as a consequence of subcutaneous injections of ether; but this has only been carefully studied of late years. Cases of this kind impress upon us the necessity of being cautious in giving the injections for therapeutic purposes and of avoiding especially a too deep insertion of the needle where we should be liable to strike branches of the musculo-spiral or other nerves. Paralysis of the extcnsoi^ of the Bngers has been relatively often observed. References bearing upon this subject will be found at the end of this chapter.
In the treatment of neuritis our first aim should be to re- move the cause ; only when this is possible can we hope for permanent results. The therapeutic measures differ according as the case is recent or of old standing. If the former is the case, the salicylates, antipyrin, phenacetin, and, if the pains are very intense, morphia are indicated. According to our experi- ence, inunctions are of comparatively tittle value ; nevertheless an ointment containing chloroform, veratrin, and morphia may be tried. Wet packs (Priessnitz bandages) are sometimes serv- iceable, and warm baths (at 90" to 95°) may be beneficial, but cold water is usually dreaded by the patients. The most important measure in these cases is the electrical treatment. Where this can not be used, or where it can not be properly applied, it is impossible to do much, and it is then best to leave the case to Nature, a course which frequently results in re- covery, though this is apt to be slow. The constant and the combined current (De Watteville) should be used somewhat in the manner described for the treatment (or the motor nerves in my Text-Book on Electro- Diagnosis and Electro-Therapeutics (Stuttgart, Enke, 1893, pp. 142, 143). Next to the correct ap- plicilion of electricity, the most important point to remember in this treatment is that we must not give it up too soon, and that we should not dcsp.iir if at first no results can be seen. Several weeks, even two or three months, will be necessary in any grave case. Sometimes even the protracted use of elec- tricitv has no effect, and we may well sav that the treatment of multiple neuritis is rarely a grateful task.
MULTIPLR AfBL'/llTlS.
395
I
V
It
LITKKATURE.
A MtiltifJf tVmritit.
Sinimpctl. 7.iit KennlniM Art niiilti|ilcn dc^iKmliven NcuriliK. Arch, t
l^>ch. 0. Ncri'cnkrJiikli., 18S3. »iv. 2. Hm. llriii.i^iurP.iihoIvgirilcrniuUiplcnNcuRlk Neurol. On rralbl. 1884, 31. Upprnhcim. Multiple Nruriii--^ DcuiKhct Arch, f. kiln. Med., 1S85. Ud. jft.
Heft S. 6, |>. 561. Buuanl. Pfimlyias (kpmdcnl upon IVtiphcr, Neuritis- ' Lanc«l, November s8,
D«cnil)ef f J. 1885. PUm cl Vailbnl, Peripheral Neurilit in Tubemilosls. Revue de m^l.. 1886,
No. 3. lL*ti!ni iM- Aitiociated with AtTn|>hy i>r Sensory l)i»litfbMce«.) Francude. Nfvrite muliiple. Ktvuc de mid.. 1886, Nol 5. Opprnhrim. Urber Jntcrslitiellc Neuiiiis, ihr VorkuniriiEn liei Nctveti> uml
Midervn Ertcraiikunt.'efi. Neurul. Ceniralbl., il$86. No, tl, ppL i}5 ri 11^. UMuloiigo Le ncuriii multiple [lerifericlie )iniiiiUvees|ieciu1niente(ldUrurina
<li polincuritc acuu. Oai. ttegli ospiuli, 1886. Nus. SJ. jA. $S-4i. Hitm et VailUnl. N6vriic% jifnphftiqucx dant Ic liiunutLime chinniqu^. Ke-
vue de mM.. 18S7, riii. 6. p. 4^6. Cnmuilic. Oinlribution A r^iidr dc l« pathogenic des n^rites pf nplvrn(|urs.
THtw de Pan*. 1887.
LVtiet .Neuritis pueipcralit. Muiicliencr mnL WixImHClir., 1^7. No.
9. (Aiiucks tiKMl frr(|ucntly the ulniii and the miiliiiii nerve.) Suddnunn. Nnirol. CVntnilbl.. 1S87, 17. (i'eculiur Cuniltiion (muimI in » Case
of Ncuntit a( ihr ltra< hial t'leiu» coming on .-iftcr Typhoid.) CioUtlLim. On ihr to^cnllcd Multiple Neutiiik. Mcdycyna. lUt?, xr. 13-28. UpfirahHra und Siemerltnt;- UeittX)^- tut I'niholiiKie dcr Xabn tIrirMlH luid
drr |>nipheri««bcn NftvRiMlcianlcunKcn, Arch. (. Piych. und Ncrveukh.,
1887. wiii. I. 2. Ikibois. Uebrr n[K)plectirormes tlin»el<cn ncuriliKhrr Lahmurigm, Conv-
nfKiiHlenibt. (. 8chuiri(. Ae(/ie. 18X8, 14. Senaiuc I'dier iicuir niiilii|ile MyiMilit bci Neuritis. Deutsche nwd, W^
chrtiKhr. t888. xiv. 13. (MilHain. /niichr. t hliii. Med.. 1888. xiv, 4. Dury. rrnpliemJ Neuritis in Acute Rheumatism arxl the Relation at Muscular
Amiphy to AfTectiunf of tiK Joints. From tlic Medical Chronicte, June.
18X8. KInmpke [let polyn^rilc* en g^<ntl «i des juralysict ct atrophies Nitumti>es
en parlirulirr. I'aris, F. AU.in, iKSi*' Udik><Dar]Hi). Uetier die hrkr^nkuiiycn dcr pcriphemi Nerven M Lepra.
IVtcrtlMrgrr nied. W'xritensclir.. 1X89. 41. lobiu*. Untnii- >ui Lrhre von dee Nruriti* purrpcnlb. Muncheiter med.
Wiiclimtchr., 18901 14. f akticnfclcL Nentitis mubiplex cum glycosuria Deutsche med, W<Khenschr.,
HnoK I'ebrt nruntisclte Uhtiiuiif-rn lirim t)i;ilirtes mdlitus, (" Diabcli«c)ie
Lllhiniini;en. "1 Brilinrr klin. VVorl>rn«chr.. 1890. 13. Fffnkel. A IVIw-f niiilliiilr Neuriiji Diutsche ni«l. WoclienKhr,, 1S91, (3. lU. Ucbec mullipte Ncurllis. Wtrn. Holder. 1891.
jl^ DISEASES OF THE SPINAL NERVES.
Lloyd. Forms of Pseudo-tabes due to Lead, Alcohol, Diphtheria, etc. Med. News, 1891, 14.
Engel-Reimers. Beiirttge zur Kenntniss der gonoirhliischen Nerven- und Ruckenmarkserkrankungen. Jahrbiicher der Hambuiger Staats-Kran- kcnanstalt, 1893.
Leyden. Ueber Polyneuritis mercurialis. Deutsche mcd. Wodienschr., 1893, 31. (Mercurial Treatment of Syphilis.)
Ross and S. Bury. On Peripheral Neuritis. London, Grifltn & Ca. 1893.
Giese und Pagenstechar. Beiirag' lur Lehre von der Polyneuritis. Arch. f. Psych, und Nervenkrankh., 1893. xxv, i. p. III.
Mills, Charles K. Neuritis and Myelitis and the Forms of Paralysis and Pseudo- paralysis following Labor. University Med. Magazine, May, 1893.
t. AkoheSt Neuritit.
Fischer. Ueber eine eigenlhiimliche Spinalerkrankung b. Trinkem. Atch. f.
Psych., 1882. Dreschfeld. Brain, July, 18S4. p. 100. (Chronic Alcoholism : Ataxia in Men,
Atrophies in Women.) Broadbent On a Form of Alcoholic Spinal Paralysis. Med.-Chir. Transact,
vol. hcvii. Chaivot. Les paralysies alcooliques. Gai. des h6p., 1884, No. 99. Kruche. Die Pseudotabes der Alkoholiker. Deutsche Med.-Ztg.. 1884, No. 73. Moeli. Statist, u. Klin, liber Alkoholismus. Charit^Annalen, 1884, 'a, p. 534. Schulz. Neuritis der Potaloren. Neurol. Centralbl., 188;, Nos. 19, 30. Hadden. Cases illustrating the Symptoms of Chronic Alcoholism. Lancet,
October 3, 1885, p. 6ia. (Hyperzsthesia of the Skin, Vomiting, no Patellar
Reflex, Plantar Keflex retained.) Bernhardt. Ueber die multiple Neuritis der Alkohotisten. Zeitschr. f. klin.
Med.. 1886. !ii. Biissnud. Des pamlysies loxiques. Th*se d'agrigation de Paris, 1886, Oellinger. foude sur les paralysies alcooliques. Thtse de Paris, 1885. Dejerine. Contribution k I'^luUe du la nivrite alcooiique. Arch, de Phys., 18S7,
X. 5mc ser., p. 248. Witkowski. Zur Kenntniss der multiplen A Ikohol neuritis. Arch. f. Psych, u.
Nervenkrankh., 1SS7, xviii, 3, p. 809. Bonnet. Arch, lie neurologic. Juillct. r887, pp. 79 tl seg. Suckling. Ophthalmople),'ia cxtvrna due 10 Alcohol. BriL Med. Joum., March
3. 1888. Eichhorst. Niuritis fascians alcoholica. Virchow's Archiv, 1888, 112, 2. Siemerling. Kurze Bemerkungtn zu der von Eichhorst sugenannten Neuritb
fascians. Arch. f. Psych., 1888. xix. 3. Cuilleniin. Annales Mid. -Psych.. Mars. 1888, 7me sfr.. 2. (Alcoholic Hysteria.) Wladur, Martin. Wiener med. Presse. 1888. xxix, lo. (Angioneurosis of the
Vessels of the Mead as a Ki-suit of Alcohol and Nicotine Intoxication.) Sharkey. Alcoholic I'iiralysis of ihe Phrenic, Pneumogaslric, and other Nerves.
Transactions of ihe Palhol. Society, 1888, xxxix. p. 27. Schaffer. Neurol CVnlrallil., 1889, viii. 6. Siemerling. Chariti-Annalen. 18S9. xiv. p. 443. Buzzard. Brit. Med. Journal. June 21, 1890.
DiSEASRS OF THH TROP/flC AA'D l'ASO-MOTX}X JVUKt'KS.
397
I
f, JVnm'/ii minJ fy SiitfHliUH-'ttt tu/nlimt ef Btktr.
SilnU. TMk iiiDug.. Bonlcaui. 1884.
KritiAk uikI Mendel Uerlincr kUn. WocheoMhr.. 1K85. xttj. 5. pp. 76, 77. ll.idra. KItiung <kr B^d. nicil Gi^scllxch., v, Juni 3. iSSj. |Sir« et VAilbrcL l)cs ntnitn titovoqutca |»r les injections d'tfihei au volsi- nugT (lc« troncs nenrux dejt menibres. Cu. nif<l. ile I'jris. Miti 18. itUi?,
No. 32.
4. MutttUMT Ainfhy a/ttrjmni ami Bene thimt—" Ht/ltx AInfkj" (C'itfniOV
CtttfcoL 1^. mill.. Juln-Ju>ne(. it{8>.
HanitMi. Recberches ci|>£iimeitules ct clmiques sur Irs atrophies ilea mcm-
bre*. Valence, iS8s. UactumiM. Conirlbulion k I'tiudc iXn atn>|ihies musculurea & distance, appd-
Ifes enoor«. "airophics rtflexcs," Thi*e de l^iriit. 1883. <The irophk
fom of ihc nerve ceiilteii is diminished uccording \a this suthor) Cornltlflfi. lYDgr. mid.. 1883. ». ai. p, 405. (Muscular Aitophy jifier Atlaeks
0/ (ioiit MmuUting Progressive Muscular Atrophy.) S>nini|trU. Munch, ined. Wochenschr., 1&88, 13. (Muacutar Atrophy After
Acme Antcitlar Khctinijiiism,) Wkhnun Dcr rhnin. CclcnkrheuniaiismuR und seine Beiiehuii)[cn turn
Nervensyitem. Neuw-ied. 189a Raymond. Rccherchcs cxp^rimeniales tur la pathoginie des ain>phi<^ musm-
toirei consjculives aux aithritcs Iraumaitijuu. Revue de tniA., 18901 x, 3. ibmulh. Myopaihiei n^vritique». Ibid.. 189016. Darkichcwitsch. AiropJi. niusc. arthmpath. Neurol. CetitraUil.. 1891, 13. Liirieille. Sur unc arthnte spJciale du |Med avec dcfomiaiion observfe chn les
vclocipcdiUM. I'arii, 1891, Itaploy el Caiin. An:h. %in. de tvM.. 1891. 1. (.Muscular Atrophy after Joint
Disease.) Mugh. Lane. DeuiKhe Med.-Ztg.. 1B93, 191 (The Neuroses in Chnuuc Kheu-
ruiomI Anhriib.) Cbannt. Atnyoirophies «pjciale5 riflexes d'origine MlkuUlrc. I'ro^is mtA..
1S93. 13.
B. Diseases of the Trophic and Vaso-motor Nekves.
In spile of the epoch-making labors of Sumuet (ct. lit.), who. after Kornbcrg, was the first to postulate the existence of dcfi- Dite " trophic " nerve fibres for the regulation of the nutrition <A Ihc tissues, we are to-day still unable to demonstrate such fibres, nor do wc know whether there exist purely trophic centres, or whether the trophic influence is exerted by some tXQIres already well known — viz., by the motor, sensory, or vaso-motor. On the other hand, the existence of such a direct trophic influence of the nervous system upon the tissues can not be called in rjiiesiion. Ag»in. we can not as yet decide i»bcthcr or not this influence, u|K>n which the nutrition of the
■J-fll^
^■-^^'^.l^'
.om^^^^o'^o^^rr-ix-^'
«\t^^
«as'>-
ool o"^>'
^^^^^-.;^^^-^::;vo'-l.J;e^.-
\e->^
Aou«c=
ilOS
crve*-
lopa'
,ss
^v.c«""::i,.
.. ^^^^^^^-r^^^::.^
cU^er
^«« >'"r---
o^^?'j:o\ ^^^"^
assocja'
tatn?^*'
Vc»d
»•>
xx>«>«'"!Si
vaso
uions-
ihat
s<>-^^!^;co-v^i:^vrwi-irs:;,yot.c.
l^iiSsP
(act
as (ba(
dcT
ins
ov
not
nccc
-iWify
I*.
^^■Wic^^
VtSBASes Of THE TROPHIC AND VASO-MOTOR NERVES,
399
11
^thological procc&scs in the pcripheml nerves may also have ihe same elTect. Among the central allections. which, how- ever, ttiuy remain latent inx a long time, so that one might be led lu regard ihe trophic changes as in(lc]>endent aflectEons. we uitibl mention in the ^rst place tabes — which we shall discuss in this cnnneciion later — hysteria, certain cerebral diseases due to changes in the vessels, such as apoplexy with the acute bedsore, nf which we have spoken on page 232. and again diseases ot the gray axis ol the spinal cord (Jarisch), among others the " paralyste g^n^rale spinale ant^rieure subaigue" (Pitres el Vaillard, Prog, mi^'d., 1888, 35), To the diseases of the periph- L'Cral nerves, and the infectious diseases in the course of which ophic disturbances may occur, we have already alluded. At present we can form no idea how many diseases, not ly of the nerves and of the muscles but also of other organs, we Khali have to call "trophic" when we have once become belter acquainted with the p*)siiion ol the trophic centres and [fibrei, than wc arc now. For the present the term is restricted I a small number of afieclions. and it will suffice to say a lew words about the most important among them, and first about Ihe tmpho-neuroses of the skin.
Anomalies of secretion which have to da with the sebaceous 'as well as (he sweat gLinds arc not tinconimon. It is well known that scbcjrrha-a. for example, may occur after long- standing menstrual disturbances, chlorosis. ann:mia, after over- cxrrlion, or as a consetjuence of to<t great sexual excitement. inaMurbation, etc., especially in young individuals, whereas imtnished secretion of the sebaceous glands, as found, for in> c. in ichthyosis and in ^cnilc atrophy of Ihe skin, is com- tively rare. The purely nervous origin of this, as well as i»< hyperidrtMis ami anidrosis. can hardly be questioned. Hy< pcridrtKls is seen on one side alone or on both sides in central
Idiseiucs — fur instance, in some diseases of the medulla oblon- gata (Traube>, of the spinal cord (spinal apoplexy, myelitis), and Dt the entire nervous system (tabes, hysteria). It also *»ccurs reHexlv < Kaymond). The anidrosis appears in peripheral facial paralysis in dementia paralytica, and in certain skin afTcctions, Mich .TS psoriasis, lichen, and ichthvosis.
.\m<ing the skin affections associated with exudation we have erythema nodosum, urticaria, and a disease probably akin lu it. the angio-nruroiic tedeina {Quincke), which appears some- limes quite suddenly on ditlercnl parts of the body, the patient
400
D/SEASES OF THE SPIXAL XERVES.
feeling otherwise perfectly well. The hydrarthrosis interniit- tcns. which F6r6 has regarded as an articular angio-ncurosis (Reviic dc Neurol., 1893, 17), and cutaneous swellings of nerv- ous origin accomi>anying the menses (E. BoenJCr.Volkni.Sararnl. kliii. V'ortr., 1888, xi. No. 513), have been described. Again, we have certain forms of eczema, prurigo, herpes zoster, and others, althougli (heir nervous origin is not established beyond doubt. As every one of these affections presents in its devel- opment, in its clinical significance, and in its treatment, so much that is by no means cle:ir, we deem ourselves hardly called upon to enter into a detailed dcscripiion of them here. Some, as. for instance, the herpes zoster in the course of facial paraly- sis, have been mentioned above (cf. page 90). Equally obscure is the origin of cutaneous haemorrhages — as, (or instance, the ecchymoses which occur in tabes after severe attacks of pain— of the pigment hypertrophies (e. g., in lepra), of the anomalies of cornificalion (keratosis and ichthyosis). o( the lucvus, which is said to be due to intra-utcrine disease of the Spinal ganglia, of the atrophic conditions of the skin (striae and maculx atrophicx), of the so-called glossy skin fglossy fingerst. of the pigment atrophies (vitiligo), u( the atrophy of the hair, and the atrophies or deformities of the nails, changes which vre meet with in the most varied nervous affections and under the most varied circumstances.
An interesting angio-ncurosis is the so-called night palsy, which has been described by Ormcrod, Hcrnhardt, and others. It consists in numbness, pain, and a feeling of weakness occur- ring at night in the upper extremities. I>istinct anaesthesia and actitat paralysis are not present. Women arc afTeclcd more frequently than men, and seem to be particularly prone to ilH the menopause.
I-ITERATURE.
Samuel. Die iTophisclien Ncrvcn. Leipiit;. 18601
Lustig. Zur Lehrc vun ilcn vasomaiorischcn Nrurosm. Iaaug.-Dlu>, nreil«u<
"87 s. Akx.-inHcr. l.itncel, 1881. i. 25. 36. Slillet. Wiener mt'd. Wochcnschr.. 1B81. 5. (t. Scrllgniijiler, Ucbcr Hydrops ^iTlicutoruiti inCcrmillcnt. DttiUche Bwl. **■
chenschr.. 1880, 5, 6. (It by Secligmllllcr icgardcd as 4 vm**"**'
neurosis. J Schwimmer. Die neuropalhischcci Dennalosen. Wlon U. Leijutt;. iSj. WeiM. I'raiter Zciltichr. t. Ilcilk,. Scpiembcr ij. 18S;. vi. 6. <ZostCT ewebi*''" Kopp. Die Trophoiicuruscii tier Haul. Wicn, 1886. Brjumiiller.
I
I
I I
HAY.VAUD'S DfSEASE.
■\o\
^^enaulL Note reblive dts troubtu trophiques excqttioncU il'orjginc ibumuu* ^B male Cu. hvhti., rtt87. xl"i> 34-
^Baymoiwl. Dnrphulnnn dc U face. Arrh. de nrurol.. 1888, 43, p. ji, ^BTbom*. Ucbcr da^ Verhnllcn ilcr Artericn bri Supriuirliiinlncunlgie. Ueul> Kbcs Awh, f, kitn. Med.. 1888. Bd. jilm. Hcfi 4. 5.
Srfvui. EkiKliMi Med, anA Hutg, Journ., Ociobcr. 1S88, riin. ly
Auchd CI Ltspinaue. Cas d'Knthranirliiluic. Kc\*uc dc itiM, 18S9. 11.
ScheibrT, Fialkvon Traphoiirutuiii Review ii; Wiener inccl. freMc, 18901 17.
]avi. M. Ikriincr Win. Wochecischr, 1890, 4, 5. ^^iniuncr, P. Einige neuere Arbeiien liber Irophischc Ncnen. Dnitiche mr<\ ^H WochcnKhr., 1893. t.
^^iuVe. Zur Aeiiolofpe dr* " acuien angUincurolitchcn *' ofkr "umschricbcoen Haut<id«ms." Berliner kliii. Wiichenschf,, 1891,6.
Gerhsrdl. Ucber Kr^ihrnmelatgic. IVulsclic ni«.\. Wochenschr.. 1891. yf.
\timge». [>Fr pnkiiKhc Ar/1. xi^i. \o. (Cnxc of F.iyihromrlalpa.)
I'o^. PaU von I^ryihrtimela1|{ie. i^ter med.-chir. i'resM^. 1893, ^KiUenburj;. Ueber Er)-ihroinrlalgie. Oeulschc mcd, Wocliensehr.. 1893. $a ^Ktwla und Bcndit. Ueber ErythTumeblKie. lierliner kltn. Wochcnschr. 1894. 3.
^B The so-called symmeirical gangrene of the fingers and toes ^^sclerodactyly) which was first described in 1882 by Raynaud, and wtiich has. alter liiin, been called Raynaud's disease, comes on wilh ihe following symptunis : The fingers appear at times as il dead {"doigts dt taort"). at another lime they tnrn a dark- red color and burn vioiently. Gnidually disturbances in nu- irition, at first only transitory, later permanent, develop, and blebs form, which open, leaving u sore which heals with loss (A sul>stancc. The nails fall out and are not replaced, whole Its die, the necrosis being symmetrical on both sides, and none of the usual causes of gangrene — such as disease i>f the Heart or of the blood-vessels, seplicxmia, traumatism, etc.— ■re present. The disease is, however, very rarely met wilh in its full development, while li<;hter grades, in which we have only to deal with a transient spasm (or paralysis) of the vcsfirls, especially in the hand, arc not uncommon. In such instances the hands become bluish and icy cold, and we have a condition known as local asphyxia. Raynaud's disease may be con- founded with peripheral neuritis, ergotism, diabetes, and senile gai^renc. It should, however, not be dilBcult to avoid such a miftakc if we Inlie into consideration the characteristic course of the disoaM: :md the absence of any of the a'linlogical factors before mentioned. In the treatment favorable results have been repeatedly obtained by bathing the hands in warm water and the application of alcoholic menthol !4>luiion with a camel's- ir brush.
W^.
402
DISSASES OF THF. Sf/A'AL .VEflt'tS.
LITERATURE. Weiss. Ucbcr wgea. symmclrischc Gangran. Z«it»chr. t. llrlHi.. iSSi, til. p.
=33- Ktdiattel. Zetuchr. i. kiln. MetL, 1883. vi. j. p. 977. Luu. Bayr. Snil. Intell.-BI.. 18S4. %.%\\. 14. Schuli. Ileuiuh. Arch. f. klin. Med.. 18&;. xxxv. p. 183. Vulpivi. Gu. ties h6j>., 1884. 9- Lauer. Ucber localt- Asphyxic und symmeirische CansrSn <ler EitreRUUUcn.
Innug.'Diss., Sirasstiurg. 1HS4. Iltics ci VnilUrd, Arch, dc I'hys., January. 1885, jtih; iir. v. p. 103, HochenegK- Vcber ftymmciriftchc Gangrttn und locnlc Asphysie. Wimer mccl.
Jahrb,, 188;. 4. pp. 569-658. Shaw. R.-iynuu(l'i Disifiuc. New Votk Med. Joum.. December 18. 1886. t'uwcll. Brii. Mill. Joum,. Janiur)' ya, 1886. p. 303. ColdKhniidl. Gangrinc symmJtriquc et Kl^nxjcnnie. Revue ilt nie>]., Mai,
1887. p. 404. Wifif-tirswonh. Pcripherat Neuriiis In Ra)naud*s Dimmc. Urii. Med. Joum..
Januiir>- 8. 188?. PoDin. Uai. dfs lifip,, July 36, 1887. U. 90. FcHi, R. Hingsioii, L;ir>i:ci, Decrmber. 1888. ii. 3$. Tannnhill, GI-iaKOW Med. Juurn.. nccember, 1S68. xxx, 6. BntRiJinn. Filk- voii syniinctrischc GangrSn. Deutsche Mcd.-Ztg.. i88g, 37,
StunndDrf (New York). Symmetrical Cinifrene. Med. Record. May. 1891. 40-
Schciber. Wiener mcd. WuchensLhr., 1892. 39^43.
Kornfeld Wicnrr mcd. Prrssr. 1S91. 47. 48, 501 ji.
H.iig. T^.^n^acli^m.1 of llie .Med. Society of Lomlon. 1892.
Dcliio, Deuluhe Zeitschr. f. Neri'eiilik.. 1893. iv,
Gcrmcr. Raynaud 'schc Kr.inkheii. Inniig.-Diiiv. Ilerlin. t893.
Undoubtedly a close relation exists between Raynaud's dis- ease and scleroderma. In this latter very rare aSeclion, which also depends upon tropliic disturbances, the skin, alter havin)r presented (edematous swellings in the first stage, becomes later hard and immovable, so that it Is impossible to pick up a told of it between the fingers. The affected parts, more particularly the face, neck, anil the upper portion of the chesl. where fre- quently 3 diffuse increase in the pigment is noticeable, are im- peded in their movements, the play of the features is lost, the mouth can not be completely opened, the eyes can not be closed, and rotation of the head becomes impossible, etc. The patient feels a sensation of discomfort ; the coldness of the skin, which reminds one of that of a corpse, is most distressing, and a slight fall in the outside temperature is sufficient to bring about cyanosis. Quite gradually the atrophic, the terminal, stage comes on, in which the skin gets as thin as paper, remain-
immATKopntA faciaus.
403
^
ing^, however, 5rmly fastened to the underlying tissues, so that it is still impossible to pick up .1 fold. With these changes is associated an atrophy of the muscles, which has to be regarded {uirtly as a Iropho-ncurosis. partly as an atrophy due to inac tivity, and the patient becomes helpless and unfit lor work. Alter the disease has lasted for several years, if convalescence has not set in in the second stage, a general marasmus develops which leads to a falat issue. An effectual treatment is not known. Warm baths simple ointments, the consinni current, internally tonics, iron. c«id-livcr oil. etc., may be tried, but we are not justified in placing any confidence in them.
LITERATURE.
Thibientc Revue de tn^d,, 1890, \.
HoJb. Mitnch. mtd. Wocliciischr, 1891. x%x\x, %\.
Newmufc. Amcr, Joum. .Med. Sciences. 1891. dv,} (ComplicMion of Sckro-
tlcrma and Hemiatrophy of the Face.) Vudcfvetdc Jount. de mM.. de c)ur,. ct dc (ihaTn).. 1893. li. 3$. p. 561. (No
pMtbotogical changes w-crc found in the nervaiu tj-Mon.)
The next affection to which we shall call attention is as re- sarkable as it is mre. Accordini; to our present ideas, it has abo to be ranked among tlie tropho-neuroscs. We are refcr> ring to a very gradually developing atrophy of the face (some- times ushered in by pain and panesthesias), which may appear on one or both sides, and generally embraces equally the skin, the subcutaneous tissue, the muscles, and the bones. The begin- ning is usually us follows : Whitish spots appear on the skin of the lace, which sink in more and more and are accompanied by a diminution of the fatty tissues below; gradually the atrophy increases in extent, and nothing escapes with the exception of the musculature, and this only occasionally and for a certain time. The alTecled side is sunken in. and the skin assumes a whitish-brown discnloration. The bones, especially the upper (aw. and with it the teeth, atrophy : the latter fall out. as well
the hair, which often appears of 3 light color or distinctly IfRiy. The bone atrophy is the more marked the younger the patient at the onset of the disease (Virchow). If the dise.-ise is confined 10 one side only — hemialrophia facialis— the mcdi;«n line forms a sharply defined border and the diagn<>sis is very plain. If both sides arc affected, .is happened in Eulenburg's ciw alter measles (Lchrb. der Ncrvcnkrankh,. 1878. ii, p. 620). it may be more difficult to recognize the .-iflcction. The grooves
404
ly/S^ASSS Of THE SPINAL N£Ft'BS.
and furrows which are found in the laoc greatly disfigure it (Fig. 124). The corresponding half ol the tonfj^e becomes small, and often presents ga|>-likc retractions such as wc dc- scribed in hemiatrophy oi the tongue (Figs. 29 and 30). Among the muscles not only those supplied by the facial, but also thoac
ftg, »«.— HiMIAittoniu Paciauo (pcnooaJ ubMrtiUinil.
supplied by the trigeminus, are implicated. The extension of the atrophic process to the neighboring shoulder and even to the upper arm is not unusual. Sensibility h not altered in the affected region.
Most of the few cases observed clinically have never come to autopsy. Of great interest, therefore, was the result of an examination which Mendel was enabled to relate before the Berlin Medical Socitrly. on such a patient who had died of phthisis, and who had previously been examined by Romberg, and later on by Virchow (Deutsche .Mcd.-Ztg., 188S. xxxiii, p. 407). On examining the origin of the trigeminus, all the other roots were found to be normal : only in the descending root could atrophic changes be reco>;ni2ed. a fact which would in- dicate thai the trophic fibres must be contained therein.
D/SF.ASKS OF THE MUSCLES.
*fi^
I
Other obscrvatiuns (Ruhcmanii) nlso point to a very iiili- niatc connection between facial atrophy and the trigeniinus; however, more post-mortem observations conhrmaiory of tho&e ol Mendel are needed to clear up the p;uhology oi the disease.
Of the Kliology liltic that is positive is known. Age and sex seem to have little influence. The disease has been known to occur at all limes of life and also to be congenital ; il has been observed in both sexes. According to Lcwin, the fre- quency with which the two sexes are attacked is in the ratio of .six males to nine females. Hereditary predisposition is cer- tainly not a (oitditw sinf qiid nm. because there are cases — among others, the one I have reported myself — in which the patients belonged to quite healthy families. Sometimes it has happened that the atrophy was preceded by other nervous affections — trigeminal neuralgia, migraine, epilepsy, etc, — but this is by no means the rule. In a few cases the disease has followed in- juries about the face or of the cervical sympathetic (Seclig- mUller); more frequently no cause whatever could be demon- sirated, and it was impossible to make any conjecture as to the stiolc^y. The outlook for recovery is absolutely bad, and therapeutics, so far as our knowledge goes, is powerless.
»
LITERATURE.
Eulenburg. l/cbrr progrcsbvr Gcsichluirophic und Sclcrodcmtie. Zcit«chr. t
klin. Med.. iXli:, v, 4. Wolff, J. Viic)iuw'<i Areliiv. 1883, xeW. 3, p. 393. PuimI. a Case of ITogre«ivc K*cial Hernial rojihif. The Med. Kec, Apnl 16,
18S7. Ibnvis«. Liuu^i, DcccmlKr 31, 1887. Hm-/. Archiv (. KmdcTlirilktmdc. rSS?, viij, p ?ji. Uiwenfeld. Vebcr cinen Fall h.illi*eiliKti Aitc)|)hie tier Gnidilv und Kaumns-
culaiur. Munch, med. Woclicnaclit., 18S8, xxtv. jy. McnilcL l/ebei Hcmbiropht.i fncinlin. Ueuiachc .M«l.-Zg[., 1S88, 33. LOwmfcld. Munch, med. Wochirnschr. 1888, 23, 14. Sachs. B. ProKttMiiF Faci.1I Hnnialrophy whh tome Unusual Symptoau.
Med. Reconl. >tnn;h (5, 189a HopiMT-SejIer. Deuiichw Arch. i. kiln. .Med., 1889, xllv, 5, 6. Ctdirami. Hcrlincr klin. Wochcht.chr,. 18S9, 3. p. 5$. Ruhemann. IVuiwhc med. Wochrnschr.. i88<t, 3, 55. FrofnhoUl-Tn!u. Uebcr HemlaiTDphU (nc. prog. Inau^.-DiMCTt.. Dorpai, 1893.
APPBNDIX.— DISEASES OF TIIE MUSCLES— PRIM ARV MVOPATHIES,
Dis<*ascs of the muscles, which consist in alterations in their volume (which is generally diminished, less frequently
4o6
DtSSASHS OF THE SPINAL JVSJfrSS.
increased), und consequent disturbances of function, may occur under the most varied conditions. They may be produced by cerebral affections, as we have ptiintcd out on page 232. where we spoke of the possibility of an aflectiun of trophic centres in the cortex ; they may be the result of spinal diseases, as mc shall later find out in discussing syringomyelia and progressive muscular atrophy, but they may also — and this is what intcr- esls us here more especially — occur independently of any cen- tral disease as primary myopathics.
Considered from an anatomical standpoint, this disturbance in the nutrition of the muscles, the dystrophia muscularis pro- gressiva of Erb, the myopathia progressiva primitiva of Char- cot, consists either in a diminution, a wasting of the muscular tissue, owing to which the volume of the part affected becomes smaller: or during the p-ithologiciil process there may come about an increase in volume, which is cither due to an actual increase and abnormal growth ol the nmscles — a genuine mus- cular hypertrophy— or to a growlh of the interstitial fatty tissue, in which latter case m'c speak of a pseudo-hypertrophy of the muscles. Sometimes both conditions arc found in one and the same individual, so that ccruiu muscles appear atro- phied, while others, in consequence of the simultaneous de- velopment of fat, appear strikingly large and hyperlropliicd. The microscopical examination (Oppcnheim and Sicmerling, MUnzer. and others) shows, besides an increase of connective tissue, a moderate development of fat. and in the pscudn-hyjicr. Irophic tissue a considerable increase in the inierstitial con- nective tissue between the individual fibres, which latter have retained their transverse striaiion (Charcot. F. Schultze, Strlimpellj. The genuine hypertrophy which is seen in places must be regarded, according to SlrUrapcIl, as compensatory.
About the xtiology of primary mvopathics wc know very little. It should, however, be mentioned that, according to all the observations made up to the present lime, they belong en- tirely to early life, developing as they do before the twentieth year. Heredity plays frequently a /■<?/*■ in the disease, since mrf uncommonly several cases occur in the same family. DShn- hardt raises the question (Nciirol. Centralblatt, 1890. 23) whether there might not occur a lesion of the spinal cord during fo;t;il life or during the act of birth ; if this should be shown to be true, the mother or. as the case may be, parturition will have to be regarded as an xtiological factor.
JUl'hNiI.E MUSCVIMK ATROftlY.
407
I
Lesage has shown that they also may follow cermin other diseases, as, for example, typhoid fever (cf. lit.). In such in- stances wc hnve to deal with a secondary lijximaiosts, develop- ing in circumscribed areas of the body, as the result of certain arterial changes.
In our present state of knowledge we seem justified in as- suming that these myopathics occur regularly in certain groups of muscles, so that different '* types " can be distinguished, and thai on the whole the upper hall of the body, particularly the
ne.os.'— S»CftUJU> jL-vrjiiLK Mi'icvMB ATMiMiv iEmbj I pcnoMi obwnitiM).
wppcr cxtremilies. are more often and more severely attacked by the pathological process than the lower parts, especially Ilic leg^. The latter, however, may also be affected, in which case the muscles supplied by the peroneiis arc especially apt tik suU Icr (Sachs. The Peroneal Form ol Leg Type ol Progressive Muscular Atniphy. Brain, 1890). It is important always lo observe whether the face remains intact or not. as in the for- mer case wc are dealirtg with the hereditary muscular atrophy
4oS
DlStiASjtS OF THE SPIXAL />•£/! VKS.
which Erb has described as tbe "juvenile form": in the latter. with the (orm which Landuuzy and Dcjcrinc have described, and which has by them i>een called " inyo)Kiihie atrophtqiie progressive,"
The so-called " juvenile muscular atrophy " which develops in early youth, more ottcn iu boys than in girls, attacks by
n^ it&— Ji;vKini.K UincuLAR Avimfmv 4E*«> tpmcmal ofaMtmloo).
preference (he pcctoralcs. the trapezius, the lalissimus dorsi. the !>erralus ma>>;iius. the rhomboidei, the sacro-luiubalis, and the longissimus dorsi, while the majority of the muscles of the forearm, the sterno-cleido-niastoidcus, the levator nnguli scapu* la:, the coraco- brachial is. th« tcrctts, the deltoid, the supra- spinatus and infraspinatus, remain, as a rule, intact. The small muscles of the hand, which in spinal atrophy become affected so early and in such a typical manner, are here not implicated
JUVENILE MUSCULAH ATKOrtlY.
409
't^ig- '3€). tt is hardly necessary to enter into a description n( the disturbances of function which necessarily must result from disease of so many muscles. If wc remember how much im-
I piiired are the movements of ihc arm, which can not be raised ibovc the horizontal position, etc., wo can understand llie
^gravitj' of the child's aAliction. If, us in the long course of
Pic. »}■— Juvcuii.B MiincULAti AntopifV 'Cii>| <pnwnul (AwttmIcm).
Elic disease not uncommonly hapiKns, the process extends to
the lower half of the body, the glutei, the peronei, the qundri-
C:c|>K, and tibialis nnticiis become implicalc<l and the patients
^Rl tirst walk with an uncertain gait, then waddle in a char
^pctcrinttc manner, and finally Jose the use of their legs. The
"tiiplicalion of the muscles supplied by the bulbar nerves.
^»-hich has been observed by Ucrnbandt (cf. lit,), of course lias
^p very decisive influence u|K>n the duration and course of the
<li sense.
I-'tbrillarj^«d^)ings in the afiected muscles, as wc sec it so
410
DISEASES Of-- THE SPINAL NBRyKS.
comraooly, we may say regularly, in the so-called progrewivo muscular atrophy (spinal), is here wanting with the same regu> lartty. Neither can any changes in the electrical excitability be demonstrated, with ihc exception, of course, of a diminution due to the disappearance of a more or less lar^je number of muscle fibres. The course of the disease is, as we said, erni* ncntly chronic. It may extend over a sp;ice o( twenty or thirty
Fit. ■■&— JfTKMi.K lliicvLAH Atropnt (Ekb) I pmxul obi«ntioD).
years, since bulbar symptoms occur but nircly, and we can only look for a fauil issue if the process involves the diaphragm and respiratory disturbances result. The diagnosis never pre- sents any difficulties. After careful examination, taking into account the distribution of the atrophy, the onset of the disease in early life, with the fact that more than one member of the family areaflectc<l. the long duration of Ihe disease, the absence of fibrillary twitchings. we can not mistake the myopathic for
PKOGPessfyK ATttormv myopathy.
41 r
the 5pinal form. The treatment inusl consist chiefly in good care und nursing. All attempts to arrest the process by the application of electricity ur the use of massat^e, baths, or in- ii-rniil medicines, have proved lo be oi no avail.
The lacio-humero<&capular type of muscular atrophy ot I^ndouzy iind Dejerinc, the " progressive atrojihic myo|wthy," u lorm which had, however, already been described by Du- chennc under the name ol " progressive muscular atrophy o( infancy," may manifest ilscU before the appearance of any other symptoms by a markedly laic development n( the intel. ligence (Fillet, Kevuc de m^.. 1890. S). The atrophy begins
N
»^— PnOOiCMUVi Atkoi-IIIC U> i" i h. Irubtillr KicbMCllicf)in<<>Di)ilrlel)'. lAder MAHit and Guiukml)
id the muscles of the face, and our attention is attracted by the listless, sleepy expression of the face, the smooth forehead, the faulty movements ol the mouth, the inability lo whistle and to keep the lips together. At ihe same time there is a condi> tton of lagophthalmus. so that the patient, in spite of the great- est exertion, is unable 10 shut his eyes (cl. Fig. 129). Gradually the muscles ol the upper extremities and the trunk bcc<imc affccrted in almost the same distribution as in the juvenile paral- ysis. The course Is the same in both these forms. Here also there are no fibn'lhirv twitchings and n<» ch.Tnges in the elec- trical excitability, and although the pseudo-hypertrophy of the
412 DISEASES OF THE SP/JVAL JVEXFES.
muscles, which we shall presently describe, is not uncoramon in the juvenile form and is here never present, there is no ques- tion but that the two affections are identical, and that only in some cases, from reasons not as yet understood, the inteistitial connective tissue becomes early increased, while in others nothing else can be demonstrated but simple atrophy, with in- crease in the number of muscle nuclei and here and there the formation of vacuoles in the fibres. The diagnosis is so much facilitated by the " myopathic facies " — that is, the expression produced by the sinking in of the cheek, the somewhat depend- ent lower lip, and the inability to close the eyes — that the ex- perienced diagnostician is frequently able to recognize the disease at the first glance. Marie and Guinon have called attention to the possibility of confounding the disease with lepra ansesthetica. in the course of which also weakness of the facial muscles exists (cf. lit.). It is interesting to note in this connection that sometimes disturbances of function in the facial muscles may constitute a congenital defect which under ccr- tain circumstances may be followed by an actual atrophy; further, that in sisters or brothers of individuals who sufier from this myopathy which we have just described, a certain imperfection in the development of the facial muscles may he found, although the disease never breaks out in them. These are facts which StrUmpell especially has pointed out, but the cause still remains wholly unexplained. About the treatment we need add nothing to what we have said with reference to the juvenile form.
The third form of the muscular diseases now under consid- eration— the so-called pseudo-hypertrophy — is connected with an increase in the interstitial adipose tissue which, in spite of the atrophy of the muscle fibres, lead to an apparent increase in the volume of the affected parts. The disease was known and described by Griesinger in 1864, and again by Duchenne in 1868. It begins generally in the muscles of the trunk and attacks, in contradistinction to the two forms just described, by preference the lower parts of the body, the muscles of the back, loins, and thighs. Though for a long time the patient can use his arms and hands just as well as usual, the walk, owing to the alTection of the erector muscles of the spine, becomes altered in the characteristic manner which we have described on page 363. The condition of the patient may re- main unchanged for years before the arms also take part in
PSEVDO-nYI'RKTROPmC MUSCULAR ATKOl'IIY.
4<3
process. When this happens it occurs in the same man- as in the juvenile form. The diagnosis is very much Mcih'i.'itcd by the appearance oi the patient. The enlarge- ment u( the calf muscles, the thighs, and the glutei (which are sometimes colossal), give to him the appearance of a ^iunl and suggest u su- pernatural strength yc\. Fig. 130): but the fact that these great masses feel sjiongy and soft, and that the electrical excitability is considerably decreased owing to the diminution in the number ol the muscle fibres, readily explains why these sturdy-looking persons ure feeble and without strength, and almost wholly deprived of the use nf their limbs.
In its onset the di.scasc resembles closely the other lorms. Here also only children become affected, more especial- ly those between the ages ol four and aine. Again, the disease may occur in several members of the same family, so that we must undoubtedly assume a hc< reditary predisposition : and here also the fibrillary twiichings are not met with. Duration and treatment arc the same as in the juvenile atrophy.
tMoniv or itii: Huki.u or TH« Lkih with At- KDPHT or INK Ucm.M or Tile Back. (Arm I)v-
1 Congenital atrophy of the muscles may be found in cases of malformation nf the arms and hands. Fig. 131 repre- sents a boy aged thirteen in whom the lorearms are absent ; some of the fingers are grown together and some deformed. A similar case has been reported by
Wilkin (Lancet, page 1265, December 14. 1887). where there was atrophy ol the biceps and the brachialis anticus.
Absence of certain individual muscles is rarely observed, h-is reported a case in which there was .in almost entire ncc of both trapezii (Neurolog. Centralbl., i. laSg). Among earlier insLinces the peclorales (Ziemssen). the biceps (McAI- liNter). the delloid. and gastrocnemius (Grubcr). were wanting. sc> possess no clinical interest.
" III ^was
4<4
DISEASES OF THE SP/JVAl A'E/fl'ES.
The sensory disturbances which arc peculiar to the tiius-| clcs, but about ihe exact nnalomiciil nature of which we Icnuvv ' nothing, arc called myalgias or muscular rheumatisms. .Klio- logically, overexert ion. strains (possibly rupture ol certain mus- cle fibres, which may happen during gymnastic exercises or: other violent bodily exertion), must be mentioned in this coo- nectioT). Sometimes we arc unable to find any such cause, and we have to attribute the trouble to the influence o( cold.
(iT Ui* aiuKlea of the upper wmi (pcncoal obBcrvaUonV.
There are persons who for years or tens of years suffer fnitn myatgic pains which come and go .ind may disappear (or cer- tain periiMls of time completely, and it is just possible th^' chronic intoxications — e. g.. alcohoiism, perhaps also circ«l»- tory disturbances — have a predisposing influence. Among such myalgias, which may be very painful, even sufficicni'y so as to interfere with the occupation of the patient fi>r ^ longer or shorter period of time, we have, for instance. '^" torticollis rhcumatica, in which the muscles of the mtk. i^^
MYALGIAS.
4>5
I myalgia lumbalis (liimtKigo), in which the mu»:!csof the loins. ■ the myalgia jniercustalis. in which the intercostnl muscles are (attacked. The shoulder muscles may also be aflcctcd, and rthe myalgia in this region may become very obstinate without any implicalton of the brachial or cervical plexuses being de- nmnstruble. In the diagnosis we must think of the possibility of an implication of the nerves and cndcavorto exclude neu- ralgia. We must further remember (hat central diseases may give rise to muscular pains. The inexperienced may mistake the lancinating pains of tribes for chronic muscular rheumatism, and thus obscure the correct diagnosis for years. It will hardly be difficult to avoid confounding muscular rheumatism with articular rheumatism if wc take into consideration the gen- eral condition of the patient, the appearance of the joints, the temperature, pulse, etc., which in the former affection remain normal. I In ihc treatment we should first of all endeavor to detect any underlying cause, and. if such exists, remove it. In re- cent cases, besides subcutaneous injections of morphine, salj. cylic acid may be tried internally : yet we should not spend much lime with it if we perceive no effect, but should rather prefer local applications— irritants to the skin, poultices, mus- tard plasters, liniments, also massage and electricity — especially if the affection remains localized. If this is not the case, but if the pains travel round the body and the course assumes a more chronic type, treatment by sweating, steam baths, also mud baths or b.iths of Pinus sihrstris. the non-mcdicatcd hot I springs (Gastcin. Johannisbad. Teplitz) or the sulphur springs, lamnng others PistyAn, in Hungary, will be recommended. As [a last resort, we may ad vise the patient (o goto 3 well-conducted [bydrotherapcutic establishment (GrSfenbcrg. Kaltenleutgeben, fKa»sau, etc.).
LITERATURE.
Laiuloutf et Dc)criM. IV U mjmpnthic airofihi(|ue prDSraslv«. Kevue de m6d.. r«nicr-Mar«. |8S{. JiaiAe tt Orinofi. Formes clintques <Ic la m)x>tMlhie progressive primhive. IbkL. Ociohrc. r«85. /cMphal. UobcT cinlce FBItr i-on prngrcsoh-cr Mudcehtropbie mil Iklheili* |[niig ilcr OrtMhtsmuskclfi, OMrit^Ann.ilen. 188$-
Kcvitton nmogmphlque <lc& airoplvirs niusmUire* pragreiiuves, PlDfT. mM.. Man 7. \W% »rf. Nnirol Ccniralbl.. iSS}. Iv, t. (Impliulian of ihc Facial Musclet iMvcnile kluKubr Atrophy.)
4l6 DISEASES OF THE SPINAL ffERVES.
Krecke. Munch, med, Wochenschr, 1886. xxxiij, 14-16. (Implication of I he Facial Muscles in Muscular Atrophy.)
Ladame. Conlribulionil'eludedelamyopalhie atrophiquc progressive. Revue de mtA.. Ociobre, 1886.
Landouzy ec Dejerine. Nouvclles recherches sur la myopaihie atrophiquc pro- gressive, elc. Revue de m^d., Decembre, 18S8.
Lichlheim. Ueber hereditare progressive Muskelatrophie. Schweiier Corr- BI,. 1888, xviii, 19, p. 603.
Bernhardt. Ueber cine herediiare Form der progressiven spinalen, mit Bulbar- paralyse complicirten Muskelatrophie. Virchow's Archiv. [888. Bd. 1 1 5, 2.
Lesage. Note sur une forme de myopathic hypertro]ihique secoridairc i la fi6vre typhoide. Revue dc mid., 1888, viii, 11, p. 903.
Sachs, Progressive Muscular Dysirophies. Journal of Nerv. and Ment. Dis- eases, November, 1888, xiii, 11.
Slern. Ein Fall von progressi\-er Muskelatrophie (juvenile Form, Err>), mit halh. seitiger Betheiligung des Cesichtes. Mittheil. aus d. med. Klinik in Kdmgs- berg. Leipiig. Vogel, 1888.
Lichlheim. Ueber hereditare progressive Muskelatrophie. Centralbl. f. Net- venheilk., 18S8, xi, 20.
Souza, Antonio Veiga de. Zwei FSIle von juveniler Form dtr Muskclairojihie. Inaug.-Dissen.. Kiel. 1888.
Troisier el Guinon. Deux nouveaux cas de myopaihie progressive primitive chez le pSre et la fiile. Revue de mfid., 1889, ix, i.
Rfmond. Une observation d'atrophie musculaire myelopathique i type scapulo- humeral. Progr. mkA., 1889, 2.
Winkler en van der Weyde. Primaire mjopalhie (type facio-scapulo-humi'rall Kccombineerd med ophlhelmoplcgia proj^r. superior. NeiliTl. Wecklil.. 1889. i, 3.
Schfulhaucr. Histol. Unlersuchung eines Falles von Pseudohypertrophic di'r Muskeln, Arch, f I'sych, u. Nervenkr., 1889, xx. 3.
Herringham. Muscular Atrophy of ihc Peroneal Type afTeiling many MemK'rs of a Family. Br.iin, 1889. xi, p. 230.
Pal, Ueber einen Fall von Muskel hypertrophic mit nervosen SymptoiTii'n, Wiener klin, Wochcnschr., 1889, ii. 10.
Aucrbach. Zur F'rage der wirklichen culer scheinbaren Muskel hypertrophic. Ccnlralbl. fur ilie med". Wisscnsch., 1889, 4,5.
Limbeck. Fall ion complctcni Cucullarisdefccl. Prager med. Wochcns- lir., t88g, \\v, 36.
Hi(/ig. Arch, f. Psych, u. Nen'enkh., i88g, xxi. 2. p. 650.
StiiiUing. Deutschcs Arch. f. klin. Med., 1889, 45. 3, 4. (Congenital and Ac- quired Defect of the Pectoral Muscles.)
Gombault. Sur I'elal de,^ nerfs periphcriqucs dans un cas de myopathic pro- gressive. Arch, (le med, c>r|)^rim, et d'anat. path., 1889. ;,
Duda. Fall von Pseudohypirtrophie der Muskeln. Inaug.-Dissert,, licrlin. T889,
Muselier, Maladies gfnerales chroniques et amyotrophiques, i~,ii. nii-rt., 1889, 20.
Klaas van Roon. Over chronischi: en jirogrcssive alrophie van spicren. .AUi proofsch,, Utrecht, 1H89.
PKfMA/tV MYOPATHIES.
417
' cl Doon^n. Myop. prOKr. primlt. (l)|)e LAnilouty). Revue de mM..
189ft 4-
tAnncquin, Arch, de m^d. et dc pharm. mil., 1S9CV xr, 4. (Alrophy or (he
Rhomboid Muicles.) tBran* ct Krcdd. Forischr. d. Med,. 1890. 1. (Congcniul Defect of the
Pectoral MuKleit.) ' ItlctKhow&ky. Neurol. Centralhl., tSqo. 1, Krallmnnn el Haushjiier. Retue dc m6il,. 1S90. 6. Koni;hi e Levi. Coniribuiiune alio studio delta <lislro(i3 mniwol.ire pro^retBVa.
Regg:io Emili.t. 1891, Ciidmnnn, P. Dcultchc med. Wochm^chT., 1891, 34.
IKmuu. William C. Mu»cului Atrophies. A Clinico-Pdiholiigical SitMly. The BufTilo Medical and Surgical Journal. ApnI. i8gi. IsneL A. Ueber Uystcopbia muNculurum progrcuiva. I naug.- Dissert., Fici- burg, L B., 1891. Eib. W. DyMrophia miKCuUriK progressiva. \'olknMnn's S.imml. k8n. Vortr.,
N«ie Folgc. Noi-ertiber. 1892. 2. Mwm(tr. Zur Lchre von der Dystrophia muse, progressiva. Zeltschr. f, Uia,
M«l.. 189J. ii»ii.6, Sciutor. Ueber acute Pulymjositb und Neuromyositis. Deutsche med.
Woehenschr.. 1893. 39. HIgier (Wanaw), Ueber primkrc und secundSre Amyotrophicn organischet
und dynainiKher Naiur. Ibid.. 1S93. 38. 39. Situmpcll. Dcuische Zciischr. f. Nervcnhk., 1893. p. 471.
PART HI.
DISEASES OF THE SUBSTANCE OF THE SPINAL
CORD.
Diseases confined to the substance of the spinal cord are rarer than those of the brain substance. The cause of this may lie in the fact that not only are the vessels of the spinal cord actually less frequently the seat of disease than those of the brain, but also that when they become diseased the conse- quences entailed are generally not of so grave a nature as those resulting from lesions of the cerebral vessels.
As in cerebral diseases, here also two questions must ever be kept in view by the physician : (i) Where is the spinal lesion situated ? (2) What is its nature ? As we shall see later, it is especially the second which is of importance for the prognosis and choice of treatment. Both, however, are of equal weight for the proper recognition and conception of a given case. As in the study of the brain lesions, the topical and pathological diagnosis should here no less go hand in hand.
I. CONSIDEUATEON OF SpINAL DISEASES WITH REFERENCE TO
THEIR Seat — Topical Diagnosis.
As a thorough acquaintance with the anatomy of the parts is of the highest importance in making a topical diagnosis, some remarks on these points may in this place not be un«a^ ranted.
Without being separated by any sharp line of demarcation fmn" the medulla oblongata, the spinal cord extends from the upper mar- gin of the arch of the atlas to the first lumbar vertebra, where" ends in the conus medullaris. From this point it is seen as a innS filiform continuation — the filum terminale. The Cauda equina con- sists of the longitudinal nerve bundles which accompany the fil""' terminale. and corresponds to the lumbar and sacral part of ih' vertebral column. As it is apparent that the diflerent pairs of nerves 418
ANATOMICAL RELATIONS.
4>9
I
do not teave the spinal cord at the level of the vcrltbrtc after which they arc named, but that they most net'e»sarily do so higher up, it it) ini|Hirtant i<) know to what nerves certain parts of the vertebral column cor- respond. Thus wc mu&t rcRicmber thai the first three cervical vertebra: correspond to the origin of the third, fourth and fifth cer- vical nerves, and that the seventh cervical Tcriebra corresponds to the first dorsal nerve. The spinous process of the fifth dorsal vertebra corresponds to the origin of the seventh, that of the tenth to the twelfth pair of dorul nerves. Opposite the eleventh dorsal vertebra originates the first, between the eleventh and twelfth the second, opposite the twelfth the third and fourth lumbiir nerves. Between the twelfth dorsal and first lumbar vcricbra the fifth lumbar and first !uicr;il nerves take their origin, the other sacral nerves opposite the first lumbar vertebra. The cervical en- largement corre^pondit. ihctcforc, to the spinous processes of the cervical vertebra:, the lumbar enlargement to the spinous pro- cesses of the last dorsal venebr«. All these relations, and, moreover, the fact that the spinous processes, which alone can be our guides, ate not always on the same level as their corresponding vcrtcbrs, arc demonstrated in Fig. ija.
The relation between the white matter and the gray which it incloses becomes ap- parent in a transverse section of the spinal cord. Here we see also that an anterior and a posterior fissure divide the spinal cord into two halves. These fissures, how- ever, do not meet, but are separated from each other by the so-called "commissures" which connect the two halves of the cord. The anterior part of the gray matter, the so-called "anterior horn," does not present the same diameter and form throughout, and in the cervical and lumbar enlarge- ment is larger than tn the dorsal part of
fkU
I>li
m
'I
'^
10.
t.t[
S<
FiB 1.13.— Tn« RirtJiTioiii ow Titi Omoiw or -niE NmvM m THE Bonir.* oi' rltB Vui- risR.c *sc nil Srtnou* ymoatm*. (AfxrCowcM,!
4«
DISEASES OF SUSSTAXCE OF SPIXAL COftD.
the cord (cf. Fig. 134). From this anterior hom proceed the xnI^ rior nerve roots and |>aita through tlie white matter which 1ir« cxtet- nally. The posterior horn '\% much &inaller and extends alitum to
the entrance of the posterior roots, which reach it after passing through the external part of the postcfiw columns ("root zone" of Chai- cot). The arrangement o( the white s-ubsiance aod its subdivi- sion into columns and tracts b determined (1) by the existence of the above-mentioned fissures, (1) b)- the entrance of the nerve roots, (3) by the shape of the gray matter. We distinguish roughly an " antero-lateral column" and a posterior column on each side. The farmer contain (it) the crossed lateral or pyramidal tracts, {b) the direct cerebellar tracts, (^) the an- terior direct pyramidal tracts, also
Fig. lai.— ScHUMB OP TUB Coxournsc Paths in the Spixai. Coho at Tue
LaVKt. at IKl KirTH DoBitT. Nkhvk.
(Afur FLKClliia,) kv, anlerlor. ka. pcaterior root. «, direct. /, atjouA pf- niinldal irBCM. A, anitriiircoluninETmnd bundle, e, Ciell'* culumn. i, Ilurdoch't celumni. r txA /. vAx^ laltnU pftthk A, clireL-l cciebelliu Iracu.
called columns of TUrck or un- crosud anterior columns. The posterior columns consist of the col- umns of Goll (at the inner side) and the columns of Burdach, which latter have also received the name "root zone" (cf. Fig. 13 j).
I'hyKiologically, the spinal cord it primarily important as a great conducting system, and next as the seat of numerous centres. The motor impulses originate in the brain, and travel down along the antero-latcral column chiefly in the crossed pyramidal tract of iIk
IV- ■,»!-— CHow-sRCTiod T11H0UC11 Tiie SnHAL Conu at DirntHEirT Li:v»ul «.fcrf
o( (he trcond. #. \evt\ of the HTFnih frrvKal nrUrbn. c. lent o( the tBCOad. t. k"l of th« thud lumbar Trrtcbra. i.MlU QuAIX.)
Opposite side, the decussation, as has been repeatedly poinle<l out taking place for the most pari In the medulla oblongata, ThrOUE'' the large ganglionic cells of the anterior horns these crossed pytiB'' dal tracts are continued into the anterior nerve roots and le*^' as such the spinal cord. The sensory impressions are transniiK''' through the posterior roots, hence (some passing through the ^^
^am
TIIF. REFLEXES.
421
ttero-lateral columns) they reach the posterior horns and at once cross (over to the opposite side of the spinal cord. The further course of the sensory fibres as ihcy pass to the braiti is not clearly understood; especially imperfect is our knowledge with regard to those for (he different t|ujiliiie8 of «cniui(ton — e. g., the sense of touch. It seems, however, that the central frr^y substance mum be looked upon as the path for impressions of pain (of. the inve»iigatii>n» of Rdinger aliuat the continuation of the posterior spinal roota up to the brain, Anatom. Aniciger, iH^ iv, 4).
I We know that reflexes originate by the stimulation of a sensory nerve, lly thi» an impulse is conducted to a centre, and hence is transferred to a motor nerve — reflex ate (l-'ig. 135). Among such
Ifls. ijs-'-tti"''-rK Arc M, mmot puh. S, vimoFf jMik. mi, MMOf (oiiiBtM*, t,
PreAcx movements ue distinguish (1) sVin rellexes, caused by irrita* hion of the skin, (i) tendon reflexes which are produced by tapping Ion a tendon. To the former belong the plantar teflcx, the centre for 'which is situated in the lower part of the lumbar enlargement, the
gluieJil, the anal retlcx (Rossolimo, Neurol. Centralbt,, 1II91, 9). the icremisteric, and the abdominal reflexes, which arc obtained hy irri- |tating the skinof the buttocks, the anus, the inside of the thigh, and
the abdomen respectively. If we find these present in a patient we FiOiay assume the centres, n-hich are s.iiuaied in the lumbar and the [donal cord respeciii-ely, to he intact.
One of the diagnnstically most important signs is the condition ^of the ko-called palvllar reflex. When the tendon of the quadriceps
422
It/S£AS£S OF SVBSTAXCE OF SPIRAL COKD.
fcmoris is lapped, a reflex contraction of this muscte ensues by which the leg is jerked forward with more or lc«s vigor. This ii found in most hcallhy persons. It has been called by Erb "paieltiu tendon reflex "; by Westphal, who doubled its reflex nature, "knee phenomenon " ; by Gowers, " knee jerk."
To 3 certain e.xtent the mode of tapping this tendon and the position of ihe patient arc matters of indifference, The only points to remember are these : The lower leg should be held perfectly loose, and no superfluous clothing should prevent the proper Ktrikingof the tendon. The simplest way is to place the patient on the edge of a i.ibte, remove all etothint; from his legs, then, while conversing with him about indifferent matters so as to distract his attention from what is going on, to observe the effect of the percussion of the patellar tendon. The exact determination of the strength of the rcilex by means of the rcflcxograph (Ilechterew, Neurol. Centralbl., iSga, a) can be dispensed vriih in every-day practice.
If we find the rctU-K present, we may at once conclude thai the spinal cord at a certain place — that is, from the second to the fourth lumbar or first sacral nerves, according to Westphal — is intact.
If, on the other hand, the reflex is not obtained on the first and after repeated examinations, the patient ought to be directed to in- terlock his bent fingers and pull strongly (jcndrassik), and only if the knee jerk does not occur after repeated trials in the way de- scribed, should we assume its absence (Jcndrassik, Neurol, Central- blatt, 1885, iS). It has for some time been Jendrassik's experience that the tendon reflexes, more particularly the patellar refiex, is much enforced if the other muscles of the body are put into strong action (Dcutsch. Arch. f. klin. Med., xxxiii). Tliis method of Jen- drassilc is an excellent and indispensable means in doubtful cases fur establishing the presence or absence of the knee jerk. Sternberg has recently investigated various conditions under which the tendon re- flexes meet with inhibiting, diminishing, or increasing influences in the spinal cord (Die Sehnenreliexe iind ihrc Hedeutung fUr die P»- thologic dcs Nervcnsystems, Leipzig und Wien, Oeutike, 1895).
Itesides the patellar reflex, the Achilles tendon reflex, and the ankle clonus (the foot phenomenon of Westphal) must be mentioned. The latter consists of a succession of clonic contractions of the tendo Achillis which occur on a shaqj dorsal flexion of the foot. Tu the violent shaking movements of the whole leg, which occasionally occur under these conditions, the very inappropriate name of spinal epilepsy has been given.
If the reflex excitability is much increased, a simple tapping on the front of the lower leg is suflicient to produce a contraction of the calf musclci. This is what the English writers call the " front tap."
tOCALIZATtOy OF SPiNAL COHD LEMONS.
423
Whether all thcM so-called icndon reDexeii are really of refiex luature. or whether they are not rather phenomena due to a direct stimulation of the muscles (Wesiphal), is still an unsettled ques- tion.
The same tinccitainty exists about a symptom which has by Wcst- ll been (eimcd "paradoxical contraction/' and which consi&le in a \k remnininj; in tetanic contraction for quite a lime after it hus been passively shorleiivtl. For itistance, if we flex the foot of a puiient lying in bed, the tibialis anticus may under certain conditions remain for some time in a state of contraction; its tendon becomes prominent, and only gradually relaxes and allows the foot to return to its normal position of rest. Only rarely has this phenomenon been observed in other mu&cle».
Further, reflex centres are found in the lumbar region of the ttptnal cord for the emptying of the bladder and rectum, for the erec- tion of the penis and the ejaciilaiion of the semen — retlexex whit h are concernrd with the scsual functions. According to the tcscatches of Sarbo (Arch. f. rsych., 1893, xxv, >) the centre is situated between the levels of the first and fourth sacral nerres.
I.llKriATL-KE.
— ^Ldinbaril. Pie Varialionen tlrK norm-ilcn Kniesiotses und <ler«n VnUUtiuH ■ uir IMligkeit <les Cent r.>lneTvcn systems. Arch. f. Anal. u. lliysioL, 1889, ^^ Sujiplcmenlbanil, p. J^J.
KupfertxT);. nriing «ur Kcnnini« dcr Haulrrflne bci Nervengewinden.
Iiuuu.-Disterl.. Kreil>urj[. l88<». llcncilKt. tin>f,-cqtMlti4iiic Vdrwi.i!cndcsKnirpl)Jinonien«. Nnrol.Ct-niralbl..
18891 19- £rbra. Ncuc l)e'tn|[e rur Keniilni» dei RcUcw. Wiener med. Wochenschr., H 189a kI, 31 el u^.
'binkler. Localisation und klinischn Vcrhaltcn dcr Dauchreflcxc Deutsche Zritschr, r. Ncrienhk., 1891, ii, 4. EichhorsL l>anMtoxcr PaiclLtrsrhiKiirrflcx. CralnlM. f. blin. Med.. 1893. )i. 4>*tg«l, DiiklnUKhc IViifun); iter H.iulrcflexc. Deutsche med. WuclKASchr.,
1893.8. StfTitberg. Die Schtwrnrcflc^p un<l ihrc Be<lciitung fur die t'alhologic des ft NervduyMcms. LrijMis uiul \\'icn. Deultcke, 189].
With regard to the Iwali/alion of tbc spinal cord lesion. two quesliuns arise: (i) Which portion of the cord is dis- riued ? Ik it the cervical, dorsal, or lumbar? (a) Which part ol the cross section of (he cord? Is il the gray or the white
• matter, or boll) ? The first question can be answered without diAiculty In cases vthere the vertebral column is diseased : we only need to examine the latter by pressinj; upon the vcrlcbrae or by applying a but t>pongc. etc., over ihcm. Those spots at
424
D/SBASES OP SVBSTAXCE OF SP/XAA CORD.
which tcndeniess is cliciti-d by the apjilication ore the seal o( the disease. The occurrence ol spontaneous jNiin is rarer in diseases of the cord. It should, above all, be reiiictnbercd that lesions o( ihc spinal cord, as such, wherever (hey may be, almost never produce pain in the back, but that this is in a majority o( cases due to trouble in the muscles or their nerves. It is a characteristic (eature of these pains that they become especially marked after prolonged standing and stooping, and that they are very bad on rising in the morning. They may occur someiimes after a quick movement, in which case some muscle bundles have been overstretched or even torn. Pains in the back which persist lor months and years unaffected by any therapeutic measures justify a suspicion of the existence of an aortic aneurism which may be pressing against the vcrte. bral column or of enlarged carcinomatous abdominal glands (Johnson, British Medical Journal, February u. 1881). In dis- ease of the vertebral column, especially if it be cancerous, pain in the back is a prominent symptom, as we have said.
Hut, leaving out the tenderness on pressure, there are other symptoms which may help us to decide what segment ul the cord is diseased in a given case.
Diseases ol the cervical cord generally produce symptoms of motor or sensory irritation or of paralysis in the upper extremities, pains, parxsthcsias, feelings of weakness, jerkings. and the like in arms, hands, and fingers, to which may be added also trophic disturl>anccs. Muscular atrophies and loss of rellexes in the upper extremities arc often observed. The lower extremities, however, remain intact, and the patellar re- flex is present and sometimes increased. Repeatedly a very decided slowing of the pulse (as low as thirty-two beats to the minute in a case of Lebrun's. Bull, dc TAcad. de mid. dc Bel- gique. I, 1887, 1) has been met with in lesions of the cervical cord, and has been attributed to a chronic state of irritation of the vagus due to compression or some similar influence.
Affections of the dorsal cord arc mostly accompanied by sensory disturbances, parxsthcsias in the back, intercostal neu- r.ilgias, aching, boring pains, which sometimes radiate into the lower extremities. AnxMhcsias, though they are not the nile, may be found. If a distinctly circumscribed zone of anaes- thesia is made out, it corresponds exactly to the place where the lesion in the spinal cord is situated (c(. what wEU be said about lesions of one half the cord on page 456).
I
m^^
LKSfOXS OF TIIF. CXA Y MA TTER.
48$
Lesions of the lumbar cord eiUftil symptoms in tlic lower extremities, tfiving rise (o weakness and paralysis, sometimes also jerkirigs and stiffness; furthermore, lo pnins, numbness, anicsthcbias of the legs and feet. The reflexes are lost and vesical and rectal symptoms arc present, the former consisting o( retention or dribbling of the urine, pains, strangury, etc. Of course, the symptoms may greally vary according as the whole Iransverse section or only some or even one system of fibres alone is affected in the given level of ihe cord. Fracture of (be 6rst lumbar vertebra causes a lesion of the conus ter- minalis: a lesion at the level of ibe second lumbar vertebra and below it gives rise to affections of the cauda equina; the clinical symptoms of these conditions have been ably described by Valentine, who worked under Licblhcim ; besides (he symptoms above referred to, he has called attention to the atrophy of certain muscle groups (the glutei, flexors of the thigh, muscles of the lower leg and foot) and the reaction uf degeneration occurring in them.
An answer to the second (|uesiion demands a thorough ac- tpiaintancc with the symptoms produced by lesions of ilic dif- ferent portions of the cross section. These we will therefore now consider.
I. I.ESIOXS OK THE CRAY MATTER—" POLIOMVEl.lTIS.
In giving the name poliomyelitis (itoXm?, gray) to all spinal affections confined to the gray matter, wc must at once insist that these lesions are almost entirely limited to the anterior portion of the gray matter, the anterior horns, and more espc- cially to the large ganglionic cells in them. Other portions have only rarely been found affected, and then only in connec- tion with the just-mentioned lesiim. The diseases of the gray substance proper which have come under observation were confined lo the groups of ganglionic cells of which we have just spoken. Clinically, there are two such diseases lo be dis- tinguisbed. namely, poliomyelitis anterior acuta, or spinal pa- ralysis of children (infantile spinal paralysis), and progressive muscular atrophy.
CHAPTER I.
POLIOMYELITIS ANTERIOR ACUTA — INFANTILE SPINAL PARALYSIS.
Infantile paralysis, first accurately described by Jacob von Heine in 1840, is one of the best-known diseases of the spinal cord, both as regards its anatomical seat and its clinical course. As has been demonstrated beyond doubt by Charcot, Provost, and Jo0roy, it is an acute inflammation of the anterior horns, or rather, as is usually the case, of one of them. This leads to an atrophy and sclerosis, so that a dense tissue remains, con- taining the dilated vessels and small remains of ganglionic cells, which are not rarely found to be calcified (Friedlander, cf. Fig. 136). The seat of the process is usually either in the
Fig. ijG. — Transverse Section from the Cervical Portion of the Spinal Cord. Airopliy anil sclerosis of ihe right anterior honi. (After Charcot. )
cervical or the lumbar enlargement. In the former case the paralysis affects the upper, in the latter the lower, extremity. The secondary dcfjeneration, which ensues as a consequence o( the atrophy of the ganglionic cells, extends to the anterior
416
/XFA.VTILE SP/A'AL PARALYSIS.
4*7
nerve roots, the motor nerves, and the muscles supplied by Ithem. It is n genuine degenerative atropby, just as much as (he one described as coming on after peripheral paralyses.
Symptoms.— The clinical picture ol the disease is very characteristic. The onset bears a striking resemblance to that of cerebral infantile? paralysis, described on page 271. In the midst of perfect health the child is suddenly seized with head- [ache, vague pains in the limbs, and fever, the temperature reaching 104" F. or even more; he becomes stupid and som- nolent, and soon, while complete unconsciousness is developed. I general convulsions set in, which last usually from one to three 'days and then disappear The patient's condition becomes I better, consciousness is fully ri'gnin('<l. lie become*, bright and ulkalive, and the relatives think that the malady has already
Flf, ■a.'-'-An**!. InI-AMIU. rAMM-Y-
i
-mtlon).
Spent itself, when unfortunately a nu>re carelul examination re- veals that the movements of the child are impaired, that one,
'more rarely both, upper or lower extremities arc paralyzed.
'The paralysis, which usually affects one arm (Fig. 137) or one leg, has developed rapidly and reached a considerable extent.
428
D/SEASES OF SL'BSTAXCF. OF SPIMAL COflD.
which, however, is rarely mniiUained. On Ihe contrary, as ■ rule, it partially recedes and confines itself to certain mus- cles, which then remiiin permanently paralyzed. According lo Beevor (cl. lit.), the affection sometimes embraces groups of muscles corresponding lo those which Ferrier in his ex- periments on monkeys savv contract after stimulation of the djITcrcnt cervical nerve roots. In the majority of cases the paralysis takes in one leg. The paralyzed muscles rapidly atrophy, and the electrical cxcilabiliiy undergoes quantiiaiive as well as qualitative changes — reaction of degeneration. The whole extremity is stunted in its growth, and even the bones may be found several ccntimclrcs shorter than those of the other leg. The appearance of such an extremity, in which at first all passive motions arc possible, is quite characteristic. The skin is pale, cyanotic, and feels cold, but retains its sensi- bility completely. Skin and tendon reflexes arc lost, but there arc no vesical symptoms. Later on secondary contractures develop, among which Ihe so-called " paralytic clubfoot " is the best known. In consequence of the paralysis of the peroneal muscles, their antagonists, the calf muscles, become perma- nently contracted and cause the point of the loot to bang down. In the arms analogous conditions may be found, the non-paralyzed antagonists always assisting in the production of the contractures.
Roughly speaking, this is the course in most cases, only occasionally the initial fever may be slight enough to be over- looked and the paralysis develop without the child ever ha%*ing taken to his bed. In rare cases the convulsions, instead of last- ing for days, continue for weeks. In others, again, several months may pass before the onset of the actual paralysis: but all these arc the exceptions, which need not contuse us in mak- ing a diagnosis. The further genyral development (with Ihe exception of that of the paralyzed extremity) is perfectly nor. mal. and neither, as happens in the cerebral infanlile paralysis, does the mind become in any way impaired nor do the initial convulsions ever recur. The child grows up in gmxl health, but always remains, especially if one leg is aflected, a cripple. It. as often happens, contractures or a spontaneous paralytic lux- ation o( the hip develop, the patient has (or years to be under the care of the surgeon, and needs braces and the like. K an arm is allcctcd. the capability of the patient for making his liv- ing is naturally considerably and permanently intcrtcrcd with.
\
/Xf^.Vr/Ui SPINA/. PARALYSIS.
4*9
^
Diag;nosis. — It is not difficult to avoid mistaking the disease lor an)' other it we bear in mind the characteristic onset, the lociilizalion, the behavior of the [Kiralysis itself, the flaccid con- dilion of the muscles, the absence of the reflexes, and the cold and cyanotic skin. Where we find a hemiplegia — i. c., where the arm and leg of the same side are paralyzed — we should in children always first think of infantile spastic hemiplegia (page 371), as it is one of the rarest exceptions for the spinal paraly< sis to take on this distribution. Confusion with the syphilitic pseudo-paralysis, also known under the name of Parrot's dis- ease, is avoided by remembering the fact that in this disease the panilysis makes its appearance iromcdiatcly.orat least wilh> in a few days, after birth (Dreyfouss, Revue de mid., aofit i8$5.
while Heine's paralysis of children does not occur at such
early age.
Prognosis.— The prognosis, as soon as the iniiLil acute Kvmploms have passed, is, so far as life is concerned, absolutely favorable ; so far as the recovery of function in the affected ex- tretnity is concerned, equally unfavorable. Any notable im- provement is very rare, complete cure out of the question. These points should be carefully considered before inducing a poor and struggling father to let his child undergo year after year .in expensive and useless course of treatment.
iCtiology. — Of the ;etiology of the disease we know noth- ing. It is doubtful whether cold is ever a causative factor. It (s possible ihat infectious influences, the action of certain micro- organisms, will at some time be proved to be the cause of the disease. For the present, however, this is nothing more than a hypothesis which has not gained any firmer ground Irom the report of Cordicr of an epidemic of the disease (Lyon m£d., 1888, I, 2). In a small village thirteen children were inside of (wo months taken ill with anterior poliomyelitis and four died. According to Cordicr, the appearance of the disease in sum- mer, the sudden onset, the similarity in course, speak for an infectious origin, the infection, as he supposes, taking place through the air passages.
Treatment. — Little more is known about the treatment than nbout the aetiology. All measures to cure or even merely to improve this rapidly developed paralysis are more or less use- leiLS. Electrical treatment with the faradic or galvanic current, fcystematic massage, gymnastic exercises, together with rubbing with all sorts of salves — all these have been tried without any
430
DISEASES OF SUBSTAXCB OF SPINAL CORD.
noteworthy success. In a few cases 1 have seen the mclhiKl- ical use of heat, in the form of hot sand baths, warm packs, etc.. bring about at least a pcrcepiible impro%'en:jent : but even here this was out of proportion to the care and trouble which had been taken. Certain it is that the influence of the different baths has been greatly overrated, whether it be the brine baths of Kvcuznach, Hclchenliall. Kolbcrg, or the chalybeate springs o( Pyrmont, Flinsberg. Schwalb;ich, or the sodium waters of Kchme, Soden, or, finally, the non-medicated hot springs ol Castcin, Johannisbad, and many others, each of which has its advocates. The most appropriate appear to be those last mentioned, but in most cases we shall even then find that while perhaps the child's general condition is improved and it becomes strong owing to the good hygiene and fresh air. the paralysis, (or the sake of which all has bten undertaken, remains absolutely unchanged and presents no improvement.
In view of these unsatisfactory results, the interesting but still scanty communications, according to which the growih of bone can artificially be increased, deserve our deep interest. In 1887 HeUcrich proposed to tic round the affected (paralyzed, atrophic) limb elastic rubber tubing so as to pro<luce an arti- licial engorgement, and through this a more active nulrition of all the tissues, including the bones. Schtiller also bus re- ported before the Berlin Medical Society, November 28, 18S8 (Deutsch. Med.-Ztg., 1888,99, page 11S2). several cases which were thus treated and which showed decided improvement Tu judge from his communication, this treatment undoubtedly should be tried in all suitable ciises. It is, however, a proced- ure which, as well ,^s the orthopaedic Treatment so important for the prevention of dcConniiies, should not be undertaken without consulting u surgeon.
I I
I
I
UTIvRATURE.
Charcal. t.«ctUTeii on the I)i>ea-«cs of the Nervous SjrKiccn, driivered at La
Salpttriire. Tr.iiulaicd by tieorgc SJgcrwn. New S}HknlMin Society.
L.on(ton, 1877. FrierilKnder, C. Uebcr Vcrk.ilkung der C.-in);)icnzelten. Virchow** Archlv,
1881, S8. t. Rockwiix, Deutsche Zcilschr f. Chir,. 1883. \\t.. i. 3. Sahli. PcutwhM Arrhiv f. klin. Med.. 1883. xnxiii. 3. 4. Loreni. Ueber die Entsichung der Gi-lenksconlriW turcn nach spinaler Ktmt(r>
IShmuiig. Wiener med, Woehenschr., 1887. 17-31. K.ucn-iki. Die der ijiinalen KliiilerlSlitDUdS Tol^ndcn CelcnkscontracturcD
a/ftoytC AMTESIOK POUOMYEUTIS. 431
und die panJyttschc Luxation dcr Hurtc Archiv f. klhu Chir., 1888, 37, 3,
p. >t6. Rkdcr. Hermann. Pdiomyvllils ant. acuU. Miincli. mrd, Wocliciuchr. 1889,
%wn. 2. Luknburg. SubKuteamyi>trophiKheSpinullahinunx'*><t pandyibchn^SchultM^
Krirnktnohlaffung. Hchaxidluiig durch Anhioilesc. Ikriiner klh). Wo
chciuchr, 189% 4, ;, 3S, Ko*rrit>rrg. Die DiOcrtnialdiagnoM iter Poliomyclilb nnlrrior acuU uixl
chronic.-i adultoruin und dcr Neuritis roulliplox. liuug.-Di&Ktt., HciikU
berg. 189a Gokbchckler. Veber Poliomyelitis anterior. Zeitschr. Ttir klin. Med., 1893,
ixtil. Heft ;. 6. Stcmcrling. Acuter Befund bti spin.iler KindeTl;thmur>|[. DeutKlie Nfcd.-Ztg.,
1891,96. Kohnaumtn. Schr)iitscrien Uiitcrxuchung eincs Fulles vod ipinalcr Kinder-
Uhmung. Ibid,, p. 556. Miirie. P, Lefoftt sur let maladies dc la moclk. Pnris. Masson. 1891. (This
work should be consulted Tor each chatilcr of this ponioit.)
Though the lesions of the gray anterior horns when occur- ring in children are well understood, both in Iheir nnutomicul and ihcir clinical aspect, yet when the same process takes place in adults our knowkd^e becomes very tiinited. Merc the mu- lerial at our disposal is still so small that only in rare excep- tions can we say definitely whether we are dealing really with an anterior poliomyelitis and not rather with a peripheral dis- ease, a multiple neuritis. Clinically, the dilferenlial diagnoi^is between the two can only be made in the initial stage, as the jtcriphenil disease is accompanied with pains and sensory dis- lurhatices which arc absent in the central aflcction.
A patient is taken ill with grave general disturbances— (ever, somnolence, convulsions, delirium, etc. — and within a shun lime, perhaps in one or two weeks, a widespread paralysis in all four extremities is developed. The paralyzed muscles become flaccid and atrophy, the tendon reflexes disappear; sensation, however, as well as bladder and sexual functions, present no abnormity. With a history like this we must think of a lesion of the anterior.gray horns. Thi* idea becomes more than a conjecture if on examination the aiTt-cied muscles are found to be such as arc supplied from ganglionic cells, which m<ist probably lie in close proximity to one another in the spinal cord. In such cases, as Kcmak has shown so bcaulilully. certain types of paralysis arc observed — the forearm type (paralysis of all the extensors without the supinator longus) and the upper-arm type (paralysis of the biceps brachialis
432
DISEASES OF SUBSTA.VCE OP SPINAL COKD.
amicus, delloid, and the supinator lungus) — but unfortunately such instances arc rare, and therefore even quite an experi- enced physician may feel uncertain about the diagnosis.
The difficulty becomes greater if the paresis or paralysis is not extensive and does not develop rapidly, but slowly and by fits and starts. In these cases not rarely a temporary improve- ment may be noted and arouse hopes of complete recovery, unfortunately never justified. These arc the instances in which we find not complete but partial reaction of degeneration in the paralyzed muscles — intermediate form of chronic anterior poliomyelitis (Erb), It %iiz% ivithout saying that wc must have the other symptoms, especially the loss of reflexes, even to jus- tify a conjectural diagnosis. Moreover, it is necessary that there should be absolutely no sensory changes, and that bladder and sexual functions should be normal. Of the points of difference between anterior poliomyelitis and tabes we shall speak later.
We can hardly expect much from any treatment. Elcc tricity, however, should be tried, if for no other reason tfian that something is done. Duckworth recommended, besides, belladonna, iron, quinine, and cod-liver oil, and claimed to have cured cases with these remedies.
With reference to the aetiology, nothing certain is known. Whether traumatism can ever cause anterior poliomyelitis re- mains dnubtful, notwithstanding the report of Gibbons (Mod- Times and Gazette, September 5. 1885). He had among his patients a hoy nine years of age who after a fall on his knees developed the symptoms of an anterior poliomyelitis (and re- covered completely !). In cases of chronic anterior poliomye- litis which came to autopsy, sometimes atrophy in the gangli- onic cells of the anterior horns through the whole length of the cord, as well as atrophy of the anterior roots, was observed, while the peripheral nerves remained intact (Oppenheiin).
LITEBATURE.
Eib. Ut'Iier (la^ Vorkommeti der chnn.-atmph. Sptnnllthmting l»fm Kini't
Neurol. Ceniralbl.. 1883, 11, B. Remhanlt. Virchow'it An:hiv. 1883. Rd. 9s, p. 3691 Duckwonh. Clinic.nl Lecture on Subacute Anterior Spinal Paraljuit (A*
Comual Myelitis) in the A<lii1t. Lanrci. November 14, i88(. Lecleic ei Bliinc. I'aralyiiic spinale dr Tadultc. Lyon mdd.. i886h $1. Buss. Eln scltener Fall von airopliiicher SpinallShmunj; ([\iliom ant. cb""
adult.) mit Uc'icrgAHg in ficulc B;ilb]trmyelitis. Berliner kllii. Wochcnviit'
18S7, No. a«.
\
caxomc anterior poliomyelitis. 433
Oppenheim. Ueber Poliomyditis ant. chron. Deutsche Metl.Zig., 1887. 95,
p. 1087. Oppenheim. Arch. f. Psych, u. Nen'enkr.. 1888. xix. 2. p. 381. Raymond. On Essential Myopathies. Gaz. des hop., 1888. i$o. Hoffmann (Heidelberg). Ueber progressive neurasthenische Muskelatrophie.
Arch. f. Psych. U, Nervenkr, 1889. xx, 3. Hig'ier. Ueber primSre und secundSre Amyotrophien orgnnischer und dy-
namischer Natur. Deutsche med. VN'ochenschr., 1893, 37, 38.
19
CHAPTER ir.
ATROPHIA HUSCULARIS PROGRESSIVA SPINALIS PROGRESSIVE
MUSCULAR ATROPHY.
Progressive muscular atrophy was first described by Du- chenne and Aran in 1849 and 1850, and was recognized by Cruveilhier in 1855 as a spinal affection. Thanks to the work of Lockhart Clarke, and especially that of Charcot, the occur- rence of a pathological process restricted to the gray substance of the spinal cord, which is accompanied by a muscular atrophy of typical distribution, is now established beyond the slightest doubt.
Pathological Anatomy. — The process, which is usually most pronounced in the cervical cord, consists again of an atrophy and transformation of the gray anterior horns into a fine fibrous tissue containing spider cells. The large ganglionic cells are partly or wholly destroyed, or at any rate are diminished in number and perceptibly smaller. Here, too, the lesion extends to the anterior nerve roots and corresponding fibres of the motor nerves. On microscopical examination we find that ihe muscles supplied by them retain their transverse striation, bul the fibres are decidedly diminished in size. Some fibres also show the so-called degenerative atrophy — that is, a fatty, wai- like degeneration, with increase of the interstitial conneciivc tissue and multiplication of the muscle nuclei. Which of the described processes has to be regarded as the primary one, in other words, whether the disease actually does start in ibe gray matter of the cord, and not perhaps in the peripheral nerve endings; whether both processes may occur at the san"^ time, or whether they may succeed each other in the same individual, and at what age they occur, all these points have recently given rise to much controversy, as has also the qufS- tion of the importance of hereditary influences. Those who wish to inform themselves more thoroughly on this subject are referred to the articles by Hoffmann (Deutsche Zeitschr. '■
434
PftOCKESSfVE MUSCULAR ATROPHY.
435
'Ncrvcnhtilk., 1893, Hi, 6. p. 437). Strlimpeil (ibid., p. 471). Bern- luirilt, Ueber die spiiwl-neurolischc Form dcr Muskclatrophic (Virch. Arch., rSgj, cxxiii. Heft 2), and others.
Symptoms. — The onset of the disease is in many cases very characteristic. The p.ttirnt begins to complain of weakness in the arms, sometimes more in the right than in the left, which soon interferes to some extent with his ordinary actions. Sen- sory changes and pains are absent — a point which is of vast diagnostic importance. Not many weeks after these symptoms ha%*c appeared the competent observer will notice a peculiar flatness, a sunkcn-in condition ol the ball of the thumb, while at the same time the thumb is more than usually approximated I to the second metacarpal bone ("ape hand," Fig. 138). The ' intcrosscal spaces on the back of the hand are sunken in and
lA ij»— PRooHuugvK UVMCUB ATlMniv. {M^»t KictiHomcT.) ('!(. ijS. •(• bawl Fls- 139^ MnlMB^B tniarauaiJ •pan* oa ilv l>Mk o4 th* haod.
terminal phalanges of the fingers are in incomplete exten- sion (Fig. 139). The hollow of the hand seems flattened (atro- phy ol the lombricalcs), and the atrophy of ihe muscles of the thenar and hypnthenar becomes more and more apparent. As Ihe lunctiun of the intcrossci becomes disturbe<l to a greater extent, the same claw-like position of the fingers develops which has been described on page 349 as occurring in affec- tions ol the ulnar nerve (" claw hand," "' main en gf'ffe ")■
After this condition has thus for weeks or months under-
no marked rh-tngc. the disease bcginfi lo attack cither the
:lcs ol the fureariii, or, passing over these, implicates the
436 DISEASES OF SUBSTAXCE OP SPf.VAl COKD.
muscles of the shoulders and with special preference the del- toid. In the former case the extensors arc attacked earlier and more seriously than the flexors. The muscles of the trunk and legs are cither later or never aflcctcd, but if invasion of ihe diaphragm and other respiratoiy muscles occur this may prove
Pif, l^a— PHI0*HIE»IVC bl-lNAL UUSCULAK
' pcnan»l otaenalinX
fatal, as may also an extension of the process from the cord w the medulla oblongata, in which case the symptoms of pr^ gressivc bulbar paralysis are superadded (page 154). U 1^'* do6s not take place and the respiratory muscles arc spared, the disease may last for years and tens of years, and death ison'j caused by an intercurrent acute malady.
fe
i
PROGKBSStVB MVSCULAK ATROPttY.
4J7
Apart from the characteristic onset, the following signs help to mak<; the diagnosis certain; 0) Fibrillary twitchings in the adecied muscles, which can at limes be produced by tap- ping the muscles, but which are often seen to appear of their own accord and continue without interruption. (2) The con-
ns- Mi.^PnooscMiVB SniuL Mi/kllar Atrotiiv (paraonal ofcwrvuloa).
diiion of the electrical excitability, which depends directly on the number of muscle fibres left. If the greater number of the libres are wasted, then the excitability for both currents is equally decreased. If all the fibres of a muscle have disap- peared and only fat and connective tissue remain, the excita- bility of tbe muscle is completely lost. It is only exceptionally
438
e/SSASES OF SUBSTANCE OF SP/.VAL CORO.
that the excitability also tmdcrgocs qualitative changes and wc find reaction o( degeneration. (3) The loss of the tendon re- flexes, which is sufficiently explained by the disappearance o( the ganglionic cells, a part ol the retlex arc. 1 1 is only because the lower extremities arc rarely aHccted that the patellar re- flexes arc usually retained. (4) Sensibility remains everywhere and lor all kinds of impressions intact (touch, pressure, pain, tempcmlure). The coldness and bluene$s of the hands is to be attributed to the disuse of the muscles. True trophic disturb- ances of the skin, as well as bladder and rectal symptoms, are usually ab.scnt-
Diagnosis. — Remembering, then, the different points just alluded to, the diagnosi.s should be easy, and it will not be difficult to avoid confounding the disease with myelitis, neu- ritis, or syringomyelia. The flaccid paralysis, the absence of all symptoms of motor irritation and sensory disturbances, is especially of moment in differentiating this disease from mye- litis. More particularly characteristic is the commencement, the onset of the disease in the small muscles of the hands. If this has been well pronounced, an error in diagnosis is unpar- donable.
.(Etiology.— With reference to the aetiology a little morci* known about this disease than about spinal infantile paralysis; for certain cases at least it has been shown that overexertion of the muscles, as happens sometimes to those who work with the sewing machine, has a causative influence, or at any rale the disease has been preceded by some overexertion of ihc muscles, to which we are then justified in attributing an :clio logical importance. The conditions, however, under whic^i paralysis and fatigue of the muscles lead to atrophy — why, \*j^ instance, the serratus magnus (Chvostek) is in some cases first thus affected— we arc wholly ignorant of, just as wc not know the conditions under which the genuine hypertropl — ^H develops which wc often find in the biceps of blacksmitte""^' Recently, again, attention has been called tu the f.ict that tH disease may be hereditary, by Bernhardt (\*irchow's ArcH 1889, 1 15. 3) and by VVerdnig (Arch, f, Psych., xxii, 3).
Little need be said about the therapeutics: there is ir effectual treatment, and all measures that have been tri have not been efficient in hindering tlic progress of the di ease.
I
LBSiOAS OF IVt/lTE MATTER OF StINAL CORD.
439
I
I
LITERATl'RK.
Chvosiek. Oesicrr. Zdtschr. \. praki. Hcilk.. 1871, svii, 13-16.
LcKklun, Ciller. Mcij.-Chtr, Transact.. 187}. Ki. p, 103.
Charcot. Leciurt;^ i>ti [he ni-icaio of the Nervous System. dHivrivd at the
Salptlh^rc. Tr^n&taied liy G«orgc Sigerson. New ^lieitham Society.
LomIoo, 1877- Pierrei ei Troiwcr. Arch, tie phifiiol., 1875, imc \k\.. it, a. Bode. Caituist. Rciirttgc (tir Actiologic. Symplomc und Dutgnusc dcr progress.
Musk«blru|>hie. Inaux-Disten.. Halle, 18S1. Westph*). Charlti-Annjlen, tSSti, kI. p. 357. {riogreuive Muscular Atiopliy,
with Implication cf the Facial Mu*ctcs,) Schuliic. F. Ucbcr den niil Hyiicrlrophic vcrbiindcnen progrenivcit MuskeU
schvmnd und flhnllchc Krankheiltfotmen. Wieshadcn. Bvri^tann. 1886. Landouiy « Dejerine. NoiivcUcR rechcrches cliniqun « aniitotna-p.itholo|;i(iues
Kir la mjropaihic airophiigue pro|[icsMve 1 piuiiot de sis obHcrvatiiinK nou-
fHles doiil une at-ec auiop&te. Kcvue dc ni^d., 18S6, vL I3. 977-1017, Charcot et Marie. Sur unc (oime paniculi^rc d'atrophic niuKuUirc progmsirr,
etc. Ibid.. |SS& vi. 3, p. 97. Lailanve. Coniribuiioit A r^ludc dc la myopallitc airophlque proKfruivc. Ibid.,
1886. vl. lo, p. 817. Sirumpcll, A. I>cuim;I)cs Arch. f. klin. Med.. 1887. Dd. KUi. 1-3. p. 330. Itcrnhardt. Ucbcr clncn Fait von (juvcnilcr) progrriiuvrr Muthrtairophie mil
B«thc)lt{CunK der GeaichTunuiCulatur. tkibiicr Uiit. Woi:hcnM.-hr.. 1887,
No. 41. SpUbnann et >tnu«halter. Obftcrt'aiion de n^yopatbie proi^ressire primitive 1
type facio-iapulo. humeral. Kcvue de n><d., 1888. vi Rsymond. Alroi^ks muKulaircs et tnalailies airophi<|urs. Paris. Doin. t889. Sach*. TbcPcroncalKonnorLcg-(>i)caM'ro|[rc»ivcMu»cuUT Atrophy. Br«m,
189A »)»ii'. p. 447- OoinbdulL Sur I'^iat des nerfs |>^ri|thH()Ucs dans un cas de mj-opathie pro-
gmsirc:. Arch de m^l expirim.. iS'^o. t. 4- S- BemhJtnlL Ncurtipatholi>t;iKlic lleubachtungen. Zdtftchr. f kbit. Med., ivii.
Suppl.-Hca. 1889. FRyhan. Ihid.. 4. 1891. x<(- Bfwu. Schmidt'i Jahrbuclier, 1894. ccxti. No. 3.
II. LESIONS Ol' THE WHITE MATTER OF THE SI'INAL CORI>— •* LEUCOMVE LITIS."
While, as wc ha%-c said on page 434, the lesions affecting [the gray mailer (poliomyelitis) arc almost entirely confined to I one portion of il — namely, the anterior horns — we shall soon see th.it this is dillcreiit with the lesions of the white matter, W which the general name Icucomyclilis may be given (Xnwet, white). Here different parts can be attacked, cither alone or in conjunction with others, and it is of great importance to diUcrcntiate between the clinical symptoms which occur in
44°
D/SEASSS OF SVBSTAKCe. OF SPIJfAL COKD.
ihc diseases ol the different columns or "systems" (Flechsig), hence called " system diseases."
The afTectton is either a primary one. when it is often im- possible to ascertain any xtiologica) factor, or it occurs sec- ondarily and as a consequence of certain affections of the brain and the spinal cord itself, such as traumatic inftamma- tiotis and compression. We shall consider both separately.
A. Primary Lesions of the White Coiumns.
Regarded from an anatomical standpoint, the primary' tract- degenerations of the white substance consist in adestrSctionof the nerve fibres and a simultaneous increase of the neuroglia. The medullary sheaths are the first to disappear; the axis cylin- ders, which are more resistant, do not degenerate till later. Compound granular corpuscles, which remove the detritus from the diseased regions (Ziegler), accumulate in the lymph sheaths of the vessels. The increasing neuroglia crowds in and displaces the empty ncI^-c tubes, a process which, in con- junction with the thickening of the walls of the vessels, whicb develops at the same time, is described under the name of scle- rosis, or gray degeneration.
An affection confined to one nerve tract or system has up to this time only been observed in the anlero-lateral but not in the posterior columns. In the former, the anatomical arrange- ment of which has been described above, we meet especially frequently wilh sclerosis of the so-called crossed pyramidal tracts, ibut the lesion does not necessarily extend over the whole length of the tract, but may be only partial (Westphal)' Most of the cases which have come under observation were, however, not pure instances, but presented other anatomical changes as well, and there is only one case reported, by Drcschfeld, in iS8i, which, viewed from an anatomical stand- point, can pass for a pure lateral sclerosis.
The primary sclerosis of the lateral columns — spastic spinal paralysis, tabes Jorsale sptismodiqiie — was first described by Erb and Charcot in i^y^, and characterized by them as a motor paralysis with remarkable increase in the tendon reflexes; and, indeed, if we examine such patients, all we find is that they have lost to a greater or lesser extent the use of their legs; they arc unable to walk, the feet arc glued, as it were, to the floor, and the patient can only shutTlL- along, the inner margin of the foot never leaving the ground. At the same time the
PKtMAKY /.ES/OXS Of THE WHITE COLUMNS.
441
I
muscles feel tirm and hard, the leg^ arc in extension, and any attempt at flexion is diflicult. 1( such a patient is made to sit on the edge of a tabic the legs do not hang down flaccidly, as might be eicpectcd, but are thrown into a state of tetanic tremor, produced by contractions of the quadriceps extensor. There is an enormous cxaggcratinn of the patellar reflexes, and IIk' ankle clonus is obtained without the »li{{hlcst difliculty. With the exception of the inability to walk, the patient has no subjeclive complaints; neither sen&alion nor the functions of the bladder, rectum, or the sexual apparatus show any abnor- mity. An implication of but one of these would at once exclude the diagnosis of lateral sclerosis, as would also (and this should be especially remembered) the existence of any muscular atrophy. The very characteristic spastic or spasiic- paretic walk of the patient, the traces which his feet leave on a gravel path, for instance, and which can be followed up as distinct continuous streaks, the shuffling noise which accom- panies every step when he attempts to walk about the room, these ire of great diagnostic value; the examination of the soles of the patient's shoes, which appear thinner and moi% worn down on the inner side, will be of interest and value.
The disease may be congenital (Lorcnz. Ilernhardt, cf. lit.), and may occur in more than ore member of the same family, as wc have slated above (page 274), but it oltcn begins later in youth or in middle life, attacking first the one then the other leg. without, as a rule, extending to the arms or trunk, yet the upper extremities arc said to be occasionally affected (Slrilm- petl). The disease may last years or tens of years without pre- senting any decided change for the worse. Death is brought about by intercurrent diseases. It is not known whether, as in progressive muscular atrophy, overexertion is of a;liological importance ; instances, however, in which acrobats (Donlcin) and bod'Carriers (Munler) yt^rt attacked seem to suggest Ibis. Mof^an pointed out that exposure to cold, such as long standing rn water, may be the immediate cause of the disease (Mortem, l^incel, January 19, 1881).
The form of spastic paralysis, analogous to a tabes devel- oping on a syphilitic basis, which has been regarded by Charcot ua transverse syphilitic myelitis, and which has been studied carefully first by Erb. later by Muchin, P. Marie, and Kowa> lewsky (Neurol. Centralbl., 1893. IJ). must be regarded as a dis- tinct disease. It occurs much less frequently than tabes, and
442
D/SBASES OF SUfiSTjtXCK OF SP/XAC COKD.
differs (rom the spinal paralysis just described, inasmuch as here wc find sensory and trophic changes as well as eye<musclc paU sies. The differential diagnosis may. however, be impossible.
Much more (reqitcnt than a lesion confined to the crossed pyramidal tracts is one which implicates not only these, but with them the posterior columns and the direct cerebellar tracts, in which, although not always, Clarke's columns take part. The anatomical character ol this "combined system disease" which results from these lesions h.is been repeatedly described (Westphal, Gowcrs, Striirnpell). The symptoms vary according to the distribution of the lesion; thus, if the disease of the lateral columns extends low down, while the posterior columns in the dorsal and lumbar region present no changes, rigidity of the muscles and increase of the reflexes M-ill be found. If. on the other hand, the disease in the poste- rior columns extends farther downward, these symptoms will be absent, the lesion in the lateral being neutralized, as it were, by that in the posterior columns (Wcstphal).
Not rarely tlie affection seems to depend on faulty devclo|>. ment, a condition which wc may meet with in more than one member of the same family, and which may be hereditary. In these cases the disease appears in early childhood, and. as wc said, sometimes in several children of the same family. It has been called, after the author who first described it, Friedreich's " hereditary ataxia." Senator (cf. lit.) has called attention to the possibility of a congenital atrophy of the cerebellum, the meditll.1 oblungata, and the spinal cord. The motor disturb- ances in the children begin in the feet, the walk becomes awk- ward, lliey stumble, and in passing over small obstacles have to look at their feet to keep from falling, etc. (Fig. 142). The paicllar reflexes disappear; the arms are not affected until later, and, indeed, they are by no means always implicated. The second motor disturbance establishes itself in the muscles of the tongue and the lips which are necessary for speaking, and this produces a very characteristic defect of speech of mo- tor origin. Finally the muscles of the eyes become implicated, and there resulls a distinct nystagmus. The combination ol these three symptoms is pathognomonic for this rare disease. It has no connection with tabes and sensory changes, and blad- der symptoms, manifestations which arc probably never want- ing in cases of tabes, are never met with in the disease under
y
fJt/EDRElCJfS D/SEASK.
443
'considcrnlion. Korean it be mistaken for multiple sclerosis,
I ns vertigo and "scanning speech " arc never associated with
it. The course is tedious, the prognosis always unlavorable,
the muscles undergo atrophy in consequence of inactivity, and
contractures occur in the joints.
Similar symptoms arc obscr\'cd in adultH in cases of com. bined lateral and posterior sclerosis ; yet there arc certain peculiarities to which Cowers especially has drawn attention.
Vic- Lfi-— FMcnncinil DiauuiK. The imkni it Iwld uixWi ihc irau. (Alur CHAurrkHD, i (SMtuio* mM.. t^a, N<i. jj.)
i'Thc disease was named by him "ataxic paraplegia." The lower extremities are ataxic and paretic, which gives rise to an H uncertain, swaying walk ; but this is associated with pararsthe- Bsias, weakness ol the sphincters, and decrease of the sexual ^bpwer. The patellar reflexes arc at first increased, and only ^8? times become lost later in the disease. Such an increase is never known in hereditary ataxia. During the period of in- crease, rigidity of the muscles, spasm, and ankle clonus are present. It is evident that cases of this kind may be mistaken
444 D/SF.ASES OP SVBSTA.VCE OP SPIXAL CORD.
fur tabes, especially if the patellar reflexes are alisent, as excep- tionally occurs. Then the history may be of use to us, as syphilis seems to possess no etiological importance whatever ill ihc combined sclerosis, while exposure lo cold and over- exertion seem to be of considerable moment.
LITERATURK.
Sfaitit Sfinal Pantfyiii.
Le>-[lcn. Arch. f. Psych, u. Ncrvenkrdnkh., 1878, viii, i, p, 761. (Experi-
meniatly l^roduced Spln^tl Kctcrosi&.) Mdbius. y.\n ipruiiichrn Spin iil paralyse. SchmiiJt's Jabrb., 1880, Bd. clnmiii,
p. (15. (Miiny red- nn CIS.) Donkin. Biit. Med. Joum,, December 9, 1B81. {Spastic PampIegU in an
Acrobat.) WcsiphdI. LVber cincn Fall von sog. spastischcr Spiiulparalyse nut anaL
Qcfunik. Arch. f. Piych. u. Ncrvcnkmnkh.. i8!<4. xv, I. 214. Pitres. Un cas de paralysic g^n^rale splnak sntcrlcure tubaiguC suivi d'auiop-
sie. I'rogr. miA.. 1888. 35. Knmh. I'lbcr ^pa^iischc SpiD.-itparalyse mit Dementia paralytica. Kiel. 18SJ, Kicli:inl«i>n. Cum o( Infantile Spastic Paralysis. Lancet. November. 188S,
ii. 19- Biiicli. Ikitrilgc lur Pathologic der spaitischc-n Spinal paralyse. Inaug.-Diuert.,
Bcrlm. iSyOL Fecr. Ucbcr die angeborcne spnslischc GlicdiTstarrc. Mttlhcil. nus item Kin-
dertpiial zu Iktsid. Jahrli. f. Kindcrhcilk., 1B91. pp. 116-190. l^reni. Lieber angehoreiie ipailische Paralyse. Deutsche Med.-Zlg., 1891,93. Williamson. TheChsngrs in ihf Spinal Cord iii a Case of Syphilitic Paraplegia;
.Sclerosis of the Lalcr^il I'yrairid.-il Tracts. an<l Goll's Columns with IV-
rlphcral Sclerosis. Medical Chronicle, Manchester, 1891. xiv. pp. 36(>-i;c> £rb. Ucbcr syphililischeSpiiialptralyse. Neurol. Ccntralbl,, 1891,6.
Fritdttifk't Ditftiif,
Drnuue. Dc I'ataxie h^rjiliiaire. Paris iSSi. (Maladic tic Friedreich.)
Kijtinicyer. Virchow's Arch., 1883, Bd. xci, 2.
Erlcnnteycr. Ceniralbl. f. Ncrvcnhctlk., 1883, vl, 17.
Wille. Schweixcr Currespundenzbl,. 1S84, xiv, 3.
Musso. Riv. din,, 1884, xxiii. 10.
Longuet. l.'Union, 1SS4, 73.
Schuixe, F. Aich. f. Psych, u. Ncr\-enl(r3nkb.. 1884, xv, 1. p. j6a.
.Seguin, Nc* Yiirk Med. Record, 1885. xxvii, 19.
Sinkler. Joum. of Ncre. and Mem. DiscJtscs. i88j, xii, J.
Ormcrod. Mcd.-Chir. Tranwcl., iSSj. Ixriii, p. 147.
Jud»on, S. Bury. Brain. July. 1886. ix.
Slintiing. MUnch. nicd. Wochenschr,, 1887, Bd. xxxiv, 21.
Charcot. Progr. m6d,. 1887, 13.
Rulimcycr. Ueber herediiSrc Ataxic. Virchow's Arch.. 1887, 1 10, i.
Ormerod. Hrain. 1888, xxii^ and xl.
Gilles de la 'ruurclte. Noui-. tconograph. de la Salpjir., 1888, 3.
SSCO.VDAJtY ISS/O.VS Of THE WHITE COLUMNS.
445
I
\t. Li malaxtie i)c Friedreich. CicnKr, Schuchtrcit, 18S9. Dtjrrinc ct Lclulte. La nulodie de FricUreich. Me<t. Modeme, 1890, i. 17. p.
331. Mcniel. Arch, t I'tych. u. Ncr^^nkrnnkh., 1S90, p, 160^ l)t<x^q « MjriitMCo. Arth. cic Neurol.. 1890. xw. No. 57. Mml Cumplcic Sclerosis or Coil's Columns and Chronic Spina) Lcplotnen-
ingilis, wilh Detfenerative Changes In ihr Fibres of the Anler. nnd Posl.
Roots. AnicT. Joum. Med, Sciences, a. Januiiry, 1891. Ccieel, R, Ueber hemliiare Ataxic. Sil7ungst>ericht dcr Wiinburgcr ph)-).-
mrd Ccstlkchjfi, 1H9:. Senator. Berliner ktin. Wochenschr.. 189^ 11.
V
I C^mUurJ Sjit/m DitMiet.
Kshlrr und Pfclt. Arch, f, ["sych. o. Nenfenkrankh.. 1877, sill. p. 151,
{"revoot. Arch. <\e )>h)>iol., 1877. sme str.. tv. 3. 4, j. (CocnUncd Sclerosis of
Ihe Pouerior an<l Literal Trad*.) IStruiBpell. Arch. f. IHych. u. Nervcnkfankh., 18S0, xl, I. Edcs, The Somewhat Frequent Occurrence of Regeneration of the Poslero-
laicral Column) of ihe Spinal Ciinl in so-called S|niial Concuujon. Boston
Med. and Sorg. Journ.. September 11. 1881. tnaan. Do tabu combing (auio-spaxmodique) ou scKrotc posl^ro-latf rale de
la morlle. Arch. de. Neurol.. 1886. ai. lii. ^Cowen. Ataxic Paraplegia. Lnncet. 1886, ii. 1, 3, Babinskl et Clurrin. Sclirose mMulUire sy«i^matJ(|ue comlnnfc. Revue de
trM.. iS8(>. iii. II. pl 961. Suuinpell. I'elJTT cine bcj^titnmic Form der primSrvn combinirtcn Syslcmer-
■ bmnkuni; ilei Kiickcnm.irlu. Arch, f. r»)-ch., CIc. 1886. xtii, I. BErtlcki el Kylialkiit. Zur Fi.igc ubei die combin. S)rsicinnkr3nkun£cn des H Kucknunirks. Ibid.. 1RS6. xvii, 3.
HDoiu. Progmsit-c S|ms|Ic Ainva (Combined FaAcicul.ir Sclerosis) and tbe
■ Combined Sclerosis of the Spinal Cord. The Med. Record, July i. 1887. Adamklewic/. Wiener n>ed. Wijcheiuchr.. 1888, 17.
Ktevrlic/. Arch. f. ISych. u. Nervciikrankh.. 1889. ax, 1. fMjvltlis Trans-
veriu. SyrtnKom)'elia, Multiple SclrrmiK, anil Srcnndary DeKencralioni.) FraiKolie. £tu<lc vtt I'anaiomie p.-iihulogique dc la modle epinifav. Arch, de
■ Neurol. 1S90. xix. S7.
^^^P fi. Setomlary Ltswns of tkt While Columnt.
H Lesions o( the motor centres of the brain cortex, or lesions of ihc path between these centres and the motor ganglia of the spinal cord. Ihe so-called cortico-nnisculnr tract or pyramidal tract, give rise to a descending degeneration of the motor fibres 00 the same side as the brain lesion. This secondary degen- eration is in the cord continued in the crossed pyramidal tract
iof the opposite side, while the direct pyramidal tract presents only trac« of it. About the causes of this sclerosis wc possess
I just as little dctinitc knowledge as about the clinical symptoms
446
DISEASES OF SUBSTAffCE OF SPtNAL COKO.
U
by which it manifests itself. The former is sought in the cut- ting off of the parts from their trophic centres, and with regard to the latter it is gcnerallj' supposed that the gradual developing rigidity of the mus- cles, the increase of the reflexes, and the later contractures depend on lliis degen- eration. The cases, however, in which at the autopsy an exten- sive degeneration was found, while during life not a trace of such symptoms was pres- ent, do not speak much in favor of this view.
Lesions of the whole transverse section of the cord also produce secondary degenera- tion, which, however, extends not only down- ward (in the pyrami- dal tracts), but also up- ward— (i) in the inner segment of the poste- rior columns (Goll, cf. Pig- '43)' i>i>d (2) in the direct cerebellar tracts (Flechsig), which arc in connection with Clarke's columns (cf. Fig. I44.I- While this ascending degcner. ation is physiulogically extremely interest- ing, as ii indicates that the trophic centres of these two tracts must be situated nmre peripherally (as, for instance; in Clarke's columns), wc are not as yet able to attribute any clinical im- poriancv to it.
Ucscocmm Dkcuih-
ATIOJI 111 Tut SnsuL CuHD. A. prlnurr ^n* □( dt^aeiaUan llotbiiK B, degBtcTWJaa r4 tM\'% coluaiDi UxciMllni; ^ C. dcc<B<i>llcin □( Uie
(dondullns.i. (After COWKMA.)
Fte. ■M.—SCCOHDAKr .\x- CCl'MMI AKV OOGOII- I MO DBOEVCIUTNn IH
A Tmnvuibk Arnc- Tiott or TKK Urm DnRMi. Cor IK Th« as- nndioc dqcfocntioa oc cuiria^ in Goll'i eotaniu and Uk ilimt cmbtlbi tracU, Itw dmvndini; dc- i:Fnmt>nn in Itar croisnl PTranidjil Itaiti. t Aflei &TKUNPei.t.j
HI. LESION'S OF THE GRAV AND WHITE MATTER OF THE SI'INAU COR[>.
Charcot and Joflroy were the first to show Ihat the large ganglionic cells of the gray anterior horns and the pyramidal tracts can be affected simultaneously by a disease which pro-
AMYQTKOPltlC LATERAL SCLEROSIS.
447
I t
I I
I
I I
duces charactcrislic clinical symptoms, but it was not unlil FIcchsig announced his discovery ol the system of conducting fibres that these clinical ol>scrvations became fully understood. Now we know that the disease tvhich the tVench authors, foI> towing Charcot, have termed i<{ir4>it latfraU-amyotrolihiqtte — amyotrophic (more properly myo-atrophic) lateral sclerosis — consists of a lesion of the cortictvmuscular tract, which begins as a degenerative atrophy in the lumbar cord, and which, as Charcot and Marie, and more recently Rott and Mouraloff (Moscow. 1890), have pi>in(ed out, can be traced as far as the motor nerve cells of the central convolutions. Attention has already been called to the fact that, just as the nerve ceils of the anterior horns, in the same way the motor nuclei ol the medulla oblongata may be implicated, and thus the clinical picture o( progressive bulbar paralysis develop. The two dis- eases are therefore analogous, and akin to them is a third — namely, the progressive spinal muscular airo|»lty — in which utTcctJon also the large nerve cells are diseased, as we have already pointed out above. From the nerve cells the atrophy spreads toward the periphery to the anterior nerve roots and the muscles supplied by llicm.
That the clinical manifesutions are strictly motor and trophic, and that no sensory changes can occur, we can well understand from the anatomical distribution uf the lesion. The patients at first complain of weakness in the arms and the hands, which soon interferes with their occupation. This loss o( strength increases fairly rapidly, and the atrophy in the muscles of the hand — the thenar, the anlithcnar, and interossci —becomes more and more apparent.
The muscles of the arms also waste, more especially those of the extensor side, and the former roundness of the shoulder is soon lost owing to the atrophy of the deltoid. The triceps and other muscles also then take part in the lesion, and the helplessness of the patient, who has but little use of his up. per extremities, rapidly increases. At the same time the ten- don reflexes arc increased, and tapping of the bones of the forearm elicits lively contractions of the muscles ("periosteal reflex •■).
That the so-called " jaw-jerk." which has been described by De Waticwillc, is characteristic of the disease 1 am very much inclined to doubt, since in a number of perfectly healthy per- sons 1 found it in some present, in some absent. It certainly
44»
2>/S£ASES OF SUBSTAXCE OP SPINAL CORD.
docs not possess anj- diagnostic value. This jerk may be pro- duced by pressing down the lower jaw by means o( a broad paper-cutter and tapping the latter with a percussion hammer near the teeth. The lower jaw will then respond with a con- traction of the muscles of mastication.
In a relatively short time the paralysis of the upper ex- trcmiiies becomes so complete that not even the slightest motion is possible, and gradually contractures develop (by preference in the wrist and elbow joint). In the lower extremities the same changes may be noted, but they make their appearance later and do not reach such a high degree. Here, loo, we have first wt-akncss, dilBculty in walking, and general awkward* ncss in making tnovements. then rigidity and sliSness of the muscles, enormously increased patellar reflexes and ankle clo- nus, later on total immobility atid contractures in hip, knee, and ankle joints.
A case in one of my wards, a woman thirty-four years of age, has been for two years without power of motion, and is so entirely deprived of the use of her lour extremities that wich- out assistance she is unable to make even the slightest motion with either fingers, hands, arms, toes, feet, or legs. The dis- ease goes on to invade the motor nuclei of the medulla oblon> gat.1, and hence is produced difficulty in swallowing, which ultimately amounts to a total inability to get food down, and the patient dies of starvation. At other times a disturbance of the respiratory apparatus may bring about a fatal issue. It is exceptional that the whole course of the disease comprises a period of more than two or three years. The diagnosis is not alwayse.isy, though it is not difficult to differentiate ihediscase from progressive muscuLir atrophy if its duration and the con- dition of the reflexes are borne in mind. But it is not always possible to decide between this and hysterical conditions — forei* ample, the hysterical amyotrophia — as Charcot showed shortly before his death (Arch, dc Neurologic. i8gj, xxv, 74). Of tiK cause of the disease, as well as of effectual means wherewith to combat it, wc arc equally ig^norant.
LITERATURE.
dnrcot M Marie. Arch, dc Neurol.. 1885. i. j8. 29, Kojcwnikolf. Ccntralbl. f. Ncrvrnhcllli.. 1885, viii, 16. Dc Wjittcvville. Neurol. CcriraM. iSSGw \: 3. (Jaw-jerk,) Rybalkin. Ccnlralbl. f. Nervcnhcilk.. 1886, Ix, 8. Jaw-jak.)
rjt/tJVSFf.XSE MYHUTIS.
449
Neurol. Cetitralbl., \%tib. v, 13. |Amyoirophk Lainral Scl«fi)sis Coni- pbcattil l>y Uetncntia Paralytica.) itiuk. Ohkcri'ationfi dc «cl(totc latf raJc, amyolropluqwi <!■£. Arcltde Neuinl., 1887. jxa, p. 387. I'Miusa. Kit'isu clinbcA. June. iftS?. ' Lcnnmalm. t/p»dl« Hlcaiefuren. F'urh.. 1887, xxii, 7. Flaraii<L Contribuiion i I'iiudc <le U sctdrosc lat^ralc amyotrophiquc. Thtte
de I-aris. 1887. (•• Maladk de CKarcot.') Roiighi e \x\\. Conlributione alio «ludio delta SclenMi blende amioiralica.
Rcgj^o Emilia. 1S88. Kiuc. DcutKbes Arch. i. klin. MecL, 1889, iJir. 5. 6, p. 533. JofTroy el Achard. Note sur un cajt dc Ml^rote lal^rale amyoiropbiqiM. Arch, de hl«il. eipirim. et d'Anat. juih.. 1890. pp. 434-44&
While the diseases of the cord which we have studied so far were confined to certain systems of (ibres — in other words, were "system diseases" — the afTcctioti now to be considered does not present this peculiarity, but the process which aflects the gray as well as the white matter is more or less widely ex- tended over the cross- section of the cord, forming a small number of large or numerous small foci. In other words, the disease is what we call "asystemic" or diffuse. It isnn inftam- mation of the cord, which according to its course is called an acute or chronic myelitis, and to which the name transverse myelitis has also been given.
Patholos^caJ Anatomy. — Anatomical changes may in such s be scarcely demonstrable even though thcscvercsl para- lylic symptoms may have existed during life. This is more especially true in cases of spinal paralysis due to pressure, occurring in consequence of dise^ise uf the vertebra.'. Here we must assume that even moderate pressure is (Mpabte of bringing about a break in conduction without any destruction of ncr^'c elements. Usually in cases where changes can be demonstrated we find a diminution in the size and an atrophy of the nerve fibres. The axis cylinders may appear swollen and may have lost their myeline sheath. The nerve cells, which are not affected until Inter, become shrunken and lose their processes. According to Fricdmann. the degeneration be- gins in a circumscribed portion of the cell, secondarily the nucleus and the processes degenerate, and finally the whole cell shrinks or disintegrates (Neurol. Centralbl., 1891, 7; of. also FUrstner and Knoblauch. Arch. (. Psych., 1891, xxili, 1). While thus the nerve tissue undergoes disintegration the sup. porting tissue increases, the meshes of the neuroglia become
acut ■ myc
I
450
D/SE^SSS OF SVBSTAXCE OF SPiNAL CORD.
broader, and in it are seen the cells of the supporting tissue first described by Deiters, which, owing to their luinieruus prtv cesses, have also been called spider cells. In the mciibcsof the neuroglia rcliculum compound granular corpuscles are found which have taken up the lat and disintegrated nerve substance. These arc leucocytes, and in turn undergo, sooner or later, de- slriictton. The vessels are dilated and changes are seen in their walls, consisting of thickening or hyaline degeneration. In cases where this process h.is run its course in a compara- tively short time the cord is found al the autopsy to be soft and of a grayish-red color, whereas if the process has been slow the cord appears, in consequence of the increase of the support- ing tissue, hardened, or, as we say, " sclerosed."
Macroscopically, litllc is to be seen. At the most some portions may. when the cord is put into Milller's fluid for the purpose of hardening it, look light yellow, while others arc dark green. The former are the riiscased parts, which can not become stained because the myclinc sheaths, which are turned green by chromium, arc absent. With this exception all in- formation about the pathological changes must be derived from the microscopical examination of fresh as well as of hardened sections.
According to the location ol the process we dislinguisha dorsal myelitis, the most common; a lumbar myelitis, the rarest: and a cervical myelitis, a relatively frequent form, la the first and second the upper extremities arc entirely intact. while they are implicated if the process is situated in the cer- vical cord.
Symptoms. — It is very natural that the clinical manifesw- tions ot myelitis should, on the whole, very much resemble those which we have learned to recognize in the " system-db- eflscs," and, as a m.itter of fact, almost all that will be dcscrib«I has already been said. I k-re, as there, we have to do with ini'> tor. sensory, and trophic disturbances, with changes in the reflexes and symptoms referable to the bladder and rectum The motor disturbance* may consist of symptoms of panik>is and irritation. The f<)rmer are usually the more prominent"' the two, and weakness of the legs, which sooner or latf amounts Incomplete palsy, is one of the chief symptoms oU myelitis. As a rule, both legs are about equally aficcicd-' paraplegia : sometimes one retains its strength longer than ik* other. Recording to the extent to which the pyramidal traclS
T/lA.VSr/i/tSS .UY£Ur/S.
4S'
I
diseased. II not the Ic^ but the arms are paralyzci), the is situated in tlie cervical cord. The symptoms of irri- tation consist ol twilchings. which occur sometimes spontane- ously, sometimes as the result of slight stimulation ol the skin. In many instances the removal of the bedclothes and the change of temperature resulting therefrom arc sufficient to cause quite protracted clonic spasms of oneur both legs. This and similar phenomena seem to be of reflex origin.
The sensory changes are less regularly met with and are of less importance than the motor disturbances. There arc in- deed cases where they arc almost entirely absent, or where they at least do not annoy the patient or do not become marked until relatively !atc in the course of the disease. They consist mostly of pararathesias. numbness, formication, also of decrease in sensibility, which may amount to a complete anaesthesia, varying in extent and situation, .^ctual pains, which arc suffi. cient from their duration and intensity to cause much suffering to the patient, and which arc so commonly seen, as we shall learn, in tabes, belong in this disease to the exceptions. In fact, we may say that they arc usually absent, or, at any rate, not ai all severe. If we are able to detect sensory changes on the trunk itself, the level up to which these extend gives us valuable indications as to the seat ol the myelitis. If it is tn the lumbar cord, sensibility is intact above the navel : if in the lower dorsal, above the middle of the sternum. Sensory changes in the neck and upper extremities indicate the seat to be in the cervical cord. The more prominent the sensory dis- turbances and the |>ains, the greater is the extent to which the gray matter of the posterior horns and the posterior columns participates in the inflammation or degeneration.
Trophic disturbances appear when the trophic centres — that is. the ganglia of the anterior gray horns — arc diseased. Thus, if we are able to demonstrate atrophy, with reaction of degeneration in Ihc legs, this denotes a lesion of the gray an- terior horns in the lumbar cord, while the same condition in the arms indicates a disease of the anterior horns in the ccrvi. cal cord. The electrical examination should never be omitted in such cases, because it may happen that the legs present a certain degnre o( atrophy without the presence of any reaction of degeneration. This atrophy is. then, purely the result of Isuse — the atrophy of inactivity. Oiher trophic disturbances
vaso-motor changes in the skin arc not the rule. Herpes
452
DISEASES OF SUBSTANCE OF SPmAt CO/tD.
and urticarial eruptions, slight oedema and changes in the sweat secretion occur, but possess neither diagnostic nor prognostic value.
One symptom remains still to be mentioned, because k(i rarely wanting, but rather plays an important rJfic in myelitis^ and causes end Ic^ annoyance; and discomfort to the paiicnl— namely, the bed-sores which occur in the sacral region, and become the more extensive the less the care exercised in ibe nursing and (or the cleanliness of the patient. This is one of the most important trophic disturbances, and one which, even with the most careful attention, can not in all cases be avoided.
The condition of the skin as well as the tendon reflexci depends (i) on the state of the reflex arc in the spinal cord, {i) on the stale of the Hbrcs coming from the brain, which have probably an inhibitory function. I( the reflex arc is normal, but the conduction of the inhibitory fibres interrupted, then the corresponding reflex is increased, while if the re(!cx arci* diseased the reflex is lost, no matter whether the conduction of the inhibitory impulses be intact or not. This holds (or the skin as well as tendon reflexes. Therefore in cases of lumbar myelitis not only the skin but also the tendon reflexes are diminished or lost in the lower extremities. Those concerned are the patellar reflex, the reflex arc of which corresponds to the cord between the second and fourth lumbar nerves; the tendo-Achillis reflex, the arc of which corresponds to the fini sacral nerve; (he cremasteric and abdominal reflexes whicfc have their arc at the level of exit of the first lumbar and a por- tion of the cord between the fourth and seventh dorsal ncrm respectively. On the other hand, in a dorsal or cervical nw litis a marked increase of the tendon and skin reflexes of tfi< lower extremities takes place, because the (supposed) inbibi- tory influences are cut off.
A symptom which, perhaps, causes the patient himscK morf annoyance than any other is the disturbance in the funcrioaf ^ the bladder, which in a myelitis is hardly ever totally absent At first there is some difficulty in micturition, which mayC"' in complete retention, so that the patient can not void I"* unnc, but requires to be caUieterized. In the later stage** the disease, however, the urine is passed involuntarily, ih'^ being either a consUinl dribbling (incontinentia iirlna;) orfW time to lime an involuntary cvacuaition ol the bladder. '■
TKA.vsyE/tsn M yf.t./r/s.
4S3
I
I
either case ihe patients can not dispense with a portiihle urinal. Occasionally there is a painful burning sensation when the urine is passed (ischuria) so that the patient dreads every evacuation o( the bladder. As might be expected, cystitis frequently develops in these cases, partly owing to the length of time that the urine remains in the bladder, partly owing to the frequent use of the catheter. The rectal symptoms consist either of a most obstinate constipation, or, if the sphincter ani becomes paralyzed, of incontinence of faeces (incontinentia alvi). which a^ravates to a very serious extent any bed-sore that may be present. For the localization of the myelitic process neither bladder nor rectal syn\ptoms can be used. They are always present at whatever level tlie lesion may be. ' Etiology. — Ol the xtiology of myelitis little is known. It seems justifiable, however, to divide the causes into those which act chemically and those which act mechanically, the former being either of an infectious or of a toxic nature. That infectious diseases may produce myelitis is shown by the fact that it occurs occasionally after diphtheria and gonorrhcen XL.cyden, cl. lit.), more frequently after small-pox, and also dur- ing the course ol syphilis, and that the inlluenceor poisons may at least favor the development of myelitis has been upheld since the action of arsenic, of mercury, and of lead, and the symptomatology of the resulting intoxications have been more accurately studied. I^yden has recently published studies upon the relation between grave anxmias and some forms of chronic myelitis: Eisenlohr, upon the connection of primary atrophy of the mucous membrane of the stomach and intestines and myelitis.
Among the mechanical causes the most important is pres- sure, which can be exerted upon the cord by structures sur- rounding it. as happens, for instance, in spinal meningitis and meningeal tumors. Of greater importance in this connection is the chronic caries of the vertebne (malum Pottii), spondyl- •rthrocace. the tubercular spondylitis, and carcinoma of the vertebra: (cl. Figs. 14S and 146). in which either the dislocated (diteased) vertebra: themselves or the caseous and inflamma- tory products which arc found between the dura and ihe bone may exert a compressing influence- That there arc still other causes which may give rise to myelitis we do not deny ; we would only mention bodily fatigue and exposure to cold, but arc inhnitely rarer. On the other hand, there exists not
454
D/SSASES OF SUSSr^yC/i OP SPINAL COKD.
the smallest ground lor the assertion that sexual excesses ever produce it.
Course. — The course in general is the (ollowiufi : After the ]Kitient has for weeks and months managed with difhculty to get around, his legs becoming weaker and weaker, he has to take to bed or to the rolling chair, where he spends one. two, even four years, harassed by various afflictions, among whicb the bladder symptoms and the motor disturbances are espe- cially prominent. Recovery, if it occurs at all, is only vcr)- exceptional, and the prognosis must therefore always be very
Tit- MS- 'kt. '46. _
COUfUETV IlTTKIUIUFTIOK Or CONDUCTtOM OP THR SPIKAI. CORCi IMmtlKI LIFE. FV
■4S. anlerior. Fig- M^ pcalrrlor HipMl of the ipiiuti cord. TTi« iluta nlMtr to Hliidrf and (i>klt<rj baik. Circulat mmprpviinn ami narniv-inc v( lh« -qiinal n>nl >x K \n cam*- qumtF of cjidnoma of tht vrtlFbtir in a wiiman ihitlj-l'iur ytxn <A ngt. NiUiml illt Tlw dravHiii' u maile (rom a Irmli (irepaialiun. { A(E«' Eickhomst.)
unfavorable. Death occurs iti consequence o( bed-sores, which arc seldom absent, or is at least precipitated by them, .Some patiems die from intercurrent diseases, others from the cystitis. The course ot ihc so-called pressure myelitis and its resulting pressure paralysis, the symptoms of which have before been alluded to on page 424. is so far characteristic Ihal wc can here distinguish a pnidromal stage, a sla^e of trritalion, and a stage of paralysis. The protninetil features of ihc first are rigidity oi the vertebral column, dull, vague pains in the back, and the first signs of a commencing deformity. In the second stage we have severe neuralgic pains, hypera-sihcsias. iKincs- thcsias. and girdle sensations. In the third, finally, paralytic symptoms, increased refiexcs, vaso-motor and tr<iphic disturb- ances (herpetic eruptions, muscular atrophies. l>cd-sores, etc.).
TJtAiVSI'fiK.IS AfVEUrfS.
4S5
This distinciion, liuwcvcr. is only possible in isolated cnses. Bladder and rectal symptoms are absent in no case of pressure
■ paralysis.
F In our prognosis we must not leave otit of consideration the possibility tlint the tiiHummatory new formations in the vertebra; may disappear, and thus, the cause which pnKlticvd the break in the conduction ceasing to act, it may be possible for the spinal cord to recover completely all its normal func- tions, provided, of course, that none of the nerve elements have been destroyed.
ft Treatment. — The treatment of any case of myelitis necessi>
^tates much patience on the part of the sufferer, because weeks and months may pass before any sign of improvement can be perceived, and much circumspection on the part of the pliy- sician, because we are never able to say beforehand how cer- tain measures are going to be borne by the patient, and because what often helps one is harmful to another; hence one must proceed carefully and systematiadly, and as it is likely that the course of the disease is going to extend over years, one should always have something new and as yet untried in re- serve. If the diagnosis has once been made with certainty, it is our duty to inform the patient in a delicate w.iy of the true state of affairs, and how seriously his capacity for following his occupation will be interfered with; further, to see th.tt he ia properly fed on a nourishing diet, and obtain for him as far as possible mental and bodily rest. It is a gross error to recom- mend such patients, who arc easily fatigued and who on the slightest provocation are attacked by all sorts of pains, to take as much exercise as possible, or even to prescribe gymnastics
Jor them.
■ The electrical treatment is indicated and ought to be begun early. The coni^tant ciirreni should be applied near, the s*-at of the lesion (the anode iKiitg ]>laced on the tender parts ol the spinal column If there be such), the faradic to the periphrrnl parts, especially the lower legs- flefinite rules can not be laid down, il I!) best to seek information from a reliable texl-lKiok, and to try which mode of treatment is best borne by ihe pa-
Kirnt and by which most is acc<implished. Tepid baths— 84" D 88' Fahr. — three or (our times a week for fnim fillcen to thirty minutes, best taken in the forenoon, usually have a favor- able influence, and are. if not of lasting benefit lo the pnlieni, lucnily productive of at least a transient feeling ot comfort.
456 i>/SEASBS OF SUBSTAXCB OF SPINAL CORD. ^H
The addition of rock-salt, sea-salt, nt tyc (one or two quarts) should only be ordered if the patient himself seems to lay much stress on it, as we can not expect any especial effect iroin them. Neither should we raise our expectations too liigh when we recommend warm brine baths containing' carbonic- acid gas, or non-mcdicatcd warm baths, or mud balhs and the like. Of course every patient, rich or poor, expects us to send him in summer to the springs, but he will gradually find out that the success attained dues not compensate for the expense and the trouble which the yearly course al such places entails, and that it is wiser to remain in his comfortable home or to betake himself into the country and enjoy the mountain or for- est air in some place where he can live in peace. The life in modern watering-places is not adapted for a patient with mye- litis. Mild cold-water treatment in an intelligently conducted sanitarium (Oraefcnberg, Nassau, Elgersburg. and others) may I well be recommended. All internal medicines {strychnine, silver, ergotine, iodide of potast^ium, etc.) are of no avail. The treatment of the retention of the urine and the consequent cystitis must be carried out accordinK to strict surgical princi- ples. In the treatment of a compression myelitis we must not forget the necessary extension apparatus, braces, etc., for the vertebral column. These means, however, belong to the do- main of orthopaedic surgery.
Sometimes the effect of a unilateral section of the spiiial cord, where we consequently again have a lesion of the gray as well as the white matter, can be observed in those rare in- stances in which traumatism, a tumor, or the like, has rendered the half of the cord incapable ol performing its functions. The clinical picture resulting from such a lesion is much more rarely observed than we should be led to suppose from the accounts in the tcxi-books. The disease is called Brown-S^uard's spi- nal paralysis. It, in short, manifests itself as a motor paralyjii on the side of the lesion, and a sensory paralysis on the oppo- site side. This is explained by the distribution of the fibres, inasmuch .is the sensory fibres cross over to the other side soon after their entrance into the cord, while the motor fibres pass upward to the medulla oblongata without crossing (cl. Fig- 147) ; thus. if. for instance, the lesion be in the right half of the lumbar cnrd, a paresis of the right leg ensues, tvhile the left is anesthetic: if the lesion is high up in the right half of the
BMOIVy'Sf.QVAKD'S PARALYSIS.
45?
I
cervical cord, the right arm and right leg are paralyzed ("spi- nal hemiplegia"), and the other half ol the body is anaisthelic. The Tact that on the side on which there is motor paralysis there is often a hypera-sthesia (Kiver has reported a case in the Neurol. Centralbl., 1891, No. 2, in which there was no hype nest hcsia) for ccr- tain qualities of sensation — with the exception of the muscular sense, which appears diminished — is explained, according to Brown -S6qiiard, by the fact that the fibres for the muscle sensibility do not cross over as the other sensory fibres. Above the bypcncsthetic there ts an atissthetic zone, due to the destruction of the pos- terior nerve roots. Fur- ther, there is an increase o( the rcllexcs on the side aflccted with motor paral- ysis, owing to the cutting off of the inhibitory influ- ence, as well as a vasomo- tor paralysis, manifesting itself by an elevation of tempera- lure. On the ana:sthc(ic side the reflexes arc normal : a narrow hypersesthetic zone (on the trunk) is here also noticeable above the area ol anxsthcsta.
On the whole, the descriptions which wc possess of unU lateral cord lesions arc of no great practical use. because, as has been stated, the clinical picture just described is but rarely distinct and complete, and may pre5«nt all kinds of variations (cl. Hoflmann. [leuisch. Arch. f. klin. Med., 18S6, 38,6, where three cases of this class which occurred in Erb's clinic are described).
LITERATURE.
Pnbody- New Vorfc Medkiil Record, Febniary S, iSSj, iriii
ChjqirniKT. Hfvuc d'hyi*,, Miirch j. iHSj. v.
iUrkntr. Laikci. November jo. 18S6. ii. (M)«litto afkcr Mcasics.)
Fic. Ill-— SC'isuA OF TIIB Oouus or -nir Nb«vr Fimm n tiiR SnnAL Cokol *, u»- crawd motor flbnw. t/, uncmuol vmo-owiiw (ibn*. tm, uncniwnl fibna for iha i— initor (enx. I. dcmaMlntc tciUMf iibiw. (Allcr
BlM>W»-Slqi-ASIX)
458 DISEASES OF SUBSTANCE OF SPINAL COED.
Crassct el Eslor. My^Iite cervicale. Revue de miA., 1887, vii, 2.
Schiitz. Prager metl. Wochenschr.. 1887. xii, 38. (Cure of Myelitis.)
Cramer. Arch. f. Psych, u. Nervtnkrankh.. 1888, xix, 3, p. 667.
Kroger. Beilrage zur Pathologic des Ruekenmarkes. (Recovery from Com- pression Paralysis.) Dorpat, 1888. Inaug.- Dissert.
Cessner, Arch. f. Augenheilk., 1888, xix, 1. (MyelitisAcutaafter Loss of Blood.)
Herter, A. Christian. A Study of Experimental Myelitis. Joum. of Nerv. and Ment. Diseases. 1889. xiv.
Schmaus. Die Compressionsmyelitis bci Caries der WirbelsSule. Wiesbaden, Betgmann, 1889.
Schaffer. Neurol. Centralbl., i8gi. 8.
Oppenhcim. Zum Kapiiel der Myelitis. Berliner klin. Wochenschr., 1891, y.
Rosenbach. P, und Schtscherback. Ueber die Gewebsvetanderungen des Ruckenmarks in Folge von Compression. Vireh. Arch., Ixxii.
Eulenburg. Spinale Halbseitenlasion mil cen'ico-dorsalem Typus nach In- fiuenza. Deutsche med. Wochenschr., 1892, 38.
Leyden. Zeitschr. I', klin. Med., 1892, xxi, I, 2, 5, 6.
II. Spinal Lesions regarded from their Pathological Asi'ECT— Pathological Diagnosis.
I. affections of the sriNAi. cord due to diseases or
THE BLOOD-VESSELS.
A. Diseases of the Arteries of the Spinal Cord and thdr Consequences.
The vertebral arteries which arise from the subclavian, and which unite to form the single basilar artery, give off, after having entered the skull, an anterior spinal anti a posterior spinal artery by which the spinal cord is supplied with blood. The anterior spinal arteries of both sides unite to fonn a vessel which runs along the spinal cord ill the anterior spinal fissure, while the posterior spinal arteries anas- tomose freely with each other without, however, completely uniting; the horizontal branches run along the septa. White and gray matter are nourished in tlie same way, but the capillary network of the latter is much denser than that of the white substance.
The venous blood is collected into two fairly large veins, which are called the central veins of the spinal cord, 'i'hey anastomose freely among themselves, and are connected with the anterior and posteriiir spinal veins. From (hem the venous blood passes into the vertebrals, ivhich empty into the innomiiiate or the subclavian vein. About the diseases of the spinal veins up to the present nothing is known.
/, Sfiiiii/ Ihcmorrhagf — Hirmorrliagia {or Apoplexia) McdnUii Spina lis — Hic matomyilia.
While, as we have shown above, a primary haemorrhage from the cerebral vessels is uiie of the most common causes
i{^..\tA7VUY£UA.
459
of lesions of the brain, sjwntaneous hjcmorrhages from the spinal arteries arc exceedingly rare, and iiiflecd it seems hardly possible that a hsemurrhage could take place into the sub- stance of the cord, so 5rnily held together as it is by the tough Hpb mater, without the previous existence of alterations in its consistence; besides, the anatomical conditions of the arteries are such that the blood pressure is decidedly lowered bclorc Uic blood wave reaches the spinal cord : furthermore — and this is perhaps the most important reason for the rare occurrence of haemorrhage into the cord — miliary aneurisms, which in the brain arc the most frequent source of ha;morrhage, arc never found here. For these reasons the existence of primary s|Ktntancous spinal ha:morrhages has been absolutely denied, and it has been assumed that in every case changes in the con- sistence of the cord substance must have preceded. VVc fully agree with those who believe in their extreme nirily. but. never1hctcs<i. we arc of the opinion that under certain condi- _ tions primary ha'niorrhages actually do occur. Such condi> f tionsurc: (l) in old persons the coexistence of cerebral ha:m- orrhages in consequence of arterial disease: (2) the presence of such artiological factors as excessive muscular exeriinn (heavy lilting, ciitlinf; wood, etc.); (j) the sudden and violent suppression of haemorrhages in other places (the menses, ha;m. —^orrhoids. etc.): (4) the exposure to a sudden marked diminu- Btion of atmospheric pressure, as happens to those who follow Bccrtain occupations, .is, for instance, workers in compresses) Riir in building bridges or winning amber (c(. Mirt. Gcwcrbc- Hkrankheiien im Han<lbuch der spec. Patliologie und Thcrapie. ^MO^ i. third edition, reprint, pp. 83 rt seif.). ^F The pathological condition is cither one of capillary hicm- orrhages or of a hwmorrhagic infiltration in which the escaped blood extends between the nerve fibres along the course ol ihc vessels, or finally wc have ha:morrbrtgic foci, in which the bkKKl coining from the vessels in larger quantities presses the nerve
ttissiir apart and forms a sort of cavity. The focus usually ex. tcnd> In the longitudinal direction ol the cftrd. Haemorrhage )aiay occur at any level of the spinal cord and in any porlirm of ihc cross-section, and may produce the same change:!, in ils sub- stance as cerebral ha>morrhage produces in the brain— changes with which we have become familiar in a previous chapter.
Clinically, spinal apoplexy is characterized by paralysis with a &udden ousel, sometimes attacking the p;itient without
460
DISEASES OF SUffSTAJVCE OA SP/XAL CO/fD.
any premonition and while he is apparently in the best of health: he suddenly sinks to the ground without losing con- sciousness, and is deprived of the use of his limbs; occasion- ally prodromata, such as tearing pains or formication in the limbs, may precede for hours or days. The extent and the degree of the paralysis depend entirely on the seat ol the ha;morrhagc ; il may be confined to one half of the body, or to both legs or to both arms, or it may take in all (our extremilics simultaneously. It develops extremely rapidly, and reaches its fullest extent within twenty-four hours. If this is not the case it is not a spinal hxmorrhagc with which we are dealing. Pains and rigidity ol the back and clonic muscular twitchings are equally constant, as are the bladder symptoms, which are prob- ably never absent in ha^matomyelia. With regard to sensation and the reflexes no general rule can be given, yet an increase of the reflexes immediately after the catastrophe is not exactly rare. Ocalh may occur within a tew hours, an event which is especially likely to lake place if the ha-morrhagc is situated high up. In other cases the patient lives for days and weeks, and dies from the effects of bed-sores, of a cystitis, etc. Finally, at leasl relative recovery is not excluded ; the patient may either get over the effects of the lesion, or he may be left with motor or sensory disturbances of the most varied kinds. The diflcr- ential diagnosis between hxmatomyclia and hxmatorrhacliis (meningeal apoplexy) has been discussed above- For the treat- ment we may try the application of ice to the spinal coliimn and the internal administration of ergotine. The success at these measures is always very doubtful, and a careful attcnlton to the nutrition and the cleanliness of the patient should in all cases be considered the thing of most importance.
J. Embolism attii Thrombosis of fhr SfitMa/ ArlrrifS and
Myelomalacia. Embolism of the spinal cord, the de%'clopment of which hat been studied experimentulty by Pa num. is extremely rarei» man, probably owing to tlic smallness of the spinal arteriesin<l the fact thai they arise at right angles- The symptooisbT which emboli manifest themselves arc not definitely knw**: possibly ihere is a connection between embolic processes w the so-called choreic movements, but this is still hypothetical- It is about the same with arterial thrombosis, the indepf""' cnt existence of which is, to say the least, doubtful, but $>»'*■
ENnAftTEK/r/S SPIJVAUS.
461
\
Is Leyden has pointed out {Riickenmarkskrankheitcn, ii.41).
iiseasc of ihc spinal vessels is extremely common, the occur- rence of arteri:ii ttirombosis is very e.isity possible. Not only ^the inflammatory processes in the spinal cord, which are ac- companied by arterial disease, but also the senile changes, which consist in fatty degeneration and thickening of the ves- sel walls, predispose to it. The necrosis which occurs in the substance of the spinal cord in consequence of arterial obstruc- tion is similar to that described on page 244 as occurring in the brain substance. The condition ol softening is called mye- lomalacia (cf. also Kcdiich. Ueber cine cigcnthumliche. durch GelAssdegencration hervorgerufeue Frkrniikung der KUcken- markahinterstr^nge, Fragcr Zcitschr. i. Itcilkunde, 1891. sii).
J. EndaTteri(i% {typhiiitua).
That the spinal arteries participate in the process which Hcubncr has shown to occur in the cerebral arteries (page 2;:), according to competent observers, does not seem to ad- mit ol doubt. It is equally certain that this process plays here relatively smaller r^le than in the brain. Heubncr himseK, Knapp. Leyden, and others have reported interesting observa- tions bearing on this, and it seems that an endarteritis oblit- cnins in the spinal cord leads cither to a myelitis or a multiple sclerosis. RumpI, in his excellent treatise on The Syphilitic Diseases of the Nervous System (page 349), has published in full a very interesting case of syphilitic disease of the spinal arteries, which was followed by a similar rcjwrt by Knapp <Ncurol. Cenlralblatt, 1885, 21). and another by Gracfr(Arch. f. Hsych. und Nervcnkr., 1882, sii, 3). There arc, however, only comparatively few cases to be found in the literature, and. fn Almost all, syphilis of the brain coexisted with syphilis of the spinal cord, and endarteritis obliterans was almost always demonstrable in the brain as well. Two interesting cases have been reported by Schmaus (Deutsch. Arch. f. klin. Med., iSSg, vol, xliv, 2, 3. p. 244). In one of them the syphilitic af- fection took the form of an arterial disease, running a subacute course with hyaline fibrous thickening of the intima and simul- t:inrous inflammatory infiltration ol the whole ve^rl wall, which was lollowcd by an irregular disseminated patchy scle- rosis of the white matter, a marginal sclerosis, and a degenera- tion t>( Goll's columns in the cervical c<ird. That the degen- ctmtioQ of the nerve jvarenchyma was attributable to the low
462 f>fSSASSS OF SVltSTAJ^CB Of SP/AfAl COSD. ^
Stale of ntilrtlioi) In consequence of dimiiitition in the blood supply seemed beyond doubt. As for the symptoms, sensory disturlwinces f|>.iii)s, par;esthcsias, hypcraesthetic zones) and motor dbturbunccs (at first fatigue and tinully complete [mn- plegia). furthermore incontinence of the urine and ficces. con- stituted the clinical picture. In the second case a svphillric degeneration of the vessel walls combined with a poliumyclilis was found. With our present knowledge we must cnnteot ourselves with diagnosticating a diffuse affection of the spinal cord, a transverse myelitis, a tumor, and the like. The diag- nosis of a syphilitic disease of the arteries must be made with reservation during life, and must only be assumed when llie luetic history is certain.
f LITKRiVTURE.
EvrakI Udi^syphililisiheOriisu^rkraiikung. BtTl. Win, Wochenscbr., i$89,4K. Kei'ndds. SyphJIilic Uisc-uconhc Spinal Cord. Um. Mcd.JiMirn., iS89,p. IIII. Siemcrling. Arch. f. Psych., 18901 xjtii, i. Mtillcr. Siu<ticr aivtr ryggnvArgasyfilia. Nonlisk. med. Arfc,, 1890, XxU, 4. N(k II
^. Dilatalittn of fht Spina! Arlfrits.
Wc know very little about aneurisms of (he spinal arteries. Besides the case reported by Liouvillc, which is also quoted bj" Leyden {he. (it., 2, p. 42). none can be found in the literature. The question, therefore, whether syphilis may give rise to aneurisms here can not be answered. It is possible that bodily exertion has a predisposing action. A symptomatology and a therapy do not exist for aneurisms of the spinal cord. (Spen- cer, Sequel of a Case of Traumatic Aneurism of the Spine, Brit. Med. Journ., 1891, December 5.)
I 5. Nfurases cf the SfiiKal Arteries. ^^|
The vaso-molor nerves of the spinal arteries behave jus^ like those that supply the cerebral vessels, and upon whelhcr they are in a state of irritation or in one of paralysis the amount of blood in the spinal cord depends. But easy as it is to dem- onstrate hyperieniia and anaemia of the cord in the cadaver, it is difficult, on the other hand, to say in what way changn><* ihe amount of blood in the spinal cord influence the health of the patient, and ivhethcr a greater or Icsst-r fullness of the ft*- sels, or frequent l^uctuations between the two, are atieinicu with any marked symptoms. All views on this subject »f^ entirely hypotlieiical. The palhologic.1l changes in the sjiin*
Af£C'»OS£S OF THE SPINAL ARTEHtES,
m
Hcord, due to an artificial transient anictnia produced by liga- Htion of the abdominal aorta, Spronck (Arch, de physiot. norm, ct p.ithol., September I. lS88, xx), (ollowing out the earljr re- searches of Bricger and Ehrlich, has lately dcmonslratcd. with- ■out. however, throwing; any further light upon the clinical symptoms caused by spinal .-inxmia.
ijince the time ol Peter Franck ( 1 791) there has been a wide- spread opinion that hypera-mia of the spinal cord can give rise to a number of symptoms of irritation, some of which bcin^; motor, some sensory, iO|relhcr make up the clinical pic* ture ot what has been described as spinal irritation. But the (act that it was found impossible to accurately define a clinical picture indicative of this condition and the difficulties which arose in the diagnosis have led most observers to abandon the term. The disease used to be described somewhat as follows: The patients, who. as a rule, are females belonging to the best classes of society, complain of an occasional feeling of fatigue und of pains in the back, which are intensified by the erect pos- ture. Walking becomes difficult, and the gait is that of an old t person ; ibey walk with a bent b:ick and take each step with care. Painful sensations, parnesthcsias, formication, and numb- ness in the lower extremities arc complained of. The functions of ifie bladder are more or Ic^ disturbed : often there exists a uterine catarrh. The patient is low-spirited, and has a tend- ency to hypochondriacal notions. On examination, we find the reflexes either normal or cxaggirratfd ; sensibility is somewhat aScctcd, and disseminated anaesthetic plaques are demonstra- ble. A certain tenderness over the s'ertebrcc is almost always noted: it is usually more pronounced in the lumbar and dorsal than in the cervical region. The course of the disease is cmi. nently chronic; often months and years pass, notwithstanding all therapeutic measures, before any decided improvement oc- curs, and ihosc unfavorable cases in which the patient finally becomes bed-ridden and, after having been lor years affected with paresis or paralysis, falls at last a prey to an intercurrent malftdy, are by no means exceptional. A cause was often looked for in vain. Overexertion or sexual excesses were regarded as sometimes indirectly giving rise to the disease 1 at times the immoderate indulgence in lokicco was blame<l, but more fre. (|ucnily »ll such (actors were wanting, and a congenital weak- ocs* of the nervous system had to be made responsible for the kflcction.
464 />/SEASES Ot- SUBSTANCE OF SPINAL COHD.
Further investigations must teacli us tu what e):tcnt ibe aScctton described by M<)bius under the term akinesia algcra is ^alilied to replace "spinal irritation." Certainly only Ibe severest lorm o( the tatter could l>c represented by this condi- tion, which, according to MiSbius, is characterized by severe pain on the slightest exertion, so that there exists a total inabil- ity to move. Tiie observations o{ Mijbius have been confirmed by many others, but it is not yet clear whether the condilion represents a separate disease or not.
The treatment in this condition, just as was the case lor spinal irritation, should be local and general. The forracr con- sists in the early and energetic use ol the Paquclin cautery and of the constant current (descending); the latter in the use ol tepid baths and tonics. Yet often all measures arc fruitless, and it is advisable to be very guarded in giving an opinion with regard to the duration and probable outcome ol the disease.
l.rrKKATlJkE.
M^AIus. Akinesia algtra. Ucutiiche Zcitschr. t Norvenhlc.. 1891, i. I, 3.
Konig. Ccnlralbl f. Kcn'cnhk.. l8gj, «i. p. 97.
Iktbbiut. UeuUchc /cilschr. t. Ncnenhk., 1893, ii, 5.
Longard. Ibtd.. 189a, ii. j.
£rb. Ibid,. 1893. ill. \~\
Putnam. Baiinn Meet, and Surg. Jmim., 189Z. cxxvii. \o.
Moj-cr. Med. Standard. Chicago, January, 1893, xiti, 1.
That a chronic anaemia of the substance of the spinal COfd may give rise to a paralysis, especially of the lower cxircmi- ties. which may last for years, seems probable according to ihc thesis ot Meunicr (Paris. [886), yet nothing certain can be slid. especially as in the cases in question it may be difficult inei- clude hysteria.
Just to what cla.s5 we must assign those instances of paraly- sis, described more especially by Russell Reynolds, which de- pend on the imagination — whether they arc due to funciioml disturbances in the spinal cord, or whether, under the influncc of psychical activity in consequence of auto-suggestion, a dis- ease of the whole nervous system develops — is not known.
The various disturbances in the sexual functions — (of in- stance, the impotcntia cncitndi, which i.s quite a common ra*"- testation of a functional disturbance of the sptnal cord in yonnf^ and middle-aged men — we shall enlarge upon in the chapli' on neura!<tticfiii;i.
I
ACUTE AtYEUnS.
465
n. ISFLAJIMATORV I'K*)CESSES IN THE SUBSTANCE OF THE SflNAl. COKI>.
/. t*uruUni Myditis — Abuess 0/ the Spinal Cord.
Wbile circumscribed pus fonnnlions in the brain subsrance are by no means rare, the (ormaiion of an encapsulated pus (ocuB in the spinal cord is one o( the greatest exceptions. Al- thougKLeyden succeeded in producing such foci expcrimen- tally in dogs, the clinical observations in man arc so few that it %*> impossible to lormulatc from them a dchnitc symptoma- tology- Pathologically, it is interesting to note lliat Ollivier and Jaccoud (quoted by Lcyden, loc. eit.. li, 205) have seen ab- scesses which varied in size from that of u bean to that of a ha/el-nut and were filled with a grcenish-whitc pus. They were situated some in the cervical, some in the dorsal cord. The symptoms, on the whole, were those of a grave, acute soft- ening. In an article by Ullmann (Zeitschr. f. klin. Med., 1889, xvi. 3. page 39) an interesting discussion -on .ipinal abscesses and an exhaustive collection of references wiSl be found.
2. The NoN-fiuriiUnt Myelitis.
Inflammatory pnKcsscs in the spinal cord are very fro>
quent. In the majority of cases they are ol a chronic type
and less often acute. With reference to their situation, we have
already stated that ihey may implicate the white as well as the
gray matter.
A. Thr Acute Form.
As we said on page 449. we have in acute myelitis a process which is characterise*! by the death of the nerve elements and n secondary increase of the connective tissue. In (he acute stage a change in the consistence of the cord takes place ; the parts become softened and appear swollen and Infiltrated. Sec- lions of the cord arc not so distinct, and the demarcation be- tween the white and gray matter is less sharp. The color may be reddish (hiemorrhauic). yellowish-red. rusty brown, whitish, or of any intermediate shade. The extent ol the process of «ottening varies. It may be spread over the whole or only a pmrt of the cross-section, and may extend longitudinally for a greater or less distance. Sometimes disseminated loci are found not only in the cord, but can also be demonstrated in the brain. We shall speak about these later.
In exceptional cases, which are difficult Id explain, abso>
466
DtSSASES OF SUBSTA.VCE OF SP/.VAL COSO.
lutely no changes were found at the autopsy, although itic course of the disease seemed in every way to suggest iin acute lesion. These pntionts were (or the most part young, and up to the time of their illness vigorous persons. After a short prodromal stage, in which there were headache and some (ever, ihcy were attacked by a flaccid paralysis of both legs, which developed in a few days. To this was added in a very short while paresis of both arms, so that the helplessness of the pa- tients reached an unusual degree. The condition of the reflexes _ and the electrical excitability varied in the few cases reported \ up till now. According to the records, the functions of the bladder and rectum as well as sensibility remained normal The prognosis is very doubtful. Sometimes bulbar symptoms appear, and the patient dies within from eight to fourteen days after the onset. Sometimes the course is more protracted and some improvement occurs, which, however, is never coniplete. The affection which presents the clinical picture just described is called Landry's paralysis (1859), paralysu ascetidanlt' aijiut; aculc ascending spinal paralysis, although it is not definitely known %vhelhcr we actually have to deal with a spinal affection and not rather with a very acute infectious peripheral ncurilis. Until we possess the results of a larger number of anatomical examinations it is of no use to theorize any more about ibc nature of the disease (cf. Schultze, Schwarz, Bernhardt, von Recklinghausen, and Klebs (who found hyaline tliromboses). Mijnch. mcd. Wochcnschr.. 1890, 52, pp. 923 ft sfg).
With regard to the a;tiology of Landry's paralysis, al>ou( which so little is known, it is possible that it may be caused by infectious diseases, for instance, by whooping-cough (Miibiusv t)( great interest is the communication of Cursctnnanii (Vfr- handl. des fiinften Congresses (tir inncre Med., Wiesbaden. 1886, p. 469), in which he speaks of a case of acute asceixfinj paralysis where at the autopsy typhoid bacilli were found io the spinal cord. U may also develop in the course of perni- cious ana>mia (cf. also Minnich, Zeitschr. f. klin. Med-. tSpi. xxi. t. 3).
The symptomatology, diagnosis, and treatment o( ac" Rtyelitis have been discussed on pages 450 to 456.
LITERATURE.
Sctiuliz^. n«rlin«r klin. Wocheiischr. 1883, y^ tlofTmann. Arch, f. Psych, unii Ncrxcnkrankh.. 1884. xr,
14OL
spfXAL rcvoxs.
467
iBtmhardl. ZeilcchT. f, kirn, Med.. 1886. p. 391.
I^ilrcs Fi VAillard. Arch, de phyKiol. norm, ct pathol. Kvr. r887, p. 149,
>ixon Mann. British Med. Jouin.. Maich 16, 188;. Flvnuiow. Zwci F9llr i-on aculvr aufstcigcndcr Spitvalpral. Ihrtcrsb. rned.
Wocbenschr.. 1888. 46. Schwin. Zcltschr. f. klin. Med.. 18SS, xtv, 3. p. 193. Woodward. Rmish Med, Joum., November y 1888.
tNeuwtnk uiul Raith. Zur pathol. Anatomic dcr Landry'Khen Uhmung. Bcglcr's Betira^ lur pailiol. Anni. und allgeto. PiUhoL, 1S89, He<t I. Bchmef. Die Ijindry'sche l^mlyse. Inaug.-ni&K'Tl.. Berlin, 1890. Le>'den. Uebcr goniwrholMihe Myelitis. Z«it5chr. fur klin. Med.. 1891, ku, ;, 6,
p. 607. Eixcnlohr. Ueber primlttc Alrophie der M>gen- und Darmschlcimh«ut tind
deren Buiehun^ <u ichwerrr AnKmte- und Rtickennutrkterkrankung.
Deutsche nied, Wocheniclir,, 1S9:. 49, HIavi. Poliomyelilis acuta di&MtnlnaU (Pjiralysis Landry). Arch. tioMme« de
mhL. 1891. t. IT. Kuc. 2. ABki. Zur Aeliologic der Paral. mc. aeul«. ZciWhr. {. klin. Med.. 189J. xxiii
5.6. Lejrdrn. Multiple Neuritis und aufsieigendc acute Paral]rM nach InSuaua.
ZciUchr. f. klin. Med., 1894. ixiv, 1, 3. Jolljr. Uebcr uute3iu(»tci^eii<le i\ird)y»e. Berlinef klin. Woe hcnschr.. 161M. U.
II B. The Chronic Foim.
Chronic myelitis is much mure commonly observed than the acute (orm. It is charncterized by the death of the nerve elements mid a consequent increase- ol the supporting elements, which gives to the tissue a peculiar firm appearance and con- sistence— sclerosis. That this sclerosis is (requently confined to certain nerve tracts, giving rise to the so-called " system-dis- Heases," we have pointed out above on page440. On page 451 "will be found some account of the sensory, motor, and trophic changes which .ire found in these affections. It is in all cases of great importance to look to rhe condition of the reflexes, as
■this may have a decisive significance for the diagnosis. The disturbances nf the bladder and rectum in chronic myelitis and the treatment ol the disease have been discussed above.
IP
IM. Spinal Ti'mors. Pathological Anatomy. — In the spinal cord, just as in the brain, liit- glioma is relatively the most frequent form of pri- lary neoplasm. What has been said on page 289 about its Icvelopment holds good here also. The cervical and dorsal part ol the cord seem by preference to be the seat of the gli- OOM. Sarcomata, which from the onset present a sarcomatous nature, and gliosarcomnla — that is, glioniata with unusually
468
JJ/SKASES OF SUBSTAA'CB OF SP/A'AL CORD.
marked proUrcration of cells — have been observed, althuugh but rarely as primary tumors. Angiomatn, small reddish, probably congenital (Virchow) foci, have been found, and Ganguillct has observed a cylindroma in the lowest portion of the spinal curd. Solitary tubercles and syphilomata arc much rarer here than in the brain. Cnrcinomata usually start from the veriebnvKnd afterward spread to the spinal meninges. The secondary chanj^es are, of course, not nearly so well marked here as thow found in the brain, since the spinal cord is in a position lo ofltr greater resistance to the growth that presses upon it, Only when the tumor has reached some considerable size— c. g., tliat of a hazel-nut — do symptoms analogous to tht- so-called "indi- rect symptoms " in the brain make their appearance.
.£tiology. — The astiology is absolutely unknown. Though in certain cases traumatism has been made rcsjwnsiblc lor gliomata in the spinal cord, we arc still in complete if^iio ranee about the real cause, as we confessed ourselves to be when treating of their occurrence in the brain. The in- fluence of age and sex here is the same as in tumors o( lh( brain.
Symptoms.-~If a patient complains of persistent patnsaml stiffness in Ills back, if at the same time there are found sensory disturbances in the form of parivsthesias. circumscribed arcv of anaesthesia, and motor disturbances in the form of slowly but steadily progressing paralysis o( one or more extremities, the suspicion that a tumor of the meninges or ol the cord itseli exists, is justifiable. The likelihood is greater i( other spinil affections can lie excluded and i< occasional remissions iii (he progress of the disease can be noted. It is true the diagnosis of spinal tumors always remains a very difficult thing, and nl times, for instance, wc may not be able to definitely diffcreati- ate a myelitis from a spinal tumor. This is easily understood if wc consider that spinal tumors may give rise to the most varied clinical pictures, according to their position ami !i« and according to the greater or lesser involvement ofibf white or gray matter. There is no doubt but that a tuax" of the spinal cord may give rise to symptoms of a comprt*- sion myelitis, of labcs, or of a mycliiis, and that if it be con- fined to one sidu it may produce the symptoms of a BrO"«'' S^quard paralysis. Roth (cf- lit.) claims that loss of the tem- perature SL'nsc is frequently observed in spinal glioma, and I^' this, combined with analgesia, paresis, and muscular atroptiy-
SPWAL TVAfOJlS.
469
sufficient to settle the diag^nosis. The considerable mate- rial which Koth has at his diKpo»:il makes his monograph very vaUi.nblc. It is only to be expected that vaso-molor us well as trophic s)'inptoiii« should be found. To interpret these must
pK IcU to the physician's skill in diagnosis, upon which so much depends in the r<.-cu^nition of tumors of the cord. Sudden changes in the spinal symptoms, temporary remissions, then again sudden changes for the worse, sliould all be made to have ihcir proper diagnostic value. In cases of well-marked paraplegia d<>ti»rosa, where we have tearing ]>ains in the small of the back, radiating into the exircmilics, together with atro- phy of the muscles of the lower legs, we should always think of one or several tumors of the cauda equina. In these cases contractures of such severity sometimes develop that the heels
Uoucli llic buttocks (Leyden).
t Prognosis. — The prognosis depends upon the nature and
■lie seat of the tumor, although the ultimate outcome is always unfavorable. If the growth be benign and be situated in a relatively indiflerent area, the patient may last for years, and even enjoy periods so free from discomfort that he may deem
f recovery r)uite possible. Treatment. — The treatment can only be of any avail if sur- gical interference — that is. excision of the tumot — is possible. IjA case o( this character has been reported by Oowers and plorsley. An oval myxoma which had pressed upon the cord was, after removal of the spinous processes of the third, fourth, and tilth dorsal vertebne, excised, and the patient recovered completely. Bruce and Mott (cf. lit.) diagnosticated iitfra vitam a tumor which, originating in the fifth left dorsal nerve, pressed upon the middle of the dorsal part of the spinal cord : the pa- tient presented the symptoms of a compression myelitis and died. At the autopsy softening with ascending and descend* ing degeneration was found. The authors regret in their paper not having decided upon an extir]>ation of the lumor. L .All other means are fruitless. If there is any suspicion that ■the case is one of syphilis, inunctions with mercury ought tn be given a trial.
UTKKATtlKK.
iinil HMvet. A Cjisr of Tumour <rf itie Cefvic*! Regloti of ll»r Sjilfle. Jciurn. of Nptv. ami .Men!. DiM-.)t««, 18)19. tiv, p. llH. irr. A Coninltuilwi m iIm fjitholofiry of Solitary Tulirrch) or the SpMtl Cord. Joum. nf Ncrv. him) Mcnt. l>iiwwv«, 1S90, xv, p. 631.
470
i>/S£ASES OF SUBSTAA'CE OF SPtffAL CO/ID.
Laqu<rr. Uebcr Compression drr Cauda rquina. Neurol. Ccitinlbl., 1891,7.
(LymphiinKioma Cavemoxum Out.Mflc of (he Dura ; Kenxn'ol.) Culentiurg. Jteiu^g tu ticn KrkcutikuncL-n ilea Coiius n>edullaris and Aa
Cauda cquinn bcim Wcibc. Zeiischr I. klin. Med.. 1891, xvUL 5. 6. Rditi. Com|>Tcssiun <ler Cauda c(|utna <luich ein Lymphangioma cavtmosum.
Operative Hcllung. Arcli. t klin. Chir., 1891. xUi, Heft 4.
APPENDIX.— l'AKASlTf:S IS THE SPINAL COW).
About parasites in the spinal cord we mny look in vain for infonnution in the text-books, probably because their occur- rence is very unusual, and also becauiw. if they are present. they may not give rise to any symptoms. Out here we ought to make at least brief merilion of the cysticerci which have been found nut only in the brain, but also in the spinal cord. Leydcn devotes only a few words to this subject in his Klinilc dcr RUckcnmarkskrankhcitcn (1.445): '■Still more rare [than the cysticerci in the br:iin ], and as yet uf no clinical significance whatever, arc the cysticerci which may develop ... in the adnexa of the spinal cord, etc." I have shown in a case which came to my notice, and which I have reported (c(. lit.), ihat cysticerci of the spinal cord — there were fifteen or iwcniyin the dural sac — may give rise to symptoms simulating those of tabes: some clinical sig^nificance has. therefore, to be alirib- uled to them. That the symptoms of spinal irritation, whidi arc associated with such parasites in Ihe cord, are not to t>e attributed to the incre.ised intraspinal pressure, but that ilie; are of a reflex nature, seems beyond doubt. To diagnos-licMe intra vititM the existence of intraspinal parasites is only posi)()ic in exceptional cases, as, for instance, if the patient is a bulchtr b)' trade, or if his frequent indulgence in raw meat gives riw to the suspicion of cysticerci: but even in the most lavonhle cases the diagnosis can not claim to be more than conjectural-
Almost as rarely do we find echinococci in the vcrteb''' canal. A case of this nature, however, which is ol a groi d«al of interest, has been published by Jaenicke (c(. lit.). A» echinococcus, which had existed in the subpleural tissue in y^ region between the ninth and the twelfth dorsal vertebra, l)cn^ traled into the vertebral canal, and, owing to the compros* thus exerted upon the spinal cord. g,A\i' rise to such cbaractc- tstic symptoms that the diagnosis intra vifaw was to a certW degree justifiable. More recently Friedeberg has reportctl a case of this kind in (he Ccntralbl. t. klin. Med., 1893. xiv. s<-
V. CUNtiGNITAL DISEASJ:S — MyHRORRIIACIIIS — SpIKA BtFlDA.
To a collection ol fluid in Ihc skull we have given ihe name i^-druccphalus (page JoS) ; sitnilurl}' a like culli-ction in the rertebral caoal we call liydrorrhachis, and specify two forms ol he disease — the hydroirhachis externa and interna — accord- Dff as ilie fluid is situated in the meshes ol the pia or between Jic meninges, or, on the other hand, in the interior of lite ipinal cord. In the latter case we find a dilatation of the ccn- ral canal, which is either uniform throughout or beaded.
At the autopsy we not rarely, instead ol the normal central banal, the ordinary diameter of which measures from one enth to one millimetre, lind a canal with a diameter of two, ve. or even ten millimetres (" hydromyelia "). or alongside of he usual canal abnormal cavity formations (" syringomyelia "); luring life, on the other hand, such conditions are by no means lltet) cot;reclIy recognized. The practical significance of these bnormities is not great, as, for one thing, the signs during life re so uncertain and changeable that a correct diagnosis has llmost to be regarded as accidental, and, secondly, because the disease, even if rccoj^nized. is not at all accessible to any ircat- nent. Notwithstanding this, it is of course desirable that the treitent state of our knowledge of hydromyelia and syringo- yelia should be given briefly here.
With reference to the origin of hydromyelia. it is more espe- ia\ly abnormities in development which we have lo dc.il with, nd rarely does the influence ol pressure — e. g., a tumor in be posterior fossa of the skull— Kxime in. For the devch>p* lent of syringomyelia, central gliosis, with secondary disinte- nition and cavity formation, is said to play an important part Fr. Schultzc). It has recently been doubted that congenital cvclopmental anomalies (L/Cvden. Kahler and Pick, StrilmpeU, Jid others) are necessary for the occurrence of the alteration, toscnbach and Schtschcrback (Virchow's Arch.. 1S90. csxit, left I ) have shown cstperimentally that cavities may develop ) compression myelitis as a result ol direct or indirect pressure, 'hese cavities may connect with the fourth ventricle, and cx- end through the medulla oblongata as far as the conus terint- alis. and in a cross-section two or more lumina may lie seen. They are of varijiblc lengths, and arc, as a rule, situated in be lower cervical, in the donuil cord, and especially in close roximity to the central canal, sometimes also in tlie i>o«tcnur
47*
DISEASES OF SVBSTAXCM OF SPWAL COXlt.
horns. Their width varies from a half to ten millimetres ; their contents are sometimes watery and thin, sometimes milky and viscid. The relation of the central canal to these cavities varies so much that no rule c:in be given on this point. Id certain instances it rcm.iins intact in its whole length.
The clinical symptoms which are observed in syringomyelia were first described by Morvan in 1883 under the term ol par£sic analgt-sique it panaris : hence the condition b some- times called Morvan's disease.
There are, more especially, three symptoms which Rhoutd arouse a suspicion of syringomyelia, namely, (1) localized mus- cular atrophies, more especially in the upper extremities: (2)8 widespread, non-typical hemiana'sthesia (especially analgesia): and (3I trophic disturbances of the skin and deeper parts (whit- low, phlegmon), also of the bones and joints, the former breiik- ing more easily, the tatter showing a widening of the capsular space, and being covered with villi of varying size and consist- ence which arc more or less hypcraimic (Ssokolow, Nisscn, cf. lit.). Extensive neuropathic destructions of bones and jointi. which occur in consequence of the analgesia, arc met with (Karg). The muscular atrophy ol the upper extremities is always associated with more or less pronounced paralysis, as we might expect in lesions of the anterior gray horns. In such instances amyotrophic lateral sclerosis or peripheral ncurilJi mav suggest itself as a diagnosis. The sensory changes are readily explained by the fact that the posterior commissure, Goll's columns, and the posterior horns are preferably the seat of the affection. In one of Schlippel's cases (Arch. d. Heilk.. 1874. XV. p. 44) general anaesthesia was found. It should, hou- ever, be said that in many instances, instead of anxsthcui. hypersesthesia has been found, which suggested the lancinating p.iins of tabes (Hoffmann, Eisenlohr), and that often all sensorr changes are absent, so that even these symptoms are far from being pathognomonic. The condition of the reflexes varit-i much, as does also the appearance of trophic and vaso-rooti* disturbances under the form of exanthematous eruptions, veii- cles, ulcerations, erysipelatous swellings, etc., which arc sonK> times present, sometimes absent.
From what has been stated, it is obvious that we may n«<i with insurmountable difficulties in attempting to make a diaf:- nnsis in cases of syringomyelia, as has been shown, lor ex- ample, by Charcot in one of his masterly lectures (Arch. iJ*
I
i
Sr/.VA BIFIDA.
475
Neurol.. 1891, xxii, No. 65). Toxic paralyses, leprous neuritis, I pachymeningitis ccrviculis hypertro[ihia>, trauma of the spinal cord, even amyotrophic lateral sclerosis and tabes, may pre- sent symptoms which suggest syringomyelia, and the rcsem- blnnce may be so great that not infrequently the real scat of the disease may only be discovered at the :iutupsy.
Sumcwiiat related to these dilatations of the central canal are those congenital cystic tumors which, penetrating through the walls of the vertebral column, make their appearance below the skin on the back. U the cyst, the size of which may vary ' from that of a walnut to (hat of a man's list, is situated in the ' middle line over the sacrum, it is called a sacro-tumbar myelo- meningocele, or spina bifida. The skin over the tumor is cither normal, or the seat of a hypertrichosis; the latter is the case in spina bifida occulta (Joacliimsthal, Berlin, klin. Wochcnschr., 1S91. 22; Jones, Brit. Med. Journ.. 1891, p. 173; Bariels. Bcr- ; liner, klin. ^Vochenschr.. 1892. 33; Brunncr. V'irch. Arch., cxxix, p. 246; Joachimsthal, Virch, Arch., 1S93, cxxxi. p. 488). Below the skin arc found the bulging dura and arachnoid. The con- tents of the sac, which has sometimes smooth, sometimes rough walls, arc as clear as water, and identical with the cerebro- spinal fluid. The spinal cord is attached to the inner wall of the sax by a broad tuse. or at its point of entrance divides into several strands which pass directly into the wall of the cyst. ^Thc coexistence of a hydromyelus with a spina bifida, llie for- mer causing an atrophy of the substance of the spinal cord and I communication between the central canal and the cavity of the spina bifida, is a rarity.
I In a child Ixirn with spina bilida we find, as we stated, in the middle of the back, in the region of the sacrum, a soft, doughy, elastic, not rarely fluctuating tumor, which c:>n be made smaller by pressure. The position of the child influ- ences the condition of the sac. It is tense in the erect posture ; when the child lies down it becomes flaccid and soft, a fact which must be referred to the communication usually existing between it and the cranial cavity.
Although the child thus affected may at first develop fairly rnnrmally, his life is endangered from the first moment. Not lonly doc* the pressure exerted upon the spinal cord by the in- creasing tumor lead to motor and sensory changes, as well as blad<lrr symptoms, but there exists a constant menace to life )ich the rupture of the sac would entail, an accident which
474 DISEASES OF SUBSTANCE OF SPINAL CORD.
is favored by the gradual thinning of the overstretched skin. Such a rupture is almost always followed immediately by con- vulsions and death.
The EEtiology is not known. Possibly we have to do with a developmental anomaly, possibly, as Virchow believes, with an early formation of partial hygromata (hydromeningo- cele).
The treatment of spina bifida belongs to the domain of the surgeon. We may either endeavor to get rid of it by repeated puncture and subsequent injections of a solution of iodine in glycerine (Morton), or we may content ourselves with method- ical compression. Owing to the danger of meningitis, how- ever, the whole treatment should always be undertaken with great care.
LITERATURE. /. Syringomyitia.
Kronthal. Zur Pathologic der HAhlenbildung im Riickenmark. Neurol. Cen-
iralbl., 1889. 20. Miura. Virchow 's Archiv, 1889, cxvii, 3, p. 435. Dejerine. Soc. de Biol, de Paris, Stance du 25 Janvier, 1890. (Changes in the
Cutaneous Nerves in Syringomyelia.) P. Rosenbach und Schtscherback. Zur Casuistik der Syringomyelic. Neural.
Cen(ralbl., 1890. 8. Uruhl. De la Syrnngomyeiie. Paris, 1890. Holschewnikoff. Virchow's Archiv, 1890, cxix. Heft l. (Changes in the
Peripheral Nen-es.) Frnncotte. Arch, de Neurol.. 1890. 56-58. JofTroy el Achard. Arch, de niM. e.'(])^rim., 1890. p. 540. Knrg. Arch. f. klin. Chir., 1890, xli. Heft 1.
HofTm.inn. J. .Syringomyelic. Samml. klin. Vortr., N. F., 1891, 20. Ssokolijw. Wratsch. 1891. 23-25. (Joint Affections in Syringomyelia.) Sch.-ifrcr und Preisz. Hydrorayehe und Syringomyelie. Arch, f Psych, u.
Ner^'enkh., 1891. xxili, t. Iiernh:irilt. M. Deutsche med. Woehenschr., 1891, xvii, 8. Charcot. Progr^s mM., 1891, 4. Charcot, .^rch. de Neurol.. rSgi. xxii. No. 65. Nissen. Arch. f. klin. Chir., 1892, xliv. p. 204. (Joint Affections in Syrins'*-
myelia.) K(i|i])en. Deutsche Med.-Ztg., 1892, 64, p. 744.
Oppenheim. Ibid., 1892. 97, p. 1138. (On Typical Forms of Gliosis Spin^li') Sihli-singer. Zur Klinik der Syringomyelie. Neurol. Centralbl, 1893. *». -"■ IkTnliardt, M. Liier.ir-histor. Bcitrag zur Lehre von der Syringomj*-
Deutsche med. Wcchcnschr., 1893, 32. Minor. Arch. f. Psych, u. Nen'enkh., 1893, xxiv, p. 693. Opptnheim. Ibid., 1893. xxv, 2. (A Typical Form of Gliosis Spinalis.) Lcilcrc el Chapuis. Gaz. hebdoiii. ik nicd. el chir., 1893, 2. sir, xxx, 51.
SPINA BIFIDA.
475
a. PaTontis and Spina Bifida.
Jaenicke. Ein Fall von Echinococcus dcs Wirbelcanales. Breslauer 5ml,
Zeilschr., 1879, 21, November 7, Dullinger. Die osteoplast ische 0|«:ration der Hydrorrhachis. Wiener med.
Wochcnschr. 1886. xxxvi, 46. V. Recklinghausen. Virehow's Archiv, 1886. cv, %, 3. Brunner. Ibid., 1887. cvii, 3, Hirt. Ein Fall von Cysticerkcn im Riickenmarke. Berliner klin. Woctienschr,,
1887. 3. V. Recklinghausen. Unlersuchungen iiber Spina bifida. Virehow's Archiv,
1887. 105, pp. 243, 275. Holt. Remarks upon Spina Bifida. New York Med. Joum.. November 5,
1887. Bland Sutton. On Spina Bifida Occulta and its Relation (o Ulcus Perforans
and Pes Varus. Lancet, July 1, 1887, ii. Beneke. Fall von unsymmetrischer Diastetnato-myelie mit Spina bifida.
Leipzig. 1888, Festschrift. Wichmann. Wiener med. Wochenschr., 1888, 24, p. 837. Ribbert. Beiirag zur Spina bifida occulta lumbo-dorsalis. Virehow's Archiv,
1893, cxKxii, Heft %. Scholl. Fall von Spina bifida occulta mit Hypertrichosis lumbalis. Berliner
klin. Wochenschr., 1894, ;,
DISEASES OF THE GENERAL NERVOUS SYSTEM.
I\ diseases of the general nervous system, the brain and spinal cord and the nerves which come off from them all share in the morbid process, yet the extent to which the different parts are implicated varies very much in different cases. Some, times, in so far as clinical symptoms would lead us to con- clude, the trouble lies mostly in the brain, sometimes in the spinal cord. In the latter case, again, we may have a more marked implication of the substance of the cord itself, lesions of certain tracts, or perhaps the lesions of the peripheral spinal nerves mav come more into the foreground. Between such extremes there exist manifold intermediate forms, but to say much about the course of these diseases which would be appli- cable to ail becomes all the less possible because a second point has to be taken into consideration, namely, whether, and if so how far, the whole orf^anism shares in the disease of the nervous system. This [jarticipation varies in many ways, and there arc diseases of the general nervous system which can ex- ist [or years without any serious implication of the general or- ganism : while there are others, and these are far more numer- ous, ill which sooner or later the nervous disease grows, as it were, into a general disease, in which the organs which have to do wilh digestion, circnialion, secretion, excretion, sometimes even respiralion, are affected more or less seriously. That the course of the disease and the prognosis must sometimes be materially influenced by this we need not say, and one rule is forcibly impressed npon ns by such cases, a rule which must never oc lost si!,^ht of by the physician, viz.. never in a case of disease of the genera! nervous system to content ourselves wilh an exaniinalion of ihe nervous system, but to remember 47*.
D/SEAfieX OF rUH GENP.ftAI. .ve.RVOVH SYSTKM.
^77
fiat the same care must be devoted to all organs without exception. This rule, self-evident enough to the conscientious libserver, we have dared to <?mpliusize again because ii is more especially in nervous diseases that it has been allowed t<i (all into abeyance. As to the pathology o( the diseases which we are about to consider, our knowledge is unfortunately in many respects very scanty, and in mniiy of them no lesions at all have been found after death, although the assumption, that in llie majority of cases some anatomical changes, macroscopical or microscopical, must have been present, would appear to be justifiable. Unly for cerlaiii of the diseases in this category, as tabes, dementia |>aralytica, multiple sclerosis, and cerluin chronic intoxications, have anatomical changes been dennm- ^Iratcd. and even here we are not always clear about their significance. Again and again it has happened that after an accurate analysis <»f the clinical symptoms a diagnosis hits been made intra vttam and this and that anatomical change has been rcckuncd upon with certainty, and then at the autopsy the whole nervous system was found to be abM)lutely intact. Among such cases we may mention that of Westphal, where a niulliple sclerosis w,-is diagnosticalctl : that ol Killian. a sup- posed chronic myelitis, a certain rase of ophthalmoplegia ex- terna progressiva ol Eiscniohr and an apoplectic bulbar pa- nlysis of Senator (Neurol. Centralbl., 1892, 6). Instead ol the pathological condition expected, the brain, spinal cord, and Ibeir nerves were found to be absolutely normal. On the other hand, it has happened that where hysteria, epilepsy, or chorea had been diagnosticated and one had prophesied most confi- dently that the condition of the central nervous system would be found normal, the autopsy has shown extensive changes — multiple loci in the spinal cord or in the brain cortex, recent or old areas o( softening, etc. To such errors even the most reliable observer is exposed, and it is just the man who has observed accurately the greatest number of cases and assisted at the post-moriem examination of them who will be most cau- tious in his diagnosis and in his prophecies as to what will prob- ably be found at the autopsy.
Uncertain, then, as is the condition ol our pathological knowleilge in these cases, still, if we decide to treat ol diseases ol the general nervous system not simply one after the other, but to adopt some arrangement into groups, it is best lo base Itiis in a general way on the conditions which we find alter
478
DISEASES OF THE GENERAL NERVOUS SYSTEAf.
death, and to distinguish two classes, the first including those nervous diseases in which up to the present time no anatomical changes have been demonstrated at the autopsy, diseases which we therefore call functional neuroses ; the second, those dis- eases which are always associated with known anatomical changes.
PART I.
.jy/SSASES OF THE GENERAL NERVOUS SYSTEM WITHOUT ANY RECOGNJIABI.E ANATOAflCAt BASIS.
■* Functional Neukoses."
In almost all affeclions which belong to this group the so- called individual predisposition — that is. the personal inhciiicd [>eculiarities— play a jiromiticiit rSli\ and In X\\\s connection the careful studies of Anton {Wicn, Iliildcr. 1890) ujion the con- genital diseases of the nervous system are ol undoubted value. Nevertheless, it must be said that in many of these cases no anatomical changes whatever have been discovered. In pres- ence of ttie number of these conditions it would seem desirable to divide them into smaller groups, an undertaking, however, that presents the greatest difficulties, because any classification I must always appear to a certain extent forced. But inasmuch as no ]>athological anatomy enters into the question, it may, for practical purposes.be justifiable to group these affections according to the influence which the neurosis exercises upon the general condition o( the patient. It will be found that while some of them (though these cases are lew) disappear after running a shorter i>r longer course without leaving be- hind them any bad effects, or, even when they last for years. never entail serious general symptoms, there arc others which are characterized not only by their long duration, their obsti- nate resistance to treatment, and their tendency to recur, but also by the baneful influence which they exert on the general system. The former, for the sake of brevity, we shall desig- nate as mild, the latter as grave neuroses, although we do rir>t mean to exclude the possibility that now and again among the ordinarily mild ly|>es we may encounter a serious disease run- ning a tedious course, while among the grave forms we may have cases of far less severity than usual.
459
48o D/SEASES OF THE GENERAL NERVOUS SYSTEM.
A further classification might be made according to the symptomatology. It is true that the symptoms present so many variations that it appears difficult to arrive at any prin- ciple according to which we can conveniently group the dis- eases, despite the fact that in some cases the symptoms point rather to a cerebral, in others more to a spinal affection. Nev- ertheless, since we find that in some cases the motor nerves, in others the sensory nerves, and again in others the trophic nerves, are pre-eminently implicated in the morbid process, we may for the present utilize this fact in the arrangement of our groups. It is scarcely necessary to state that we are in no wise satisfied with this classification, and look upon it only as a temporary makeshift, to be superseded as soon as some better method shall have been discovered.
FTRST CROUP.
ATEt/Jtoses WHICH are wq.\t to kvx their covrse with.
OUT ANY F.SSEXTIAL IHPUCATIO.V OF THE GRNEEAI. OKGAXISM.
A. AFFECTIONS IN WHICir THE MOTOR NERVES ARE CHIEFLY IMPLICATED.
I
I
CHAPTER I.
CHOREA — CHOREA ST. VITI — ST. VITVS's DANCE— RAI.l.l»UUS — UllLAK- CHOLIA SALTAKS— SYDF.KKAU'h DlftF.ASK.
The term chorea no less ihan epilepsy is often too loosely .ippIicH. A person may suffer from cht>rc.i.Iike motor disturb- ances wiilioul having genuine chorea. Various cerebral and ipinal affections are capable of producing such symptoms: but a careful observer will rarely find difficulty in deciding whether they arc the outcome of a functional neurosis or of anatomical lesions in the central nervous system.
By chorea, in the sense in which tlic term will I>e used here, we mean a functional neurosis churncterized by the occurrence of peculiar irregular movements entirely beyond the control of the patient. They appear in the upper extremities and in the face, as well as, though to a lesser extent, in the lower ex- tremities and in the trunk. They attack only the voluntary muscles, and may persist for days, weeks, and even months uninterruptedly, escept during sleep. If these movements, as is f retiiiently the case, are confined to one side only, to one half of the face, to one arm and the corresponding leg, we speak of a hcmichtirea. The distinction which is made in some of the older books between chorea major and chorea minor has become superfluous, since the symptoms which were formerly described as constituting the clinic:d picture of chorea major do not represent an independent disease, but belong to the
483
mSEAsaS OF TUB GENERAL NEfiVOVS SYSTEM.
domain of hysteria. Ilcncc we can also dispense will] (he (Icsignalion " chorea minor."
The "choreic " movements may appear independently where it is impossible to find any coexisting symptorus ol another disease, or they may be no more than symptoms of another afieclion, be it of the brain or spinal cord. Our exam- ination will have to decide between these two possibilities. Wc shall deal here only with the idiopathic, genuine chorea, and we need hardly say that only this form is to be regarded as a mild neurosis in the sense pointed out abo%'e.
Symptoms. — To describe the choreic movements in detail is not easy, because they present very many variclics in de. gree and extent. In the relatively severe cases all the muscles participate, the head is thrown about and shaken, the neck U twisted, the forehead is wrinkled and smoothed, the eyelids closed and opened, and the eyeballs rolled around. The facial muscles, including those of the lips and the mouth, t-ike part iii the movements, thus giving rise to the most varied expressions —t. g., those of terror, an\iely, or joy^accordiiig to the par ticular muscles most strongly affected, llassc slates that the lip ol the nose may be moved, though I myself have never seen this. Very conspicuous arc the movements of the tongue muscles, since they interfere wilh speiiking, chewing, swallow- ing, and with the protrusion of the tongue, which in the worst cases become entirely impossible. If the muscles connected with the (unction of respiration arc affected, disorders in breath- ing arc encountered; the implication of the muscles of the trunk gives rise to rotatory and other involuntary movements of the body ; the patient rises and falls down again, and may work himself into the most peculiar and marvelous positions ("/t»/iV- Hes muscifs").
In the great majority of cases the movements d<» not lake place in the way wc have described, except, perhaps, the twitchings of the face, but are confined to the upper ex- tremities, or are at any rate most marked here. Shoulden, arms, and fingers arc constantly in motion, the affected mus- cles twitch, the arms arc extended and flexed, the fingers spread apart, and so forth. A similar restlessness is observed in the muscles of ihc thigh and caif, the feet arc alternately lifted, the toes moved, although the lower extremities are g«i- crally attacked to a lesser extent. Sometimes the movements are gone through with lightning quickness, in which rare in-
SYMProATS Of CHOKE A.
483
to i ■ how
stances the nntne chorea electnca is juslifiabie. In milder cases the patients m;iy at times be able to remain perfectly quiet, and only slight twiichings in tbe arms, the fingers, perhnps also tn ihc facial muscles, will betray the existence of the disease. It is A characteristic feature of idiopathic chorea that all move> ments entirely cease when ihc patient is asleep, although going to sleep tniiy be rendered somewhat difficult. Once asleep, however, such patients rest C]uicrly, and are not disturbed by muscular utiresl.
That the intended movements arc influenced by the patho- logical ones goes without saying, and it is quite possible that at a lime when the disease is slill at (ts beginning and has not yet been recognixed, but is already exerting its intUience upon the voluntary movements, the patient may be simply regarded as awkward and clumsy. II this happens to children who have to write in school, or recruits who have to drill and learn the diUcrcnt manipulations, much unpleasantness for the patient may arise from this condition, which might have been avoided by a carelul examination by a physician. Generally the vol- untary movement is normal in its lirst phase, but soon the muscles begin to be seized by the spasms and ihe patient is not able to carry out the movement intended. This is noticed in dressing; or eating, or in other ordinary actions of daily life. but most of all is it seen in writing, playing the piano, or in the performance of other movements re<|uiriiig a high degree of coordination, and may even be marked if wc ask the patient to put out his tongue.
His apparent awkwardness excites the patient very much, and the more he tries to execute the intended raovemenl, the more he tries to govern his unmanageable muscles in the usual manner, the less he succeeds .ind the more he is annoyed by tlie involuntary movements. Only a few particularly well disciplined patients arc, at the height of the disease, able to keep their muscles lor a few moments at absolute rest. The reflex and automatic movements are not interfered with. Protective movements arc performed as by healthy persons; coughing and sneezing arc dune normally : neither do the car* diacor respiratory movcmcnls sniTer,
The sensibility is in no way interfered with. Tenderness over Ihespine may be present, although not regularly. Other- wise nothing abnormal can be noticed in the domain o( the sensory nerves, it is remarkable to note that there is no sense
484 D/SF.AXES OF TtlR CEXEJtAL ATEXfOVS SYSTEM. ■
of fatigue, which we certainly should expect after such exces- sive muscular action. The body temperature and the urine remain normal throughout the disease if no complications are superadded. On the other hand, the psychical condition of the patients, especially if they be young people, undergoes more or less marked changes, which constitute a prominent feature of the disease if the course be prolonged ; children who have up to this time been kind, obedient, diligent, and willing, become willful, peevish, and spiteful ; although learning nicely and without difliculty and making good progress in school be- fore they had any symptoms of chorea, they become slow al grasping and understanding what they arc taught: the easiest things must be repeated and impressed upon ihem, and often enough they are forgotten again in a few hours. If. and this is not rarely the case, an impediment in speech is added iii consequence of the choreic movements of the tongue, the chil- dren become wholly un5t for school. It is at this time no longer necessary to advise keeping the child at home, since the teachers themselves will no longer permit it to attend. The influence of the disease upon the psychical functions is generally much less marked in adults.
In the idiopathic uncomplicated chorea the described mani- festations persist usually for several weeks with varying inten- sity. From the onset to the cessation of the disease from sixty to ninety days may elapse (sixty-nine days, Sfie: eighty days, JUrgensen; eighty-nine days, Ricckc), yet, as wc shall sliow later, the treatment is not without inllueuce upon its duration. By far the most frequent issue is recovery, although the possi* bility of a relapse is by no means excluded, and in giving a prognosis this feature should be taken into account. Dcalb from chorea is a very uncommon event, and occurs only in very weakly children or when complications arise; Powell. Haiidiord (Brain, 18S9). and others have reported fatal cases of chorea: in most instances, however, wc are justified in giving a good prognosis.
Complications. — The complications and the relation that chorea bears to other diseases deserve much attention, more particularly as this rcLitinn is to a great extent still obscure. In the first place, articular rheumatism must here be men- tioned, the connection of which with chorea everybody knowrs, but which, however, is not interpreted by all authors in the same manner. While the French writers especially, among
SVMPTOMS OF CIIOkEA.
4«S
I
1 Sie and Roger, regard rheumatism as an almost regular precursor of chorea, Ja Germany there is much diversity of opinion on this point. Several authorities (Lebert, Eichliorst. Sirllmpcll) only !>tatc that the two affections arc relatively fre- quently found together; others, with Briegcr, draw attention to the alternating appearance of the two (I)crlincr klin. Woch- eiischrift, 1886, xxiii, 10); others, again (Henoch, Litten). look upon rheumatism as "the most important and best-founded cause of chorea": while some, in contradistinction (o the rest, deny the existence o( any connection between the two affec- lions (Romberg, v. Nicmcycr, Prior). However obscure ibis association may be. (o deny it absoliilcly would be to set facts at defiance. According to our own opinion, we have to deal with a common noxious agent> an infection which, if chiefly localized in the brain, gives rise lo choreic movements, while if it affects the joints it causes acute rheumatism in them. Most probably, we may almost say unquestionably, it is the same infecli<^us material which, il afTecling the heart, produces endo- carditis and myocarditis, for chorea is as frequently connected with valvular disease of the heart as with articular rheumatism, though the one relationship is as obscure as the other.
II chorea, or, we had better say, if certain (orms of chorea are actually to be traced to an infection, we can not be sur- prised if choreic movements arc found lo appear after other infectious diseases — c, g.. whooping-cough, typhoid fever, diph- theria, or cholera.
The possibility that chorea has some connection with epi- lepsy can not a priori\x, thrown aside. I have twice had occa- sion to observe children who up to the age of puberty had re- peatedly suffered, as it seemed, from genuine chorea, and who afterward became subject to epileptic attacks. It is true the tongue was not bitten in these paroxysms, but otherwise all the signs of a classical epilepsy were present, not excluding the aura. K later communication of Marie ^Progr. mid.. 1886. xiv, p. 39), in which the occurrence of ovarian hyperarsthesia in the course of chorea is mentioned, led us to the idea that possibly the above-mentioned attacks were of a hystertctl nature, and to question whether there may not be certain forms of St. Vitus's dance which could be designated as hysterical.
Lastly, those very rare cases of tropho-neurotic disturb- ances in chorea are of interest ; thus, bald spots on the skull (Escherich. Mitth. aus dor med. Klinik zu WUrzburg. 188^ ii).
486
OiSKASES OF TUE GEXERAl. XER%'OVS SYSTEM.
or in places absence ol pigment in the hair or the skin, were noted (MSbius. Schmidt's Jahrb. d. gcrichtt. Med., 1886, vd. ccix. p. 251). How these are brought about we are utterljr un- able ro explain.
Diagnosis.— It is usually not difficult to recognize chorea if we remember that yoimg patients of the female sex, who arc often also anicmic, form the largest contingent of the cases, that the twiichings chieliy affect the upper extremities and the face, and that they arc entirely independent of the will of the patient. Their disappearance also during sleep is an impurtani point, and this fact by itself would distinguish them from the alhetoid muvemenls. These latter, possibly the twitchings ol the tic convulsif, the tremor of paralysis agitans, the shaking movements of the intention tremor of multiple sclerosis, finally, certain muscular spasms, which Lcclerc and Koyer {cf. lit.) have designated as pseudo-choreas, must more especially be taken into consider.-ition, but they ought never to render the diagnosis really difficult.
Pathology. — Our knowledge o( the pathology o( idiopathic, uncomplicated chorea is very imperlcct. The changes which have been found thus tar do not seem to be essential. Repeat- edly capillary emboli have been found at the autopsy in the thalamus and the corpus striatum, often they could not be dem- onstrated (Dana, Brain, 1S90, xUx). The cxperimcntsof Money on guinea-pigs and dogs ([.^ncct, 1881;, I, p-9S;) would indicate very decidedly that chorea can be caused by capillary emboli. Their mode of action, however, remains unexplained. The ob- jections which Litten has raised against the embolic theory. that the demonstration of embolic processes in ordinary cases of chorea is not proved, and that in spite of the diversity ol the localization of the foci of softening in the brain the clin- ical picture is always the same, can not bt: regarded as cchk vincing.
The communication of Flcchsig, who in the two inner ante- rior segments of the lenticular nucleus, but nowhere else, found small hodics in the lymph sheaths of the vessels, some of which were larger, some smaller than bluod.corpuscles, has as yet been neither confirmed nor overthrown. " Their arrangement resembled that of glandular structures: thev were strongly re- fractive, very firm, and almost like chalk, although they con- lained no lime. In alkalies they slowly swelled." Though their chemical nature is unknown, they resemble in the main
I
JETIOI.OCY OF CUOlie.A,
487
I
thai malertal which von Recklinghausen has termed " h^-a- line." This observation has not as yet been interpreted, and Flechsig himself declines to ^ive a decided opinion as to whether the bodies have been formed in the blood or lymph vessels or whether they have 10 be rcRarded as products of de- generation Irom ganglionic cells and nerve fibres. Allhongh we have 10 admit that lesions in the lenticular nucleus may cause choreic movements, we can as yet make little use of these bodies as an anatomiail cause for the disease. Wullen< berg regards them as non-essential (Arch. \. Fsych., 1891, xxiii, 1. p. 197). Earlier observations ol conditions which were con- sidered as significant for chorea — that is, hyperfcmia of the brain and the spinal cord, lesions of the corpora quadrigemiiia. tubercles in the cerebellar peduncles, inflammatory conditions in the vertebrye. and spinal irritation resulting Oicrelrom — pos- sess only historical interest.
Although we are then siill unable to say anything definite about the nature of the disease, the assumption that we have before us an affection ol the entire nervous system, in which, to be sure, the brain takes the most prominent part, seems the most probable. Whether certain portions of the brain arc par- ticularly qualified to produce choreic movements — whether, be- sides being produced by irritation of the cortical motor cen. tres, they may also lie brought about by lesions of the basal ganglia ; further, whether this irritation can ever be attributed to infectious material, microbes, or the like, whether it can ever be connected with fungous growths, such as, for example, Nati- nyn has found in the pia belonging to the species of the dado- thrix or leptolhrix, or whether we have to assume an autoin- toxication, as in epilepsy, urxmia, etc. (Duchateau, Thfrse dc Paris, 1893) — all these remain open questions, and we must also leave undecided whether or not the alteration of the blo<xl de- pending upon the soH^'alled rheumatic diathesis is sufficient for the development of the disease.
Etiology. — Among the causes of chorea heredily plays an important rdlt, as it does in all diseases of the general nervous system. This factor is more important, since heredity can here not only be called an indirect predisposing circumstance, ow- ing to which an individual is more prone to one or the other nervous disease, but because there exists actually a hcrcditar>' form of chorea which is handed down from generation to gen- eration and which for a great many years may remain in the
4SS
D/SE/ISES OF THE CEKERAL NERVOUS SYSTEM.
family. This chorea hereditaria, or, as it is also called, Hunt- ington's chorea, has nothing in common with chorea but the name ; it is produced by anatomical changes which have been characterized by Oppenheim and hloppe as a miliary dissemi> naled cortical and subcortical encephalitis (Arch. f. Psych,, 1893, XXV, 3). It does not come on in childhood, and hardly ever appears before the age of thirty or forty. It is character- ized by peculiar motor disturbances resembling those of alh& tosifl (p. 384), and not rarely leads to pronounced mental deteri- oration. It is incurable. The conception that it is a progres- sive doulilc athetosis seems to me worthy of consideration (cf. Rcmak. Neurol. Centralbl.. 1S91. 11, 12; Krohnthal und Kali- schcr, ibid., 1892, 19: Greppin, -Arch. f. Psych., 1892, xxiv, 1; and others). There arc "chorea families" in which a whole generation never remains free from the disease, and only cer- tain members arc exempt. On the other hand, there exists also a chorea congenita (Rau. Iiiaiig.-I>issert.. Berlin. 1887). which has to be attributed to an affection of the mother caused by fright, etc., during pregnancy (Fox, liichtcr, MJlbius. Oppen- hcim). It has long been known that pregnancy itself may to a certain extent predispose to chorea, as is shown by the so-called chorea gravidarum. Age and sex play a certain rSU among predisposing causes, inasmuch as the young and the female sex are especially prone to it. Among 439 cases, 322 (that is, seventy-three per cent) were girls, and 34o(that is, seventy-four per cent) were between the ages of five and fifteen ; 411 (thai is, ninety-one per cent) were between the ages of five and twenty (Mackenzie). In rare cases old people become subject tochorea (chorea senilis), The oldest of my patients was cighty-onc, the oldest of Mackenzie's patients even eighty-six.
Among the exciting causes there arc two kinds which arc particularly important — the one, psychical excitement, partlcw- iarly fright and anxiety; the second, frequent contact with In- dividuals suffering from chorea, which awakens an impulse to imitate the pathological movements and gives rise to what wc then call chorea imit;ituria. The latter Is far less important than the former. Epidemics of chorea have often been described: Wichniann has observed one in Wildbad (Deutsche med. Wo- chcnschr., 1890, 30). The lime which elapses between the recep- tion of the noxious influence and the development of the dis- ease usu.illy comprises from five to seven days, sometimes only one day. Sometimes, again, the cflcct follows the cause immo-
TREATMENT OF CHOKE A.
489
I
I I
I I
I
diaiety, this being so in ten per cent of all cnses caused by (righL Besides Inght. bodily or mental overexertion, particii- liirly the Inltcr, may provoke the disease. According to Mac- kenzie's report, sixteen per cent of all cases observed are at- tribiilablc to this cause.
Treatment. — Cases o( uncomplicated chorea get well with. out any interference on the part of the physician, but the re- sults of wide and varied experience have taught us that with certain measures we arc able to cut short the duration of the disease to a no inconsiderable extent. With reference to the internal treatment it is interesting to follow up the different phases and changes through which this has passed in the last half century. When the spinal c<)r<l was suppitsed to be the seat of the disease much was thought of strychnine, which had been recommended by Trousseau and which was administered in the form of a sirup. Later, when to the rheumatic basis of chorea a prominent place w.is given, colchicum and quinine were preferred. Again, camphor, potassium iodide, and hy- drocy ante-acid preparations were prescrilied when irritation of the sexual organs was held to be the starting point of the dis. case. Venesection, leeches, cups to the head and along the vertebral column, were employed for a time on the authority of Sydenham. Alt these measures have now more or less fallen iiilD oblivion, and even the zincum oxidum album, once so warmly recommended by Hufeland, has had to give way to cilhcr remedies. Among those still valued, arsenic, which was introduced by Konil>crg, stands hrsl. It is best given in the (iirm of Fowler's solution, in doses of from three lo five drops three times a day, the dose being gradually increased to twenty or thirty drops a day. The medicine ought to be well diluted with water. Instead of Fowler's solution we might prescribe the waters of the Ronccgno or Levico springs in duses of a tcaspoonful to a tablcspoonlul three times a day. At the same lime we must be on the lookout for intoxication, which has been known to lie produced even by small quantities of the drug, as was proved by a case of my own. The arsenic treat- men! is to be continued until either the symptoms abate or digestive disturbances make their appearance, which would contra-indic.ite its continuance. Wc usually attain our end in from fifty to sixty days.
Next to arsenic wc prefer the salicylate of physostigminc :), which, in the form recommended by Kiess i,Uerliner
490
DiSHAS/iS OF THE GENERAL A'EKfOfS SYSTEM.
klintschcr Wocheiischrift. 1887. 22), may be injected hypoder- mically twice a day in the dose of one milligrnmrae (Vi, gr.). Excellent results may be obtained with this mode ol treatment, and the duration nf the disease may be reduced to thirty nr forty days. We need hnrdly insist that this dni^ must be ad- ministered most cautiously, because cscrinc poisoning has been observed (Loddcrsiiidt. Berliner klin. Wochenschr. 18S8. 17). As soon as any bad eRccts begin to show themselves, such as nausea, vomiting, etc., it is advisable to discontinue the mcdi> cine at once for a coiisiderahic time. With regard to exalgin, so highly spoken ol by Datia (Journal of Nervous and Mental Diseases. 1892, July), at present i must suspend judgment; from small doses I have observed but little effect, while larf^ doses did not seem to be always well borne (c(. also Joris. Wiener mcd. I'rcssc. 1892, 44). Anlipyrin, which has been rcc ommendcd by Legroux and others, 1 have completely aban- doned. The results obtained with this drug arc uncertain and transient. We were never able to note cures within from six to twenty-seven days with this remedy, such as Legroux has reported. If Ihcse medicines leave us in the lurch wr may with caution prescribe chloral, morphine, opium, under the influence of which the movements may temporarily abate.
Among other measures we may mention the use o( cold water and electricity, which, although only ol secondary im- portance, may not be without good effects. We have in differ- cnt places spoken of the cold-water treatment, and wish again to repeat here that extremely low temperatures arc unneces- sary, but that hip baths of 84* F., with cold affusions (o the back (81° lo 7;" F-) and wet packs seem sufficient. In the elec- trical treatment the constant current is chiefly to be used, whicli is made to .tct alternately upon the brain and the spinal coni (Hirt. /w. cit., p. i8r).
Sometimes all these means of treatment which wc have just described arc ineffectual. The patients lake medicine, undergo the cold-water treatment, etc., and no improvement k noticeable, fn such instances a change of climate is to be recommended; the patient may be advised to travel, and be kept away from his family for some time; excitable indivul- uals especially, in whom psychical influences increase the motor irritation, are to be secluded as much as possible. Visits nf friends or members of the lamily should be interdicted. Chil- dren should be kept away from school, and should be spared
I I
I I
TflEA T.VEXr Of CHOKEA.
49'
•ny mental exertion. Even at home ihey should not be made 10 work : they should be encouraged to suppress the move- ments as much us possible, and a !-ni;i)l reward should be prom- iscd if (hey succeed. In this manner olten a good deal is at- tained. Only in exceptional cases need the patient be in bed for any length of time — namely, if the twitchings arc very vio- lent and likely to lead to bodily injury. In such instances
[the use of narcotics, as suggested above, becomes more espe- cially warrantable. We shall later have occasion to S|>eak of the treatment by suggestion; the results obtained with this
rmethod arc somclimes quite satisfactory.
LITERATURE.
^ _..,.
V Vauitch. £iudF sur ti-s chor^i-s dcv aduliet. Thi*e de I'arit, 1S83.
Prlpcr. Chorea bcl Typh. abdom. DcutschcninL WocliciiKhr., 1885. 8.
tOickinMxi. On Chores, wiih Rcfcrtncc 10 its Suppotcd Origin in Emboltm). Luicct. January 1, 1S86. Liiten. DelirSgc xur Anlolugie drr Chonra. Chariif-Annal.. 1S86. xi. p. 365. llirnhaum. t'cbcr ilie Chorea tier F.twachkrnriv. Inniig.-DiiscR.. Berlin. K 1886.
BHawkiflt. Charm and Epilepsy, t.ancct. Jnnuary i. 1886. HiLandois. DeuiKlicniod. WochaL^chr., 1KK7. 31.
BiMackmiic Kr|Mn on Chortn. lint. Med. Joum.. Fi^bniary >6, 1887. <R«. H pon» (>f the Colkcilve InvMtigation Comnilucc of ihc British Medical As- ^ Mcbiion.)
Koch. P. 7.\a [.chrc von <Ier Ch. minor. DeuiMhcs Arch. f. klin. Med.. 1S87.
■L S.6- Schweinitt. Euiniinittion of the Eyes in Fifty Cues of Chorea in Children.
New York Mnl. Joutn.. June JJ. 1888. Suckhng. Dni. Mrd. Journ.. April 18. 1S88. (Senile Chorea.)
tCombf. Lea r^latiimi pallio|;Jni<|ues de la cliorfe IVog. mjd.. iSSS, 16, pt JOOi
Hoffmann. Uvbrr Ch. chrotika progmtira. Virchow's Archiv. 1S88. fid. iii.
II, J. (Hunlin|;(on'K Choren.) Schromann, [>rultclir med. Wochenvhr.. t8S8, siv, 3). Mendd Cenlnill>l. t. Nervcnhrilk.. 188S. xi. tj. Lunolt. Ch. hfr^liLiin:. Krvuc At mM.. 1888. 8. ChautTrnu- \x\ lic^i rootdm^s nvrc f miction brtisque et inralonlaire dea eris
■i ilrs inuti arttrul^. Thisc de Ui^nle.iux, 1888. ^Hrrtmgham. Chfnnic Hcmtlt.iry Chorea. Krain. 188S. xl. p. 41$.
nko. 2ui- Frage der Localitalion dcf Chorea. CentralbL t. NcrvenhcUk., 188S. «l. 32. [KSppel el DuceUier. Un eas dc choree hjrtdiiain dc t'adullc. Enctfphak.
1S88. \\\\. 6. PaiellK. ConiritrailoM nnaiomo-juioluska e clinica alia ttuilio dclU corea nti- non. I'adova. 1888.
492
DISEASES OF THE GENERAL NERVOUS SYSTEM.
Sinkler. Hereditary Chorea. Boston Medical and Surgical Joum., October 15,
1888, cxix. Sturges. The Rekiion of Chorea, to Rheumatism. Lancet, 1S89, i, 3. Hegge. Ueber den Zusammenhang zwischcn Chorea minor mit dcr Polyar- thritis rheum, und der Endocardilis. Wiener med. Blatter, 1888, 41, 41, Schadle. Chorea of the Soft Palate. Phila. Med. and Surg. Rep., Octobtr 14.
1 888. lix. Gairdner. Case of Nerve Disease with Choreic Movements. Glasgow Medic.il
Joum,, 1889, xxxi, I. Biernacki. Fall von chronischer hereditSrer Chorea. Berliner klin. Wochensehr.,
1890, xxil. Remak. Ueber Chorea hereditaria. Neurol. Centralbl., 1891, ii. Jolly. Ueber Chorea hereditaria. Ibid.
Dreves. Ueber Chorea chronica progressiva. I naog.- Dissert., Gdttingen, iSgr. MacCann. Chorea Gravidarum. Brit. Med. Joum,, November 14. [8yi,
p. 1046. Lewis. Amer. Joum. Med. Sci., 1892, 3. p. 251. Mobius. Ueber Seelenstorungen bei Chorea. Miinchener mecl. Wochensehr..
1893, 51, 52. Guillemet. De la mort dans la choree de Sydenham, Thdse Ac Paris, 1893. Dana. Amer. Journ. Med. Sci,, January, 1894. (Microbes as the Cause of
Chorea.)
CHAPTER II.
TETANV — TKTANIL.LA — TETANUS INTER Ml TTKNS.
The name tetany (Corvisart) has been given to a neurosis which is chAractemed by paroxysmal tonic muscular spasms, during which consciousnr&s remains undisturbed. The spasms arc oltcn confined to the flexors n( the fingers and o( the wrist )oint. and only rarely attack the muscles of the lower cxtrcm- jiics; they arc always bilalcml. The fingers are drawn to- gether and the hand assumes, to use Trousseau's comparison, the shape which the obstetrician gives it when introducing it into the vagina. With these spasms, which arc o( (jrcai inten- sity, so that the affected muscles feel tense and hard as boards. are Msociale<l slight flexion at the elbow joint and a moderate adduction of the upper arm. hl^rard claims that the pressure of the thumb upon the other fingers may be so strong as to lead to pressure gangrene, but this is unquestionably very rare, tf the lower extremities are affected the feet assume n position of plantar flexion, and ihc big toe is drawn under the second or third. Sensory disturbances are usually entirely absent, except that the contracted muscles arc painful on pressure and the skin over them is covered with a copious sweat. K These attacks, which vary a good deal in frequency as well ^^as in duration, may be produced by pressure upon the lai^er nerve trunks or the Larger arteries of the upper extremities, as Trousseau found accidentally, by applying a venesection bandage : thus, by pressure upon the median nerve or the bra- chial artery, a spasm may be produced of exactly the same nature as the spontaneous ones. This is called Trousseau's si^. and is considered to be of great diagnostic importance.
The attacks scarcely ever occur suddenly and uneupcctedly. Generally Ihcy are preceded by prodromal svmptoms. which
klast for a few minutes and consist in a painful drawing sensa- lion ol the hands and arms. Previous to the first attack such
494
DISEASES OF THE GB.VEflAL XERPOUS SYSTEM.
sensations, together with formication, feelings of coldness, eta, may have existed for weeks. The attacks last rarely more th,in five or ten. usually they arc over in one or two miiiutcx and it is only in very exceptitmal instances that they go on fur several hours. Their frequency also varies, as vrc have said. Some patients — just as now and then happens in epilepsy — have not more than one all their life, some have several a day, and in others again weeks, months, or years pass between the indivitltial attacks, and the disease may extend over twenty or thirty years. Jaksch (cf. lit.) distinguishes an acute recurrent and a chronic tet.iiiy. and thinks that certain forms occur in the course of grave cerebral disorders. In all cases, however, pro- vided there exist no complications— such as joint alTcctions — the outcome is favorable, and in no case can any lusting bad eflecls upon the organism in general be noticed. In the inter- vals the patient docs not complain of anything and feels in perfect health. Only an objective sign is demonstrable, which betrays that everything is not going on normally — namely, an increase, not only of the eieclrical, but also of the mechanical excitability of the nerves — a condition to which Erb has called attention. Even a weak current produces a marked effect, and by simply stroking the face with the finger it is possible to elicit lively contractions of the muscles supplied by the facial nerve. Although (his sign is not constant, since it has in cases of tetany been looked for in vain, even after the most careful examinations, and although wc must not forget that it occurs not in tetany alone, but also in organic diseases of the spiitnl cord^^;. g.. in glioma — it remains, nevertheless, very valuable, and must certainly be taken into account in the diagnosis.
The anatomical seat of the disease is still obscure. It bus been referred to the most varied parts of the nervous system, to the cerebrum, the cerebellum, the spinal cord, the periph- eral nerves, even to the sympathetic, which seems anyhow tu be the part of the nervous system which is blamed lor affec- tions we cannot locate. All these, one after the other, have been suspected of playing a rSle in (he pathogenesis of tetany. but proofs have never been brought forward for the correct ncss of any of these views (cf. also the theories proposed bj Schlcsinger in the Neurol. Centralblatt, (892. 3).
The least probable theory seems to be the one which is- sullies ilie disease to be of a peripheral nature. This can hardly be bruiighl into accord with the fact that the affection has been
TSTAyy,
495
t
'Icnown to follow psychical influences, (or, just as we have seen 'to be the case in chorea, and as we shall soon Icam lor epi- lepsy, this disease also can be brought about by imitation, and indeed there have been instances recorded where in this nian> icr even small epidemics of tetany appeared in schools (Mag- nan, Oaz. dc Paris, 1876. 50, and Gaz. des hflp.. 1876. 141). The disease has further been observed in women who are suck- ling infants, in young mothers and wet nurses ; and so frC' qucntly has this been the ease that Trousseau felt himself jus- tified in terming tetany " la coniraclurc des nourrices," It has also been seen associated with variuus affections of the stomach especially dilatation. (Loeb, Deutschcs Arch. f. klin. Med.. iSi!^. xlvi. Heft 1, assumes thai in such cases there occursan absorp- tion uf poisonous products which act upon the nervous system.) Quite inexplicable are those cases occurring; after extirpation ol goitres iN. Weiss. Falkson, \. Eisclsbcrg. and others) and alter infectious diseases, especially scarlet fever and typhoid. All this speaks, however, in favor ol the central nature of the disease, as does also the fact that the occupation may have some causative influence, in.-ismuch as people who have to use ihcir arms, hands, and fingcrsa great deal — telegraph operators, seamstresses (.NIadcr, hiirt)— arc relatively fre(|ueutly subject to it According to our opinion, the cortical nature of tetany is as probable as the cortical nature of writer's cramp. In this connection it is to be noted that von Frankl-Hochwart has repeatedly observed psychoses developing in the course of tetany (JahrbUcher f, I'sych., l8c>0. \\. 1, 2).
The great rarity with which the affection occurs makes ft Ipractically of little importance. If we add to this that the cases, which we see, run without exception a favorable course, one can understand why but little is to be said of the treatment. If any interference be necessary or desirable we may avail our- selves of the galvanic current, placing the anode over the af- fected parts and the cathode in some indifferent place. This may be repeated two or three times a week, each lime a mod- erate current being allowed to pass for from three to five min- utes. During the attack this procedure is sometimes quite benefictal, whereas upon the course of the disease it has as little influence as the well-known nervines. We have used tepid baths with success, inasmuch as the patients felt very comfort* able in them and claimed to be able to notice a diminution in Uie frequency of the attacks. It is our opinion, however, that
496 DISEASES OF TUB GEXERAL NERVOUS SYSTEM.
even the baths can be dispensed with, and that it is best not to] subject the patient to any therapeutic measures at all.
LITERATURE.
Schultic. Fr. Uchcr Teianie und die mcchanische Errfghartcit dcr pcripJierm
NrrvrnMSrnmc. Deul^chc med. Wochensichr., iSSi, 20. 21. Mader. Uebcr die l)«iicliung dcr BcscliStilgung&krilmprc lur Telanle. Wiener
nidd. BISUcr. t883. 16, Ledcrer. Jahrb. f. Kindcrheilk.. 1883. nil, 4.
ttaginsky. Tetaiiie bfi SSuglingen. Archivf. Kinderhrlllc.. 1886. vili. %. Mpyncn. Archiv t Gyn.. f887. "». 3- Sthoiicn. Berliner klin. VVochensclir., 1888. xxv. 14. HofTm-iiin ( H fiddlier >■ I. Zur Lchrc von dcr Teianic. Deottches Arthtv r<
klin. Mnl.. t83S. xliii. 1. Prankl-Mocliw^ri. v. Ucber mvdiaiii»che und clektrJsciic Cmrgbuknt da
Nc-rvcn und Muskc-ln M Tel.inie. Ibid.. 1S88. xlili. 1. Escheiich. Itliopaihische Tctunie Im Kindeialtcr. WicDcrincd. WMKcnsclir,,
1890, 40, V. Jak.ich. Kliniiche Drilrtt^ lur Kcnntniu dcr Teianie. Zeiucbr. i. klis.
Med.. 1890; xvrl. 3, 4. V. Frankl-Hochwan. UicTctanie. (From Nothnagel's Ginic.) Berlin, Hiridi-
w.ild, 1891. Eulcrbur^;. Anikcl " Tctatiie " in Eulcnbur^'a Real-EncyclopCdle, 3. Aitll. Heim. Uclicr Td.mie lici Cnsrrckta»ie u. s. w. Honn, 1893. Inaug.-Disieit Nicolajevic Ueber die Be/ichungen dcr Tetanic lur HyMcrie. Wiener kSs-
Wochenschr.. 1893. vi. 29.
Tbomsen's Disease.— Under the name of Thomsen's dtM3K an alTccl-oii has been described which is charactcriKed by "tome spasms in the muscles during voluntary movements." When any muscle is moved votuniurily, ati it contracts, a tonic, painless spun comes on which eilher greatly impedes the intended movement or completely frustrate* it. If the patient wishes to perform cenats motions a sensation uf fatigue is felt in the part and a resistanct. which he lias first to overcome before the intended movement can bt execiilcd. Objects which he is holding in his hands he can net k( go at once and put down. If he opens his month, he can not doK it without the aid of his hand (Fig. 14K] : he can not rise from kit chair without assiating himself with his arms (Fig. 149). Kunnisf. dancing, gymnastics, the manipulations of the military drill, 11* absolutely impossible, and any such attempts diatrcsiS him T(r<t much and bring him into the most annoying situations. If l^ musculature of the tongue is implicated a motor speech distarbann is added. Sensory disorders arc not found, and in general t^t patients are perfectly well if they do not attempt to move. ^ jeciively may be noted, beitide* the increased excitability to the galvanic current, an unusually strong development of the muKuli'
T/lOJtrSEJf'S D/SEASE.
497
ture and an incrca&cd power which seem almost to belie the com- plaint* of the patients that they are embarias&cd in their movemefit*. Heretlit)- xtundt fur a great deal in the disease, which was evi- dent from the flrx from the devcriptiun which Thoniiten himself gave
Cllolc*. A|
iiv ol PliUwlclphii, iDlcriMtloul
in 1876. He reported that in his own family in Ttve generations more than twenty person* had suffered from it. Often it is congenital, hence SlrUmpell has prop«>«ed the name myotonia congenita.
The nature of the malady is still a matter of conjecture. The fact that on galvanic stimulation of the muscles the contractures arc stow and very prolonged, lasting even as much as thirty seconds — myotonic reaction of Rrb — the observation of Krb that on micro- scopical examination the muscular fibres are seen to be broader, the nnclct multiplied, and the inieistiiial connective tissue incrcaMrd, arc not points sufficient to warrant a definite decision about the scat of the disease. Still, the possibility that wc ate actually dealing with
33
498
D/SEASES OF THE CE.V£/tAL NERVOUS SYSTEM.
an affection of the muscles \% hf no means excluded. In favor of this latter view U the case reponed by Dejerine and Sottas, in which changes wer« to be demongtrated onlf in the muscles (cf. Deutsche Mcd.-Zlg., 1893,66. p. J41).
The dUeasL-, which interferes greatly with the occupation, is wont to last throughout the entire life. The patients learn to accominodjitc
fie- 149.— Thumikn's Ubkuil (AlletCbuta K. UlUf.)
themselves to a certain extent to the inconvenience, and by allowing for it are able in a measure to hide their awkwardnesx. In counirir^ where military service is compulsory any one sufTcring from mj^oionii is exempt. No treatment has a.'t yel been promulgated for this rare*' of affections.
UTERATURE.
Thomsen (in Ktippctn), Tonisehc KrUmpfe in wittkljtiich bewcglen MibW^
Arch. f. I'sych. u. Nervenkh., i8?6, vi. j. Wciclimann. Ucbet Myotonia intcrnii (tens congenita. I naug. -Dissert., Vialitt
1883.
THOMSEN'S DISEASE.
499
Mttbius. Schmidt's Jahrbiicher, 1883. Bd. cxcriii, p. 336.
Rieder. Deutsche miliidrSrztl. Zeiig., 1884, xiii.
Pitres ct Dalltdet. Arch, de neurol., 1885, x.
Eulenburg und Melchert. Berliner klin. Wochenschr., 1885, xxii, 38.
Erb. Die Thomsen'sche Krankheit. Leipzig. Vogel, 1886.
Fischer. Neurol. Centralbl., 1886, v, 4.
Buzzard. Lancet, May 13, 1887, i, 30.
Jacoby. Joum.of Nerv. and Ment Dis.. 1887, xiv, 3.
Blumenau. Ueber die eleklrisrhc Reaction der Muskein bei derThomsen'schen Krankheit. CenCratbl. (. Nervenheilk.. 1888. xi, 33.
Dana. Thomsen's Disease. Joum. of Nerv. and Ment. Diseases, April 4, 1888, N. S.. xiil.
Martius und Hansemann. Virchow's Archiv, 1889, cxvii, 3.
Fleming. The Alienist and Neurologist, 1890, si, p. 5[. (Typical Non- congenital Myotonia.)
Hughes. Ibid., p. 63.
Dreschfeld. Thomsen's Disease. Brit. Med. Joum., Febniary 11, 1890, p. 439.
Hale White. Extract from the Guy's Hosp. Reports, 1890, xlvi, p. 339.
Fries. Neurol. Centralbl., 1S93, p. 40, 3.
Del prat. Thomsen'sche Krankheit in einer paramyolonischen Famille Deutsche med. Wochenschr, 1891, 83.
CHAPTER III.
PARALYSIS AClTAKe — SKAKIKG PAtSY — PAKKIK&OM S DISEASE— CIIOK8A PKOCUKftlVA.
i
Among the diseases of which we arc treating in this part paralysis agitnns is the gravest, but happily also the rarest, lor, according to slatisltcs of my own cases, only about o^j per cent, or one tn two hundred and twenty-nine, of alt affcctiocu of the nervous system were instances of paralysis agitani Within the some sixty years which have passed since Parkin- son's description appeared, certain symptoms of the disease have, it is true, been studied more carefully, but our knowl- edge of the a;tiolngy, the anatomical scat, the treatment, etc. , has not improved to any extent, and in fact our progress Im J been unsatisfactory. "
Symptoms. — The first thing observed by the patient is a feeling of weakness in the extremities, followed soon after bv > slight tremor, which at first only occurs temporarily. It is more marked in the upper extremities, especially in the riglil arm, yet it is also noticeable in the legs, and exceptionally tn the head. The old idea that the head is always exempt from the tremor of paralysis agitans. and that this exemption is (tstcris paribus, characteristic of the affection, is untenable. I" rare inst.inces the tremor is confined to one half of the body, whereas the other remains quiet.
The tremor consists of uniform oscillating movements, the oscillations being nithcr few in number, not more than (nw fbur and three quarters to live and a half per second (Cnunot. whereas the tremor of Graves' disease, for example, prescnis from nine to nine and a half oscillations per second (Mjrici The lengths ol the oscillation waves have been studied by Marie, Cramer, and others, and the hand writing of the patients has gen- erally been utilized for such observations. The oscillations wcic recorded on paper by means of a Marey's drum or rubber bolt. Soo
1 (
P/iKALYSIS AGITANS.
SOI
which the patient was made to hold loosely in his hand. Re- peatedly with perfect regularity of the wave lengths a varia- bility in their height cuuld be denionsIrate<l. the physiological cause for which is not entirely clear. It is not infrequently seen that the tremor increases on forced attempts at moiion. and passes inlo a regular "shake,'* so that the patient, although nut entirely helpless, becomes very awkward in feeding himself. It is a fact of considerable diagnostic importance that the
nc. ijo.— SrtctMBH av Hanuwiiitimi or Pa-tiknt wrm Cajulvsu Aanui* (puvaul
oUcmtiun),
movement!) during rest in bed do not cease, hut continue and hinder the p;ilient from getting to sleep, and fin contradistinc _ tion to what we find in chorea) do not disippear even during Ktound slumber. Indeed, the intensity of the tremor may remain undiminished in bed, :iikI I know of instances in which the pa- tients procured for themselves iron bedsteads in order to avoid the annoying creaking of the wooden bed caused by the vio. lent shaking. In other cises the condition improved ti|>nn lying quietly in bed, and falling asleep was facilitated by the use of certain arlitices. Thus Eichhorst relates of one of his patients that he always carried a little twig between his teeth • so as to keep his jaw& quiet, and one of my own cases untjr
503 DISEASES OF THE GENERAL XERVOUS SYSTEM.
could obtain comfort and a certain amount of rest fn his fingers < and arms by rolling small objects— for instance, little wooden balls which he had made fur the purpose — between Ins fingcrsj and thumb. With the aid ot these he also could go to sleep. If by accident he left these balls at home, he unconsciously picked up other objects which might be lying belore him, such as matches, or he rolled bread pellets, and so on, and only felt comfortable when his fingers were occupied with something of this sort. The change in the handwriting caused by tliis tremor is illustrated in Figs. 150 and 151.
In connection with, and probably as a consequence of, the trembling movements, gradually a condilion develops in which
FIc. 151.— SretiMUc or Kamiiwritiiio i>t X'l.nt.sr vhjh Pamalvhiii AaiMHs i
obsenalion).
the patient gets easily tired, the muscular strength diminisli«. and the muscles assume a certain rigidity which influences the posilion of the body and the extremities when at rest as well as on voluntary motion. The position of the body is chanc- tcristic. Not only the head, which affords a good deal of K- sistancc to passive movements, but also the whole trunk is somewhat bent over, and it appears as if the patient was !' every moment ready to fall forward. The arms, which arc bent at the elbows, arc in close apposition to the trunk, the thumb rests against the fingers, so that the hand assumes some such position as it would in writing, the fingers themselttJ being flexed in the metacarpal joints (Fig. 152). The kn*« arc so close together that the trousers are rubbed against each other by the trembling movements, and walking is not a littlt 1 interfered with. The legs are usually slJghlly flexed at ihf knee joints, while nothing remarkable can be noticed abciul the joints of the toes. The patient impresses one as being fa a constant stale of uncertainty and perplexity, an impressi(« which is only diminished to a certain degree by the very cbir- *'
PARALYSIS AGITAKS.
SO3
acteristic fades. The rifridity being also marked in the mus. cles supplied by the seventh nerve, the face has an expression of majestic calm, nay, even of sublimity. The patient seems Inaccessible to psychical emotions. His smile is hardly per- ceptible, since the lowec portions of the face more especially are almost immobile. Only the wrinkling of the forehead is somewhat more marked. Sometimes the patients have a peculiar piping voice, such as an actor assumes when playing the part of an old man on the stage.
We have already alluded to the fact that voluntary move- ments are somewhat impeded. This is due not only to the tremor, but also to the already-mentioned general weakness.
an or HaifiM unt rixoiMt im PAKALnn Aoitah (u K boUbic a ptnv <A(ict EicmioiMT.)
I
lie is. therefore, helpless, and needs some one to assist him If he wishes to sit up in bed or even to change his position. If he is in a sitting posture rising is dillicult, sometimes impos- sible. The act of walking is not normally performed, for lie- sides the bent position, which in walking becomes even more exaggerated than in standing, the |Mttient once started has an irrrsisliblc tendency, owing lo the displacement of his centre of gravity forward, to hurry ahead : his steps, at first short and tripping, become fiuickcr and longer, and so great may be the force with which he involuntarily rushes forward that if there is no one there to stop him he falls on his face with great vio-
504 OiSF.ASES OF THE CBlfEHAL S'ERVOVS SYSTEM.
Icncc. The same pliciiomcnon, which is called "propulsion," mav somclitncs be anilici;illy produced by pulling the paiiait forward by the coat while he is walking quietly. He then goes (aster and faster, and finally breaks into a run alarming lo the bystanders. Much more rarely do we find a similar con. dition in the backward niotiun (" retropulsion "), so (hat the
patient if pulled from behind walks backward faster and faster. to fall over in a short lime. Charcot looks upon these plw- nomena as forced movements, a view which has. however, never been substantiated. Thcv may possibly be explained no purely physical grounds as being due to the displacement ot the centre of gravity of ihc body (Striinipell).
Trophic changes, with the exception perhaps of the Irnn- sieni appearance of purpuric spots symmetrically on the arms and legs ("senile purpura"), arc not met with. Changes in the electrical excitability of the muscles do not occur, or are, at any rale, not the rule. Sensation and reflexes remain entirely
fiAHALY&IS ACtTA.VS,
sc>s
fnormal, and bladder as well as rccui) symptoms arc not pres-
lent. All increase in ittc body temperature can never be dem- onstrated ubjcctivcly, although patients complain at times q( subjective feelings of increased hca( and a disagreeable tend- ency to sweat a good deal, which is especially pronounced when lying in bed, so that they often sleep uncovered or with but little over them. U any cerebral or spinal symptoms make their appearance these have to be regarded as complications. They do not belong to the clinical picture of paralysis agttaos as we know it now.
I Cases in which muscular weakness and rigidity, with all their inconvenient consequences, were present, in which, also, the so-called propulsion was marked, but the tremor was ab- sent, have been reported (^Amidon, New York Medical Record, 1S83. xxiv, 31), but such .ire rare.
I The nature of the disease is not yet understood. U'e do nut even know whether to refer it to the brain or to the mus-
, cics. Much less, of course, do we know where the exact seat
ithould be sought for in the nervous system. Before the labors of Charcot and Ordenstcin, paralysis agitans was often con- founded with multiple sclerosis, and various anatomical lesions were then described as underlying the paralysis agitans. Later the error was cleared up. and even to the present day we arc not acquainted with any anatomical basis for the disease.
) Etiology. — In this respect also our knowledge is very in- complete. Of course here, .is in all other nervous diseases, he- redity and the impurliince of a neuropathic family history must bespoken of, yet the rarity with which the aflcciion occurs shows that this factor alone is seldom sutTicicnt to cause the disease. Hence other exciting causes must come into pl-iy. but it is a fact difficult to undersund why the same factors which so often give rise to chorea so rarely produce a shaking palsy. The causes for all these diseases arc always the same, or at least simitar, and it is here also in the first place that psychical emo- tions of fright and anxiety are of moment. The French phy- sicinns have at no time seen develop so many cases of paraly- sis agitans as during the lime of the siege in iS^i.and for years after the relative frequency of the trouble in the Paris hospi- l;«l<i. particularly in the Salpi^triire. acted as a reminder of the
I terrible hours which the besieged must have gone through.
[In private pnicticc we also have occasion to find that psychical
Icauscs bring about the disease : more frequently, however, at
506
/>/S£ASSS OF TUB GENERAL NERVOUS SYSTEM.
least in my own experience, no cause at all can be found. The influence of exposure to cold and of overexenion of course hns here also been thought to be of aetiulogical significance with, out there being any i^rouiids for such an assumption : on the other hand, Ihcrc is no question but that certain infectious dis. cases — e. g., intermittent fever, pertussis, typhoid fever — may be followed by a paralysis agitans, a connection, however, which, although certain in its existence, is still obscure tn its nniure. Nothing definite is known about the influence of age and sex.
Diagnosis. — After what has been said little needs to be added with regard to the diagnosis, which is almost always easy. It is certainly not h.-ird to avoid mistaking paralysis agitans for multiple sclerosis or chorea, and chronic alcoholism is easily excluded if we take into account the characteristics vA the tremor, its continuance during sleep, and the whole course of the disease. It may be sometimes diOicuU to differentiate a shaking palsy from the ordinary tremor senilis if the latter occurs as early as the forties, at a time of life during which paralysis agitans is not rare, and it is the more necessary to be careful, since the number of the usci]t:itiuns in both affections is about the same — that is. ranges between (our and six per second. The muscular weakness, ihe peculiar rigidity which accompanies the movements, Ihe characteristic facial cxpres- sion. the posture, the " propulsion," etc., will in most cases be suflicient to clear up the diagnosis. Oppcnheiin has observed that the so called traumaiitr neurosis may present the picture of paralysis agitans (I'seudo-i'aralysis Agitans; Charii^-Annalen, 1889, xiv, p. 418).
Treatment — The treatment is entirely fruitless. We have not as yet seen any results from any of the therapeutic mcas' urcs employed. Neither with baths nor with massage (Ber- bez. cf. lit.) nor with galvanism has anything been achieved, and all internal medicines arc of no avail. It is impossible to give particular indications for the treatment, and it must there- fore remain for the physician in every case to treat alternately with baths, massage, and electricity, according as he sees fit. As long as he does not do the patient any harm, it does not matter much which mode of treatment he decides to use. Lately Rrb has recommended the muriate of hyoscitie injected subcutancously or taken internally. This is said to exert a very good influence upon the tremor, hut whether this effect is last- ing, and whether the bad after-effects which occasionally appear
I
I
I
I I
I
i
UiCJtAtA'E.
V>7
after a prolonged use of the drug are not a grave objection lo its administration, is not as yet decided. My own experiences with it were not favorable. Charcot's "vibration treatment," by which a quieting; or even benuinbiiiji; effect is aimed at, was further studied by Gillcs de la Tourette (Pn>gr6s m^d., i8()2, 3;). This -lutliur has constructed a special apparatus in the shape of a helmet. Five thousand to :^ix thousand vibrations a fninute arc said lo produce a hypnotizing effect and to diminish the tremor. I am inclined to think that the result is chiefly due to suggestion.
LITERATUHE.
Hnnunn. Vrhtt Paralysis t^/Ont. Berlin. HinchmM. 1888.
UblovIc. Cuniribuiion 1 1'^lude de la niiladic dc Parkinson. Tliiw dc i'uis,
18H7. (De quelques formn nnunnAlu.) Huber. MyogrApKiKbc StudKn bei VaaL agtl. Virchow't Afcb.. 1S87, to8, 1,
P-4S. Teissier. PitlMS^nie de la paralpie aptans. \.yrm mM., 1SA8, Iviii, 38. Weber. Paralysis A(,'ii.-ins, with Cases. Juuiti. of Nerf. and Ment. Diseiues,
July?. 1*88. N. S.. JCiii. t>utU. Sur un ea< de Paralysie SKilanx \ forme htmipl^ipque. avec attitude
anomute de la \He ct du trtinc. (>ai, mM. tie l^ris, i88q. }8. p. W9. Martha. Elixlc cliniijue tur In p^imlysie Agiuiit. V»ny Stcinheil. itiSS. Peterson. A Clinkal Siudy of ('oily-«even Caacx of I'anlysis Agitaiu. New
Vork Med. Journ,. October ir. r89o. fUdden. Pantlysi* Agilans in a Young Man. Ilnin. 189a Sua. Peicrebunter med. Wochenschr., n. K., 1891, riii, 19, 10. Kollrr. Virrhow's Archiv. 1891. cxxv. p. 3S7. Leva. DeulM-hc Z«i(»cbr. L Nervenhk.. 1891, i, I. (Condition of the Urnie in
Paralysis AKiUns.) Knacher. Zriischr. f Hcilkunde. 189}. xili. 6. p. 445. Dana. New York Med, Joum.. 1893. 57. Ng. ly
a AFFECTIONS IN WHICH THE SENSORY NERVES ARK CHIEFLY
IMPLICATED.
The only affection which can at present be assigned lo this group is one which deserves a good deal of attention, on ac- count not only of its frequency, but also of the obscurity which siill exists with regard to its pathogenesis. It is a mal.ndy which never seriously endangers the patient's life, but never- theless produces grave, almost unbearable, suffering.
Migraine {HemicraNta).
The disease manifests itself in attacks, while in the intervett- tng periods the patients are usually perfectly well and in no way give evidence of the severity ol the affliction of which
508
D/SSASSS OF THE GBNEHAL SERVOVS SySr£,V>
they are the subjects. The paroxysms are usually preceded lor several hours by prodromal symptoms, general lassitude, chilly feelings, a tendency to yawn, buzzing in the cars, and the like. If the reguLir attack is going to begin in the morning. the patient wakes up repeatedly during the night, and is thus able to predict with certainty that the headache is coming on. The pain is sometimes confined to one side of the head, and, according lo statistics, the left seems to be the one more com- monly implicated : but the seat often changes during the attack, so that the patient complains now of the left, now of the right side of the head. Sometimes a distinct pallor is noticeable on one side during the att.ick, associated with dilatation o( the pupil and increase in the salivary secretion, while in other in- stances one half of the (ace is flushed and hot. the arteries pul- sating strongly, and the pupil contracted. In the first case we designate the hemicrania as spastic (sympathico-tonica, con- nected with stimulation o( the sympathetic); in the latter as paralytic (connected with par.tlysiso[ the sympathetic). The former has been described by Du Dois-Reymond, the latter by Mi>llendorf. in both cases after observations made upon them- selves. But these conditions arc not constant cither, and if one h.ts seen many attacks of migraine he knows full well that the patients often change color — they are now pale, now flushed, now complain of a feeling of heat in the head, now of cold.
If the pain is very violent the patient shows ge»er.il con- stitutional symptoms. In a bad attack he lies for hours com* plctcly apathetic, meeting every question and every source of disturbance with unmistakable signs of disgust. He refuses nourishment entirely, owing to a feeling of utter discomfort and an almost uncontrollable desire to vomit. Only after copi- ous vomiting of bile-like mucoid masses docs his conditiua gradually improve, the amelioration beginning with a violent desire for food and a polyuria following the attack, which is finally ended by a refreshing sleep. When vomiting docs not occur the patient suffers for a longer period. Sometimes the eyes participate, and photophobia, flitting scoloinata. even hemianupia, have been observed during the attack. Th»e are instances of the type which Fire. Oalezowski. Dardignac, and others have described as wi^raint- opiithalmiqm. In place of the Hitting scotoinata, visu>tl hallucinations are observed in exceptional cases (Weir Mitchell, Amer. Jour. Med. Sd., 1887, October, p 415).
MIGRAINE.
SO?
It 13 not uncommon for the attacks not to reach their full de- irelopment ; in which cases only certain symptoms — flitting sco- tomata, vomiting, vaso-moior disturbances, or the like — may appear. Such isolated symptoms may be called " hemicranic equivalents " (MObius).
The duration of the attack varies from a (cw hours to a whole day ; it rarely lasts longer, and if it docs, this fact should always make us doubtful as to the diagnosiR. In the intervals the patients as a rule feel well : still, if the attacks are very se- vere and frequent, occurring, for instance, as often as once or twice a week, the after-ellects may be so tasting that the suffer- ers never enjoy perfect health. Indeed, the attacks may occur with such frequency thai we have what F^ri calls /At/ ^rwd/ migraineux and MObius status kemicranicus, a condition in which transitnri- psychoses may develop (Zacher. Berliner klin. W'o- chenschrifi, June 1 1. 1892). Fortunately, such a rapid succession of the seizures is uncommon. Once a month or six or eight limes a year is the rule, not counting slight, ab<irtivc attacks.
The course of migraine is always extremely tedious, some- times lasting through a whole lifetime. In women the climac- teric period occasionally, but by no means always, exerts a beneficial influence. At the time of menstruation the attacks seem to be especially apt to occur: and even if no definite at- tack makes its appearance, women who are subject to migraine Complain of more or less severe headaches at such periods. Not infrequently the disease has an unfavorable influence on. the disposition and appearance of the patients: they become peevish and ill-tempered, and even in the intervals between the attacks are by no means amiable or sociable. They are wont to restrict themselves considerably in their social intercourse — tor one reason, because they are rarely able to make engage- ments for definite times on account of the possibility of the occurrence of one of their attacks. The trophic disturbances which are sometimes superadded, as. for instance, the prema- ture gray hairs, make such patients look older than they rcilly .are: on the other hand, there are individuals who, notwith- jstandtng the severity of the attacks, retain for a long time their Ijrouthful freshness and vivacity.
With regard to the pathological anatomy and thepathogen-
we know scarcely anything ; it appears not unlikely that
in cortex more especially and its sensory elements are
ily the scat of the affection, and it seems more and more
5 to
/>/S£AS£S OP THE GENERAL NERVOUS SYSTEM.
probable that, besides the itiflucncc which must be attributed heredity, here too. as has been cUiimed lor certain cases of epi- lepsy, aiitn-intoxication is to be regarded as a not improbable factor. But it must be admitted that this is only a suppusition. and Ihat wc arc without any certain knowledge on this point.
Recovery, if it ever occurs, is certainly very rare, and can probably never be regarded as Ihc result of treatment. If aphasia or motor disturbances are persistently associated with hemicrania. the latter is to be regarded merely as a symptom of an underlying organic disease, and nothing definite can be said with regard to the prognosis. 1 n this connection must be men- tioncd the case ol Oppenheim, in which a thrombus uf the in- ternal carotid artery was found to be the cause of the headache and of the other symptoms (Charile-Annalen. xv, Jahrg.). The prognosis is relatively favorable if in the intervals between tlie attacks the patient enjoys sound and healthful sleep. Unfortu- nately, ill the majority of cases they are deprived of this, and in order to procure it arc forced to resort to artificial means, ul which the bromidesarethc most popular. It is not always easy to understand the cause ol the sleeplessness (i5rfrr/»«M) in migraine, and lor that matter in all nervous diseases ; it is especially diffi- cult to do so when this is the only symptom and absolutely nothing else can be delected, when individuals otherwise healthy are wholly or almost wholly deprived of sleep for weeks; and yet it is just the discovery of this primary cause that is of the greatest importance, as it will guide our action in the treat- ment : and only when this is found can we reasonably hope for improvement from our efForls. Sometimes wc have to deal with a gastric catarrh which until this lime has been over- looked, a hypern:mia of the liver, and the like, and after the successful treatment of these by Carlsbad water, etc., sleep, which in spile of all bromides and morphine has in vain been sought, returns of its own accord. Sutncliiiies a marked grade of anxmia may He at the bottom, easily recognizable by the pallor of the skin, the small pulse, and the cold extremities In such cases cod-liver oil, iron, and quinine are more service- able than the usual hypttotics. which arc rarely well borne. In all nervous patients suffering from insomnia it is advisable to examine the thoracic and abdominal as well as the sexual organs, and only to treat the sleeplessness symplomattcallr when repeated examinations have given negative results. This symptomatic treatment consists above all in the careful use of
I
I
MIGRAINE.
Sii
I
massage, which should be supervised by the physician, a prac- tice from which we have obtained very gratifying results. Next comes the systematic galvanization of the brain, for the technical details of which the reader is referred to my book on electro-diagnosis, pp. 186 tt trq. As a last resort we have the administration of quieting, calminjj. and slee|>-producing drugs, among which, notwithstanding .ill the new hypnotics, morphine
Bsiill holds the first place. Besides this, chloral, paraldehyde, urcthan, hypnonc, coniinc, lupiilinc, suKonal. and amylene hy- drate (tertiary amyl alcohol), which has recently been rccom-
■ mended by von >iering, m.iy be tried. The last is best given tn doses of three and a half to four grammes (nit-lx) in one dose once in tweiity>lour hours, and seems often to liave a favor- able action. Un account of the bad taste of this drug the addi- tion of correct ives^lr)r instance, the oil of peppermint, which somewhat masks ihc taste — is to be recommended. (Amylcnc hydrate. 7.o(«i«v): aq. menth. pip., 40^0 (3"): ol. menth. pip., t.o(^xv): syrup, simpl,, 30.0 (Sj). Sig. : Half to be taken at night.) The sleep after it is deep and quiet, and unpleasant after-effects arc rare. Nevertheless, it is well to be careful in its administration, .is symptoms ol intoxication may appear, as Dielj! has reported (Deutsche McdicinaUZciiung. 1S88, iR). Tri- onal has been recommended by Schultzc (Therap. Monalsch., i.S9t, October): its effect has also been studied by Brie (Ncu. rot. Centralbl., 1892. 34). who h.is found it very useful in dosc& of from I to 2 grammcs(r5 to 30 grains), without noting any bad after-effects. The reports with regard to meihylal and chlo- ralamid arc still conflicting (cf. lit.).
The medicinal as well as the general treatment of migraine is. on the whole, the same as that of habitual headache, which has .ilre.idy been discussed on page 6;. It may be added that Ihc so-called mtgrSnin, a combination of antipyrin. citric acid, and caffein, in certain proportions. prc|>arcd by Overlach. is deserving of further trial (Deutsche mcd. Wochcnschr., 1893. xix, 47).
I.ITERATl!RE.
H , /. Migrant,
HKJI^BcrlinCT kiln. WochenMhr., 18SS, 30. ■■■mn. I'rocr^ mtA.. 18SS. 39,
Danfiso*^ Rrrue <le miA.. OcIoIkt 10. 18SS. viiL
*N«ftcl. DcuiMhr Mml.-Ztg.. 1S90. 14. p^ i}7. ,
Itencdikl. Wkncr nicil. Prmsc, 1891. ft, Haig. Brain, Not-ember, 1S93. p. ija
512
DISEASES OF THE GEh'ERAL SERVOVS SYSTSM.
». tnMmniti inuf ilyfiolitu
Umoine. Car mitl. de Patin, 1887, 18. (MtlhyUL)
I-enu>nuli. L'Union miA.. 188;. 9. (MclhylaL)
lllingu'onh. Insomnia. Med. frcssand Circ,. August 19. iSSft.
Kcichmann. Chlorabmul. eln ncuet Schlafmiitcl. Deui*chc mcd. Wochen
1889. 3r.
Jaslrowiti. SchlafTosigkcir. Ihid.. lEiSq, 31.
Mauthner. Schlarkrunkheiieii, All^. iCdischr. C I'lj'chintr., 1891, xl^ii, &. Uric. Trional sis Sc)ilRl*miiid. Nrurot. Ccniralbl.. 1891. xi. 34. Filchne. Ucbcr das llypnal-HOcbsl. Bcrliocr klin. Wodiouchr.. \i^\.
XXI, y Koppcra. Wirkung des TrionaJs. tnaug.-DiswR^ Wunbui;^. 1893.
C. AFFECTIONS IN WHICH THE TROPHIC NERVES ARE CHIKFLV
l.\iri.ICATEl>.
Our acquaintance with the few affections to be described under this head is of very recent date. Since their pathogoie- sis and their scat are as yet obscure, and since we liavc to ojii-
fine ourselves toihc description d( (he most striking syinp- A \f' »f ^ toms, it is impossi-
ble to say whether the place here sv signed to ihcm i> correct or not.
t. ACROMEGALV i_P. Mari^
Under the name of acro- megalia {oKpov. exlremilT) Marie described, in i8tt6, a peculiar tion-congenital hy- pertrophy of the hands, (cet. and head, to which affection attention had previously been drawn by Fritsche and Klebs (cf. lit.). The extrem- ities appear increased in length as well as in breadth. The bones of the face, esp^ cialiy those of the cheeks and the lower jaw. present considerable enlariji-menl (cf. Fig. 154), and the mcav
\
f''K- 'S*-— -<. ""' l""'i I !«■ ii( .1 im11™i under Ihe c»t» iif I'lili- IT '.I,i!H>, ill I'irH. iff, ■ tower J4» u'}kirTi iiiinib.idy vruuld corrMpood (othc »i« tj( I 111' iMii<-"l.
ACItOMECALY,
5'3
lurements of the skull arc above normal. In the same way the |ip8, cars, nose, and tongue are found enlarged, whereas all the tuscles are feeble. The skin appears yellowish and pale, but is otherwise normal. The tliyruid gland was almost always
rvery atrophic in the cases observed up to the present lime.
FiC' tsj.— Case op Acroheoalv. (AlWr P. MAIira.)
< Tn spite of their gigantic appearance the patients are feeble and without strength. The sexual functions arc lost early and completely (Freund, cf. lit.).
The onset of the disease dates back to early childhood, and it has to be regarded as an abnormity in development (Freund) " which, probably beginning as early as the cutting of the second teeth, certainly sets in energetically at the period of puberty, and consists in a rapidly developing enlargement of the facial part of the skull, which by far exceeds the physio, logical limits of growth. This increase is especially marked in the lower jaw and also in the extremities, with (heir girdle attachments, while the rest of the skull and the trunk arc only secondarily altered." The observation of Gerhardt, whose patient was perfectly well up to his sixtieth year, does not agree with this view {Berliner klin. Wochenschr., 1890. 52).
A relatively large number of cases have come to autopsy
3J
SI4
D/SF.ASES OP THE GEXERAl. NERi'OVS SYSTEM.
since Marie's publication, and from the number of instances reported tlie disease would seem to be by no means rare. The results of these autopsies have not been very satisfactory, (or besides a more or less pronounced increase in the volume of the hypophysis tlJol'i^. Oauthicr, Holsti). nothing worthy of
Fie. ■56.~AcH(niEa*i.r. (Afwr BucitWALD )
note has been found ; and since we know nothing of the (ii«c- tion of the hypophysis, this finding has thus far proved of Wvk value for the understanding; of the pathogenesis of the diseax- Nor is our information any more salislaclory so far as cauK and treatment are concerned.
According to Goldschcidcr, who established the fact iW the giant growth is not confined to the distribution of asf
ACROMEGALY.
S'S
I
I
I I
special nerve, being found, for instance, in the hand, in that of the mtisculo^pirul and the median, more rarely in that of the tihiar, the etiological influence of the trophic hbres is still a matter of doubt. Pel (Berliner klin. Wochcnschr., 1891, 3) ot>serred s case in which psychical traumatism during mcn> struation was followed by acromegaly,
LITERATURE.
Fribche und Kkbs. Briing nir Paihologio dcs Rinenwuchso. Ldpilg,
(8S4. Marie. Surdeux cu O'Akromfsalie. Revue de mtd., 1S86, iv, 4, p. X97, Ffaniiel. O. Orulschc mcil. Wochcnschr. 188B. 3*. The •ame. Ueuuche tAtA.-7.\%.. 1S8S. 48, p. 581. Erb. l>euUcha Arch. f. klin. Mccl^ Fcbnur 4. 18SS. xviL Bfoca. Un iquelrtlc d'Akromigalic. Arch. g*n. tie in*d- Dwcmbcr. 1S8S. Atlkr. BtMlun Med. and .Suq;. Joum.. November 21, 188S, exit. Ffeund. V. A. Uvber Akromegjilie. Volkm^nii'iclic Sammlung klin. Vonrlge.
1889. 319. 330 (I I. Sft., Hrti i?. 30). Vinhow. Ein Kail und ein Skelcii vi>n Akromej^lie. Bertiner kli.i. Wochen-
Khr,. 1889. 5, GoIilicbcidcT. Arch. f. Anat. u. Physio),, Physiol, Ablheilung, 1889^ 1, ). Stundby. AcnMncgnly. BrJi. Med. Jouni., January 5, |8S^ Miric. P. L'Akram^K'lie. £tuiJe cliinque. I'nriti, 1889. HultchcMnUkaS'. Ein Pali von Syringomyelic uml cig«nihiimlichrr IVgrncr*-
lign der p<Ti[iheren Ncrven. v«rt)unden mit irophiKhcn Storungcn.
(AknxBegaly.> Virchuw'i Arthiv, 189a, cxix. Heft r. p. la ReckllngbniiBcn. v. Ucbcr die Akromeg.ilic. Njchbchrid lur \'or»tebendcn Ab-
lundlung. Ihid.. 1890, p. 36. Tmul Ririsu ctinka, 1^1. Hefi $. Lnthauer. Deulf<-he mnl, Wochcnschr,, i89r, 47. I>ucheuinm. Contrilniiion & I'ttude ajiaioini(|ue M clinkjua de rAkram^atic.
Paris. Bailli^. 189X Murray. G. Arroine|pily. Brll. Mrd, Joum.. Febnnry 37. 1891- Amold. Akromei^lic. P»chyakrie oder Osiiiii? ziegkr'ft B«ilr. 1. ]»ihoL
AAat., 1891. I. Ilefi I, WAxt. Ein Fall von Akto«ncg»lie fnit biiemporaler llcmianoptie. Deulsche
med. WothtriMchr, 1891. 17. ('•auihin. Progiii ni^I.. 1893. I.
Kolui. Ein FaII i-on AkrotnrgAlJr. ZrilKhr. T. ktin. Med., xx. 4-^ fiauM. Deuuche n>cd. VVuchenKhr. 1891, 40. Fralntrh. Allg. Wiener mrd. Zig.. 1891. 37, .Souquc« et Gaine, Nquv, Icono^mph. ilr la S-ilptiri^, 1893. j. CmJcr. Med. CorrespondentiL d. Wurleinb. Irtll. Lande*veretnn. Ixiti, 1S93.
16. Anu>U. Wrircrc Hritrtlge «ir Aknimegalterragie. Virchow's Arcbiv, 1894,
cuav. Heft 1 (wilh munerous rcfeicnces).
s««
DISEASES OF THE GE.VEJRAL JfEKVOUS SrSTEJU.
2. OSTEOARTHROl'ATHV.
Another affection depending on trophic alterations, which In milder cases also manifests itself by changes in the hands and feet, was described in 1890 by P. Marie under the name ostfoarthropathie hyffrlrophianu piuu»niqne. The condition is characterized by a colossal increase in the finger nails, the terminal phalanges of the fingers and toes becoming thick- ened, and the nails assuming a shape which, when seen front the side, remind one ol a parrot's beak (cf. Fig. 157). The resemblance which the fingers bear to drumsticks justifies the term "drumstick fingers" (cl. Fig. 158). In more pro- nounced cases the ends o( the bones of the forearms and ol
ng. ■s;.-OsTKoMr»BapATHT. (After (Ui-zisK: Rmie de nU., iSi|>t, H. i.)
the tibia and fibula also become thickened. The (undamenol difference between osteoarthropathy and acrutncgaly lie* i" the fact that tn the latter wc have an enlargement of all tbe terminal portions of the extremities as well asol the face. Thf aetiology of the affection, according to Marie, is to be soui^>
OSr£OAKTHltOPATHY.
5'7
in the existence o( pulmonary affections in which extensive dc- : composition of pus occurs, (or which rcasou this writer has
I
ri([. ijS. OmaMKTii»or*inr. (AhcfSt-iLutANM wkIHavhulteii; ttcmc dc (dM.. iflgo,!, 5.)
employed the term pncumique. For details in connection with this alTection the reader is referred to (he special articles men- tioned below.
LITERATURE.
Man«. Revu« de mtd,. 1890. ■, 1 (the originiil ankle).
S|iillmaiin ci HaunKilier. [bid., 189a x. 5.
Leftbrc Th^ de Paris, 1891. [)cs d^formatMns o&ito-utkubirrt consfctl-
tives a dcR maladies de I'apfMracI plniro-iMilmonaire. Certuirdu Beriiner klin. Wocbeiuchr., 1890. xviii. Ji. Arnold. Bcitr. i. path. Anai. u. allg. Path.. 1891, a, 1. Rauticr. Revue de mfd.. 1891. xi. 1. MalMua. MuikK. med. WochcnKlir., 1891. 13. Minor. Neurol. Ccniralbl., 1893. 16, p. 565,
5>8
DISEASES or TtfE CENEKAl. NERVOUS SYSTEM.
APPENDIX. — I. ORAVES" DISEASE— BASEDOW'S DISEASE (OLOTZAW- UESKKANKHEir, CAfllEXIE EXOPHTM ALMIQUE) — kXUPUTH ALIIIC OOlTlte — TACHVCAKDIA STRUMOSA £XOI>HTH ALUICA.
This condition, first described by Carry, later by Graves, and which in Germany is generally known as Basedow's di;;- casc, is an aflectiun o( the general organism in which certain symptoms referable to the central nervous system arc, as a rule, the most prominent features. According to our present conceptions, which are, however, not fully established, exoph- thalmic goitre can not be regarded as a disease of the ncn'ous system in the stricter sense, since the anatomical scat of the aScctiDn is situated not in the nerve tissues but in the ihyruid gland. The anatomical changes which have thus far been found in the nervous system (Sattler, Filehne. and others) are not constant, and, as it seems, not essential for the pathogenesis of the disease.
Symptoms. — The three symptoms which are regarded as characteristic of Graves" disease arc (i) an excited, accelerated action of the heart, wiih visible pulsation in the arteries of the neck : (z) enlargement of the thyroid gland : (3) exophthalmos. As a rule, the heart symptoms arc the first to appear. The increase in the frequency of the pulse is variable. We may count from a hundred to a hundred and fifty beats a minute, and not infrequently the intensity of the heart beat is more forcible than normal, a circumstance which adds much to (ht discomfort of the patient. Auscultation does not always re- veal abnormalities. Occasionally a systolic soufHe is audible, but this is often absent. Enlargement of the heart also has been observed. The extraordinarily strong pulsation in the carotids, which is very conspicuous and easily felt, is in re- markable contr.-ist to the smallness of the pulse wave in the radial artery (Parry).
The swelling of the thyroid is rarely very great It is usu- ally symroL-trical. In the gland itself pulsation cnn be easily seen, and on palpation a distinct thrill is communicated to tbr hand. 1 may say that 1 have repeatedly seen cases in which the volume of the gland chnnired from time to time, and that this change became perceptible in a comparatively short tiiae. sometimes even in a few hours.
.\n arterial souffle is heard over the gland, the cause "I which is to be sought in a hypertrophy of the Icit ventricle
GflAl'RS' DtSEASE.
5<9
and a disproportionate enlargement of the thyroid artery (P. Guttmann, Deutsche mcd. Wochcnschr., 1893. 11).
The exopluhalmos, which is proUably always bilateral, also differs in degree in diScrciit cases. In the majority, however, it is so marked that the protruding eyeballs can not be com< pictcly covered by the lids during sleep. This gives to the patient an appearance which to the layman is both peculiar and repulsive (Fig. 159), and is still more aggravated if the
Pit t3»— GiuvECi' Ohbaic (p«niMul<itiMrvaiio<i).
Upper eyelid docs not follow the downward motion of the ball, and thus allows a zone of the sclerotic, t to 2 mm. in width, to become visible attovc the cornea. This defective co- operation of the lid and ball (Gniefe*s symptom), which hap< pily does not occur very often, makes the |):iticnt frequently an object of horror to those about him. The almost com- plete absence of the involuntary winking of the lid (Stellwag's symptom) is quite con<;picuous, especi.tlly since the voluntary movements can be made as well as before. We can then easily I understand that our patients, particularly when they are ladies of the better classes, avoid as far as possible the contact with friends and acquaintances, as well as with strangers.
S20
D/li£ASS.S OF THE CEXE/tAL y£/trOl/S SVSTKM.
Ophthalmoscopically only one characteristic sign lias been noted — namely, the spontaneous pulsation of the retinal vessels, discovered liy O. Becker. This is not confined to the disk, but can be observed in the retina as well. With this exception there are no changes in the fundus, and eyesight, accommodit- tion, and pupils are entirely normal. Only on the cornea we occasionally hnd a decrease in sensibility, probably due to the want of moisture on the ball, the normal quantity of the bchry> mal fluid not being sufficient on account of the undue evap- oration which takes place, because the two lids arc far apart, and winking only rarely occurs (Berger, Arch. d'Ophth., 1894, FAvrier).
Insufficiency of convergence, a symptom first described by MObius. is sometimes observed. If the patient be asked to look at a near point, one eye will soon be found to deviate out* ward.
Narrowing of the field of vision has been described by Kast and Wilbrandl (Arch. f. Psych., 1890. xxii. 2),
Among the subjective symptoms, in addition to the annoy- ing palpitation already mentioned, a tendency to free pcrspira- tion may be noted. Even slight exertion produces a feeling of heat, more especially in the head and neck, so that the patient preferably remains in cool, shady places, and sleeps with as little covering as possible, etc. An actual elevation of temper- ature is, however, not always objectively demonstrable. This tendency also accounts for the blushing evoked by the least bodily exertion or mental emotion. Both symptoms I have not infrequently seen to occur unilaterally. Trousseau has mentioned the fact that the most gentle stimulation of the skin of the face and neck produces a deep-red mark, designated by him as tofht tfribraU. a phenomenon, however, which can ap- parently not always be evoked. All these symptoms arc at- tributable to asthenia of the vaso-motor nerves, as is also the decrease in the resistance which the skin offers to the electri- cal ciirrcnl, first observed by Charcot (the Charcot-Vigouroul symptom), the saturation of the skin with fluid resulting from the dilatation of its capillaries rendering it a better con- ductor than it would naturally be in the dry state. In a healthy individual using an electro-motive force of from ten to liflecii volts the resistance amounts to from four to five thousand olims. while in the course of this disease it measures from three to six hundred ohms, and only increases when the paiicnc
I
I
CRAVES D/SEASE.
5*1
improves. Eulenburg has shown that the presence of this symptom may be ol great value tor the diagnosis, but its ab- sence proves nothing (Cenlralblalt f. klin. Med., 1890. 1).
Various nervous disturbances often accompany Graves' disease, among which we should first mention a peculiar para* paresis of the legs (cffondeincnt dcs jambes). a giving way of the legs, as it is called by the English authors, a condition which is associated with a flabbiness of the muscles and a diminution or loss of the patellar reflexes (Charcot). Eulen- burg rrgards the jiymptoms as a manifestation of hysteria, and as comparable to asiasia-abasia (Neurol. Centralbl.. 1890, 23). The digestive tract may be implicated, and we may have a well-marked intestinal atony (Fcdern, Wiener Klinik. 1891, M&rz). Occasionally copious vomiting of watery bile occurs, and this symptom may be ol such persistency as to seriously re- ducc the strength of the patient. Vertigo, biiz/ing in the ears, sleeplessness, occasional transient dyspncea, have also been ob- served. Falling out of the hair ol the head and eyebrows ts not rare, and 1 have seen a case of a peasant woman, thirty* eight years old, who, toward the end ol the disease, when she was extremely emaciated owing to the persistent diarrh<ca and vomiting, had become completely bald. As complications, bone disease (osteomalacia, Kuppen, Deutsche Med,-Ztg., 1893, 25, p. 296), chorea, epilepsy, psychoses (Schenk, lnaug..Dis- sert., Berlin, 1890), e.g. mania, melancholia, neurasthenic in- sanity (Hirschel, Jahrb. f. Psychiatric, 1S93, 12}, diabetes, tabes (Joffroy, TimotheeH, lnaug..Dissert., Berlin, 1893), and Addi- son's disease (Oppcnheim) have been observed.
Course. — We should keep in mind that remissions may occur during the course of the disease, and may last even for months or years before further deterioration leading to death takes place. For the prognosis a knowledge of the fact that such remissions can occur is of great importance. Cases which pursue a rapid course from the beginning are exceptional. The onset of the disease may be either brusque or quite gradual. In the first case twelve to fourteen hours are suffi- cient lime for the development of the three cardinal symp- toms : in thf latter these appear gradually — first the palpitation. then the swelling of the neck, and finally the protrusion of the eyeballs.
Of great interest, because relatively frequently met with. are the coses in which the disease does not reach its full devel-
;22 D/SEASES OF TUB GENERAL NERVOUS SYSTEM. ^
opRient : only certain symptoms are well marked, while others may be hardly perceptible or even absent. Trousseau calls these instances " for met frusles" {fruslf — abortive), and attrib- utes much importance to them. P. Marie has subjected them to a careful study in his excellent monograph (c(. lit.), and has shown that the goitre as well as the exophthalmos may be wanting, in which case wc shall only find the tachycardia, very olten accompanied by a symptom to which he has given special attention — namely, the tremor. This tremor shows a great regularity o( rhythm, and consists of about eight or nine oscillations in a second. Ernst Cramer, in his observations made in my w.Trds. w.is generally able to confirm Marie's results. (Ucber das Wescn dcs Zitterns. I naug.- Dissert., Brt^slau. i886.'i
Prognosis. — The prognosis seems to be especially unfavor- able in man and in old age. Youth is by no means exempt from the disease, since Ehrlich (I naug.- Dissert., Berlin, 1890). Krunthal (Berlin, klin. Wochenschr., 1893. 27), and others have reported cases of Graves' disease at the ages of ten, twelve, and thirteen. Female patients have, on the whole, a belter chance for recovery, especially if they become pregnant (Charcot).
Etiology. — We are not yet able to say anything definite about the a-tiology of the disease, although it scrms fairly cer- tain that heredity and an alteration in the thyroid gland have to be regarded as indispensable for the development of the disease ; all other factors, such as emotions, bodily overexer. tion (mountain climbing), cold, other diseases (e. g., influenzal are certainly less important and arc probably never capable by themselves of producing the dise.ise.
Pathological Anatomy. — With regard to the anatomical changes it must be stated that the thyroid gland always shovr5 a peculiar hyperplasia which differs Irnm the ordinary goitre (William S. Greenfield, Brit. Med. Journ.. 1893, December 9th). The vascular development was never found to be very striking: microscopically an enormous increase in the secreting tissue was observed. According to Greenfield, this hyperplasia may exist for years before any symptoms of Graves' disease make their appearance. The changes which have been found in the sympathetic nerve of the neck and its ganglia are not constant, and although enlargement and thickening of the ganglia and of the nerve have often bceti noted, wc can not draw any coo
G/fAt'£S- D/S£AS£.
523
I
lusioRS from these results, especiallysince several cases are on record in which the sympathetic was perfectly normal.
In view o( thfsc results the disease must be regarded as due to a supcrsecrciion of the product o( the ihyiuid glnnd which has a toxic action. This assumption has received strong support from the expcrimoiils of Grcrnlicld. By giving dried thyroid extract to healthy individuais he produced tachycardia. irritability, irregular elevations oi temperature, and a tendency to perspiration. George R. Murray (Lanct-t, 1893, ii. 20v No. vember iilh)also favors this view, and JoHroy looks upon Graves' diseue as a direct aScction o( the thyroid gland (Progr, m^-d.. 1893, 2, s., xviii).
Treatment. — The most important pan of the treatment consists in the (total or partial) removal of the thyroid gland, though there is by no means a general agreement in regard to this point, and it is still doubted by some whether a complete cure ever follows surgical interlcrence. It seems ceruin, how- ever, that operation at any rate gives relatively the most favor- able results. It often happens that only certain symptoms are rcmovcfi by such procedures. Thus. \ have seen a case in which half a year after the operation the exophthalmos still persisted, while the subjective symptoms, especially the very disagreeable tachycardia, had completely disappeared. In every grave case of exophthalmic goitre, therefore, the ques- tion of operative interference should be carefully considered.
Hack, I loppmann.and others, have reported cases )n which destruction of the swollen erectile tissue of the nose by the galvano-cautcry brought about an improvement in some of the symptoms: thus the exophthalmos at once disappeared on the side of the operation. In view of such cases, a rhinoscopic examination is always indicated. In other respects Graves' dise.ise is treated as all other general diseases of the nervous system or of the entire organism. Cold-water treatment has been warmly recommended, he it in the form of wet packs or of prolonged douches : patients in g<iod circumstances should be sent every year tu a hydrotherapeutic establishment, since such courses arc frequently followed by an appreciable though perhaps a not very marked improvement. Another procedure which deserves attention is the galvanization of the neck. The cathode is placed over the angle of the tower jaw. while the anode is applied over the lower cervical vertebra; (on the opposite side); the current should be weak, and only applied
524 i>^S£AS£S Of THE GENERAL S'EltVOUS SYSTEM. ■
for a minute to a minute and a half at a time ; often the symp- toms diminish steadily after ten or fifteen sianees. usually after twenty or thirty, an improvement follows which may last for years (Erb. IJenedikt, Guttmann. Mor. Meyer, and others). Whether this result Ls to be attributed to an action upon the vagus or the sympathetic can not be decided, since both these nerves are influenced by the current in the galvanization of the neclc.
hitcrnal remedies arc of comparatively little value. The tincture of strophanthus (two to ten drops every six hours for four weeks), which has been recommended by Browcr. often leaves us in the lurch, and belladonna and iron arc only of value in those mild cases occurring in young female patients which are apt to show well-marked remissions. In these an improve- ment of longer or shorter duration may occur under various drugs, but since this also happens when none at all arc given, we have no right to attribute it to any particular medication. The marked improvement which sometimes occurs during pregnancy has already been spoken of.
I LITERATURE.
Bat«ylow. T. Kvophihalmus duieh HyperlK^hie A«% Zvllgcwcbrs in Att Augcn-
liohle. Caliper's WochenMbr. f. d. ges. Heitkunde.. 1S40. No. 13. pt 197:
und No. 14. p. 130. TrouMcnu. Du goilre cxophlh. Union ntiA., Nos. 143. 143, 14^ 147: Ca^
hcbdoni^ pp. 319. 167 : Gai. dcs hAp.. i860, Nos. 1391 143. Oppolxrr. tJcbcr Itucdnw'sche Krankhdt. Wiener med. Wochcnschr. tStt,
Nus. 48 u. 49. ChvoMck. WcitCTv B«iiRlge lur Pathologic und ElekirMhentpte (kr Basedow-
'tchcn KtankhciL Wiener med. Ptcsse. 1873, No*. 33. 37. }3. 39. 4I-4& EutcntHirjE el t^utlnunn. Die p4tholo([ie des SympaOucusL Berlin. 1873. |fL
31 tt tf^. SatlltT in OrSre-SiinuMh' Handbuch der Augrnbrilkande. Lepdg. Eni^laMRn.
1680. vi. Mjme, P. Contribution A I'iludc el au diagnostic dc9 (ormes fru«ies de b
nwiUilic ik [UsrtUnv. Aux Hutcjiux du Progris mfd.. Pant, 188& Sainie-M^c. M. Coiitntiuiion & I'Aude de U nuladie de Uasedow. TMsed^
Pari*. 18S7. Vlgmroux. Sur )e Inilement «l stir quelques partirabriUs diniqws dc b
nuladic Ae Biicdow. IVogrte m6d.. 1SS7, No. 43. Eatcnburg. Ucrliacr klin. Wochcoschr.. 1889, 1. J. Rund-ReynaMs. Lancet. 1890, 348r.
Kitmniel. Deutsche med. Wodwnschr^ 189a. 30.. (Rcn»oval ofGoitrc.) Lrmke. IVutschc mcd, Wochenschr. 1891. s. MObklS. Dmtschc Zrit>cbr. f, Nervcnhk.. iSvl, I. $. 6, Dreesmaan. Deutsche nicd. Wochcnxhr.. 1893. J.
MY.X<EDE.\tA.
5*5
I
I
I I
I I
I
Drttrmaver. HeulMhe Med.-Ztg., 1891. 103.
Wrlle. Arch, t klin. Chtr.. 1891, xliv. Heft 3.
Mrndd. Deutsche mvd. Wochenuhr. 1893. ;. (PaihologinI Anatomy.)
Illaicus. WcMn und Uehamllunx des Mi>rbus Boscdowli, Deui&clie .Med.-Ztg.,
Joffrof. Nature et trajtemeni dn goitre Oiththalm. Troj;^ mH... 1894, 10-13.
Marie. P. Dtul&clie Mcd.-Zig.. 1894. 39. p. 33;.
Mannheim. Dcr Morbus Or.ivcsii. Berlin. 1894, Hirschw^ld.
Mobios. Schmidt's Jahrb.. ccali. 3. p. 134, 1894.
II. MVXtEDEMA (GULL AS1> ORD^ CACHEXIA PACHVDERMIQUE
(CHARCOT).
Myxoedema should be considered immediately after Graves' disease, because it may be regarded clinically as \vcU as ana- tomically as the direct opposite of the latter aflectjon (Green- field). While in Graves" disease we ha%'e a hyperplasia of the tissue of the thyroid and a hypersecretion, we find in myxoe- dema an atrophy and replacement «f the secreting tissue by hard fibrous tissue— myxa-dcma atrophicum. Myxtrdcmalous symptoms have also been observed in cases in which the thy. roid gland had been removed by operation— myxtedcma oper- ntivum. The cause of the spontaneous degeneration is not known: the fact that the disease has been known to occur a number of times after exposure to wet and cold is, o( course, not sufficient to establish the a:tiologicat Jmportanct of these factors.
The general swelling has been found to be not an oedema, but to depend upon the development of a mucin-containing myxomatous new formation ; in the skin, the connective tissue, in the saliva and the blood. mucin can be demonstrated incon- siderable amount. Kracpelin has observed an increase in the diameter of the red blood>corpuscles, as well as an increase in the specific gravity of the dry residue of the blood (Dctitschcs Arch. I. klin. .Med., xlix, 6. p. 587). Symptomaiically the dis. ease manifests itself by a peculiar swelling of the whole face, the skin, especially in the region of the eyelids and the cheeks. ap])earing tt-demaious. The lips are not completely closed, and the saliva dribbles from the comers of the mouth. Owing to the stumpy thick nose and hatf.opened eyes the face be- comes somewhat uncouth and common- looking, and, later, ex- pressionless and crctinlike (cf. Fig. 160). The patients, cspe- cially i{ they are females, grow to look so much alike that they appear as il they all belonged to the same family. The color
526 D/SF.ASF.S OF THE GEXERAI. NERVOVS SYSS'EM.
of the face is pirle, the sitin Eg waxlike, but docs not pit on pressure. The ndcma of the rest o( the Imdy has the same character as that of the face. The skin of ihe neck forrnsfulds. the hands arc thickened. On the hard wrinkled skin circum- scribed thickenings can be seen, hair and nails fall out, the teeth become curious, the secretions diminish and dry up. Anienorrhoea is common. The lungs, heart, and large vessels present no abnormities. On examination the urine is found to be negative, while the temperature is subnormal. Among the concomitant symptoms must be mentioned sensory and motor disturbances, uncertainty in the gait, and general lasM- tude. Such patients get easily fatigued, and their mental faculties deieriurate {IiUolie myxoedfrnattMst, Fig. l6i).
Will
Mi
Fig. tOoL— Ca» or HvxtzpEitit. (After Cnarcdt.)
The disease is not e:isily mistaken, but Lassar has called attention to the fact that certain erysipelatous swelling nay give to the face an expression similar to that secci in niyo^ dema.
The modem treatment of myj^axlema is very satisfaclory- Thc principle is to replace the missing or degenerated thyroid
U YXGP.DEMA.
sv
f;liind. This cnn be done either by implanting a gland into the peritonea! cavity (Uorslcy). by injecting thyroid juice (Murray), or by giving it by mouth (VVichniann). The best thyroid lo be used (ur the purpose is that of the sheep. Burmughs, Wel> come & Co., in London, have made compressed tablets o(
(Aftw BouiuitviLLK : ArIl dc K<ur., tH9t^ lii, 56.)
powdered thyroid, each one o( which contains five grains o( the substance. Wiclimann has obtained excellent results from their administration {Deutsche med. Wochcn&chr., 189343). P* Marie has also spoken very favorably of the thyroid treatment (Deutsche Mcd.-Ztg., 1894. 29. p. 335).
LITERATURE.
Tnuisao*
CutL On a Cnriinoid SijIf tuprnrning in Ailull Life in Women.
Ikms of the Clin. Soc^ii^ty, iS;4. vii. \k 18a Ont. On MjnKEdrnu. Med.-ChiT. T»nuirilDns. 187S. Ixi, p. 57. lIoiRiTi'ind. On Myxcedrma wiih SpcHal Reference to ii» Cerebral and Nerv>
ou» SjmjkUBU. Neurol. Com n button s. 1886, i. 5, p. 36.
528 DISEASES OF THE GENERAL NERVOUS SYSTEM.
Charcot Gai. des hSp., 1881, 10.
Saville. Case of Myxcedema in a Male Btit. ^fed. Joum., December 3, 1887,
p. 1116, Palon. Glasgow Med. Joum., December, 1887. Reverdin. Contribution i I'itude du inyxtEdime consicuiifi I'eiclirpation torale
ou partielle du corps thyrolde. Revue m£d. de la Suisse romande, 1887,
5.6. Zielewicz. Berliner klin. Wochenschr., 1887, 22. Munk. Untersuchungen iiber die Schilddriise. Sitzungsber. der konigl. preuss.
Akad. d. Wissensch., 1888. Probnik. Die Folgen der Exstirpation der Schilddriise, Arch. f. experim. Paih.
u. Pharm., 1S8S. xxv, 2. Conclusions of the Myxcedema Committee. Brit. Med. Joum., June 2, 1888, p.
1 1 62. Mosler. Ueber Myxodem. Virchow's Arch., cxiv. Heft 3. Cousot. Idiotie avec cachexie pachydermique. BulL de la Soc. ment. de
Belgique. 1881, ji. Manasse. Berliner klin. Wochenschr.. 1887, 47. Horsley. Brii. Med. Joum., February 8, 1890. Bircher. Samml. klin. Vortr., 1890, No. 357. Buzdygan. Wiener klin. Wochenschr., 1891,31. Murray. Brii. Med. Joum., October 8, rSgi, and August 17, 1892. Howili. Ugeskrift for Laeger., 1892, 7-9. p. 109. Laache. Deutsche med. Wochenschr.. 1893. 11. Lundiz. Edinb. Med. Joum., 1893. xxxviii, p. 996. Kinnicutt, New York Med. Record. 1893, xliv, 15. Relm. Ueber die Myxodemform des Kindesallers und die Erfolge der Behand-
lung mil Schilddrusenexlracl. Vcrhandl. d. Congr. f. innere Med., 1S93.
xii, p. 224. Vermehren. St offwechsel untersuchungen nach Behandlung rait Glandula ihy-
rcoidea an Individuen mit und ohne Myxodem. Deutsche med. Wochen- schr.. 1893, xix, 43.
SECOND GROUP.
NEU/IOSES I.V WHICH THE ESTIRE OKGA.S'iSM /S MOKE OJf LESS SSyEXEtr IMPLICATED.
I
CHAITER 1.
NCt'R ASTHENIA — KBKVOUS rxrVSTRATION.
Nhurastiiknia (o, privative; o^/mk, force) or neiroiis ex- haustion is an affection of the ncni'ous system with which the ^ncral practitioner meets very Irequently, and is one o( those diseases which may give rise to a f^ood deal of error in diag* iiosis and prognosis. At the same time it makes the most boundless demands upon the forbearance of the physician and upon the patience of the sufferer. The disease is a child of the modern mode of living, ol llie desire to become rich as soon as possible, and wc look for it in vain in the old text-books. AU thoiigh it may in earlier times have occurred now and then, the neurologists had neither opportunity nor occasion enough in study it intimately. This has only become possible quite recently, and it is certainly a fact of significance that neur.as- tt)cni:i has been "discovered" in that continent, the inhabit- ants of which have the reputation of working the quickest. of living at the highest pressure, and therefore of being — of course will) exceptions — more nervous and aging sooner than those of the Old World, to wit, in America. Beard, to whom wc owe so many excellent observations, so many splendid hints for therapeutics, described it first and gave it the name it bears. Whereas the disease prior to Beard's publication was unknown, it soon began to prevail in such a striking manner and to be diagnosticated so frequently that one is almost led to think that this diagnosis is often arrived at in cases where something else exists, some organic affection possibly more ditTicult to recognixe. The disease in question is not organic and not associated wiih any demonstrable anatomical altera* lions. Nobody has ever succeeded in finding any character- istic anatomical changes in individuals who have suffered for
530
mSJSASES OF THR GENERAL XEHVOVS SYSTEU.
years from the most pronounced neurasthenic mamtcstatioos and then have died from some intercurrent disease. A large number of subjective complaints, many of which fit into other clinical pictures, make it intelligible why a diagnosis of neuras- thenia is often made, sometimes without any sufficient, careful consideration of all the factors which ought to b« taken into account. It is comfortable and presumes nothing. Its possi- ble incorrectness can frequently not be demonstrated, and it therefore rapidly attained a great popularity among physicians. Symptoms. — The first traces ol the disease develop very gradually and imperceptibly. Sometimes they assume more of a cerebral, sometimes more of a spinal character, so that it has been thought justifiable to distinguish a spinal and a cere- bral neurasthenia (Encephaiasthenia, Althaus. Deutsche mcd. Wochenschritt. 1894. 13). For the cases in which the symp- toms of derangement of digestion were most prominent the term gastric neurasthenia was coined, under which head we may possibly class certain of the sn-callcd nervous dys- pepsias. Schott (Deutsche mcd. Wochenschrift. 1890, 34) h.as called attention to the neurasthenia cordis. In the ma- jority of cases the patients complain of getting easily and rapidly fatigued after the bodily exertion which is ass<Kiatcd with their ordinary daily doings, whether at home or in thfir business, alter walks, gymnastic exercise, etc. Things which they used to do without the least difficulty lire them greatly. In going distances which were formerly covered with case they have to rest half way, and require more time to accomplish a given task. Not always are definite pains present. At times there are aches in the back and loins severe enough to be troublesome. Sensory <listurbance$, p.-ir%sthesia5, formication in the extremities, or numbness, are rarely absent. These feel- ings distress the patient and may make him fear he has tabes, and the idea that he is suffering from some spinal trouble is fostered by the circumstance ihat the sexual power is usually decidedly diminished, be it that the patient is unable to hav< connection as often as before, be it that the erection of the penis is incomplete or Ihat no ejaculation of semen occurs. For married patients this weakness is a source of great dislrcM and often is a very prominent symptom, and frequently it is this that finally decides them to consult a physician, a step which has been again and again deferred. The more we have lodcal with neurasthenias the more frequently shall we make the <*■
NEUKA STHEXIA.
53>
I I
strvation tliat the !>cxiial functions are in the majority of cases in some way ur other »l1ecte<l, »nd that the sexual neurasthenia particularly deserves the most careful attention ol the physi- cian. To determine whether the complaints of a iKiticnt with regard to his disordered sexual functions depend upon oi^anie disease or upon neurasthenia we have, besides a careful cxum- inalion of the genitals, to examine the urine. It is well known thai the urine of neurasthenics not rarely presents a decided increase of urates, oxalates, and phosphates, and that not infre- quently spermatic fluid is passed during micturition or during defecation (Beard and Rockwell, cf. lit.). Where the patients complain, as they so commonly do, of impotence, we shall have to determine what form we arc dealing with, and whether organic disease, more particularly atrophy of the testicles, is the underlying cause. Sometimes there exists only a decrease in the sexual di;sire, while the power remains the same ; some- times a decrease in the power and an increase in the desire, so that the ejaculation of semen occurs too early, sometimes he- (orc the insertion ol the penis. Again, both sexual desire and power diminish pari passu, or finally the petftttta toetmdi is iror- nial but there is absence ol spcrmaloroa ("aspcrmatism "),
All changes of this kind are noticed by the patient and their significance is ever cxa^eraled by a fervid imagination. Even in the cases in which in reality there is no disease and in which the impotence depends entirely ujton psychical inllu- enccs. it makes itself disagreeably felt, and we must not forget that such a " psychical " impotence, in spite of all cncounigement and all assurances on the part of the physician is sometimes more difficult to cure than one which depends upon organic disea^ of the sexual apparatus. Every abortive attempt at coitus exerts a depressing influence upon the paiieni lor a con- siderable lime and is quite liable to lead to a second failure, although all other conditions lor the normal performance of the act may be favorable (FUrbringcr, cf. lil.>.
The disturbances o( the cerebral functions which appear in the course of neura.sthcnia are very manifold. First, the pa- tient is down>hearted and wornetl and sees everything in the blackest colors, and. above all, despairs of recovery. He be. comes irritable and impatient, unsociable with his friends, and feared by his family. In his work he is less efficient. Duties which he previously performed without trouble seem hard to him and require twice or three limes as long for their accom-
5J2
DISEASF.S OF THE GF.XEKAL XEKFOVS SYSTEM.
pHshment. Cases in which this is nut a prominent feature, but where ihc working power rcmaiiis unchanged, are met with, hut arc exceptions. Tiie sleep is usually disturbed ; some- times a protracted insomnia adds to the trouble. Headache is not the rule, but the p;ilient often complains of a disagreeable pressure in his head, which is accompanied with a slight feel- ing of di/Jiiness. All functions share in the disorder, the appc tite becomes bnd, the bowels sluggish, the action of the heart feeble, and vaso-moior disturbances in the form of persistent coldness of the hands and feet manifest themselves. The gen- eral condition of the patient is very pitiable in the higher grades of neurasthenia, and it is necessary for the physician to make a must careful vxamiiiulion so as not lo go astray io the diagnosis.
The objective examination, in contradistinction to what the manifold complaints of the patient miglu lead us lo expect, re- veals strikingly little. Organic changes can not be demon- strated anywhere. Thoracic and abdominal organs are healthy; nothing abr>ormal can lie detected in the domain of the crani.ii nerves or in the fundi of the eyes. The condition of the pupiU varies. Transient differences in their size — that is, unilaiera! dilatation, without, however, any abnormity in the pupillan rcffex — is certainly met with. The dilatation may either al- ways be on the same side or change at limes lo the other eye The phenomenon is usually marked when the general condition is bad, while it disappears il decided and lasting improvement IS once established. The claim that tasting inequality of the pupils is always a sign of organic disease, as Beard thinks, mu>l certainly be somewhat modified (f*eliz.ieus). I have myself seen differences in the pupils persist for eight or ten months and then disappear and the patient gel well.
The peripheral nerves as well as the tendon and skin re- flexes are normal. Tenderness over the vertebra; rarely is ab- sent, but is of no signiricancc.
Diagnosis. — When we have once sufficiently informed mir- selves about these points the diagnosis will usually present W little difficulty. At first, it is true, wc may be easily led astray and think of organic diseases of the brain, especially pro- gressive paralysis of the insane or a brain tumor, ycl tlie liu- thcr course of the disease will soon clear the mailer up. Tbr suspicion of tabes which may arise on account of the cercbrjl and particularly of the spinal symptoms, the disturbances c^
NEVRASTIlKNtA.
533
I
the sexual fnnctiuiis, and so (oiih. will be discarded, owing |o the persistence of the patellar rcllcxcs, the absence ol actual bhidder symptoms and pronounced sensory disturbances, an- KStheiiias and hypera-sthesias. iis well as ol actual motor weak- ness. Fibrillary twitchings, such as are observed in proj^rcss- ivc muscular atrophy, may here also be met Hitli, but (hey arc seen rarely and their occurrence varies a |;;u<)d deal. From hysteria neurasthenia is distinguished by the fact that the con- stant change of the symptoms which is so characteristic of hys- teria, besides the circumscribed neuralgias, the contractures. the spasms, etc., is here not observed. Still, to make a diag- nosis, repeated and careful examinations are needed, to which the patients do nut submit as willingly as hysterical men and women.
.Etiology. — In every case in which hereditary influences can be excluded the prime cause of neur.is(hcnia is unques- tionably to be looked for in an overtax of the nervous sys- tem. This is brought alwiut in many ways, by excessive men- tal work or by hubiluat bodily overexertion. It may he at- tributable to repeated emotions or to sexual excesses. Under the latter head we may put masturbation, which is a wide- spread evil among the young of both sexes and the practice of which not only may begin very early, but may be continued much longer than the physician himself might suspect. One may say that there arc but few neurasthenics who have not during their youth been addicted to this habit for a longer or shorter period of time. "Sexual pcr\-crsion " (Spilzica) and the various kinds of "psychical masturbation" may also be- come of aitiological siguilirancc. Even in married life, where the satisf.iclion of the sexual desire is otherwise well regulated. the coitus interruplus sive rcservatus, which is practiced to avoid loo great an increase in the family, may afford a cause lor neurasthenia. In my experience very few men have been able ti> practice with impunity for years this coitus interniptus, and it is the boundcn duty of the physician to inquire with much tact but still with perseverance into this question.
In some cases the abuse of tobacco may lead to neurns- thenia, so that the latter has to be looked upon directly .is a nicotine poisoning, and must, of course, be treated accordingly. Persons whose occupation necessitates work not only energetic, but also associated with the emotions fartists, students, finan- ciers, speculators, etc.), also those whose occupation entails at
534
D/SHASES OF THE GENBRAL KEKVOVS SYSTEU.
the same time bodily as well as mental strain, are all more or less neurasthenics. Not rarely repeated losses of a consid- erable qnantily of blood produce neurasthenia by causing a general ana:mia, yet wc must delinitcly slate that the neuras- thenia may occur very well in such cases without the anemia. Traumatism also may cause neurasthenic conditions. About these, which are usually intermediaie forms between this dis- ease and hysteria, we shall have to speak later, under the head of " traumatic neurftses." Finally, neurasthenia has been known to occur alter infectious diseases, typhoid fever, cholera, vari. ola. In these cases the bad state of nutrition and the faulty condiiion of the blood have to be held responsible.
Treatment. — The treatment of neurasthenia is one of the most troublesome tasks which the physician encounters. It is, of course, not suffictcni to give the patient a prescription and let him go. We must frequently exauiitie him, not only on our own account, but for his own sake as well, because he is com- forted by the attention and solicitude of the pjiysician. although the examination itself is usually dis.igrccablc to him. There arc neurasthenics who are actually relieved by repeated examina- tions, although nothing is ever prescribed. They gain there from the quieting conviction that somebody is looking out for them, and this gives them hope, lint here also the direct psychical treatment, such as we usually find to be of value in hysteria, is of the greatest importance. The patient musi again and again be encouraged and told that all his organs arc healthy, that it is only a nervous overstiain which he ts suffer- ing from, a deficit in his nerve capital which it is somewhat difficult to replace. To e);ert a mental inlluence u|K)n the pa- tient in this manner time is necessary, and those physicians who can not afford sutlicicnt time for the purpose should not take charge of a grave case of neurasthenia at all.
If hypochondriacal notions are prominent features, so Ihni the patient is beyond the reach ol consoling and encouraging words, the question whether or not he should be removed lo an institution must come under consideration. In addition to the fact that change of air and scene exerts in itself a favorable influence, it is advisable to place a neurasthenic after a certain time among diRcrcnl surroundings, so thai he has to meet with different people and has something fresh to occupy his mind with, and care should be taken to keep him constantly ut»dcr the guidance of a physician. As supplying such rcquiretneots
I
A'EVKASrifEXrA.
S35
■ sanitaria for nervous people, in which insane cases arc not re>
■ ccivcd, are to be highly recommended. Of course the pecu- niary c<indition nf the family must, before decidinf: upon this, be taken into account, since all establishments of this kind in which patients are well cared for are rather expensive. Some- limes in the more favorable instances a slay of from four lo six months is sufficient to bring about a very decided improve, ment. in which case even families who are not very well off sh<mld be able to afford the expense.
There are especially two factors from which much is to be
■ expected in the treatment of neurasthenia, and these are elec- tricity and hydrotherapy, pariicularly the cold-water treat- ment. With regard to the f<irnier it may well be stated that
■ there is no other nervous affeclion in which its application Is followed by such excellent results as here. Used at (he pro|»er lime and in proper doses, so to ^peak, it i$ most benclicial,
■ The method which is best employed and to which we give by (ar the prelercncc is the so-called jjener-i! faradization as rec- ommended by Beard and Rockwell, as welt as the general gaU
ft vani/iition. The results are especially strikinf^ if we make use oi the brush, which, in Beard's method, is not only applied to the back — although it is kept here longest — but (with the ex. ception ol the head) all over the body. .Mihough the patient may compliin ol disagreeable and painful sensations for the five or eight minutes during which the sitting lists, the after effects which soon follow are most gratifying. The patients (eel invigorated and leave ihc physician with a sense of having gained a new lease ol life. According to our experience the fanidi/alioti as advised by Beard is superior in its action lo the electrical baths, which arc much more circumstantial and have not been as yet sufficiently studied.
With reference to the cold-water treatment, to which we have repeatedly called attention in different places, we must in this more than in any other affeclion warn against ovcrzcal- ousncss and insist upon caution. Low tempenitures are lx)n)e very badly by these nervous and irritable patients. They be- come excited and sleepless, and our aim is not only fnislraled. bul actually more harm than good is done. However, if wc cautiously begin with a temperature ol from 86^ to 78° F.. and confine our measures to gentle rubbings, affusions of short dunition. cool hip baths, also of short duration, and avoid douches altogether, it care is taken at the same time to insure
536 D/SEASES OF THE GEA'E/tA/. XEftyOUS SYSTEM.
proper nourishment and exercise for ihe patient, tlic best (onn of which, perhaps, is a walk in the woods, the results arc en- couraging and lasting, il nt:ither physician nor client lose their patience loo soon. A course of treatment of this kind can not, however, be compressed into the usual four weeks o( a summer vacation, but to do any good six, eight, or ten weeks should be lakcn. Sometimes sea baths will be more useful than the simple cold-water treatment, but then also care must be taken in their selection. For the excitable and nervous who suffer from insomnia the places on the Baltic will on the whole be preferable to those, on the North Sea, while the latter are especially adapted for very prostrated patients and individuals suffering from cerebral aniemia.
A long stay in pure mountain air. at a not too high altitude and where the barometer is not too low. is usually beneftcial to neurasthenics. Daily systematic, but not forced, tramps in the mountains, continued (or weeks, do more good s<.»n)etimes than all the medicines of the pharmacopa-ia lakcn during the long winter. The internal medicines arc anyhow of not much avail in the treatment of neurasthenia. Iron, quinine, arsenic, the stomachics, all will disappoint us: all will sometimes ac- complish nothing; they rather tend to derange the digestion, and with this take away the last remn.mi of the patient's courage. The only drugs necessary will be such as are re- quired (or the proper regulation of the bowels.
Among the above-described symptoms there arc two the treatment of which deserve special mcniioii — tirst, the sleep- lessness; secondly, the impotence. About the former nothing needs to be added to what has been said on page 162. To meet the latter much is to be expected — if, of course, organic disease, spermatorrhoea, and the like, have been excluded — from the local application of electricity, A lai^c electrode, the anode, is placed over the lumbar cord, while the cattiode is moved from the external inguinal ring down along the sper- matic cord or applied without being shifted (Brb). With this may be combined Ihe application of the faradic brush over the whole genital region. One electrode, the cathode, ni*y also be placed in the rectum, the other upon the sacrum or perineum (Mtibius). Finally, a bladder electrode, which has the shape of a catheter, and which is insulated up to its metal- lic tip. may be introduced into the urethra as far as the iassa navicularis, while the anode is applied over the lumbar cordt
I
I
I
I
I I I
NEVRASTIIESiA.
537
and ut the negative pole the current is made and broken sev- eral times. From this method, which has been recommended more especially (or paralysis of the bladder and incontinence of urine, wc have repeatedly seen good eflccis in the treatment I of impotence.
The feeding system of Weir Mitchell, which has also been recommended in neurasthenia, we shall discuss in the chapter on hysteria.
1.ITERATURR.
IWard. On Ncoraiiheni.v New York. i8*a.
Eocnluhr. Drutsche med. Wochcntchr.. 18S4, x, ^^, (Diflcrcntul Di.<£iiosis between Tabes and Nctirislhcnia.)
Bcanl und Kockwtll. Die sexutrilc NcunudMrnie. Wtaii. l88s-
Mobiiu. Die NctvosiiSt. Lciptig. 1S85. 3. Aufl.
Thai'cf. NeuiuihcnU. Phil. Mcil. and Suqi. Report., 1886. lir. 17, 18.
IJenIt ilovell. On »oiiie Condifion*o( NeurusllirniA. Londiw. 1886. ChurchilL
Avcibeck. Die .tculc Neursslhcnir. Deutsche McML-Ztg.. I886, tii. 30^ 31,
Langslcin. H. Die Nciirasllicnic. Wien. 1886.
Mitchell. S. Weir. An tCs^y on the Treaiinent of Cerkilti Funns of Neuras- thenia and H>'sleriA. Phila.. Llp|Hncotl. 1885.
I'berrk- Die fiincliiinelk-n Nrurntcn bcim wcitilichen C^MrhK-chl and ihre BeiwhunKtn ^U den Sesualleidcn. Uerlin, Neuwied. 1886.
Clark. Some Obscrvaiions concerning what is called Ncuraaibenia. Lancc4. January I, 18S6, L
KralTt-Ebiiig. V, Ucbcr NcurasiheiilA sexu.ilift bctm Mann. Wiener med.
Prcsse. 1887, xiviii, S- &■ 'T. Senusen. Die Neurasthcnie un<l ihre Bchandlun^. Lripi>K, Vogel, 18B7.
Hanc. Ein Mlleiicr FaU scxueller Ncuraslhrnic. Wicnei' mcd. Klmik, i, j.
Ptppinskold. On ncunulhenirns ratckomst bUnd hn>]>|i«.iil>ctar«. Fin»ka
IlakaiviJilUk. lundl.. 1S87. ikit. 11. Burkun. ilci liner Uin. Wochenschr.. 18S7. xxiv, 4(. (Recommend* Weir Milch- ell'* trcaltnenl.) Mathieu. Ncura&ihtnlc et h)-«irlc comhinfci. rrogr. mid., 1888L xvi. yx t-cmoine. PathoRtnie el irailemrnt de la neurasthfnie. Ann. tnM. pcych..
Sepitetnbre. 1S88. jnie ser. viii. Wcblier. A Sludy i>f Arterial Tension in NeuraMhenia. B<M(nn Mcd. and
SurjE. Joum., May. 1888. rxviii. 18, Furbrin^cr. Zur Kennlniu der linpotenita genemndj. neuitelie mcd. Wo-
chcMchr.. 1888. xtv. i%. W^KMir, Zur Bexrifliibeiiiimniung uni! Thmpie der Neiiraslhenie. Schwcinr
CoerespDndenzbl.. 1S88. xviii, 9. Ptiiiiwua. Zur DifltrcniialdHgnoae der NeuraMhenie. Deuiwhc .Med-Ztg..
1889^ 17. 38. LOwenfeld. Die modeme Dehandlung <ler NervenKhwUche (NrunstbcnleV der
H>^erle und vervrandier t.eiilcn. Wiesbaden, ttcrpnann, 1889^ 1. Aufl. IMm-lMM. Dc ta Neunuth^nie ct de I'h) ktiro^ncvrasihi nic lraumaik|uc. Progrte mfd., 1S90. 49.
I
538 DISEASES OF THE GEffERAL NERVOUS SYSTEM.
Bouyer, La neurasthinie (ipuisement nerveux). Paris, Bailliire. 1890. Boltey. Hydrothirapie et Neurasihinie. Revue U'hygiine thfrap., Fevr.
1892. Jacobs. Gen. Tijd. voor Nederld. Indie., 1892, xxxii, 5. Sollier. Sur une forme circulaire de la neurastlifnie. Revue de \r\kA.. 1893.
xiii, 12. Miiller (Alexanderbad). Handbuch der Neurasthenic. Leipzig, Vogel, 1893.
(Indispensable Tor special studies.) Kothe. Wesen und Behandlung der Ncurnsthenie. Weimar, 1894.
CHATTER II.
IIYSTKRIA.
Hysteria has this in common with neurasthenia, that it
docs not depend upon any demonstrable analomicnl lesions of
the nervous system, but it differs from it in the fact that for
— its development a certain predisposition on the part of llie pa-
f ijcnt is absolutely necessary. Although wc are not as yvt in a
po<iition to say ol what nature this predisposition is, wc must
• assume that the whole nervous system of a hysterical patient, central a& well as peripheral, is in some points, which wc are still unable to determine, different Irom that of healthy indi- vtduals. The greater extent to which these persons observe themselves (Oppenheim), the increased impressionability, the hyperesthesia of the central nervous organs, the increased
■ sensitiveness ol the peripheral nervous system, ilie diminished energy with which influences coming from outside as well as from within are met. the lower general power of resistance and self-control, these arc on the whole the trails which charac- ■ terixc hysterical persons, and explain why the symptoms are so manifold and change sit rapidly, and why in no other disease ol the nervous system can be lound a train uf manifestations so diverse and so numerous.
■ Only by unwearied, long-conlinucd study has it been possi* blc to show that even for the apparently arbitrary appearance of the different symptoms there exist certain laws. In a man- ner which none before or after have been able to rival, hysteria has been studied by Charcot and his pupils, to whom we owe the most interesting observations and investigations ol the past
»twu decades. LITKRATURE.
H>i*e. Kranl()i«ilen df% NenentysU^mv In Virchow's llandliiKh <kr tpecicDen PAihuiogM uml Thcmiiic. Krlnngm. r869. (Confalns the oldtrr liicraiurc.)
Briquet. Tr»tf ctlaiquc ct ih^mjirulitiuc itc )'ll|%ijric. pjrK iH;*). (Orininal ■nkk, Dpon uhich all the uudies on hpteria It)- the Frencli authors are butd.)
539
540 1>/S£AS£S OF THE GENERAL A'EJtrOt/S SYSTEM. H
Charcot Klininlie Vorlrlic'^ "''"' Krankheiien da Nenenaystemi. G«ri^|
lunslalion by Fcucr. Siuiigdn. 1874. Charcot. Nciie Unicnucbuntren uber die Krankhritcn ilc« NFTvemyilems.
bc^ondcrs libcr Hysteric. German traiuUtion by Freud. Wten und Let[h
ng. 18S6. Freud. Beitriige lur CasuiMik der Hystctie. Wiener nied. Wixh«iMchr., 1SS6
49. SO. Mol»u«. Uebn-drn RegrilTder HyMcrie. Ccntralbl. L Nen-enhk., 1S8S, xi. 3. Theinies. Traill ilfmeniaire d'Hygiine ei de Tbinipie de I'Hysitne. faris.
ie89. Charcot. Lc^ns du Mardi 1 la S.-)lp4iriire. I'aHt. 1889. (Polic Unique, 1887^
1S8S.) Gillesdc U Tnurcilc. Trnii^ cllnique ct th^Mpcuiii|ue de ('byMirlr, d'xpita
ren^^eineni dc la Salpftricrc Paris. 1891. Gilles de ta Tountte. Die Hysierie nach <leii Lvhren der Salp£(ritfc. German
Irnn»l;ition by Kail Grubr. Wien. Ucuilckc, 189}. Breuer und Ficud. Ucber <lrii ptyrhisibm Mechanismus hyaleiixcbcr Wh I noinene. Neurol. CciilralbL. 1893, xii. 1, 2.
Symptoms. — For the sake of simplicity wc shall divide, in our dei^cription of the disease, the s>'iii]>(oms into cerebral, spinal, and mixed — that is, pertaining to the entire nervous system.
The cerebral may n^ain be subdivided into psychical and somatic symptoms. The disposition of the patients is excitable, anxious, often changeable, someiimes passing from the depths ol gloominess to the most exalted hilarity. The tendency In speak of nothing else than of their own woes, the constant at- tempt to greatly exaggerate these, and to excite sympathy in their friends and physicians, the thoughtless di-tnands which they expect to be satisfied at a moment's notice, and the incon- siderate outbreaks o! anger if this is not done — all these are characteristic features of the disease with which we meet, not in all indeed, but at any rate in a large majority of cases. The tendency to get easily frightened is very common, and during a state of the highest psychical excitement hallucinations may temporarily exist. In pure cases of hysteria, however, wc need never be afraid that these will persist long or lead to anv serious outbreak on the part of the patient. Exceptionally nn instance of " hysterical sleep " comes under our notice, into which the patient has fallen after certain prodromal symplomJ have existed for several hours. The peculiarities of this curi- ous condition, (he " lethargic hystirique," which may last for many days, the condition of the organs of circulation and di- gestion, the characteristic signs by which the hysterical sleep may be discriminated from other states of coma, have recently
HYSTERIA.
S4t
been described by Gtllcs dc la Tourctte in a careful monogniph (Arch, dc Neurol., tSSS, 43, 44), and lately by Locwcnfeld (Arch. f. Psych., xxii and xxiii). The paroxysmal appearance of a marked tendency to sleep (narcolepsy) has been studied
I by BOhm and Dchio (cf. lit.). Among the cranial nerves there is not a single one which may not at one liim- or another in the course of hysteria pre- sent symptoms of paralysis or irritation. More than the others the nerves o( special sense are interesting for their anarsthcsias and hyperaeslhcias. The nerves of smell and hearing are those must frequently atlcclcd, and both functions may be so much impaired that the patient can smell and hear nothing. They may. on the other hand, become so acute that, if we may believe her oxvn statements, she is able to distin- guish any one from a number of perfumes, or to single out an individual by the sound ol his voice amid the hubbub of a Bcrowd, or. again, to recognize people (ar off by their step, and ™ so forth. These and similar faculties have in Mesmcr's time already been spoken of a great deal, and have given rise to much deception and trickery. The opticus is also not rarely afTected. Besides the cases where hysterical patients suddenly become blind in one or both eyes without there being any changes in the disk, there are instances of decrease in the acuteness of vision, contraction of the field of vision, or com- plete or partial loss of color sense. When the last-named con- dition occurs the perception of blue and yellow is retained longest, while that of violet and green disappears much ear- lier. We must ol course expect numerous variations and com- binations. I have seen in the same individual hysterical changes in the one eye and tabetic changes in the other. The ocular muscles rarely participate in the disease: hysterical paralysis of them is exceptional, as is also the occurrence of hysterica) nystagmus, on which subject 1 have expressed my opinion elsewhere (cf. lit.).
Among ihe other nerves of special sense that of taste may occasionally present alterations. The patients lose their taste either completely or only for certain substances (sour, salty), or there may exist such a perversion of this faculty that every- thing tastes nauseous and disgusting, or that everything tastes of salt or of vinegar, and so forth. Actual hallucinations of the wnse ol taste, although not so frequcnt'as hallucinations of the sense ol smell, arc not unheard ol.
542
DfSBASES OF THE GElfRRAL NERVOUS SYSTEM.
The trigeminus is generally implicated. Faceacbe and headache, among others the kind which is confined to a small spot and is known as clavus, arc comparatively frequent. The sciilp is someiimts so markedly tender that the patients can not stand the slightest pressure, not even the touch of the cum b, and in order to avoid the pain ihey abstain from all care and proper attention to the hair. The pain in the head may also be confined to one side, and resemble in every detail that of hcmicrania.
What needs to be s.iid about the facial nerve in this connec- tion has already been treated of in Chapter V, Part II. Tic convulsit, as well as facial paralysis, may be hysterical in na- turc; however, we must not forget that facial spasm and hys- teria may well coexist, and that a tic convulsif occurring in the course of hysteria is not necessarily of hysterical origin. The determination of [his question is less important (or the diag- ncjsis than for the prognosis. The outlook in non-hysterical tic i< very bad. in the hysterical variety relatively favorable (Guinon. Revue dc m£d., juin, 1887), Of much interest are the many forms of vagus neuroses which we meet with in the course of hysteria : they may aflect, in the manner described in Chapter VIII of Part II, the organs of respiration, circulation, and digestion. Among the first, not only the larynx but the lungs also are sometimes attacked. The laryngeal muscles become the seat of violent spasm, " hystcrtcit spasm of the glottis." during which the patient is afr.tid she is choking, in exceptional cases patients have died in such attacks (Leo, Deutsche med. Wochenschr., 1893. 34). The (unctions ol the vocal cords may become so much interfered with thai the patient is only able to make herself understood in whispers; to speak out loud is impossible (" hysterical aphonia "). The laryngoscopical examination reveals nothing abnormal, with the exception of some ana:sthcsia of the mucous membrane of the fauces, which greatly facilitates the examination (cf. page I tj). Peculiar disturbances in speech— for example, a stutter- ing, which, in contradistinction to the ordinary type, comes on acutely — have been frequently obsrrvcd and carefully studied. For the recognition of this symptom and its differentiation from ordinary stuttering verbal suggestion may be used (c(. the cliap- tcr on Hypnotism). The respiratory muscles may be affected in a peculiar and very striking manner ; the acceleration in the num- ber of respirations may attain such a degree that, instead of
\
ilY^TERlA.
S43
fifteen or sixteen respirations a minute, we may count (rom eighty to one hundred. On the other hand, they may be dimEih
' i^hed in Ircquency. und the patient breathe from eight to ten limes a minute, but in a labored way, showing signs of a regu* lar dyspnu;a, nut infrequently with audible wheezing in inspi- ration and expiration (" hyHtcrical asthma"). A dry and b;irk> ing cough, which is distrei^sing not only to the patient but aImj
I to all who surround her. is sometimes observed, and paroxysms of yawning, sobbing, laughing, or crying (" hysterical laughing or crying fits ") may persist lor hours.
Sometimes fulluwing aphonia, sometimes occurring abrupt- )y and unexpectedly without it. in rare instances a complete dumbness sets in ; the patient has either actually lost the con- trol ol her speaking apparatus or will not make use of it; in a word, she is completely mute, and no amount of admonitions, entreaties, or threats can succeed in eliciting a single word. This condition of "mutismus hystericus'* may be of variable duration. In one instance which came under my notice the
'patient maintained silence from the 5th of September to the 2ttih of April ol the following year. She found her voice again at once on hearing of the unexpected death of her mother. In this connection the articles of Natier, Huysmann, and of Kay- *er (Thcrap. Monalsh., October, 1893, vii. p. 500), who recom- mends autolaryngoscopy as a useful means of treating this
[symptom, may be referred to.
The circulatory ()rgans more especially the heart, take
[relatively the smallest share in the disease. Hysterical tachy-
jcardia may occur, but it is rare and never well marked:
in the apparently severest atlaclcs, which we shall de.
ribe later, the pulse is <|utet. To stenocardia we have re-
llerred on page 123.
Cases of so-called "aorlic hysteria," a condition which has been described by (*<>sl. of New York (Med. Rec, iSgi, 16). and which is charactcriiced by relaxation of the aorlic walls in consequence of diminution of the vascular tonus, simulating a tumor, are of a very rare occurrence,
\ The digestive tract and the muscles pertaining to it — which, (ust as the pharyngeal muscles, are innorvated ai least partly by the gUisso-pharyrigeal and not by Ihe vagus alone — may be the seal of various hysterical manifestations. The muscles of the pharynx may present symptoms of paralysis or of irrita* lion. In the former case deglutition is much interfered with,
544
D/SEASES OF THE GENERAL SBRVOVS SYSTEM,
and may, indeed, be impossible ("hysterical deglutition panl ysis").
A peculiar affection of the muscles of the (esophagus, which are supplied by the vagus, consists in a spasmodic con. traction which gives rise to a very vivid sensation of a ball rising up from the region of the stomach and sticking in the throat. This "globus hystericus" is so frequently met with in hysteria and is usually so well marked, that it has been looked upon as pathognomonic for ihe disease.
The musculature of the stomach and the intestines is liable to disturbances. According to most authors, paralysis of these muscles produces a distention of the bowels and of the whole abdomen which may be simply enormous (" meieorismus hys- tericus " ) ; this is sometimes associated with colicky pains. A certain amount of the air, which frequently collects in large quantities in the bowels, escapes through the mouth with a loud, sobbing, gurgling noise (singultus, ructus hystericus). Talma (Wcckblad van het Ncdcrl. Tijdschr. voor Gcneesk., 1886,9) claims that the cause of hysterical tympanites is to be souglil in a spasm of the diaphragm. As evidence in favor ol his view lie argues that under chloroform narcosis the disteo- tion will disappear without the emission of gas; and. secondly, that the position of the diaphragm is abnormally low,
Vomiling is one of the most frequent occurrences in hys- teria: sometimes it is very profuse and may persist for houre: it may be so intraclablc a.s to iveakcn the patient considerably; on the other hand, slight vomiting may occur daily for weeks without afTecting the patient's strength. Usu.illy warcry masses arc thrown up which bear no proportion to the quan- tity of food ingested. In one of my cases the amount vomited was eight or ten limes as large as that taken in.
Affections of the accessorius are not rarely seen in the form of spasmodic torticollis, while affections of the hypoglossusaK very exceptional. ""
LITERATURE.
Parinaud Annal, d'Oculislc. 1886. xcvj, I, 3. (Aniesthcsfa of the Retina.) Bri««auil ct Nt.iric. Progits m£d., 1B86, xv, 5, 7. (Dtriation Taciale diw
I 'h* mi pi, hyii^rique.) Cuinon. Rcvuc tie nijd., 1887. vii, & fTic convulsif.) Huet Hytlerii:;)! FndAl Parcsifi. Nedrrl WcekhUd, 1887. it, 31. Borel. Annal. il'Oculihte, 1887. xc\-iii, 5. 6. (llysiericAl Alliectiocis of the £;<
MuscIm. etc.) Schlctmger. Wiener med. BIttUer. 188S. xi, 3.
I I
HYSTKMiA.
S45
I
Peck. New Yurk Mexl. Rcc.. March. iSltS. xxxiii. (Hj-sicrkal Coma.) F^ri. Migrtun* o(ihthaiinu|ue hjM^riquc. Aich. <ic Nmrol,. 1890, 6a Remak, E. Zur Srmiolik A<x h)-«tr tine hen Deviation der Zungv und <les Cc-
Mchlo. ElctlincT klin. WtKheniclir.. 1891.4a Leber. I*rriphcrc S*:hnervcna4Teciionen bci H]rUrr)c. D«ultclie incd. WocheB-
Khr. 1^1. 33. Hhag. SchUfaitJcken und h)i>nolische Suggestion. Berliner klin. Wochen-
Khr. 1893. 38. iTtcbonki. Monaischr. f. Ohtenhk.. 1S93. 11. r^r^, Ch. Svnuinc mid.. 1S83, liti. 5a Uloc<|. Gm. des hAji., 1893, 13;.
Janet. P. £ut roenul de« llysl^ri<|iie« t'^rii. RuefT, i&ij. Knics. Die cin&eiiigcn ceiiinitcn Sclisiotjri^eii und ibrc Ucjicliung lur lljsierie.
INrurol. Cvnirall*),, i8(>3, I?, Ikihm. t/cher Narkolepiiie. lnau;;.-DiMen.. Heriin, 1893. Dehia PailiologlMhc Schtadu&iXntJe. PeicnburKcr n>ed. Wochcnscbr., 1893, 11.
Ilyitniial Sfftth-JiitHti»iKn.
Pelte«ohn. Ilerllnet ktin. Wochcnschr, 1890, 30.
ISooleker. Ch.tnt6.Aniulcn. 1890. xv. p. 373,
Rcsciiliikch, O. Ueber functionelle UhnmofC der tpnchlkhen Laulgebung.
Deutsche mcd. Wochenichr.. 1890^ 46. D^iUcI el TusicT. Du b^aiemeni h]rM^i)ue. Arch, dc NeuroL, Julllet. 1890,
No. SB. Kr«m<T. L*eher hjveriMhcs Stollcm. Prager med. \Vochen»rhr. i8qi, sir. CI>crTJn. A propot du Mgaiemcnl hysltrM)uc Arch.de Neurol., Mai, 1891.
N0.6J. HIgier. I'eticr hvnetitehes Stoiiem. Iki4lner klin. Wo:henichr.. 1893, m. SciflerL Dir Bchnndltinj; <lrT hysteriKhen Aphunie. Ibid., 1893. 44. Zodkr TaII I'vn hysierischcr Sluinntheii \<m tweijUiriger Dauer. NeuroL
Centnilbl., i&m, 2.
One nf ihe most remarkuble cerebral aflections which may occur in ihc counie of hysleria is an apoplectiform attack with consequent hcniiptc^ia. which in many instances is associated with complete hcmiana'sihesia. This hemiplegia may develop with symptoms similar to those of the form following arterial disease, and. as. we have already pointed out above, it may be extremely difficult to distinguish a hysterical hemiplegia irom wic due to organic disease. This is especially the case il there are no other hysterical symptoms to aid us. If the uniUtcr;il •paiim o( the muscles of the check, described by Charcot, and before him by Ortxlic (iSto), which is said to be characteristic of hysterical hemiplegia, be present, the diagnosis is easier. All the syinptoms associated with a cerebral hemiplegia — for instance, tremor, the associated movements, even atrophy of the muscles of the side aflcctcd — may accompany the hyster-
546
J>/SSASES OF THE GBXEKAl. A'EfiyOVS SYSTEM.
ical variety. The opinion formerly prevalent, lliat wliere«r ihcrc exists atrophv this must needs depend nj>on an organic lesion in tlie brain, spinal curd, or the nerves, has beert proved to be erroneous. The hysterical atrophy may not differ from that due to organic disease; it may devdup comparatively rapidly, may remain for a long time, and disappear again jusi as rapidly when motion returns. Fibrillary twitchings in the atrophic muscles and reaction of degeneration are absent.
FtK-iA).— i^leniibovn tn Pie. i6j, thiT« mnntht prrvfou* to Ibe ilnw nVa tW fMa* ot Fig. ibj WM laluH I |xnuiul oliMrvttiua t.
Whether the large ganglionic cells in the ariierior horns have anything to do wiih the occurrence of .-itrophy. and, il si>> what is the nature of the influence, we do not know,
I will here mention only one of the cases of hysteric*! atrophy which have come to my notice and which isquiw unique, owing to the intensity and the rspidil)' with whtd> An :itruphy of the entire muscular system developed. The clinical history of the case, ot which two pictures (Fig*. l&
MYSTRKtA.
547
and 163) »re here given, will 1>e found in an article by me in the Deulsclic .mcd. Wochenschrift. The time which elapsed between the taking of the two pictures was abuul three raonlhs.
UTERATURE. mMnsld. Afch. de NeuroL. Juillet. 1886^ vii. (Aira|>hy iu Hysierical Panly-
CtiMtfbrd. Cu. hl^bd.. 1. *.. 1886, kniii. 31. (Atrophy of the LcA Ut>pe* Ci-
imnlty, HystcncA] MunuplcgU. a« a Kcsuti of Tnuin.i m Ji Young Mjin.) , MmuIorkol L'atrDlu miixcoUrr nrllc (MnlHi isivnchr Napoli. I>eikcfi. 1886. De l*apo|dcxie h)->i6ri<|ue. Arch. K^nir de mM., 18S6, No. 34. iroitln. Arch. Ae Keurol.. 1886. xii, p. 30). (Hy^tcrlnl M(mo|t)eKU of Sii Monih*' SlwidinK. cured itnmrdutcly by ^ijtEeriian.)
ski Zur Diagnow dn li)'Mer HcntiplcjiK. CcnmlbL f. Ncrvcnhdik.. is. 6.
Cm t)'«pof)lexie hyst. avec auli)p«ie. Ann. mcd.- psych.. 7 M;iri. 1S87, Hnkwutl. Arch, dc phyn. aomn. el |nihol.. 1887. }. (HyWeric^ Ilemiplefia With AUvphy.)
S4S
D/SEASES OF THE CEXEKAL XERl'Ol/S SYSTEM.
Achanl. De I'npoplcxie hyxrfnquc. Arch. ^inir. Ae miA., Janv., xHy, Monvsik. C«niralbL C Ncnenhalk., 1888. ». ao. (Hysioncal Sympiocna in
Bnin Syphilis.) Souquea. Hcmtpligie hysi<rK|Ue (cbcx un vtlumifll. Cai. de Harti, 1889^ i.
Among ihe spinal symptoms ol hysteria, motor and .sensory p;iralyscs play the most important nUc. With hysterical pi- ticRts we can not feel certain for a single day or hour thai some sort of paralysis will not occur, for it is characteristic, we may say pathognomonic, of hysterical paralyses that ihcj appear quite suddenly, and happily often disappear as quickly, it may even be after persisting for months and years. There is no characlerisiic distribution of the hysterical motor dis- turbances; they may take in only one extremity, or mav ex- tend to both legs or both arms, so that these arc perfectly useless. l£xaminalion shows that the paralyses are usually uf a flaccid type. We may frequently make the observation thai the patienls arc not completely robbed of the use of the af- fected limbs, but (hat they have lost the \vill to use them. Especially is this apparent when they are asked to perform co-ordinated muvcmcnts. A patient, though able to move the right arm, may .issert that she is unable to write ; though she is able to move her legs, any attempt at walking is an utter failure ; on rising, her legs give way under her. and she simply is unable to keep herself on her feet. The inability to stand and walk, which is sometimes found in cases of hysteria, was first studied by Paul Blocq, and was termed by tiim astasia- abasia (Arch, de Neurol., Janvier, 18S8. xv. No. 43); when the patient is in a recumbent position the sensation, the muscular power, and the coordination of the legs present no abnormilT. Miibius, who among others has studied this condition car^ fully, has called atteniion to the fact Ihat the patient knows nothing of its origin ; that it develops through (unconscious) auto-suggcslion, but that Ihe subsequent amnesia hides from tlie patient the true origin of this suggested alrcration. " Tlic suggested idea docs not become a part of consciousness in the waking state ; it docs not become a molivc for the will, as do, for example, fixed ideas, but acts subconsciously" (Mtibiuf). Charcot, in his Lemons du Mnrdi. h.is distinguished a paralytic and an ataxic form of hysterical abiisia (Le^n du 5 Mars. i!!89)> A critical review by Mijbius ol all the cases published up lo 1890 will be found in Schmidt's Jahrhiicher, 1S90, ccxxvii. p. sS-
Symptoms uf motor irritation — for instance, isolated inus-
HYSTEIilA.
549
I
cular spasms — are far less frequent. Of much interest arc the involuntary muvements which arc now and nL^iu'n observed. 1 had a lady under treatment who. without wishing it, but with< out being able tu resist the inclination, would for hours at a stretch keep on raising both arms and letting them lall again without the least feeling of faTigtie.
Clonic muivcutar spasms, in the muscles of the face as well as in the extreintiies. which, appearing in paroxysms, usually arc symmetrical in their distribtilinn. and are not sulhcient to produce movements of the affected limbs, have been de- scribed by Friedreich as paramyoclonus multiplex, and by iiee- Hgmttllcr as myoclonia congenita. That they arc of hysterical origin is more than probable. The ttouble is rare, and is in most instances to be regarded as an emotional neurosis. The strength of the muscles and their electrical excitability remain uttallcrcd, and sensory changes arc absent. Sometimes there are tender points along the spine, which are best treated by the anode of the constant current. Other mrasiircs are not necessary, especially as recovery seems to be the usual out- come (cf. lit.).
Closely related to though not identical with myoclonus Is the group of symptoms which has of more recent years been described as " maladic dcs tics convulsils." Irregular move* mentsltaving the nppraranceof intended m<tv<-ments. but which have become automatic, occur in the lace and in the extremi- ties: they may be confined to one side. It is not improbable that imitation or even direct suggestion may play an important uUe in the production ol these movements <Toh:ir>ki, N'eurol. Centralbl., 1893, 16). Menial abnormities arc rarely absent in such patients; thus we hnd "a tendency to the formation of fixed ideas — i. c, a low degree of mobility o( the contents of consciousness and the frequent repetition of the same psychical processes" (Toharski). The movements present the following peculiarities: They have a psychical character: they are re. pented in a monotonous manner : ihcy appear purposeful ; but since the will has nothing to do with their appearance, they occur without effort on the part of the patient ; at times they can be suppressed by an effort of the wilt. Fibrillary twitch- ings and involuntary contractions in certain muscles, especially in those of the face and the neck, more rarely o( the bands, have been observed (Toharski). I have reported a case in which this condition was associated with allochiria, and which
550 D/S£AS£S OF TltE GEXE/lAl XERVOUS SYSTEM.
1 succeeded ifi curing by verbal suggestion, at the Intcrnalional Congress in Rome (cf. Wiener med. Pre&se, 1894).
UTERATfRE.
Starr. Allen. Taritinyoclon. Mull., with a Rejiorl of a Case. Jouin. of Netr.and
Mcni. DlsiM^FK |8!I7. xiv, p. 416, (The &i>a»nis appeared Imtncdiatcly a&ct
lifting heavy objects.) RybaUin. Ccicrih. med. Wochenichr.. 1887. 44. pl 366, Marina. Uebn Paraniyoclon. mull, und liJIupaihischc Mui>kdki£inpfe. ArtK
r. l^)Yh. untl Ncn'cnkh,. i6tl8, xix. 5. p. 684. Zidwn. Ucbci Myoclonus und Myoclimic IbJd., 1S68. xix. 3. p. 46$. Pelpcr. Ucbcr Myoclonic. Deutsche med, Wuchenschr. 1890. i$b Unverrichi. Die Myoclonic, [^jpiig u. Wicn, Dcuiickc, 1891, ColilHani. Neurol. Ccntrjlbl, 189!. 4. Weiss. M. Ucbcr Myoclonie. Wicntr Klinik,. 1893. Heft 5. Jolly. UebcT die sogcn. Maladie <les Tics cum uJtiti. Ch.nrilf-Aitnaleii, tSgi.
p. 740. Buringh Bockhotidt cl J. van der Wcyilc. Mahdie dc« tics convulsifg. Wtckli
van he( Ncdcrl. Tijd«chr. voor (lenecsk,, 189}. p. 3691 Scidinaiiiu. Malaitm dvi lie K. Accad. nicd. di Kvinu. 1893.
Often combined with paralyses of the extremities are joint cotilractures, which as a rule appear suddenly, atid may per- sist for months and years. When occurring in the upper ex- tremities, ill the elbow, in the wrist, and in the finger joints, they arc usually flexor contractures; in the knee and ankle joints, extensor contractures. The way in which they disap- pear under chloroform narcosis \% very remarkable. Individ- u;d muscles may also be the scat of contractures, and we have described a case on page 38; in which during the erect postun a contracture in the quadratus lumborura made its appe.irance. which disappeared when the patient lay down.
LITERATURE.
Zesas. Zur DUTereniialdLigniMe der Odenknniroara. Chir. CcntralbL. ■:
hiii, i& PitrcK. De I'analK^ie cb« les hy«t jriqucK i I'iiat de willc cl dans le sommrf
hypnulique. Joum, de mit\. At Uonkaux, 1886, (ol MUllcr. Mitth. d. Vercino d. Acfile in Stci<Tmart[, 1886. xxiL (IiMnMlnt
Senftury Clianj^ex.) Lichtn-itx. Lcs antsihfsia hystMques <to mu(|ueus« t\ ila oi^gnna dn ■m^
et let ion» hysttroginct dct muqiKu«n. Cnris, 1 S87. F«lcone. l><ru<!u:he med. Wochenichr,. iH8£, xii. 41. (S|)0«uacou3 TaUiiS
Out of the N.iils.) WmiI. thlUdelphia Med. and Surg. Rep-. 1887. ML* J. (Hysierical tUmor-
t)-sis.) Rkhcr. Paul. P.tralysles ct oontncuns h>'5t.. Paris, 189a. Ddn.
1
IIYSTEKIA.
551
I
Among the scnsnry disorders the dimimilion or complete of sensibility is llie must important : this m»y be so exten. sive that the patients can feci nothing on any part of the sur- face of the body, not excluding the mucous membranes (con- junctiva:, nose, tongue, motilh, vagina, rectum), so that one can touch them with the hot iron (t her mo-cautery) or prick thcni with knives and needles, and they will not make the slightest sign or attempt to draw away the part; nay, more, there are cases in which the deeper tissues take part in the anaesthesia, so that (olds of skin maybe transfixed and tine needles thrust into the muscles down to the bone without (he knowledge o( the patient if she be blindfolded. Besides the general abolition of sensation, we may meet with circumscribed spots of anaes- thesia, anarstheiic zones, on the back, on the hands, etc. The hemianicslhcsia, which is strictly confined to one side, and which impliotes the mucous membranes as well as the skin, has already been mcntionc<l. These sensory changes also may appear and disappear suddenly.
Less common arc the hypcriesthesias, which probably never take in the whole body, and never even one whole half of the body, but are usually confmcd to circumscribed areas, to cer- tain internal organs, or by preference to certain joints. These circumscrilxTd areas, Charcot's hysterogenic loncs, vary in their situation : they may be on the back, on the chest, in the extremities, or elsewhere. .Among the internal organs, in women ihc ovaries, in men and boys the testicles, arc the parts that usually suflcr. The ovarian hypera'Sthesia, which Ch.ircot has studied very carefully, is closely related to the "major attacks" to bcdescribc<l later. That it is actually Ihc ovaries which give rise to the acute pain when pressure is made over them Charcot has proved on pregnant women ; during preg- nancy the position of the ovaries is changeil, and it was l(nm<l that there was a corresponding change in the position of the tender points. The women who suffer from this hyperarsthcsia ire in Paris called •• ovariennes."
Neuralgiform pains, which often afTecl the joints and which ■re very obstinate, arc so common in the course of hysteria that whenever we finfl a joint neuralgia we should think ol and search for a hysiericil b:isis. Dnxlie has subjected them to a •mry accurate study, anfi has pointed out that it is at limes ex* tremely hard to difteretitiate between a neuralgia and an actual disease of the joint. The hip attd knee arc must usually attacked.
553
DISEASES OF THE GEXERAL XERVOVS SYSTEM.
The joint is painful, especially on pressure or on motion : hence such patients arc. a,s a rule, found in bed or lying on the sols. On closer examination the puin proves not to be confined to one spot, but to be distributed over more or less large areas ol llie lower extremity. Tlie patient cries out if pressure is made ill the neighborhood of the hip or the knee or lower down over the malleoli. She seems to be especially sensitive when watch- ing and following our manipulations; but if the physician is able to divert her attention, pressure over an otherwise painful point will often evoke no complaint. In the course ol the dis> ease the glutei may undergo some atrophic changes; now and then traiii^icnt swellings arc noted. On the other hand, there are instances in which hysterical joints are the only cause which keeps the patient persistently in bed. and in which, in spite of an inactivity lasting for years, not n trace of atrophy can be recognized, while the general health shows no signs of impair- ment (cf. lit.). All these and other spontaneous pains, which we need not dwell upon here, occurring in hysterical individuab arc to be regarded as being of psychical origin, and therefore as pain hallucinations (StiUmpcU, Hoist).
I
Among the abnormities of the secretory organs, those which concern the urine chiefly deserve our attention. Hys- terical ]>aticnts may urinate very little and not without diffi- culty (ischuria). On the other hand, wc find some who urinate frequently and pass almost incredible amounts (cf. Mathieu, La polyurie hysi^rique. Revue nturol.. ;893, 19). In the former case the specific gravity is high and the solid constituents o( the urine are increased in amount. In the latter the urine re semblcs almost clear water, ll would be erroneous to assume that the small or large amount of urine always depends upon ihc amount o( water ingested. Indeed, patients who drink hardly anything may void very large quantities of urine, while those who drink a good deal m.ty pass only a (ew drops at a time. Here, again, as with the manifestations of hysteria in general, no hard-and-f.-i<)t rule can be given, nor can anything certain or constant be said about the salivary and sweat secre- tions, since they arc equally subject 10 variations.
Among the trophic disturbances we will only mention the hysterical oedema, which occurs as the white or as the blue type : the former is soft in character, and the skin pits on pros- sure ; the latter is hard, is associated with diminished surface
UYSrE/tlA.
553
Jlcmpcralurc. and tlic skin sometimes presents a peculiar raot- l.llcd iippearancc (Charcot; cf. also Athanassio, Des troubles < Irophiqiies dans I'hyst^rie, Paris, 1890).
-that
ihose
I
The combined hysterical manifestations- originating in the bruin as well as in the spinal ci»rd — consist uf the so-called "paroxysms" or "attacks," in which conscious- ness is not lost, as in epilepsy, but which are associated with convulsions. Vague pains, ructiis, yawning, the globus hys- tericus, ischuria, etc., may constitute the premonitory signs, which arc immediately followed by violent respiratory move- ments, regular respiratory spasms, with laughing, screaming, weeping, barking, and linally the climax is reached in muscubr spasms and convulsions resemblitig Xhmc of epilepsy. During such paroxysms the whole body may be thrown from side to side, and it may be impossible to restrain the patients, because they exhibit a strength far greater than that which they ordi- narily possess. Alter the ht — which may last from half an hour to an hour — has spent its force there follows a condition of gen- eral prostration, which usually docs not lust long and is fre- quently accompanied by polyuria. It is just these attacks which make the "home treatment" (or hysterical patients so very difTicull or finally even impossible, li has been found by experience that the sight of such patients — of the various contortions into which their bodies are thrown and the gro- tesque positions they assume— has nn injurious effect on the other members of the family, especially if there are young girls amcmg them. Such a scene and the consequent mental excitement have been known to cause similar attacks in other females.
Duration and Course. — The ditralion and course of hyste- are by no means uniform, although this much may be said. Fthat it is always chronic and may Inst for years and tens of ' jears- There are patients who from the time of puberty until I afler the involution period are hysterical, and thus never attain [to the full enjoyment of life. At the beginning of the trouble Ihcre is usually nothing more than a certain tendency to nerv- ousness, a certain proneness to eccentticiiii'S. annoying to the patient and still more so to the family. Soon various pains, which are apt to frequently change their seat and to vary in intensity, make their appearance, and certain rc&piratory phe-
554
d/sejISEs of the cenekal sekvovs system.
nomcna, perliaps shorinrss of breath or a barking cough for which physical examinaiiun reveals no cause, begin to ailract our attention.
Severe iiiutor disturbances are by no means noted in all cases ; even contractures arc not very common. On the other hand, there are tew cases in which the sensibility does not at various times undergo striking changes. Ana-slhcsiasand an.il. gesias alternating with hypersesthesiasand neuralgias, especial- ly of the joints, and persistent headaches, all help to sour the disposition ul the patient. During menstruation the condition is usually aggravated. The patient is still mure excitable than usual, and her complaints are louder. In those in whom the paroxysms arc an important feature o( the case this is more especially true, and sometimes the first menstrual period is the signal tor the first attack, which is at regular intervals followed by others. In many cases of hysteria "attacks " never occur. The patients, indeed, may without any provocation have fits o( crying, laughing, and screaming, but no convulsions. With advancing age, and when the sexual functions arc becoming inactive. \ he liysterieal phenomena fade. As the hair turns gray the disposition becomes calmer and more equable, and even egotistical, exacting, peevish women, who have tormented their families continually and who were extremely hard to manage, be- come yielding, amiable old ladies after the hysterical manifesta- tions have once left them. Still there arc, unfortunately, excep- tions in which these persist even after the seventieth birthday.
The prognosis may be inferred from our dcscrtpiiun of the course ol the disease. Doubtful as it always is, it is made stilt more gloomy from the fact that persons who have for ye.irs suffered from hysteria are apt to be subject later in life lo actual organic nervous diseases, especially of the br<iin (Pehl- mann, Inaug.-Dissert,, Leipzig. 18S7).
Hysteria was thought, as the name indicates, to occur ex- clusively in members of the female sex. That it is more preva- lent among them there can be no question, but Charcot and his pupils have shown convincingly that it does occur in men and boys, and that, too, much more frequently than might a />rhri hnvc been supposed. From him we have learned that it occurs frequently among the French soldiers. Further inves- tigations may prove that this would hold good not only for ihc French but also for other armies. Age seems to Iiivc much less influence than was at first assigned to it. Hyslent
HYSTEIilA.
5S5
I
in cliildren is by no means rare. The (ull development of all hysterical manifestations in the young, who arc far from being sexually mature, proves that puberty and the sexual or<;ans are of less importance in the causation of this neurosis than has formerly been supposed.
I
LIIEKATUKE.
IVbmv. C^i. (Ics Hdp.. 1886. 30. (Hyaima in the Male.)
Tucick. Ikflincr kliii. U'ochcnuhf., 1886. xaiII. 31-}3.
FfTuA Wiener med, UUiticr. 1BS6. ix. (Hyslcna in the Male.)
Dmcbrfid Med. Chronicle. 188b. v. 3. (Ily«ma tn Ihe M»l« aDer Traunu.)
DupoiKhel. L'hyM^rir ilans lariii^. Riviic dc niM.,6 Janl. 18S6, vi.
jjrutcf). Nedcrl, Weckbl.. 1887. ii, 1 j. (Myitirri.i in Soidicrt.)
KicM^fcld. IliKirnc hri Kiitdcrn. Inaut-.-Oisteit,. Kiel. 11)87,
Dubois. Schwciter CotTe»|iondcnil>t.. 1887. ivii, 13. (Hysterii la Men and
ChiUren.) CouMan. Aich. dc m^l, ci dir |>hamt. mil.. 1S87. x, 5. (Hysteria in ilic Mak.) Handford. Ilniish Med. Joum.. October. 1887. 11. (tl)iuena in a Mule.) ^loricoun. C.14. dcs HA)!,. 1887, 6. (HyMcna in (he Mile.) Enj^hberX' Wienrr mcd. U'orhcnscbr.. 1S88. xxxnli. 14. H)-stctia In a Uoy
aged Thirteen.) Lees, David, lancet. June 33, 1K88, 1. (H)Uerla In Two Uoys.) Ray. llyUerin in ihc Nrgro. New York MrIk'aI Krcord. July 3. 1S88. x»ir. CUric Joum. of Menl. Sc. J.inunry-. 18S8. xxiiii. (ll)'Slaia in the Mal«'.> Biioi. L'hyM^ie mAlc dans Ic ten ice <lc M. litres A I'hApU^ Si. Amhi tk
nofiknux. Parit, 189a Retschauer. Iniiu|[.-Diswrt.. Uerlin. 1890. (Cue of HystcrU la « Man after
External Urethrotomy.) Sollkr. Iji France mfd.. 1891. 3S. ilnfnntde Hvsirri»HiihConvuI»i>« rorm.) Duvoinin. t'rbcr inf4nlilc Hy^vrie. InnuK.-UuMrt.. IbM^t. 1891. Chaufltier. Srnuinr mM.. 1891. jS. (H)«eria in ibc New-bom(!) and tn
Children Two Vears of Age.)
Diagnosis.— The diagnosis of hysteria may at one time be ver}' easy, at another we may encounter no inconsiderable dif1i> culdcs. When we have an array oi evcr.%-arying symptoms occurrins apparently without order, when the patients com. plain tu^ay of this, to-morrow of that, while the physical signs show no grounds for their troubles, it does not need an expert to suspect and diagnosticate a hysterical condition. If, on the other hand, the discti^e sets in suddenly without previous dis- orders of any Wind, in one case with a hemiplegia, in anollicr case with a severe hip trouble, it may be by no means easy to say whether and. if so, why the hemiplegia is of hysterical origin, and wlielhrr or not Ihc joint affection is to be regarded as a hysterical coxalgia.
556
DISEASES 0J-' THE GENERAL NERVOUS SVSTEAf.
The following points will in the majority of cnscs be found sufficient to clear up any difhcullics which the diagnosis pre- sents :
With regard to the cerebral symptoms, and more especially those belonging to the affections of certain of the cranial nerves, we have in previous chapters pointed out some features char- acteristic of the hysterical varieties. It will be necessary in every se;>aratc cisc to exclude scrupulously anatomical lesions and to determine whether there arc in addition to those bc^ longing to the cranial nerves other symptoms which point to a hysterical condition. II such be found, and more especially iE our objuctive examination gives negative results, the diagnosis of hysteria is wtrraniablc.
These rules arc pariicuiariy applicable where we have lo decide whether a hemiplegia is hysterical or due to a lesion in the internal capsule, whether a coriiraclure has to be regarded as hysterical or cortical (page 184), and whether the disturb- ances of the respiratory organs depend upon diseases of the lungs or the larynx, or arc to be referred to a neurosis of the vagus or of the recurrent laryngeal nerve.
The recognition of the hysterical nature of spinal manifesta* tions belonging to the motor apparatus may give rise to the greatest difficullics. It Is upon the electrical examination that wc must rely in deciding whether the paralysis ol an extremity depends or not upon a peripheral cause — that is, upon a neuri* lis. A well-marked reaction ol degeneration always points to a chronic inflammatory condition. The age of the patient is of some value, hfysterical paralyses occur between the agcsol fifteen and thirty. and more particiilurly in women. Further, we observe nhnosl always nssi)ci;iit.-d with hysterical paralyses grave sensory disturbances which are not necessarily prcscni in the other kinds (cf. Luinbroso. Lo Sperimentale, Fircnzc. 1887; reference, Neurol. Ccntralbl., 1888, 7). The existence of muscular atrophy is not sufficient to determine the organic nature of the paralysis becau.se an atrophy of muscles does not exclude hysteria, as we have pointed out above (Brissaud, Arch, dc physiol. norm, et pathol.. Avril, i887,p.339). Schlapo- bercki (Inaug.- Dissert., Berlin. 1895) has pointed out the sig- nificance of relapses in the hysterical paralyses.
Contractures, if of hysterical origin, set in suddenly, and arc almost always accompanied by other hysterical manifestations mctcorism, ovarian hypera^lhesia, and ischuria. Where such
UYSTF.firA.
S57
I I
i^toms arc absent we must be very careful in our exami- nation am) take into account Ihc possibility of an anatomical lesion cither of central or of )>enpheral origin (c(. Otocq. Des Contractures, Tliisc de Paris, 1888; Progr. mid.. l««8, xk, p.
397).
Hysterical muscular spasms may be taken for tetany, as the case of Caiger, in the Lancet of August 20, 1RS7, shows. To the frequent occurrence of rhythmical sjxism tn certain groups of muscles in hysteria, Pitres has drawn attention in an article in the GaJt. mid. dc Paris, 1SS8, 13.
Trembling and shaking movements, which somewhat re- semble those of inlenlinn tremor as they become more marked on voluntary motion, have been noted, but are rare (Charcot, Progr^smid.. 1S90.37). The possibility of mistaking such con- ditions for multiple sclerosis (or vice ivrs^) should, however, always be kept in mind. In our account of the latter disease we shall come txick again to the points for the differential diag- nosis between the two conditions.
The sensory changes in hysteria, the anarsthcsias, affect, as wc s:iid. not only the skin, but nbo the deeper tissues, so that needles may be inserted down to the bone without being felt. Usually all qualities of sensation take part in the disorder, so that the so.callcd muscular sense is also lost and the patients are unable after closing their eyes to give any account of the position of their limbs. Pronounced anursthcsia is found dur- ing ihc hysterical paroxysms. An anivsthesia extending over the whole body and taking in all the mucous membranes is almost always hysterical in nature. These grave sensory dis- turbances render explicable the pn<>sibilily that patients some- times for some reason or another produce sores on their own bodies. With regard to such lesions which may at limes be mistaken for those of lupus or carcinoma the reader is referred to the Deutsche Mcd.-Ztg., 1S9;. 8S (.\ccount of the session o( the Berlin Medical Society. October 26. 1892).
Hype nest hcsias and neumlgias occurring in hysteria arc typical in th;U ihey are very changeable, so that to-ilay cranial. to-morrow spinal, nerves are the scat of the pain. Neuralgias of joints, if org:inic disease can be ruled out and il they are very ntmtinaie and resist all the ordinary therapeutic measures, may be safely looked upon as hysterical. The "attacks" may
mistaken lor cpiU-plic fits. The important point to remcm- ir in this connection is that in the hysterical attacks con-
558 DISEASES OF TUP. GENERAL NERVOUS SYSTEU. ■
sciousness is never lost as completely as in epilepsy. Biting o( the tongue is an exception in the lormer. The liysterical at- tacks arc, moreover, attended with noisy laughing and crying, etc., while epileptics, with the exception of the initial cry (which is not constant), pass through the whole convulsive sta^e quietly and without uttering a sound. It has been claimed that there never occurs an elevation of tcm]>craturc during the hysterical seizure, while the epileptic fit is accom- panied by a slight rise, 1.2" lo i.S* F. This statement can not easily be controlled, and certainly needs further confirmation. Finally, it should be remembered that hysterical attacks may in some instances be produced by pressure upon the ovaries or the testicles, while in epilepsy this is never the case.
Pathogenesis and Etiology.— About the nature of hysteria we arc absolutely in the dark. Xut one of the many attempts to explain the disease can be regarded as more than a vague hypothesis. This one fact may be rcijardcd as certain, that the existence of grave anatomical changes is excluded, or, at any rate, is highly improbable, otherwise the suddenness with which the symptoms come and go would be absolutely iiiex. plicablc. The old idea that the uterus must be held rcsponsi- I ble in every case and under all circumstances for the disease, which was consequently called hysteria (i^r^ia), has been shown to be untenable by the number of cases observed in ■ men and young children : and the more cases we see. the clearer it becomes that the hysieriiis occurring in males and in lillte children furnish a considerable proportion of the total number, ■ and the more ridiculous becomes the term " hysteria," which sooner or later will be given up completely. The influence of the sexual organs on the disease will be discussed later, but we would state emphatically that the opinion thai these are always the starting point of the disease is indefensible.
But how shall we explain the disease? If we agree that all symptoms of hysteria have certain characteristics in common, they may pi-rhaps all together be traced to an increased excita- bility oi the whole nervous system, to the quicker response to stimuli from without and within. Just .is we have morbid conditions in which the excitability of the nerves and the mus- cles to the electrical current is found to be increased, we may imagine also an analogous condition in which all the nerves, including the nerve elements of the central organs of the bmin.
HYSTERtA.
5S9
I
I
especially o( its cortex, those of the spinal cord, and also of the peripheral nerves, are in a constant stale ol abnormal or pntlio- logical excitability. That in such a state the imagination plays an imporlanl riU is self-evident— not, however, in the sense that all the suflcrings of which the patient complains arc imaginary and merely dc|>end upon the imagination; we rather mean that, in the condition described, the ideas arc consciously or unconscious* ly influenced by the will, they are formed and disappear more quickly and are constantly changing. Such a quick and unnat< Ural change can not but exert an unfavorable influence, tirst upon the mind and disposition, and later upon the bodily condition.
In reality it is in the majority of cases a disturbance ol tlie psychical equilibrium which produces the disease. It is not impossible that careful study of the a-tiology may do much toward a clearer understanding of the nature of the malady : Guinon has shown this in his excellent monograph, Les agents provocateurs dc I'hyslirie, Paris, 1889. The causes may be subdivided into direct and indirect. To the former belong a hereditary, physical as well as psychical, predisposition of ihe individual. There is no doubt that only those persons can become hysterical who are from birth so predisposed, because Ihey have a nervous system which presents the peculiarities that we have just described. This congenilal, because heredi- t:try, predisposition finds favorable conditions for further dcvel- opmcnt in (d) sex, (^) age, (c) education, (d) nationality or race of the patient. That the female sex and those just arriving at the age of puberty are prone lo the disease we have said before, although the male sex and other periods of life besides that o( puberty arc by no means exempt. The hysteria which occurs in early childhood, and which has been observed between five and ten years of age, deserves special study.
Much must be attributed in the causation of hysteria to a faulty education. The brain may be overtasked at Ihe ex. pense of the body, and. in consequence of too little firmness on the part of the parents, capriciousness, inconslderntencss. lack of truthfulness, of energy, and of will power arc fostered in ihc child, and. finally, when the children have behaved badly, the mysterious threats, especially of injudicious servants, o( sending after them wild beasts, ghosts, ■• Ihe black man," etc. can drive them into such a chronic stale of fear that ihey can not go into a dark room without palpitation and the most tn> tense feeling of terror. All such and many other mistakes in
jfio DISEASES OF THE CEKERAL NERVOUS SYSTEAT. ^
the early education of the child become indirectly causes of hysteria. The occupatiun may have an influence if it be at$o- cialfd with bodily and mental overexertion, and in certain call- ings the possibility ol intoxication (lead, mercury, bisulphide oi carbon, etc., must not be forgotten) (Rouby, Contribulinn k r^tude dc Thyst^ric toxiqitc, Thfesc dc Paris, 1889). As I" race the Slavonic (Poles. Russians), the Latin races (the French and the Italians), and, above all, the Semitic peoples, are more liable to hysteria than the Teutonic. The severest forms of hysteria are seen in French women and in Polish Jewesses. This may depend upon the national characteristics; the lively, impetuous temperament which we find on an average more frequently in the Slavs, etc.. than in the Teutons, forms a par. ticularly favorable soil for the development o( hysteria.
Among the direct causes disorders of the sexual organs play the most important part, and in both sexes this factor it equally potent. We must not think that the affection, which, C5pcci:illy in women, may, from a gynaxrological standpoint, be very insignificant — for instance, a flexion, or a change in posi- tion of the uterus — has in itself much to do with the matter: it is much rather the idea that the trouble exists, and the anxiety lest it should interfere more or less materially with coitus and parturition, which constitute the direct cause of the depres- sion of spirits. The conjugal obligations — coitus, pregnancy, parturition — play such an important rSU in the life of every woman, if she h.is not missed her calling, that the mere idea that the sexual organs are diseased or incapable of performing their function is sufficient to give a severe shock to her hap- piness. In a man it is much less the potenlia generaHdi than the potftlia cocmtdi that causes him anxiety. The above-meti- tioncd psychical impotence, if it exist for a long time, in itself suffices to bring about a hysterical condition, and sexual neu- rasthenia is not rarely accompanied by pronounced hysterical manifestations, so that we can well speak of a coexistence ol the two diseases.
Secondly, fright ought to be mentioned as a direct cause of hysteria: a girl upon whom an attempt at rape has been made, or a man who has been attacked by a robber, may be- come the subject of a hysteria, which may last for years, or may even be incurable. It is not necessary in such cases that fright be assocLitcd with any trauma, the mental shock suff- cing to produce all the symptoms.
HYSTERIA.
561
w bcci
y
by
I
I( bodily injuries arc associated with fright the parts aflccted frequently become ihe seat ol hysterical diMirdcrs. Thus, wiih a history of a lesion of the hip joint, after the injury has long been recovered from, we may hnd a hysterical coxalgia, etc. It is important to recognize the fact that an injury inflicted n a person who is already suffering from hysleria or who heredity is predisposed 10 Ihc disease, may be followed different consequences than would be the case in a normal individual. Thus a fall un the back which has produced noth> ing more than a contusion of (he soft parts may, in a hysterical Individual, lend to a monoplegia or a paniplegia of the lower extremities, while such an accident would have had no such results in a healthy individual. I have seen a number of such cases, to which the term hyslero-traumatic affeciion, rather than traumatic hysteria, w<iuld be applicable. In this connec- tion the |>aper of Miura. Sur Irois cas de iiiuiiopl^gie brach. (Arch, de Neurol., 1S93, xxv. 7;). should be mentioned.
The psychical iranmalism ni.iy be of such a nature as to have an immediate influence, or may act gradually and insidi- ously. Among the former we have fright, emotions of anger, rarely ol joy ; to the latter belong grief, anxiety, wounded sell- rcsjwct or vanity, and the like.
A special kind of ncunisis due to fright has of recent years been much discussed and carefully studied by many investiga- tors, although thus far no unanimous conclusions in regard to its nature have been arrived at. To this condition which thirty years ago was described under the name of commotio medullx spinalis, or railway spine, the term " traumatic neurosis" is now often applied. Certain investigators claim that the aHection is an entity /vr J/ which, like any other distinct disease, should have its own name ; others disagree on this point and regard the old name as sufficient ; still others consider both terms to be incorrect, and simply speak of an " accident neurosis."
Whether this aflcciion is to be regarded as a form o( hys- teria is a question of very little practical importance. It is certain, however, that a!tiologically as well as symptomalically the two mnditions show much that is alike. The " traumatic neurosis" is producetl by the fright alone, the bodily trauma is a non-essential ; the latter may be present or not, but the ncurf^is appears if the psychical shock has been sufficient. Hence we see that etiological ly we have here the same factcir that frequently leads lo hysleria. So far as the subsequent J6
562 Diseases of the ce.vbral nervous system.
manifestations arc concerned the results arc similar ; the sub- jective symptoms more especially are often of a typically hys- terica) character, though neurasthenic disturbances are also eticountered. Motor and sensory disorders arc met with. Among the former may be mentioned a general motor weak- ness, an abnormal pioneness to latigue, among the latter pain in the head and back, paraisthesias, hyperesthesias, and anarv thcsias. Narrowing of the visual field, diminution in acute- ness of vision, photophobia, disorders in color vision or hyper- esthesias of the auditory, olfactory, and gustatory nerves have been observed. Again, wc may find cutaneous anxsthcsias, situated chiefly on the back, in the shape o( irregular plaques, or having the distribution of a well-marked hcmiansslhcsia hysterica: at other times, again, they may extend over the he.-id, neck and upper chest (doll's head form). In all case». however, the results of two separate examinations may differ as the anesthesia may shift its place or vary in extent. The rules for making sensory examinations have been excellently formulated by Goldscheidcr (Neurol. Ccntralbl., 1892. 12). The skin and the tendon reflexes vary as they do in hys- teria. L'rinary symptoms may be present or absent. While walking, and in general in making any motion, the patient avoids all movement of his spinal column. He fixes his trunk and moves with his back held stiff, using his hands as much as possible whenever he wishes to change his position (Oppenheim).
Psychical abnormilics appear chiefly under the form of de- pression, fear, irritability, hypochondriacal depression, and the like; these symptoms are, however, not always due to the bo cident, but often result from the trouble and annoyance enlailcd by the interminable negotiations before the degree of disability and the amount of damages to be paid arc settled upon.
It must be remembered that every patient with a so-called traumatic neurosis who has any damages to claim is suspected, if not of simulating, at least of exaggerating his symptoms, and it is certainly well for the physician to be cautious. On the other hand, it would be absolutely wrong to regard all sudi a patient's complainis simply as exaggerations 01 lies. We must examine him carefully, and in no case should an expert opinion be given alter a single examination (Burcbardt, M, Prakt. Diagnostik der Simulation von GcfUhlsllfhmnng, SchwerhUrig- keit unj Schwachsichtigkeii, IJerlin, Enslin, 1S91).
I I
I I I
I
JiYSTEKU.
563
H The objective symptoms which are Ireqtiently, though not B regularly observed, art*, of course, valuable for the purpose of excluding simulation. They are: (t) The concentric narrow- ing of the visual field (especially for red and green) when this is found to be constant on repeated examinations (Schmidt- Kimpler, Deutsche mcd. Wochenschn, 1392,24)1 (2) a peculiar narrowing ol the visual field which was hrsl described by Fiirster in cases of anxsthcsia retina:. The value of this sym|>tom has recently been pointed out again by Kiinig (Ber- liner klin Wochcnschr., 1891, ji) and by Flaczck (ibid.. 1R92, 35).
■ "The essential features of (his symptom may be thus summa- rized : Objects moved into l!ic field from the periphery to the
• centre can be seen farther out than those which arc moved in the opposite direction; if the patient fixes the while spot of the prrimeter and we now" make two examinations, in the one bringing the object in from the periphery and marking the points at which it becomes visible, in the other moving the object from the centre to the periphery and mat king (he points at which the object ceases to be seen, we shall obtain two fields of vision of une()unl siie, the former being the larger in every direction " (Kiinig). Simulation is here excluded unless the patient knows the symptom and has practiced with the perim- eter. (3) WcAnd (hat it we press on painful poinls(in Iraumatic neuralgia) the heart's action becomes increased so that (he pulse may rise from nineteen to thirty beats to the quarter of a minute (Mankopfl). a condition wtiichcan only very rarely be pro- duced at will by the patient. The absence of Mankopfl's symp- tom does not. however, necessarily prove simulation (Strauss. Berliner klin. U'<ichcnschr., 1892,48). (4) Rumpf hasdescribed a sign which he has called " traumatic reaction ol the muscles." II a strong (aradic current be allowed to pass through a (pain- ful) muscle for from one to two minutes, the muscle does not at once return to its position of rest, as it would under normal conditions, but presents for a considerable time fibrillary or even clonic (wilchings (Dctilsche med. Wochenschr.. 1890,9). II we add (5) the quantitative diminution of the galvanic exci- tability of the molar nerves which has also been pointed out by Rumpf {loc. cit.). we have at our command means sufficient to meet the attempts of simulators, who, according to some physicians, are constantly increasing in number.
■ Among all (hese symptoms there is, with (he excepdon of
5(S4 J?/SEASSS OF TUP. GE.VERAl. NF.ftVOUS SYSTEM. V
notnonic, and the clinical picture, which we possess, is nol sufiicientW definite la warrant us in regarding the uffeclioo as a disease by itseil. After a personal experience with sixty- eight cases, and alter a perusal of the literature, 1 must still regard it as belonging to the category of hysteria, an opinion which is not shaken by the (act that Schmaus has described as following spinal concussion anatomical changes consisting in a necrosis of the axis cylinders, which often occurred long after the trauma (Schmaus. MUnchencr nicd. Wochenschr., 1890. 281 also Arch. f. klin. Chir., 1891, xlii. Heft 1), In all cases of hysteria, particularly in the neurosis produced by fright, we can scarcely be cautious enough in our prognosis. It is always very uncertain so far as complete recovery is concerned, especially in individuals who arc badly endowed psychically, in cases with a bad heredity, and in alcoholics. It may also be said that the hurdi-r the former occupation of the patient the worse, c<eUris pariims, is the prognosis.
With regard to the very important and difficult pnictiati questions we may with Ronier (irrenlrcund, iSSy, xxi, 9, 10) mention the following: i. Is the disease the consequence or the exclusive consequence of the accident? 2. Is it curable, and, if so, in what time? 3. Will the patient be completely or partially incapacitated ? The discussion ol such questions can not here be entered upon; the general points of view from which they can be answered will be found, however, in what hiis been said aba%*c.
LITERATURE.
Charcot. Vru^r. raiA . 188$. xiil. 18.
Oppenhpiin. Arch, f. Pii^-ch. u. Ncncnkh., 1885. nvi. 3.
Troisier. Cm. hctMlom., 1886, i. s£r., xxiii. 18. (Hysterica] Paralysis m a RC'
Sull of TrAumj.) Charcot. Wiener nicfl. Wochenschr,, 1886, xxxvL 30. 11. (H)-5terica] 0»a%i*
as A Result of Tr:iunia in u M;iii.) Dcbovc ct Cnirtn. Kcmarqucs sur I'hyslfric tTaumatique. Gu. hebdora., 1X7.
2. sit., WW, 43. Vlbert. Ann. d'Hy;;. |iubl., IHe.. 1SS7. xviii. 13. (K^iilwTiy -Spine conMknd
from a Merfico-lfgal Point i>t View.) Lyon. Kncfphnle. 1888. viii, i. (Hysteria afier Grare Trauma.) Charcot. Atthrnlgle hystiro trauinatique du gmou. Progiis mM., ^Vi■
xn, 4. Bemhintl, Deutsche metl. Wnrhcnschr.. 1S88, 13. Siruin|ieil. Uclier die Iraumntischcn .Scumscn. Berliner Klinik. FiKlter, 18W
xvi. Heft 3. Gnust^l. Hyttiro-traumaiUmc. Lrcons rccueilliei, Monipdikr, 1S88.
HYSTEK/A.
565
[Oplcr. F, Beiing cur Lehre von den Iraumal, Aflircltonm des Rtlckenniaiia,
Itiaug.-Iiissnt.. HcrUn. Schadc. 1888. l)^£in>k)'. Itcrliner Uin. Wi)chen»chr., iSSS, 3. Woltr. t»Kf K.iila';<) -Spine. Dcoischc Mcd.-Zlg.. 1S8S. 79. to. OcnilianJL Vun den ^Igciii. u. (raumu. Neuroscn. Berliner kiln. WochcnKbr..
1889. !> Sirpp. DcuixSe nml. Wochcnschr, 1889. 4.
UrasMl. Lc^nx mi( rh)'«£ro-ifaumaiiame. Parit, IxcroKnict, l8S9> Mejct, Monu. Uctlmcr kiln. Wochcnschr.. 1889. y AucriMch. Dk iraiunadtche llyslcne bcim Mani>c. Inau^.-UisMn^ St(M»-
Uirg. 1889. StrumpeU. Uehcr (mumatiKlK Hysitrie. Munch. mrJ. Wochcn»chr., 1SS9. &. Eilenluhr. Ikrliner Uin. WocKcnKhr,, r8S9. 53. CuiK Uclicrdcn dugnoMiticlMin Wtrrihcinxclner S)inplonie<l«r Iraumatudwn
Ncunnr. Inaug.-DisHrt.. Ucrlin, 1S9J. Cramer (Eticrtualilct- Munch. mc<l. Wochcnschr., 1891, i. 3. (CoBUllU on
eacclltni summary ol ihe mofc recent (M|ieT».) SchulKr. Fr. Udwr Nrurwm ufkI Ncuruptychcucii nuch Trauma. Volkmann's
S.)inml. IcUn. V'i>nr., 1891, iv, v. 14. ,
nige. Kartway InfUrfe!t. Liimlon. r.iffon & Co.. 1891. Wkhinniin. Kiitf. Ucr Wcrthdcr Syni|Hotnc4l«rsiigcn. iraumatisclien Neurose
u. K. w. Kraunwhwcig. Vieucg. 1891. Oppmhrim. Uie intumaL Neuniscn u. «. w.. 3. AulL Berlin, llirvchivakl.
l89t.
Frenixl. C S. EIn Ucbrrblick liber den f|:rgTnvrBnige«i Stiind <lrT Frage tan
den u)(;rn, traumat. Neuroien. V'oikmann's Sjniml. klin, Vtirtr., n. F.,
1891. ji.
iFriednwnn. Munch, ncd. Wochmsrhr, 1893. 30. [ l)mn^ Keuere .Arlieiicn ulier itir imunwt. Ncuroien. Schmkll's JahrU, 1893,
ccxxxiv. |v 35; 1873. ccxixvilt. |>.7^ (This |>«pcr 1* in(lb|)ensalik for any
one inakiii); a ^(lecol Mudy of ihc xuh)rct.)
The syaiplomb that appeitr atlcr a person h»s been struck by lightning Mimetimcs resemble the array ol sympioms ob- served in traumatic neuroses. Paralyses in the ricri'esot spe- cial sense, and motor and sc»S4)ry paralyses, iippcar and last (or a shr>rtcr or longer time. In the spring of 1889, when thun- derstorms were so frequent, I had (he opportunity o( examin- ing a man who, u& a consequence o( bein^ struck by li);htnitif(, |oo recovering consciousness after three quarters of an hour. presenied loss of the power of sipht and smell on ihc side on which the li^httiin^ had entered and left the bi>dy, while on the same side hcurinfi; was diminished, and there was total an- teMhesia. These symptoms were associated with an obstinate insomnia. By hypnotism, frequently rciH-aled. we were enabled to lessen this insomnia, and under the use of the galvanic cur. rent and the (aradic brusli the hernia nicsthcsu disappeared.
I
566 I>/S£ASES OF THE GEKEKAL NEftVOVS SYSTEM. I
The nerves nf special sense implicated becnme ftilly normal after a month's trcitment. In this case moior disturlxinccs were never seen. According to the investigations of Limbeck (Prager nied. Wochenschr., 1891, 13), we have to distinguish belwccn direct and direct paralyses due lo lightning: he re gards only the furracr as due to an action upon the nervous system, and has observed that the sensory paralysis disappears sooner than the motor. For further symptoms in such cisej and for the post-mortem coiidiiions found after death by light- ning, wc would refer the reader to Scbmitz's article in the Deutsche Med.-Ztg., 1887, 73, 74, in which further references on the subject may be found.
Treatment. — The treatment of hysteria is always a very tedious riiatier. ;ind for the physician sometimes the most lire- some and thankless task imaginable, and one to which he should only devote himself if he be assured of the implicit confidence of his palicnt, so far as this is possible in the case of hysterical individuals. This confidence is indispensable because the treat- ment of the disease does not consist in the main in the admin- istration of drugs in a routine fashion — valerian, asafictida.cas- toreum. and the nervines — but must dcpetid more upon the psychical influence by which wc endeavor to diminish ihcatv normal scnsitiveiiess of the patient to external and internal stimuli, to arouse her energy, and to strengthen her will poll- er. This is, we admit, much more easily said than dooe, a&J we shall often have to confess that the patient's views about her trouble have not changed in the least, that she is as irri- table as ever, that her moodiness and capriciousncss are in nu way improved in spile of all our lectures — in a word, that we have obtained no positive result after " preaching reason '* lor hours. Still, we must not allow ourselves to become dtscour aged, but ever again and again renew our efforts to obtain the desired end.
If wc clearly see that these are fruitless, and especially i/ we arc convinced, as is often the case, that the family, far frotn assisting the physician, are virtually acting against him during his absence, we must impress upon them the necessity ol re- ■ moving the patient to some institution. French physicians Lir the greatest stress upon isolation in such cases, and arc inclined to attribute the relatively favorable results of Ihcir irealmcnt to this factor. In this country j>eople are not so easily p<^
MYSTEK/A.
5«7
I
I
I
I
laded to 3^r«e to this procedure ns \n Paris, where in the city itself or in the suburbs there are various admirably conducted institutions which receive only hysterical |>ntients. With us, therefore, home treatment ought lirst to be tried. In France this is usually discarded from the tirst. It is a diderent matter, ol coursct it we have to deal nut with a mild degree of hy»> teria, but with hystero epilepsy and major attacks. Then a transference to an institution, as soon as practicable, ought (o be urged.
The bodily treatment may be cither general (that is, direct- ed to tlic nutrition, to the condition of the blood, and the strength of the patient) or symptomatic (that is, intended to re- lieve the troubles of the patient as they arise). In the treat- ment ol contractures we should never make use of plaster-of- Paris bandages (Charcot).
With reference to the nutrition, it was Weir Mitchell and Playfair who first recommended absolute rest in bed, with massage, electricity, and copious (ceding. Their patients were forced to take considerable quantities ol milk, meat, bread, etc., and it was found that with the increase of the body weight the hysterical symptoms and attacks diminished. Uf late years good results have been obtained from this practice by Bins- wanger (Allgem. /eilschr. f. Psych., i88j, xl, 4), and the com- munications of Lcyden(BcrI. klin. Wochcnschr., I8S6, xxiii. 16) and Durkari (ibid., 1886, 16) should encourage us to further trials with this mclh<Ml, although as far as my own experience goes the results have by no means always been brilliant. The cases in which the excessive ingcf^tion ol food was badly borne and led to a disagreeable gastric catarrh were by no means un- common, and even where the food was well assimilated the de- sired results were not always obtained tcl, alM>Gilles de la Tou- retlc el Chatelineau. Xa nutrition dans rhystiric, Progrds m^l.. ■888, viii.48 ; 1889. ix, 18, ig. 31). That muchatteniion has tube paid to the nutriiton there can be noqucstion, and the increase in the body weight usually can be regarded as a favorable indi- cation. To attain this, however, in many cises, not absolute rest, but, on the contrary, systematic muscular exercise is need- ed. Well-rcgulate<l home gymnastics, undertaken according^ to definite principles (.Schrcbcr, Angcrstcin.and Eckler), are to be preferred and will be oltcn found an excellent means of combating the distressing insomnia.
In certain cases, to be selected of course, with care, general
568 D/SEASES OF TIIR CEKEHAL XRRVOUS SYSTEM.
faradization as recommended by Beard and Rockwell is of great service. The palienl for llii* purpose is placed npnii a stool with bis bare (eel upon a moisi large electrode, which is connccled with the negative pole o( Ihe secondary coil. With the anode, which consists of a large sponge electrode, all parts of the body are treated in succession. Instead o( the moist we may avail ourselves of a dry electrode in the form of a soil brush. The pain which is caused by the latter method is, at least with strong currents, quite considerable ; nevertheless, the method deserves warm rccommendatiou in ceriain hysterical affections and especially in joint neuralgias.
About the influence and the value of static electricity as a ihcrapfutic agent our experience is not sufficient lo warrant any detinite conclusions. It is not easy to judge of the useful- ness of the treatment, as it is usually combined with other measures, the iherapeiiiic stgniBcance of which must not be left out of considcraiion. Whether the action of static elec- tricity differs essentially from that of the faradic and galvanic current, and, if so, in wh.it this difference consists and under what circumstances the one or the other is indicated, we are not as yet in a position to say, Clemens has used it with good results in cases of hysteric;il aphonia by applying one pole with condensers directly over the muscular branches of the acccsso- rius as spark- producing electrode (Therap. Monalshefte, tSgo, iv, Heft 8, p. 402).
It is rare that we treat a case of grave hysteria without ai one time or another during the course of the disease being obliged to resort to massage— for one thing, because the pa- tient desires as much variety as possible : but at the same lime we must not overlook the fact that by its use many of the pa- tient's troubles arc considerably relieved. This is not the place to enter into the minute details of this method of treatment. They may be found in the writings of Schrcber, Rcibmayr. Zabludowski, and others.
The cold-water treatment is indicated where we desire tn harden the constitution against exiernal influences, changes of temperature, etc. We should be very carciul, however, in env ploying low temperatures, and the water with which the pa- tient is sponged or in which hip balhs and the like are taken ought to be al least So" F. For the use of ice-cold douches, in the way recommended by the French, certain facilities are requisite. The pressure of the water should be very great and
I
I
\
MYSTEKIA.
S(59
ihe duration of the bath should be so short (from ten to fifteen seconds) that the patient hus not time to become aw.tre how cold the water really is. I have watched this practice repeat- edly in some o( the well-known hydrothcrapeulic establishments of Paris, and have had occasion to notice the immediate benefi- cial effects following the application. The lasting results, as Charcot and others arc quite convinced, arc so marked that (in F^aris) cold douches arc considered to be indispensable in the treatment of hysteria. It would be a very desirable thing if the necessary arrangements (or this treatment could be inlr<». duccd into our hydrutherapcutic institutions. The ordinary shower bath, which comes down upon the juitieni just about like rain, is, of course, not sufficient. In the treatment ol M>me of the particularly disiressini; symptoms it is. of course, in the first pUicc the paroxysms which deserve our ariention. because they, more than any other o( the hysterical phenomena, are liable to render home treatment almost impossible. We may tomclimes be able to cut short an attack by steady pressure with the hand over the ovaries continued lor some time, but this can be better accomplished by allowing ihc patient to in- hale a little chloroform. To guard against a rcpelitinii ol the attacks we have no reliable means, yet co<il piulongcd bcitlis with affusions of colder water deserve a thorough trial. If these do not seem to be beneficinl, and i( the jwiticnt complains, before the onset of every attack, of pains in the ovarian region, and if wc, moreover, can succeed in bringing about an attack by pressure over the (tender) ovaries, the qucsiion ol oi^phorcc* t()my has to be considered. The family relaiiims, especially the sterility which naturally follows the operation, have to be taken into considcniti<m, nor should we forget that the opera- tion has olien by no means l>ccn followed by the desired cflect, although the fact that it frequently exerts a favorable influence, ns Hegnr and Schriklcr have seen, can not be questioned. Whether the ovaries are actually diseased or not is altogether of minor importance. It is the presence of pain immediately before or after the attack in the region of these organs which should suggest an operative interiercocc. Cauleri/atiouol ihc clitoris, advised by Frie<ireich, is a procedure which should only be resorted lo in the most exceptional cases. In all in- stances the sexual organs ought to be carefully examined, and small operations, such as dilatation of the cervical canal, repo- kjtion (^ the uterus when in a position of flexion or version, if
S70
D/SEAS£S OF THE GESERAL NEHVOUS SYSTEM.
indicated, should be undert»ken. V'aginiscnus, if it cxUts.sbould aUn be treated.
The motor and sensory disturbances have to be met in the nnanncr indicated above. In cases where we suspect nia lingering or Hillliil exaggeralion, procedures which are diu grceable or even painful arc to be preferred — fur inslunce, the cold baths, the fnradic bntsh. the actual cautery, etc. The more minute details of Ihc treatment must be left to the pcr> sonal tact of the physician, whose capability of individualiza- tion, of treating every case by and fur itself, should make it unnecessary for us to enlarge upon all the principal phases of this disease. With regard to the internal medication, let i! Suffice to warn against the use of narcotics, especially morphine. which can not be given in a disease of such long duration in effectual doses without creating the habit.
UTER.VTURK.
Stein. Uie allgemeine Elcklriution <lo menichliclxrn Kfirpcrsi. Halle, iM].
3. Aull. Widmer. Schwciier ComspnntltTiib).. 16S6, Kvi. 9-1 1, <Cun through Cattn-
Uon.) R«ibmayr. Die Technik tier MasMgc. Wlcti. 1886. s. Aufl. Tail. L,aw«on. Lancci. 1887, li, 35. (Cure cRtxted b)- the RetnorjJ of
Pessarits.) Pitre*. Progris m(ri,. 1837. iv. 8. (Sialic Elortricily.) Gtcfliee. Ue I'^leclricil^ tutique ei de s« appliCAtiaru i ia ih^pnib^
Piiriv 1887. Zabtuduwski. Zur Indlcniion unil Technik ilcr Mastagc Berliner kttti. VTocicn-
schr. 1887, j6. Biirkan. Berliner kiln. WocHienschr. 1888, n«iv. 45-47. Gilierinaiin. beutsche Med.ZiK ■ 1888. U. 14. (Feeding Syxtem,) Oidier. Sur riteciricit^ rjrulii{ue dans rHyslfri^uc L}<on ra6d.. 1888, bikp
356- Dutton. Lancet. June t}. 1888. f. (Miuaage. Feeding S^nlem, SeduBOn.) BielichowKky. Ucbcr InDiicniclrkiriciiai, tic. Therap. Munatsh.. Mirj. i*to Hin. Lelirbuch <ler Etcklrudiagnjstik uiul Elckirulher^pic. StuKgul. Kolc-
1S93. pp. xiT tl stq.
CHAPTER III.
triLKPSr— FALLINC SIC KNK&S— MORBUS SACEIt— HORKUfi COMITIALIB.
The term epilepsy is olten misused, inasmuch as it h ap- plied not only to liie genuine classical epilepsy, but also to many conditions, characterized by convulsive atucks. in which on careful cxaminaliim wc can detect various other abnormities, and which, unlike genuine epilepsy, have a tangible cause. If a person in consequence ol traumatism, of fright, of peripheral irritation (pressure upon a sensitive scar), or in consequence of cerebral syphilis, etc.. becomes " epileptic" — thai is to say. suf- fers from convulsions with or wiibout loss of consciousness — these convulsions clinically m.iy resemble very closely those of genuine epilepsy, but patholoKically as well as gcnclically the biwo conditions are entirely different.
For all such, cases the term "epilepsy" ^s unjustifiable. I Traumatic epilepsy. Irif;ht epilepsy, and reflex epilepsy are [ not genuine epilepsy. The difference is still greater between [the so called Jacksonian and the genuine epilepsy. Injackso- >nian epilepsy the convulsive attacks depend upon a disease of a portion of the cortex. Hence the term "cortical epilepsy " is also applied to this condition (cf. p. i8^>.
[ The genuine epilepsy is a general neurosis, and we do not know that it ever produces a permanent anatomical alter.tlion in the brain, and that the changes arc not rather molecular in character, appearing from time to time in the brain, most prob- ably in the brain cortex, and leading to the "epileptic attack " Mnd then disappearing again. About the riVi- of auto-imoxica- tion we shall speak later.
I
jEtiologjr. — We are not acquainted with any essential cause (or classical epilepsy. Physicians with a lai^e experience have often enough occasion to sec geniiinr epilepsy develop without tticrc being any appreciable etiological lactor.
572
D/SEASeS OP THE GEXERAL iVEATOt/S SrsrSM.
It has been the custom of most writers to distinguish prcdis- posing or general (roin exciting or special causes; only the former arc of importance. The latter have an influence only upon llic frequency and the severity of the individual attacks, but are never responsible for the production of the disease. Among the former heredity has been given the first place, and there is no doubt that hereditary neuropathic tendencies in- crease the susceptibility to nervous diseases in general and cer- tainly to epilepsy ; but this heredity does not by itself suffice to make of an otherwise healthy individual an epik-ptic. For this usually an additional cause is nceded~-for Instance, syphi- lis. If an individual with hereditary tendencies acquires syphi- lis, he is more likely to become epileptic — that is, to suffer from a genuine epilepsy, which is neither preceded nor followed by any appreciable anatomical changes, cither in the brain or in its vessels — than a person infected with the s-imc disease but burdened with no family taint (cf. Kowalewsky, Uerlincr kliii. Wnchenschr., 1894, 4). Important, therefore, as heredity m-iy be. it h in itself not siilTicient to constitute a cause for epilepsy, The manner in which the tendencies were acquired is also irrelevant, and the quesiiim whether the (alhcr or mother, or both were given to alcoholism, and whether both or eitherol the two was intoxicated at the moment of generation of the child has no si;^niticancc. Notwithstanding the relative fre- quency with which epilepsy occurs, the number of cases would be much larger if cither of these factors could have a decided influence in the causation o( the dise.ise.
Age and sex seem to*bc of little moment in thisconnectiun. Although it is true that in the majority of cases tiic disease affects individuals in the first half of their lives, more especially between the ages of ten and twenty, the attacks miiy begin much later and may not appear until alter the age of forty or fifty. Indeed, cases in which the first convulsion made its ap- pearance between the sixtieth and the seventieth year have been recorded (c(. Mendel. IJie Epilepsia "tarda," Deutsche med. Wochenschr., 1S93, 45). With regard to sex, it has been noted that during the period ol puberty, between twelve and sixteen, more girls than boys become epileptic; if. however, the aver- aj^e of all cases be taken, the difference between the numbers in the two sexes is very slight, and in early childhood — from the fourth to the seventh year — it is nil, the cases being eciually distributed between the two sexes.
EFflBPSV.
573
I
Among the so-called esciling causes intercurrent gastric afTccliuns play a very iinporlant part : overloiiding of the siom. ach or the ingestion of unusually indigestible food often pro- duces an "attack" which without this ietiological factor would have occurred, only later, or perhaps not at all. 1 have had lor years a gentleman under observation who after eating pork an<l beans invariably has an attack a few hours later. Indi- gestion is all the more hurtful i( the stomach has been over- loaded before going to bed.
Certain substances which arc taken into the system, whether as food or for the sake of their agreeable effects, or again as medicines, arc very dangerous to the epileptic. Among these are alcohol, mushrooms, certain spices (cayenne pepper and paprika), also all narcotics, more especially, as wc have learned in more recent ycai-s, cocaine. The " cocaine epilepsy " has been described by lletmann (Deutsche med. VVochcnschr.. 1889, 12). Under certain circumstances other medicines — aniipyrine. for example — may act as puisons and provoke an epileptic attack (cf. Tuczck, Die Antipyrin-epilepsie, Berliner klin. Wochenschr,, 1889, 17). In view of the wide employment of aniipyrine with- in a comparatively short time since its dlsc<tvery, and the popu. Lirity which it enjoys, on account of which it is used in all po»- nible kinds of perfectly different diseases, this observation must be regarded as pi>ssessing great practical inipuriance.
It is gciiemlly knoivn that anything which exerts a sud- den influence upon the cerebral circulation may be the direct cause tor an individual attack, although it is an open question whether the bUKtd current is accelerated or retarded by these influences. In an epileptic, who has been free from att.icks for years, a seizure may suddenly develop in conse<|uencc of fright ; indeed, a person who has been apparently well up to that time may have an epileptic seizure in consequence of (right and the disease may then continue for the rest of his life. Such a condition seems only possible in individuals whoare predis- posed tu the dise;ise, and in whom it only needs a slight stimu- lus to produce the attack. The (right is the drop which causes the full vessel to overflow, but which in an empty vessel would make no dtlTcrence; a sound person never becomes an epilep- tic owing to (right.
In the second place we have traumatisms and more espe- cially injuries to any ]>ortion of the head. It may happen that a person previously perfectly well is taken with an epileplic ht
574
D/SEASES OF THE CEXERAL NERVOUS SYSTEia.
after a fall or blow upon the head and post mortem not the slightest changes can be detected in the brain. In such cases wc should always carefully examine the skull and overlook no scar, however trivial, because any one may be the cause of the first epileptic attack. IE this is the case wc have the so-called *' reflex epilepsy," which has already been mentioned, and which in the stricter sense is not genuine epilepsy. Reflex attacks may also be determined by painful cicatrices on the peripheral ■ nerves on any part of the body, or by the existence ol ulcer- ative processes, for instance, of the linger nails. In one of my patients it was possible every time to produce an attack by ■ pressure upon the diseased matrix of the nail, ttie same thing occurring also when he accidentally struck it against anything. The amputation of the terminal phalanx was followed by com- plete recovery after all other measures had proved fruitless. In a similar manner polypi of the car (" ear epilepsy "), inflam- matory processes in the car. intestinal parasites, an incarcerated hernia, and lastly diseases of the sexual organs, in the male as well as in the female, may give rise to epileptic attacks. Fur- ther, we must mention the influence of the imitative impulse upon the occurrence of epileptic attacks. If nervous individu- als frequently see cpiieptiform convulsions it may happen lltat they succumb to them themselves. In the royal prison ol Breslau I have known thirteen of a large number of female inmates who were working logclher in a room to become epi- leptic a short time after another prisoner, who had been suf- fering from epilepsy for years, had been brought into the same ward.
I have reported the occurrence of an epidemic in a school (Berliner klin. Wochensch., 189J, 50). Bad air, especially in taf^s, where there is a good desil of tobacco smoke and poor venlilatinn. predisposes the epileptic to attacks, especially ii loud talking or music is going on. The mental excitement produced by such stimuli may precipitate an attack. Epilep- tics should be warned not to go to dances, since the many dif- ferent factors which arc here combined may aid in producing an attack.
The manner in which an epileptic patient can spend hislif^ the possibility of doing justice to the requirements of his call- ing and of being a more or less useful member of society, liw outlook for improvement or even recovery— all these questiw* depend in the main upon the " attacks " to which he is subjcc:,
EPtLEPSy.
57S
their nature, Ihcir duration, their frequency, their after- cts. and so forth. Hetice it is our hrst duly in taking charge ol a case o( epilepsy to study carefully the attack itscil. Symptomatologr.— The " Attack." — There are cases in which the attack occurs suddenly and unexpectedly, so that the patient, until now in apparently perfect health, falls to the ground as il struck by lightning. In others — more numerous — it is announced, so to speak, by certain premonitions, which, to maintain Galen's old expression, we call aursc.
In the study even of the aura we can not help being struck with the (act, which, on a closer examination of the attack, is
■Klill more impressed upon us. that no two cases of rpiltpsy are ■like, that almost every one has its own peculiarities, so that a comprehensive description is almost impossible. The premo- nitions are countless and many attempts have been made to di- vide them into classes. Bven if we have obtained a classifica- tioa we are (ar from possessing with it a description ol all.
First of all, we may subdivide the aunc into psychical and somatic. In the former case the patient may either become surpri<iing]y quiet and look meditative, or he may present
Iat^ns of excitement, walk anxiously up and down the room, •nd seem bewildered. The transition from the aura to the •ctual pre-cpileplic disturbance of consciousness, the pre-epilep- tic insanity, i.s not appreciable Olendel, Eulenhcrg's V'icrtel- iuhnschrifl, N. F.. l8«5. Bd. 42. licit 2). This prodromal state ^knay extend over several hours, although it may not last ^■nger than thirty seconds or a few minutes. In two cases ^Hn patients told mc that, immediately before the attack, ^reminiscences of bygone days forced themselves upon their minds, and that portions of their past lives rapidly passed before them. A psychical aura of this kind is rare. Some- times an irresistible desire in the patient to run away constitutes the aura. Just as wc shall see in the form of epilepsy called epilepsia procursiva, (he patient escapes from his home and runs great distances. While he is running he is seixed with the attack. Midway between the cases in which there is a psychical and those in which there is a somatic aura come Hnhose instances in which the patient complains of vertigo, Hviolcnt headache, and sli};ht disturlxknces of consciousness, ^bymptoms which m,'iy last but a very short lime, and which, indeed, m.iy be of such brief duration that the patient ■Jias nut time to guard himself against falling. Here, loo, be-
S76
DISEASES OF TUB GENERAL NERVOUS SYSTEM.
I
long the hallucinations which occur in the dornnin of the nerves of special sense, which we are accustomed to call "special sense" aura:. The patient hears, sees, smells, tastes things which cither are not there at all or are in reality differ- ent Irom what he deems them. I know instances in which im- mediately before the tit the patient thinks he is standing in a sea of li^ht : mnsl intense brightness surrounds him, and he \i cogni7ant of wonderful light eSccls. In other ciscs again the patient thinks he is standing amid utter darkiics;^. he sees noth- ing, and the densest obscurity reigns everywhere. To this _ class belong the instances reported by Hcincmann in which ■ bilateral amauroses constituted the aura (V'irchow's Arch,, I02, 3, 1885, p. 522). The optic as well as the auditory aura: vary in didcrcnt patients. Sometimes they hear delightful melodies, sometimes they find themselves amid the wildest tu- mult of confused noises. Comi>lclc los-s of hearing, transient deafness, which would be analogous to the transient umauro> sis, I have never had an opportunity to note.
Sometimes, not often, the patients imagine they hear dis- tinctly different voices. Then the aura is n genuine hallucina- tion and inlriiiges upon the domain of pre-cpileptic insanity. Well-pronounced gustatory and olfactory auric do occur, but are decidedly less frequent than those just described.
The somatic aura: arc cither motor, sensory, or vaso-mol The motor more frequently consist of symptoms of irritation than of paralysis. There are isolated twitchings in the fin- gers or toes, in the arms or legs, which progress from the periphery to the centre; conlracliircs in certain fingers have also been observed. In addition to or in the place of these ■ there may be twitching movements of the head or neck, twitch- ings of the facial muscles, or well-marked strabismus. Paretic symptoms, heaviness and fatigue in the extremities, are morf f rare. Spasm of the glottis, bronchial asthma, palpitation oi ' the heart, retching — all have to be regarded as varieties of motor aurse.
The sensory aur.-c consist of peculiar paresthesias in the extremities, formication, numbness in the fingers, the [>3ticat feeling as if these were working their way up to the head ori" the heart. Not uncommonly they arc associated with a pii> nounccd feeling of anxiety and oppression. The sensatiooi which appear in the extremities, sometimes in the fingers, sometimes in the toes, are cxtretnely variable, from a plciuaxi
{
EPILEPSY.
177
'slight tingli
painful
■^'
I
£
burning and stinging, wliicli, as wc have said, proceeds from the periphery to llic centre.
In vaso-motor aura: the hands become cold and pale, the neous veins look less full than normally, and the patient plains that he is getting cold. A general feeling of chilli> ness, a&socialed with chattering of the teeth, has also been noted (Douty. Lancet, March 20. 1SS6). In other instances, possibly on account of a paralysis ol the vaso-motor nerves, blushing of the stein and sweating occur. The degree of liill- ness of the cutaneous vessels and the larger veins of the skin in some cases sufficient to tell the patient whether or not he will shortly have a fit.
Innumerable transition forms and countless combinations of dilTerent kinds of aurje occur. No definite laws can be given, and we must here again recall the inexhaustible varieties of the ^prodromes by which the attack may be ushered in.
The question whether the origin of the aura be central or peripheral c;*n not as yet be answered. Certain facts point to the first possibility, others to the second (cl. Oliver. Lancet, April 31, 18SB, page 769). That the aura may have an anulom> ical basis is proved by the case reported by Hughlings Jack- son ilirit. Med. Journal. February 25, 1888). The patient, u man of fifiy.thrce years of age. complained regularly of a hor- rible, indescrilxible stench which immediately preceded every attack. At the autopsy a tumor was found situated in the lemporo^phenoidal region. We would remark, by the vruy, that this case is a point In favor of Ferricr's localization of the tense of smell.
The attack itself is characterized by complete loss of con- tousness, and is sometimes ushered in by an initial piercing TV or a noise like the roar of a wild beast which the patients emit at the moment of falling. This cry is by no nieaits 10 be regarded as the expression of (ear or surprise, as it docs not occur until consciousness is lost and is a reflex act. It is ob- rvcd in alxiut fifty per cent of all cases, while in the remain, der it is either absent or replaced by tears. A tonic muscular contraction accompanies the cry. The head is at the moment of the fall drawn backward or to one side, the jaws arc pressed together, the bcick is spasmodically curved, and the fingers are clenchc<l over the adductcd and flexed thumb. Kespiration ceases, because the muscles performing the function take part the spasm, and the face becomes discolored and cyanotic. 37
5/8
D/SF.ASF.S OF THE GENEKAL NEkVOVS SVSTKXr.
A convulsi%-e tremor runs over the wliolc body, and in ihc nuisclc.-<i of the face as well as in the rigid extremities twitcb ings begin to a[>i)ear. which spread, and spare no part of ihe body. The head is violently knocked against the floor or Ihe couch, the tongue rolled around in the nioiiih, protruded, per- haps, and retracted altcrnalely, so that it is often injured by the teeth : the eyeballs are deviated, the pupils dilated and in- active. Arms, legs, and trunk are now the seat of violent, ir. regular, rapidly changing jerkings. The mechanism o( these motions has been studied by Unverriclit ^Ueber tonischc und klonische Muskelkrampfe. Leipzig. 1890). Corneal and skin reflexes arc lost. The tendon reflexes can be obtained if the tetanic rigidity of the e\iremiiies allows it. The pulse if slightly quicker, the respiration greatly hurried. With eadi expiration the saliva, often foaming and mixed with the blociii coming from the injured tongue, bursts forth and covers the Hps. The temperature remains normal. In more prolncletJ cases it may rise from one fifth to half a degree Fahrenheit The involuntary evacuation of urine and fa;ces, possibly aUoof semen, is not rare. In one case only have I seen the attack regularly associated at its onset with vomiting.
Gradually the body becomes covered with sweat in col)S^ quencc of the excessive muscular strain ; next, the convulsions lose some of their violence, the limbs gradually become le» rigid, the cyanosis disappears, respiration, though it may siiU be difficult and snoring, becomes more regular, the comi abates and passes insensibly either into a deep. long sleep or gives place immediately to complete consciousness, so that iB some cases the patient may in a few minutes again be in an apparently perfectly normal condition, without, however, hav- ing the slightest idea of what has been going on during llie attack.
We have said that the symptoms immediately preceding the attack present an endless variety of forms ; the same must be said of those that belong to the period following it- Th«c " post-cpileptic " phenomena may again be divided into psychi- cal and somatic. The psychical phenomena are very inierejt- ing, because they are not always of the same inlcnsily, but may assume all gradations between .t complete insanity ("poft- epileplic insanity," post-cpileptic moria, Samt) and a slight bewilderment. In the first case the pnlienl has to be regarded as a m.idman, and must not be held responsible for his aciiun*.
F.PtLEPSY.
%n
I I
not excluding any crime that he may commit at such times: in the lallcr he resembles a drunken man, who, although he inter can not remember what has happened, will answer ques- lions if they are repeated often enough and in a .sutTicicntly loud lone. Not uncommonly there exist on first waking up speech disturbances, in the form of a motor or sensory- aphasia, which lasts from a few minutes to several hours. Total apha< sia following the attack has also come under my notice, and I have seen it persist (or half an hour. The patient appeared to have regained consciousness pretly well, he understood, appar- ently, the questions which were asked him, but was not able to answer ihem in any other way than by signs. FUrslncrhas re- ported instances of post-cpilcptic stammering (Arch. 1. Psych, und Ncrvcnkrankheiten. lSS6, xvii, z).
Among the sJimatic postepileptic phenomena there is, be- sides the difference in the size of the pupils, which is of some value for the diagnosis of nocturnal allacks occurring during sleep, a concentric contraction of the field of vision, which may last (or twcnly-lour hours. Of this I have been able to con-
ince myself several limes positively. Purthcr. (here arc cer- tain conditions of motor irritation, "cortical movemenls " (Kindenbewegungcn of i^acher), which consist of cither lypl- clonic twitchings. or of choreoid or alhctoid movements, and which may persist (or hours. Contractures, occurring more frequently in the upper than in the lower extremities, usually on one side, have been observed only in exceptional iLemoine, Deutsche Mcd.-2lg., 1888, 30). Among the motor changes there arc circumscribed reddenings which may occur symmetrically on both sides of (he body in (be most diverse places. Transient incre.ise of the patellar rcflcs. transient albuminuria ixwX violent vomiting are common after
pileptic attacks. As to the time at which (he attack may be expected, we tnay broadly say that there is not a moment in the life of the 'patient in which he can (eel safe (nmi them ; that any particu- iir lime, either of (he day or o( the night, is especially danger- ous in this regard can not be maintained. This much only can be said, that in some individual cases the (its occur only during the night while the patient is in bed and asleep; this so-called epilepsia nocturna possesses great practical imporlance. be- cause it may persist (or a very long time unremarked and un- recognized, especially if the patient sleeps alone. If such be
t^
S8o
I>/SEMSES Of THE GENERAL NERVOUS SYSTEM.
the ca!ic, ttic dingnosiR cnn only be made from certain charac- teristic signs observed in the morning — from ihc pain of the bitten tongnc, tlic dull headache, the slight extravasation of btood into the conjunctiva:, or the unequal pupils {jViiV sHfira). [n one of my cases of nocturnal epilepsy there occurs after cacli attack a deep-red spot, the size of the pnim o( the hand, on the forehead, which does not begin to fade nnltl one or two days have passL-d. For years the attacks in:iy be confined to the night, and may go on without interfering to any extent with the patient's business and social life. Above all, he is not ex- posed to the usual injuries caused by the falls, but he never can feel absolutely certain that some time or other an attacic may not occur during the day. These nocturnal fits arc heralded by an irregular respiration, snoring, grunting, or moaning. Convulsions may not occur at all, but the whole body gets into a condition of tetanic rigidity which is followed by a relaxation of the muscles; during the whole time the patient docs not awake, and has no consciousness of what bn» been going on.
There are certain things which seem to exert an unfavor- able influence upon the severity and the frequency of the fiU, and against which the patient must be strictly and rcpcatcdlj' cautioned. These have been mentioned on page S75- It need only be added here that coitus does not always have a bad in- fluence, and that there is no reason, from the physician's point of view, tor forbidding it altogether. Whether the clim.itc hflS anything to do with the fits we are not sure, and the idea of the supposed influence of the moon must be relegated to the domain oE the unknown. It is interesting to note, howenr, that when an epileptic is taken ill with typhoid fever, pneumo- nia, facial neuralgia, etc.. he may hope to enjoy immunity from the attacks as long as these diseases last. This, however, does not hold good for pregnancy ; according to Ncrlinger, to wlwm we owe an interesting monograph on the relation between child-bearing and epilepsy (Heidelberg. Winter. 1S89), ft dimt nution of the attacks during gestation is observed only in rare instances.
On the other hand, there arc cert.iin things which exert ■ favorable influence, either by aborting or preventing for cer- tain periods the occurrence of the attacks. Mow these factors work is quite inexplicable. Among the former may be men- tioned the application of a tight bandage or strap to the pirt
EPfLErsy.
o) ihe body — e. 5., the finger or Iiand — in which the motor aiira occurs; to the latter belongs frequent cpistaxis. as I have repeatedly had occasion to observe ; if it was profuse it seemed 10 produce an intermission in the occurrence of the attacks which lasted for a relatively long time.
Besides the classical attack which we have just described, and which is known as "gram! ma/," there occurs ihe rudimen- tary abortive attack, as it were, which has received the name "fieiil mal." Of this latter kind there exist countless varieties. There may be nothing; more than a momentary vertigo, with- out any loss of consciousness ; this is termed epileptic vertigo ;
['Or in place of or following this there may be a brief loss of consciousness, lasting but a few seconds, the "abs^nif" of the French writers, of the onset and the duration of which the patient is unable to give any account. An individual may in the middle of any kind of occupation — speaking, eating, read. ing, and so (orth — suddenly stop what he is doing ; lor an in- stant he stares vacantly before him. remains as he is, standing or sitting, and immediately after the " attack " resumes his oc- cu)Kition as il nothing had happened; the unrinishcd sentence
, is alter a short pause completed, the spoon which was ready to bring the food to the mouth, alter a short stop reaches fts goal. If an "absence" occurs to the patient on the street when he is out walking, he keeps on mechanically, loses his way per> haps, and only finds it again when consciousness returns. The instances in which such periotls take in a much longer time, during which the patients undertake voyages, spend money, transact business of which they are not conscious later, or do things which arc against their intention and entail disagreeable consequences, must also be looked upon as coming under the head of epilepsy. They are undoubtedly rare, and up to this time have been carefully observed only by French physicians, more especially by Charcot (•' aittomatisme awMatoirf "), Insig- nificant as /vtil mal may seem, it often has a very deleterious effect upon the general condition of the patient, especially upon the mind : we should be cautious, therefore, with our prognosis. There are still other seizures in which typical convulsions do not occur, but in which the patient suddenly begins to walk first forward, then backward, to run around in a circle (•' mauiffttfitts de manig€"), or spin round and round; or lie may rush out of his house and run for long distances without knowing why or whither. This form, which has been dc-
583
D/S£AS£S OF THE GENERAL .SERX'OVS SVSTF.M.
scribed by Gourncvillc, t^damc, Wcinstock (TnAugur.-Diss«r Berlin, i88g), and others, is calltxl "running epilepsy," cpi- tepsta procursiva. It oltcn appears in childhood, and later gives place to the usual classical attacks. Us frequent com. bioation with moral insanity is intcrcsring. Anatomical changes have not been found in the cases which came to autopsy up to the present {cf. BUttncr, Allg. Zeitschr. f. Psychintrie, 1891. xlvii, Heft 5).
Again, instead of the convulsive riliacks, we may have from lime 10 time transient psychical disturbances, which consi&l of stales of excitement or depression : iti such instances we speak of "epileptic equivalents" (Saml), We must leave to the psychiatrists the task of investigating their cause and their significiince. From a medico-legal point of view these puzzling conditions possess great interest.
About the frequency of the paroxysms no definite state- ment is possible. There arc people who during their whole life have not more than one. two, three, six, or ten attacks, and again there arc others in whom ihcy recur once a week or still more frequently. Sometimes there arc certain periods in which they increase in frequency, and others of months or years during which only an occasional attack occurs, [n rare instances, in periods of the former kind, the fits may succeed each other so closely that there may be one or even many every day. Before the patient has had time to regain his full consciousness another attack looms up. This is what we call the status epilcpticus, Hat lii mat. The tcinpcrature may rise steadily (or from three to eight days as much as 5* to 7° F., so that it may reach 104° or 106° F. If, then, in the intervals consciousness does not become fully restored, but the patieol remains dull and bewildered, there is very great danger lliat death may occur during the status epilcpticus. and the friends should he made acquainted with the seriousness nf the siluiv- tion. Only in e^ception3l cases docs rccDvcry take place and the temperature fall to normal again (Witkowski, Ccber epi- leplisches Fieber u. s. w.. Berliner klin. Wochenschr., 1886, xxxiii. 43, 44).
Course. — The course of the disease, the general condittw of the patient in the intervals between the ait.icks. the itiAu- ence ol the attacks upon the mind and body — all these may present great variations.
The course is very chronic and the disease lasts in most
SPfLXPSV.
583
cases years .ind tens of years. Frequently the patient is sul>. jvct to the adectinn during his whole life. The earlier the first attacks make their appcinince the less chance is there of their complete disappearance. In some cases of " late epilepsy," " ffUfpsit fartihff," in which the affection does not begin until late in life, it may hapjteii that the attacks completely cease as unexpectedly as they came on. Slill, a course so favorable as this is rare and can never be predicted with certainty. Mendel has pointed out that this late form runs in general a milder course, and that the mind is less likely to become affected in these cases. If the disease has set in in early childhood, the influence of the period of puberty is generally very marked. The attacks become more frequent, and in women the increase in number is observed every month at the time of the menses until the time of the mcnnpause. Pregnancy has little influ- cncc on the attacks, according to my own experience; some- times it appeared as if shortly after conception the number of (its was considerably lessened, while in other women there seemed to be no change.
The general condition in the intervals between the attacks is by no means the same in all cases. In some, loriitnately not rare cases, the paroxysms do not cause any bad effects (or years and nothing morbid can be discovered. The mental fac. ulties develop normally or, il already developed, rem.Tin good. The disposition is cheerful, social intercourse is enjoyed, as there is nothing in the bodily condition to interfere with such pleasures. The pres<'nce of epilepsy d<x.'s not necessarily pre- vent the full development of a genius, as is proved by the uni- versally quoted historical examples of Ca:sar, Alexander the Great, Uousseau. Napoleon I, and <)thers.
In other instances llic general condition in the intervals leaves much to be desired, and as a rule it is the psychical part of the man which suffers most unpleasantly. Either the dispo* sitJon of the patient is changed for the worse, so that he is easily excited, irascible, suspicious, peevish, unsociable, and disagreeable to those around him, or the mental faculties suffer, he Ixrcfuucs dull, slow in grasping ideas, indifferent, anx- ious, abstracted, and so unreliable in his vrork that he is no longer able to fulfill his duties as a man of business and as a g(KKl citizen.
In such cases we are sometimes able to note bodily defects, as, tor example, abnormities in the (orm.-ition of the skull, in
584
DISEASES OF THE GEXERAL NERVOUS SYSTSAf.
tlie furm ol the auricle, in the condition and arrangement of the teeth, and quite frequently flal-toot (F^rA et Demanlkd, jKuriial do I'Anat. ct dc la Physiol., i8gi, 5). Such "signs of do- generation." however, are often absent.
The final issue of the disease is almost always the same. The patient remains an epileptic all his life, from time to time having attacks, and finally dies from some intercurrent malady. The mental faculties may remain throughout, on the whole, good and the capacity ol the patient for following his calling be retained. In other instances the mind becomes gradually impaircd, so as to necessitate the transference of the patient to an institution, or again, in very exceptional cases, there may be complete recovery or. at any rale, so marked a decrease in the frequency of the attacks that the patient may well regard him- self as cured. This cure may come about spontaneously or may be caused by some unexpected psychical emotion, pnr- licularly a fright. However, wc should beware of being too precipitate in callinij a patient " well," because now and then even after intermissions of years an attack may again make if appearance.
Death rarely ever occurs during an attack, but iudirccffT the paroxysms may ciuse a fatal issue. The patient during a fit may receive serious injuries; he may fall upon his face and be suffocated, or fall into the water and be drowned. The average life of epileptics is considerably shorter than that uf other persons.
Pathogenesis. — The pathogenesis of the epileptic attack ii totally obscure ; although we know from the experiment* of Kussmaul and Tenner that the source of the attacks must be sought for in the brain, the exact scat of the disease is not known. Since the work of SchrOder van der Kolk special attention hxs been given to the medulla oblongat.i, and the discovery by Nothnagel of a " spasm centre " in the pons seemed to alTofd mnch support to the " bulbar theory." but of late years this has (alien more and more into discredit, and it is now the brain cor- tex which is regarded as the starling point of the convulsions (llitzig, Albertoni. Francket Pit res, P. Rosenbach). For alooff lime the motor area was thought to be the only region coiv- cerned, but recently Unverricht. who, with his convincing ex- periments on animals, has proved himself the most sucocaful defender of the cortical theory (after extirpation of an area in
KFlLEfSV.
585
I
corlcx he found that he cnulcl not obtain spusms in the muscle groups corresponding to it^ has shown thut excitation I'of the posterior cortical regions is also capable o( producing an attack, hence that these too possess cpilcpto<^cnic proper- ties, and tlial irritation oE the same may by extension of the stimulus to the motor area give rise to general convulsions (Deulsch. Archiv \. klin. Med., 1&88. 44. ■)•
Binsvvangcr agrees that in the lateral portions ol the (toor of the fourth ventricle there are points the stimulation of which gives rise to spasms, which, however, he considers 10 be of a reflex nature, and assumes the reflex centres to be sit- ft uatcd in the dorsal hall of the pons. According to his opinion, " these represent, as it were, a collecting station for the centres of the spinal cord, and can not, in the physiological sense, lie termed "s|>asm centres." He mainiains that we never can succeed by electrical or mechanical stimulation of the pons in producing real epileptic attacks (Arch. f. Psych, u. Nerrenkh., 18S8, xix, 3).
However probable an association of the cortex wjlh the
appearance of symptoms of motor irritation may seem, such
Kan association is far from explaining the increased salivary
Hijwcretion, the involuntary evacuation of the bladder, the in-
|nmse in the frequency of the respirations, etc., and we must
(or the present leave the question open whether or not such
» phenomena depend upon some influence acting on certain cen- tres in the brain and spinal cord, the situation and function of which we do not as yet know. The question raised by J^ichcn
»as to the significance of the subcortical ganglia in thecausa- tiun of an epileptic attack deserves lo be looked into more closely ; for the present only this seems certain, viz., that (in dt>g<i) the clonic pan of the convulsive movements produced by stimulation of the cortex is connected with the corlcx itself, while the tonic and the running movements seem lo be ol sul». ^ cortical origin (XIII. W'andcrversammlung siiddeulschcr Neu- ■ rologcn. Archiv f. Psych., 1889. xx, 3. p. ;84V The possibil- ity cnn not be excluded that in man, as in animals, both regions, tthc cortex as well as the bulb, may be responsible for the Dltack. In the second place we arc entirely ignorant of the cause of the attack: it is unlikely that a palpable anatomical alteration exists, and the claim of Chaslin (Note sur I'anatomie patholo- giquc de r^pilepsie.ditc essentielle. Journal desConnaiss. mid..
$86
D/SEASES Of THE GENERAL XERi'OUS SYSTEM,
1889, 5 s. X, 12). that a gliosis, which he designates a "sclerose nevrogli<iiie," is to be regarded as the cause of epilepsy, is by no means proved. Much more plausible is the llicory that the amount of Wood in the brain is of importance in this connection, but the different writers have never been able to agree whether an increase or a diminnlion in the amount of blood is the cause. Many clinical observations speak in favor of ana-mia: thus Leyden has seen epileptic attacks in cases of aortic stenosis undoubtedly as the result of a temporarily instiflicient blood supply ; Sommer noted their occurrence in a case of anchylosb of the atlas which had produced narrowing o( the vertebral canal in its tipper portion (Vircliow's Arch., rSgOj cxix. Heft 2, p. 362). Results pointing in the same direction have been ob- tained by Sutnikow in his experimental studies on hypcncmia and anemia ot the brain and its relation to epilepsy (PftUgcr's Arch., 1892, xc, p. 609). On the other hand. Bechierew, whose opinion is based on experiments of Todorsky, holds that during the attack there occurs an increased blood-flow to the brain and a dilatation of the capillaries, and that this condition ts the cause of the attack. We see, therefore, that the question is by no means decided ; we should also think o( the possibility that vaso-motor changes, or a rapidly or gradually developing autointoxication, perhaps by ptotnaincs (Qcncdikt)niay pro- duce the attack. Since epileptic attacks are also sure to occur after acute infectious diseases (influenza, typhoid fever), also after vaccination (.Mthaus), an infectious origin can not be ex- cluded. But whatever may eventually be shown to be the cause, a hereditary abnormal excitability of the psychomotor centres has to be regarded as ^ (ondtlu) iint qua nan.
A peculiar kind of epilepsy, which is said only to occur in heart disease, has been described by l,«moine (Dc I'^pilcpsic d'originc cardiaque. Revue de m£d., vii. May 5, 1877) ; yet wnce the connection is not absolutely proved, and since, moreover, the attacks themselves presented no peculiarities of their own. we shall limit ourselves to saying that they disappeared under the administration of digitalis.
\'on Jaksch (Zcitschr. t. kiin. Med- 1885, x, 4) has shown that epileptic attacks may be produced by auto-tntoxication. not only by urea, but in a similar way also by acetone, )o cases of "epilepsia acetonica " large amounts of acetone were found in the urine, which besides contained neither sugar nor albumen. The physiological connection between the occur.
EP/LEPSr.
587
Rnljpf acetone in large quantities in the urine and epilcpli- ittack-s is not as yet (uily established, nor do we know how poisons — (or instance, lead— introduced into the oi^anism from outside are able to produce such attacks; as a matter of (act, however, lead workers suffer so frequently from epilepsy that we are justified in assuming the existence of a definite " epilepsia saturnina " (Hirt, Krankhciten der Arbeiter,
• iii. 49)- Briefly, epileptic attacks may occur as a symptom also fn meningitis, dementia p:iralylica, during delirium tremens, in sclerotic processes, more especially in sclerosis of the cornu
■ Ammonis. They may be associated with tumors, hydro- ccphalus. or abscess of the brain, in which cases they are the result of the increased intracranial pressure, as we have
H pointed out above. From what has been said in this and in previous chapters it will be understood that these and the so- called epileptiform attacks above mentioned have in all probii- bitity nothing to do with (h: genuine classical epilepsy.
B Diagnosis. — Wc can well understand, then, how cautious we must be in our diagnosis. Only after repented and careful examinations, alter which we are able to exclude organic brain diseases, abnormities in metabolism, in consequence of which abnormal or poisonous substances occur in the urine (urea, sugar, acetone), are wc ji)sti5e<t in making the diagnosis of genuine epilepsy. The skin and tendon rcHcxes should always be carefully examined. Sometimes, from the absence of the abdominal or creni.-isteric reflex, or from a unilateral increase of tlie patellar reflex, wc may be able to diagnosticate an org.inic brain trouble when we otherwise, without any inquiry
^into the condition of the reflexes, might have regarded the case
^*s one of genuine epilepsy.
Quite frequently wc meet with malingerers who, (or some reason or other, feign epilepsy. The situations in which the simulation of this disease would be likely to be advantageous to the deceiver are quite numerous, and it would be impossible
_ lo enter into the consideration of them here ; we will only mcn-
Btion that epileptics are exempted from military service, good grounds enough for many to sham this disease. The more cunning the malingerer the more perlcct will be the attack, not excluding the foaming at (he mouth (made by soap) and I the (not very deep) wounds oi the tongue ; there will be con*
S88
DISEASES Of THE CEXEJtAl. S'EXVOUS SYSTEM.
tbly
ic(Icigncd)loss ol consciousness is possibly pro- ihaii is iitrcfssary : if ihe rogue lias courage
I
vubions, and the (feigned) loss of
lunged more _ -. . j . „_- . - „-
enough he will not betray himself either by a reflex motion ul ■ defense, or even by the slightest twitching, il hot scaling wax is, as a test, dropped on dis chest. Under certain circuin stances it may be extremely difficult to unmask ilic fraud; it might, indeed, be impossible, did we not know one reflex over which the will has no power, namely, the pupillary reaction in light, which in the epileptic is lost, in the malin;;;erer naturally is retained. In doiibttul cases, therclorc, this reflex has tu he carefully observed, and the further measures should depend upon its condition,
Treatment.— The treatment of epilepsy confirms the old experience thai the greater the number of remedies which become known and are recommended for a disease, the more difficult and uncertain becomes the cure. In the course of centuries such an array of medicaments have been recom- mended to combat this disease that there is hardly a drug ia the shops which has not at one time or another been regarded and praised a$ an infallible "specific" Unfortunately, all these claims have been proved to be false. We are to-day as little in a position to cure epilepsy as we were one or five centuries ago. Only by the discovery of some causes which may pni- duce epilepsy, the removal ol which lies in our power, has any progress been made in the treatment of the disease. This more particularly applies to the above mentioned reflex epilep&ifs, and the Jacksonian variety, which, it is true, is not a genuine epilepsy. Here a cure is possible— nay, we may say even cer- tain— il we are able to remove the cause. To discover it muft be the physician's aim. Sometimes it consists of a bone splinter which has been left alter an injury to irritate the cories, iii which case a cure will invariably be effected by the operaiion of trephininfj for the removal of the splinter. The principJfs which should guide us in such an operation, the (oremostol which is to make as large an opening as possible, have been formulated, among others, by V. Horsley at the Trench Con- gress for Surgery (Wien Med. Presse, 1891, 16). In other in stances painful cicatrices h.ive to be excised or aficctionsoi the inlestinni tract or the sexual apparatus treated. In chiliirm the natural openings of the body have to be examined lor the possible presence of a foreign substance, the removal of which would then be absolutely necessary.
EPILEPSY.
589
iich arc the favorable cases in which it is in (he power of the pliysician to bring about a cure. Uiiforluuutcly, their number is nut great. In the largest majority of instances we are not able to lind any c:iuse. the removal of which would re- move also the disca&c ; but tn-day, as centuries ago, wc are re- duced to the sad necessity of trying all sort* of remedies, trust- ing to gwid luck that at some time wc may hit upon one which is truly efficacious. Before relying upon the action of any drug, or together with the administration of the remedy chosen, strict attention sliould be paid to the condition of the stomach ; indigestion should be prevented, or if it exists shttuld at once be treated, if necessary by emptying the stomach with the lube (Alt. Mtlnch. nicd. Wochenschr,, 1S94. 14). The fiict that I have observed the occurrence of attacks to be more (re(|uent when much food w.i8 given which was rich in nitrogen, has prompted me to limit the use of nitrogenous articles of food and to advise total abstinence from meat at least three days in the week. Some epileptics have improved their condition considerably by becoming vegetarians: whether they ever re- cover absolutely under that regimen I am unable as yet to decide. To counteract any intestinal sepsis Fir6 recommends naphthol and salicylate of bismuth.
Atnong the internal medicineslheso-cilled specifics possess an interest purely historical : fnim artemisia (in hot beer. 10 to 30 grm. at a dose — grs. 1 jo lo joo) and Valeriana down to M]uilla, gratiola, sedum, cardaminc, and hellebore, many herbs have been lauded as effectual. .-\<af<elida, caslorenm, and camphor have been recommended, although no better results have been obtained from them than from silver nitrate, ammonio-sulphate of copper, an<l arsenic. ,\ great sensation was created by Mcg- hn's pills, which, in addition to zinciim album contained hyos- cyamus. Some have sti-orn by oxide of zinc, and Merpin, for instance, claimed that out of forty-two cases he cured twenty- eight with it. To unprejudiced judges who continued their observations for a sufhciently long time these "cures" could not hold their ground. They proved to be deceptive, and we were as helpless as before. Keconrse was had also to narcol. ics, and much was hoped from the action first of opium and later of ether and chloroform. It is true that here and there an attack has been cut short by inhalations of the latter, but that U all. It is not to be wondered at that under such dr. cumsiances secret remedies were used to a tremendous extent:
590
DISEASSS OP THE CBNEKAL KTERVOVS SYSTEM.
and to what a pitch the humbug and impudence were ricd may be seen {rum the compoiution of some such remedies, for itislance. the epilepsy powder of the Institute for Deacon- esses in Dresden, which consisted of charred bone of magpies which had to be shot at some time during the twelve oighls following Christmas, and again from the epilepsy powder of W'eplcr, which was nothing but charred and pulverized hemp thread (cf, Richter, Das Cchcimmittclunwcscn, Leipzig. 1871. pages IS. 16). ■
A new era in the treatment of epilepsy — that is, of the at>* ucks — was initiated when Locock in 1853 recommended bro- mide o( potassium, which obtained a wide acceptation through the elTurts of Legr:md du SuuUe. Its power of diminishing \\\i reflex irritability and of towering the blood pressure in the brain has placed it first among the aniiiipasmudics, and Io-(l.iy it has to be regarded as the best and most important medicine in the treatment of epilepsy. In order nut to be disappointed, however, in our expectations, it is necessary that wc should be familiar with the proper regulation of the dose and with cer- tain unpleasant effects which are apt to arise in the course of the treatment. The small and moderate doses of 0.5 to 4 grm. a day (grs. viij to 3j) formerly used arc generally ineflectuaL It is necessary to employ much larger amounts, which are best given in one dose. It is, moreover, better to combine the three bromides, viz., the bromides of potassium, sodium, and ammonium, in equal parts than to give bromide of potassium alone. The minimum daily dose (or adults in cases of prti- nounccd epilepsy is eight grammes (3ij), >i"d we should fol- low Mendel, who advises that it should be taken in valerian tea immediately before going to bed (potassium bromide, am- monium bromide, Jia 2.5 (grs. xxxviij); sodii bromidi, 3.0 (grs. xiv). For children and young people up to sixteen yearsof age the daily dose should be half a gramme (grs. vij) for every year. If the two drachms are not sufiicient— that is, if an at- tack still occurs now and then — ihc dose may be increased to ten or twelve grammes ( " ijss. I0 3 i'j). and this continued until four or five hundred grammes or from six to nine ounces an taken.
In this w.\v I have treated hundreds of epileptics in private as well as in dispensary and hospital practice, and have let iJip no opportunity for observing the action of the bromides. Tbis action is by no means the same in all cases. There are peopk
I I
F.PILEPSV.
591
n tvhom an idiosyncrasy against tli<: mt-dicinc rapidly dcvel* ops. so that it is impossible lor ihcm to take it any more. It nauseates them and may cause voniilinj;, and after repeated unsuccessful trials to resume the treatment we have to discon- tinue it entirely. In other instances the desired eflect on the attacks may show ilscK; but after a lew weeks the patient be- gins to complain of general bodily and mental ieebleness, a constant desire to sleep, some loss of memory, and other symp- toms, so that Ihe dose has to be diminished. At the same time, sometimes without these symptoms, an eruption on the skin appears, more especially an extensive, obstinate acne distributed over (ace. trunk, and extremities, which is most distressing, especially to young female patients. 1 have seen this eruption particularly after the prolonged use of small doses, and have also seen it disappear comp;initively rapidly under the use of mild laxatives and the administration of arsenic in the furni of Fowler's solution. Finally, cases come under our notice in which bromide, no matter in what form or dose it be given, is entirely without elTect. The attacks twcur just as they did previous to the administration of it Here wc have, of course, again to suspend the treatment, more especially if symptoms uf intoxieuliim appear in addition to the continuance ol the fits. II we wish to express the elTects of bromide in epilepsy by ipcrcentagcs, wc could say that in about ninety per cent of all cases the paroxysms diminish in number and violence, that in about as many signs of bromism appear which render neces- sary a diminution of the dose or gradual suspension of the medicine. In from two to three per cent of all cases bromide is borne so badly that it has very early to be discontinued,
»l( it is established beyond doubt that the bromides exert a [avorable action, we must insist upon their prolonged use for months and years. To add some variety to the treatment they may be combined with belladonna and pills may be ordered which contain both, 1( every evening two centigrammes (gr. V») of belladonna and two grammes (grs. xxx) of bromide arc iven, about the same results are obtained as with eight rammes(~ij) of bromide alone, [fit Extr. bcllad.. 0.5 <grs. ijss.); pot. brom., sodii brom., ammonii brom.. SA 15 (5^5. circ.) : pulv. et succ. liq., US q. s. u(. f. pil. No. 50. Signa : One to two pills in Ihe evening.] When the action of llie bromide radually becomes lessened owing to Ihe establishment of a tolerance, Ihc ndminislratian of belladonna is also indicated.
I
592
D/S£ASES OF THE GESEHAL NERVOUS SYSTEH.
I.
nnd it may then be given in the form of Trousseau's pills. (3 Extr. bell.. Fol, bell.. Jill i.o (grs. xv). succ. q. s. ut. f. pil. No, lOO, Signa : One to two, later three to (our, or even six pills, in the evening.)
Compared with bromide and belbdonnn. which, accordinf^ to our opinion, are the only reliable drugs to be used in the in- ternal treatment of epilcjjsy, the medicaments which have been recommended of late year.'! — curare (considered to be ineffect- ual by Buurncvilte), antipyrine by Beaumelz. tinct. simulo (the (ruit of Cappnris cortaaa). which has been used by While — do not play any important rSU; and only deserve a trial in desper- ate cases. With my trials with borax, which has recently been so often recommended, I have been somewhat disappointed. On the other hand, amylene hydrate, recommended by Wilder- muth (cf. lit,), must be given a trial in cases of distressing bro- niism or if the attacks increase to an alarming extent. The watery solution «f Kahlbaum's preparation, in the proportion of one to ten, is the best to use in doses ol from twenty to forty grammes (3 v to 3x) — i. e., two to four grammes (jss. to Z'\) of the drug itself. U may be given in wine or water or in a glass of beer, well shaken up. and from five to eight grammes of the drug(3)ss. to 3ij)may thus be used daily. Flcchsig (Neurol. Ccntralbl., 1893. 7) has recommended extr. opii. 0.2- 0.3 p. d. (3-4J grains) fur six weeks, followed immediiitcly by large doses of the bromides. I have no personal experience with this treatment.
Surgical interference h.is also been resorted to. at first wHh the view of innuenciiig or dimitushinj^ the amount of blood in the brain. Several times ihc carotids have been ligatcd, »od two casts thus treated were reported as completely cured (llasse, Krankheiten dcs Nervensystems, p. 397). Owing to the great difficulties of the operation and the gnivc responsi- bility which the physician takes upon himself, this measure will only in exceptional cases be made use of. With blecdii^. strong revulsives to Ihc skin, such as Autcnrieth's ointment 10 the shaved head, mr)xas. setoiis. blisters, and purgatives, possi- bly the same results can be obtained.
More recently both vertebral arteries have been ligatcd (von Baracz. cf. lit.). !n my clinic the ligation of one verir bral, the right, was performed several months ago by Jantckc without any noticeable effect upon the frequency or the seW- ity o( the attacks: hence the patient was not willing tosulxnit
EP/uwsy.
S93
the ligation of the other. The operative treatment ol trau- Fina(ic epilepsy aims at the removal ol bone splinters which press upon and injure the brain cortex ; but the operation should only be performed, as von Rergmann holds, if the con- vulsions constantly occur in the same groups of muscles and extend in a characteristic manner, or if transient hcniipareses occur. At the operation the affected area of the cortex has to be carefully excised. If the attack begins like a flash without an aura and is associated with opisthotonus, etc.. operative measures are contraindicaled. Neurotomy of the sympnthetic, a procedure described by von Jaksch (Wicn mcd. \Vocbcn- schrift, 1S92, 16, 17), has produced a cessation of the attacks for several months in a number of instances; but wc do not knovr whether it is capable of bringing about a permanent cure.
Marshall Hall's advice to perform tracheotomy, on the ground that the spasm of the glottis is productive of the as- phyxia and the clonic spasm, is purely and entirely of histor* ical interest. The operation has been performed several times without, of course, the least benefit to the patient. The same may be said of the cauterization of the glottis with nitrate r>( silver, suggested by Brown-S6quard. which has been justly condemned in such cases.
In connection with the surgical treatment we should men- tion the application of strips of cantharidal plaster around the forearm or lower leg in which the motor or sensory aura oc- curs. Only when the aura constantly appears tn the same member can any success be expected from this measure, which has been recommended by Buzitard. The plasters must re- main on for a considerable time. Following the advice of Buit- zard, I have ordered the application of these plasters in some cases, without, however, having been able to sec any good re- sults. In one instance of partial epilepsy a transfer was pn>> duced by the application of the plaster (Hirt, Neurol. Central. bbtt, 1884, I).
Finally, we can hardly be surprised that attempts have been made to combat epilepsy by electrical treatment. L'nfortu- nately, the results with this have been even less encouraging than those from internal medication. Neither the attacks them- selves nor the so-called "epileptic change in the brain," the nature of which, as wc have above stated, is still obscure, have been influenced by It in any way. The constant current was emploved and the sympathetic galvanized by passing the cur-
594
DISEASES OF THE GES'f.RAL NEKVOUS SYSTKM.
rent from one mastoid process to the other, and attempt!) were made to influence the cerebral hemispheres, and more especially the motor regions, according to Erb's method (Erb, liandbuch der Electrolhcrapic, p. 5S1). In other cases the current was passed through the lobes o( the thyroid ginnd. as Sighicelli (Kiv. sperim. di freniatr, iSSS. vol. xiii, 3) has more recently done, but in none of them could any last- ing success be remarked. No better results have been ob- tained with the faradic current in all its different modes i>I application.
Although with all our treatment we are practically power- less against the disease, it would be very wrong to assume that to the epileptic the physician can be of no use and can not im- prove his condition in any way. On the contrary, there is hardly another class of patients affected with nervous diseases who require so much a physician's advice, and hardly another class who have to be so carefully watched by him. Above all, attention has to be paid to the general condition. The bowels must he kept regular and the skin and muscles stimulated I0 their proper activity by appropriate cold-water treatment and home gymnastics. The patient should constantly be wariiH against every kind of excess. Too large a supper, a few glasses of wine or beer taken too quickly, any indigestible food, ex- cesses in '.vHcre — all these may give rise to an attack, the con- sequences of which arc incalculable. To guard against these, therefore — in other words, to employ prophylactic measures— is the chief task of the physician who is taking charge of an epileptic. Besides this, ihe bromides, or. if these arc not suil- abic. the next best treatment, should be begun. Finally, care must be taken that the pnlicnt does not hurt himself during the fit. and against this he should be protected as well as possible. All tight clothing must be removed and all ordinary emergen- cies provided for. .\ regular treatment of ihe attack iiieM we do not possess, and all attempts to cut it short should be avoided. Even inhalations of amyl nitrite, which O. Bergcr suggests, chlorolorm. and similar remedies are only allownWe if administered with the greatest caution, and it would be bet- ter still to discard them entirely.
Note. — Eclampsia is one of those terms which up to the present do not convey to our minds any clearly defined clinical or pathological picture. It is a term under which are coinprc-
I
ECLAMPSIA,
595
H as IK Ktorti
hcnclcd the most heterogeneous conditions which hnvc not the least cotincction with each olhcr. If a woman during preg- nancy or during parturition without any appreciable cause
iJBDnsciousness and (alls into convulsions, which may recur times, and which Ircquently lead to a fatal issue, we speak of eclampsia gravidarum or parturientium. tl children, as not uncommonly occurs, have paroxysms, consisting of dis- tortions of the face, trismus-like clinching of the teclh, general ms, and more or less marked disturbances of consciousness, we designate the affection ae eclampsia infantum, and use the same term if at the onset or in the course of acute diseases or certain intoxications (more particularly lead poisoning) attacks occur characterized hy (bilateral, more rarely unilateral) con- vulsions and loss of consciousness, which, therefore, difTer clin- ically cither not at all or only slightly from the genuine epilep- tic seizures. The nature of the attacks is as obscure as their ictiology. Whether in eclampsia parturicntium the diminished excretion of urea has to be held responsible for the convulsions, And ihcy thus are to be regarded as ura:mic, whether in the convulsions of children reflex action plays the chief rdie. or whether wc have to deal with autointoxication in which dia- cctic acid occurs, in the urine, or whether in all cases the pres- ence of a bacillus is necessary (Gerdes. cf. lit.) — all these ques- tions have to be left to future investigations. Every one ad- mils that, in the second form, dentition, digestive disturbances, or intestinal parasites, play a certain part, yet there are cer- tainly other factors which deserve consideration in this connec- tion— for instance, heredity, a general neuropJitbic diathesis, the health of the parents, and the possible existence ol rickets. The convulsions of children (eclampsia acuta infantilis) are extremely common. Clinically, all cases of this kind are very much alike, whereas aitiologically difTcrcnt cases differ greatly. In a given case we shoiiUI. first of all. try to determine whether wc have to deal with, anatomical lesions (of the cortex, etc.), r whether these can be excluded ; and only by the most reful examination can we avoid errors and are we able to make n correct diagnosis. Conical diseases (cerebral ith paralysis), epilepsy, spinal paralysis of children, the
I stage of acute diseases, etc., must be uken into cott-
ilion. The prognosis is always doubtful, both in adults and {a hitdren, and the danger is usually greater in pregnant and
inUlc
596
DISEASES OF THE GENERAL NERVOVS SYSTEM.
parturient women than in children. Death not rarely occurj during the convulsions, as we have said above, and wc may assume that out o( a hundred oiscs of this kind there are thirt)', forty, often fifty who die, and the danger increases with ibi; duration of the labor and the long continuance of the pains. In children a fatal issue is often brought about by a spasm of Hie glottis, rarely by exhaustion. Recovery frequently is incom^ plete, and there may be left some psychical disturbances, amau- rosis or disturbances of speech, etc.
About the trcAlment of eclampsia the opinions are even at the present time very much divided. In pregnant or parluri- enl women cold affusions in a warm bath, as recommended by Scanzoni, also the application of large cantharidal plasters to the neck, ought to be resorted to as soon as possible ; from the nervines wc can expect nothing. Mild laxatives, cautious venesection, regulation of the functions of diuresis and dia- phoresis arc in most cases indicated. Often we have no time to think of such measures ; in urgent cases Veil (cf. lit.) has recommended large doses of morphine, beginning with three centigrammes (circ. gr. ss.) and increasing the dose tolwoor three decigrammes (grs. iij- grs. ivss.) a day. The eclampsia of children is. according to some — among them Henoch — beM treated by inhalations of chloroform, which will soon stop the convulsions. One ought, they think, to first cut shoi;t the con- vulsions, and then proceed to find out their cause. Sometimes ihis advice is good. viz.. in cases in which there exists no cere- bral lesion. If one docs exist, or if there are grounds for stis- peeling it, the inhalation will prove to be of no use, and miy rather have a bad eScct. It will therefore be necessary to attempt to settle this question by as short an examination as possible. If wc are unable to make up our minds, a tepid baib and careful affusions, vinegar enemala, or evaporating lotions, etc., to the skin can do no harm. For the beginning this suf- fices ; afterward it may be advisable to prescribe ice to ihe head in congestive conditions, possibly even leeches 10 the head, and in cases where collapse seems imminent, vinegar Cll^ mata. strong wine, or injcciions of ether. The nervines may as well be discarded in the treatment of the convulsions. aS they do no good in this stage ; they niay. however, be used later when the immediate danger has passed. Wrapping the chil- dren in warm moist sheets (after the method of PriessnJul while ice is kept to ihe head. I have known repeatedly to be
EPnEPSY.
597
eflcctual. On the whole, even ihcse measures are not rcltablc. and lite piit't which a physician plays in the presence of Heclampsia ol children is by no means enviable.
I
■ Soun
H>biR-
I
UTERATIIRE. 1. EPILGPSV.
tJnwmcht. ExjxrimenKllc und klinlKhc Unicriuch. iiher Epileptic.
Ulionucliril't, UrcsUu, 1883. (Coniaini all th« oltkr rrficrcncn.) Sourncvilltf, Comtuuicn et S^las. Rwherche* clin. ct ih^rapeut. xur I'tjiilep-
»ie, ITiysiifw, rte. Paris, f8«6. vol*, i-vi. Erlraine)cr. Die Principien dcr EpilrpiirlKh.-indlung. Wlcsbsdcn. iSSA. HotnCii. B«ilr3|[ lur Lvhre t-on (l«ii ejiilvpiugeneii Zonen. Ccnintlbl. f. Ncrvcn*
hcilk.. 1S86. No. 6 OiMl>fcaw«ky. Ucbcr die Alteralion der SeniibilitKl bci Epile]>tiK:hen. MfiL
ObonrtnM, 1886^ 9. UnveirichL Uebcr (rt|>erimcnlrllc Epittpsie. Vcrtiandl. des CongTCMO fitf
inncn Med.. Winbatkn, \t%j. LciiicsikMrl Wteiier tned. Wucbenichr.. 1SS7. j. 6. (On Epilepitic EtpihalenU^) Vnier. DcuiMhes Arch. f. klin. Med.. 1887. ltd. %\. Hcfl 3. 4. V. tkijETiunn. Die operative nchnndlung dci imunuii.iclicnEpileiiae. Deui»che
mlUiarilnil. Zig.. 18S7. ivi. 8. BoatnevUle el Brioon. Dc I'tpilepsje procunivc. Arch, dc NeuroL, NorcmbK;
18SK. xvi. Alane. )>. hMgr, mfi).. tSSS. Kr. 43. Htif. NeuToi Ccntralbl.. |8S3. vil. 5. (Connection of Epilepsy wtlh ihc Evcrr-
lion vS Ure^) BtniwanKFr. Arch. f. Pi>'ch. a. NcTvenkrankb., 1888. xii, ). {Experinicnial
Studies on the Paihogenesit of the AiMck.) Foumier. (iai. dn hAp.. 18S8. Ixi. 10;. (Epilepty nnd Syphilis.) Lcmoine. Sur U pAlho£{aie de r^>ilcp«iie. t^ot;r. ni^l.. iSSS. 16. LjMbmc. Uchcr procuruve Epiteptir. Inicmal. klin. KuntUchau. 1889. V. Baraci. Wienct tned. Wocheokchr.. r889. 7, S. (Ugaticm of the Vcnebrat
ArleriM.) fM. Note wir I'tini iVk forreii et mit le iremhletneni cha ten fjiitepliquca
aprfa les jiita4|iia. Nour. iconof^. de U Sjdpjir.. rSSq. ii. 1. Wigmwonh an'l llickcrton. On n Conncciton between Epilepsy and Errors of
Ocular Refraction. Drain. 1889. xliv, p. 468. WlMcmttiih. Am)knhyiiral inil'n Kp>lcp»ic. Neurol. CcniralbL. 1889, 1$. Pfclia«hv. Tbtse de I.yon. 1S89. ZacdiL Lo spcrim.. 1890. Jan. Meanig. Deutsche med, Woclicnachr. 189a 36. Mairel. Progr. mtd. 1891. 41. (Trratmer»l wiih Doran.) Eulenlnirs. Uel>et den jelii|[en Stand dcr Epilepii&behandkini;. Tbcrap.
Monauh. 1891, \\. 11. 13. Cerner and Sachi. The Surgical Treatment of Epilepsy. Am. Jotim. Med.
ScL 1691. November.
598 DISEASES OF THE CEHERAL NERVOUS SYSTEM.
Ktimmel. Deutsche mecL Wochenschr., 1892, 23.
Babes. Ibid., 1893, 12.
Eloy. La mtthode de Brown-.S<quard. La mMication oirhidique, thyrradinM,
puicrfatique, capsuUire et cirtbrale, ks injections d'cxtraits organiqiwi, la
transfusion nerveuse. Paris, 1893. PoehL Spcimin bd Autmntoxication. Berliner Idin. Wochenschr., 1893, 3& Serin. Deutsche med. Wochenschr., 1893, 41. Beekhaus. Ueber den Einfluss intercurrenter Kiankhciten und phyaol. Processe
auf die Epilepsie. Inaugnr.-DisserL, MOnchcn, 1893, Bouraeville H Cwnet Pn^. niCd., 1893, 49, 5a (.Spcrniin Injections.)
h. JatJUmUn EfUrftj.
Unger. Wiener med. Blltter, 1886, xi. 40-^44. (Jacksonian E[»Ieps]r in Onl-
dren.) Mendel. Ueber Jaclcstm'sche Efnlepsie und Psychose. Allgem. Zdtschr. I
Psych,. 1887, 44, 3. ChaufTaid. De rurfmie convulsive i Torme de I'i^Hlepsie Jacksonieniw. Arch.
g<n<r, de mtA., July, 1887, pp. 5 tl stq. Bouchard. Les auto-intoxications dans les maladies. Paris, 1887. Lloyd. Boston Medical and Surreal Journal, October 15. 1888, cxix. {Cure bf
trephining; and incising the Motor Region.) Lowenfeld. Ueber Jackscm'sche Epilepsie. MUnchener med. Wochenschr,
1888. XXXV, 48.
Pitres. Revue de mM., 1SS8, viii, 8, (Oioical EquivalenU of Jacksonian Epi- lepsy.) Jackson, Hughlings. Brain, July. 1888, xi. Berbez. Gaz. des h6p., 1888. 50.
II. Eclampsia.
Lewandowski. Berliner klin. Wochenschr, 1885. xxii, 37,
Ballantyne. Sphygmographic Tracings in Puerperal Eclampsia. Edinb. Md.
Journ., May, 1885, xxx, p. 1007. ProuK. On the Treatment of Eclampsia Infantum. Bull. g^n^. de thirap,, Mif
15, 1885. cviii. (Recommends belladonna and chloral hydrate.) Rosenstein, L. Die Pathologic und Therapie der Nierenkrankheiten. Berlin.
1886, 3 Aufi. Soltmann, 0. Eclampsia infantum. Real-Encyclopadie der gesammten Heil-
kunde. Wien und Leipzig, 1886. Virchow, R. Ueber Fettembolie u. Eclampsie. Berliner klin. Wochenjchr..
1886, xxiii, 30. OslholT. BeitrSge zur Lehre von der Eclampsie und UiStnie. v. Volkmann's
klin. VortrSge, 1886, 266. Stumpf. Miinch. med. Wochenschr., 1887, xxxlv, 35, 36. Pfannenstiel. Cenlralbl f. GynSkoI., 1887, xi, 38. (Death from Apoplexy.) Baginsky. Archiv f Kinderheilk., 1S87, xi, 1. (Acetonuria in Eclampsia.) Veil. Ueber die Behandlung der puerperalen Eclampsie. Volkmann's klm.
Vortt3ge, 1887, No. 304. Hermann, Ernest. Transactions of the Obstetrical Society of London for the
year 1887, vol. xxix, pp. S39-548. London, 1888,
ECLAMPSIA. 5£)C)
Lantos. Beitr^se lur Lchre von der Eclampsie und Albuliiinurie. Arch. r.
Gynilkol., 1888, xxxii, 3. p. 364. Feustell. BeitrSge zur Pathologic und Therapie der puerperalen EcUmpsie.
Inaug.-Diss. Berlin, 18S8. Love. Weekly Medical Review, iSSo, xix, i. (Eel. infani.) Olshausen. Deutsche Med.-Ztg., 1891, 103; and 1892, 9. Herff. Miinch. med. Wochenschr. 1891. 5. Gcrdes. Ueber den Ec lam psie- bacillus, etc. Eleutsche med. Wochenschr.,
1892, i6. Hofmeister. Zur Charakteristik der Eclampsie-bacilius Gcrdes'. Fortschr. d.
Med., 1893, II, 13. Favre. Virchow's Archiv, 1893, cxxvii, i. Diihrssen. Arch. f. GynSk., 1892. Heft 3. Haegler. Centralbl. f. GynSk., 1892, ji. Doderlcin. Ibid., 1893, i.
CHAPTER IV.
BYSTERO-EPILEPSY — MAJOR HYSTERIA — HYPNOTISM — TREATMENT BV
SUGGESTION.
The reason why we have not treated of the disease, we are about to describe, in immediate connection with hysteria, but have placed it after the chapter on epilepsy, is because the "at- tacks" of hystero-epilepsy appear to the observer as a result, or perhaps we had better say as a sort of mixture, of hysteria and epilepsy. It would, however, be a mistake to infer from this that the affection has any close physiological or patholog- ical connection with epilepsy. It is more likely that we ought to regard it as a higher, or indeed the highest, grade of hys- teria (cf. page 553).
The " major attacks " have been studied exclusively bv Charcot in the Salpetrifere. To him alone and some of his pupils, more particularly P. Richer, we owe our knowledge of their nature and characteristics, and of the rules and definite laws which they appear to follow. Almost every, nay, we can well say every publication on hytero-epilepsy that did not emanate from the Salpetrifire was, at any rate, based upon Charcot's observations and communications, and hardly any- thing new has come from any other source.
The attacks can usually be divided into four distinct peri- ods, though one or other of them may so predominate, as re- gards its duration and intensity, that the rest are somewhat obscured. The first period embraces the epileptiform attacks; the body is suddenly shaken, respiration stops, the palicnl lets fall anything she happens to be holding in her hands, and is thrown to the ground. She is now seized with general convulsions or there develop rapidly extensive contractures affecting almost all the voluntary muscles. In the second stag^c, which immediately follows this, the patient is bounced up .ind
down in bed, she assumes marvelous positions, stands on her 600
i/yS TERO-BFllEPS K.
601
' head, curves the body in the form of an arch {are He tcrde), and howls and roars at the same lime like a wild beast. This is the period of major movements, "clownism." It is fol- lowed immediately by certain hallucinations, under the influ- ence of which the patients assume postures indicative of the most varied passions, the "aitiiuiies patsiotttllcs" of the French. The face takes on. according to the particular hallucination, nn expression of anger, rage, devotion, love, voluptuousness, curiosity, pain, etc., which would give us the impression that the patient is passing in her mind through a period of her life the details of which are unusually vivid in her memory. The postures and expressions may change, although sometimes they remain the same throughout this stage. That of the "crucified " has obtained a certain degree of celebrity, because it seems to be particularly frequent. Finally, the fourth stage is marked by a delirium, in which hallucinations recur with the greatest persistency, some patients imagining they see animals, others terror-inspiring objects of different kinds, and so forth. Automatic movements are nol rare; sometimes an- aesthesias or at least analgesias arc noted. This delirium re> sembtcs in many respects an alcoholic intoxication. The dura- lion and frequency of the attacks %'ary greatly. Some only last from one to hvc minutes, and recur ten. twenty, or even one hundred times a day {^tat dt ma/). It is a characteristic feature, and one very valuable in the differential diagnosis, that firm pressure upon the ovaries invariably suffices to cut short an attack.
If this prenture is exerted conntantly, a% can be done by meant of belts provided with pads, the iitUick^ may l>c ke|)t ulT fur quite a considerable time. At llie celebrated t>all which every year at mi- carfmf is given to the hysterical and bystcro-cpiicptic patients of the Sali>^triire, in which, of course, only females take part, each dancer wears her belt. If this, owing to the movements in danc- ing, slips from it« proper place, no that the prexsure ih taken off the ovaries even for a moment, a major attack comes on, and the patient, twisting and iiiming herself and presenting the most in- crcdit>lr (tisloilions, is removed from the ball-room, without causing the least Interruption in the dancing.
The outlook for complete recover)" in major hysteria is not fttvorsble. All attempts to cure the patients remain in many {ostances fruitless, as we may observe in the Salp£tri^re, where
602 D/SEMS/iS OF THE GEXEHAL XERVOUS SYSTEM. V
some palients, in spite o( the best care and the most excellent treatment, remain (or years without presenting any marked or latiling improvcmi-iit cither with regard to the violence or the Irequency o( the attacks.
Sometimes, especially if the patients come early enough under the care of the physician, inimcdiiite removal from their homes into an instituliuii docs much good. The attacks become rarer and cease entirely after a few months. The treatment in these institutions consists in the "feeding system," which we have menrioncd on jKige 566. as well as the ice-cold douches, to which we have also alluded above.
The brilliant success o( Charcot in the treatment of hystero- epilepsy i<i due to these three factors: (1) The removal Irom home, (3) the cold douches, and (3) the feeding system. With the removal of the ovaries, the use of static electricity and the magnet, the results have been shown to be much less favorable, and we may consider that these procedures, so far as the treat. raent of the major attacks goes, have in the main been dis- carded (cf. the references to mctallotherapy).
Reliable and correct as are the descriptions given by the Charcot school of the major attacks, which wc may incidenLil- ly remark are very rarely seen in Germany, accurately as wc can follow up the different phases or periods of the attack in many such palients. we slill must be very careful in accepting the accounts of the influence of hypnotism upon hystero-epi- leptics and the conditions produced thereby,
In the Salp^lri^rc the patients were hypnotized by means of fixation of the eyes, by the action of a bright light, or the sound of an instrument called a tam>tam, or by similar means; and, as every one must know who has been present at Charcot's experiments, certain individuals were hypnotized in a very few seconds. According to Richer, who, as we said, has made the most careful studies nf this subject in conjunction with Char> cot. which appeared in various numbers of the Arch.de Neurol, from i88t to 1883, there may be distinguished four different stages: (1) The cataleptic. (3) the stage of suggestion, (3) ttic stage of lethargy, (4) the stage of somnambulism.
In catalepsy, whether artificially produced or whether oc- curring spontaneously, as it does in hysteria in very exceptional cases, the members of the body remain in any position tnia which they have been put. Thus, if wc passively bend the arm at the elbow and raise it up, it remains fixed va. this position.
L
HYPNOTISM,
603
\
I I
I P
I I
Flexion or extension in any joint can be produced without (he slightest resistance on the part of ihc patient — " fitxtbililas (crea " ; even the most unusual, uncomlorUble, and strangest attitudes arc retained without any difficulty. How (his most remarkable regulation of the necessary innervation is brought about we do not know as yet, neither have we Ihe slightest (grounds whereupon to base any theory by which we could seek to explain this condition, which is not infrequently also associated with disturbances of consciousness.
The state of hallucinations excited by slight stimulation of the special senses (in reality by suggestion), and designated as automatism, is characterized by total analgesia. The eyes re- main open, and it is a remarkable (act that positions which arc given to the body evoke the corresponding expressions of the face, and, vUt tvrsa, the body assumes the corresponding posi- tion if on the face, by faradization of the muscles, a certain ex< pression — e. g., of sadncsn, hilarity, spite, voluptuousness, or fear — is produced. Dy firmly shutting the eyes of the patient it is claimed that the second stage may be converted into the third, the automatic into the stage of lethargy. In this latter (he excitability of all the nerves and muscles is greatly in- creased, so that, for instance, slight pressure upon the stem of the facial nerve suffices to bring about contractions in all the muscles supplied by that nerve. The ooniraclion l.-tsts much longer than the stimulation, and therefore takes on a tetanic charaaer. At the same time the patient is apparently com- pletely unconscious, and there is total anwslhesia. Now it is impossible to create hallucinations. The tendon reflexes are greatly cxag^rated. If we now stroke the patient lightly over the top of the head, the hypercxcitability vanishes and a new stage comes on, that of the hysterical 5omn.-imbulism. In this condition the patient is susceptible to external influences, inas- much as the organs of special sense are performing their func- tions to a certain degree. He answers questions (with clo&ed eyes and, .is it were, aulomaticnily). carries out instructions, and so forth. By tncal stimulation of (he skin — for instance, by vigorous rubbing — we are able to produce omtraclures. By energetic pressure upon the eyes the patient can again be transferred from the somnambulisiic lo the lethargic condi- tion. The occurrence of hallucinations and illusions is not constant.
For a long lime the theory that this condition was peculiar
6o4 DISEASES OF THE CS-VEKAL XEEt'Ol/S SYSTEM. ^
to hysterical patients when hypnotized, jit&t as the other condi* tions were peculiar to them when awake, was nut doubted, nnd the so-called major hypnotism, as the hypnosis ol the hystcro- epileptics was called, created everywhere great astonishment and admii'ation, especially in those who could actually observe it in Charcot's clinic at the SalpClriiirc. It is only more re- cently that doubts have been raised about the correctness o( these claims of Charcot. Many are inclined to believe that the above-described four stages, which the hypnosis ol hysteria presents, can be produced in any hypnotized individual, and not only in those who are hysterical. and that therefore the "major hypnotism " is no neurosis at all and has no characteristics of its own. Whether the members of the Salpfiriire school will be able to defend their former assertions, and what arguments they can put forth, and whether they will be able to continue to uphold the existence of dilTcrcnt .stages of hysterical hypno- sis after all possible sources of error have been excluded, we can not tell. Mow they will be able to demonstrate the ncuro- muscular hyperexcilabiliiy as physiological and not perhaps as produced voluntarily, as many are inclined to think now, has to be left to the future to decide, and more especially to the abso- lutely necessary repetition of the experiments. Here it is our part only to show on what grounds Charcot's doctrines have been attacked, what proofs have been brought forward to show his doctrine to be untenable, and to state clearly the stand- point which is now generally held as regards the origin and the phenomena of hypnotism.
This is not the place to enter into a consideration of th; mysticisms and the charlatanisms of a man who a hundred years ago propounded the doctrine of the so^ialled magnetic fluid, which, emanating from the magnetizcr. and being capable of spreading itself in space, could receive all impulses of nK>> tion and impart them, but as a matter of historical interest and justice we arc compelled to state lh.it it was Franz Mesmer, born in 1733, who gave the first impulse to a movement which, founded on his arrogant and wild teachings, has passed through manifold phases, and to-day still exists, now that it has been found possible to sift the chaff from the wheat. Magnetism ti> day has succumbed to the same fate as alchemy, and has been discarded, but both bore good fruit; the one opened the door to chemistry, the other to hypnotic suggestion (Bcrnheim).
The fact that there is no such thing as a magnetic fluid, that
UYPKOTiSM.
hypnosis and the phenomena occurring during it arc entirely subjective in nature, and arc to be attributed to external in- fluences upon the nervous system, was disco%*crcd by J.imes Braid, of Manchester, in 1S41, and we are justified in opposing " braidism " to ■• mesmerism " just as wc oppose truth 10 lalse- hood. Braid concentrated the attention of those he wanted to put to sleep by making them keep their eyes fixed upon a bright object ; he assumed that the faligue of the levator pal- pcbne supcrioris, which was simuluineously produced, was the cause of a sleep during which the imaginatiun was so active that spontaneous mental pictures, as well as impressions im- parted by others (■■ suggestions "). obtained the power of actual perceptions. If such impressions are imparted frequently, ac- cording to his observation, a certain habit is established, so that it becomes, caUrh paribus, easier and easier to put the patient to sleep. Braid was also acquainted with the fact that corre- sponding sensations and passions can be produced in hypno- tized persons by putting (heir facial muscles and their extremi- ties in appropriate positions, although he made no attempt to cxpbin these phenomena physiologically. This has only been done quite recently, and even then the study was evoked only by a purely external stimulus, viz., the exhibitions which a Danish magnetixcr named Hansen gave in the German cities. The impression which these made upon the public at large was of such an exciting and uncanny nature, and the whole thing was so puzzling to men of learning, that physiologists and neu- ropathologists were impelled to approach the subject to see whether the apparently supernatural and inexplicable could not be traced to natural physiological laws. One ol the most prominent physiologists. Heidenhain. put forward the theory that, by weak but steady stimulation of the nerves of special senftc, the cells of the cerebral cortex were induced to discon- tinue for a time their activity, thus causing the subcortical reflex centres to fall into a slate of irritation, partly because, owing to this inactivity, the reflex inhibitory inlluencc of the cortex was suspended, and partly because every impulse reach- ing the brain was propagated to a limited area which nece»- •arily led to stronger excitation of the part of the cxcito- motor apparatus Ix-longing to it. With this ingenious hypoth- esis, which many others — Weinhold, of Chemnitz, Grtltzner, IRumpf, Bcrgcr, and Schneider among them — have accepted, wc had to be satisfied, and for the physiologists the interest
eo6 DISEASES OF THE GENERAL NERVOUS SYSTEM.
in ifae matter was thus exhausted, and the subject was aban> duncd.
In patliolc^y and general practical medicine, including, aa we shall see, surgery and obstetrics, the matter obtained a new and increased significance when, mure recently, the observa- tions, which twenty years before had been made by an investi- gator in Nancy, Li^-bcault, were again taken up. Li^bcault had published u work in t866 with the title Du sommeil et des ^tats analogues considdr£s surtnut au point du vuc dc I'actioft du moral sur le physique, in which he expanded the observa- tions of Braid ; he showed that it only needed a concentra- tion of the attention un a single idea, viz., the idea of going to sleep, to make the body immobile, and to produce a certain kind of sleep, which, however, differs from the physiological form (suggestion theory of hypnotism). The same author was the first to show that neither an optical, an auditory, nor a tac- tile stimulus was necessary to bring about hypnosis, but that the impressions from outside, the suggestions that the sleep must and will occur, arc perfectly sufficient ; the hypnotiicd sleeper — whose ideation, in contradistinction to that of the ordinary sleeper, remains in contact with that of the hypnotiicr ^-can be influenced by the latter in his ideas and actions. The fundamental observations of Li^bcault remained unappreciated for twenty years ; the work was not read, hypnotism remained a curiosity, and it seemed inadvisable for a scicntihc physician to occupy himself with it. unless he were willing to gain for himself the reputation of a charlatan or of a man whose actions were suspicious or even dangerous. The credit of bringing to light the work of Li^bcault, wc might almost say of having discovered Li«5be.iull, belongs to Bcmheim. of Nancy, whose merit was still more augmented by his own c«>ntributions to the subject, lie published his first article on hypnotism in 18S4, and with his book, I>e la suggestion ct de ses applica- tions k la thirapeutique, he has, to use a popular but expressirt phrase, " hit the nail on the head." He and the Nancy school have to be regarded as the founders of the successful attempt to make a 5ystem.iiic use of hypnotism for therapeutic pur- poses, and should the treatment by suggestion ever be gen- erally accepted, and beci)me an integral part of our ttier* peutic armamentarium, althnugh at present there seems liit'< prospect of this, Bernheim will be mentioned as its scientific originator. For the adverse attitude which prominent c)in>-
I
I
I
HYP.VOr/SM.
607
I
I
ctahs and physicians in general show even to^ay toward ihe treatment by stiggeslioii there exist a variety ol reasons which it is nut necessary to discuss in the present work. This vne point only need be emphasized here. In order to employ the treatment by suggestion with any real success, not only lime and patience, but, above alt, much experience is needed, which, of course, not every one possesses. Curiously enough, there exists, even among medical men, a widespread naive opinion that anybody can hypnotize, and that the treatment by suggest tion is a branch of therapeutics that comes to a man without any study or practice. It is interesting and even, in a way. amu&ing to see how many, especially of the younger physi< cians, who have had a chance to obscr\-e the results of the treatment, make a few attempts at random, and if they do not succeed almost from the very first in obtaining good results, immediately begin to talk and write about the treatment as "humbug," which once for all should be regarded as unscien- tific. The habitual use of hypnotism is denounced as danger- ous, the condition produced as a pathological one which may ruin the whole organism, or at least the nervous system, etc. Nobody, certainly, who is acquainted with hypnotism will deny that pathological conditions may be produced by it and that it may be dangerous, but is this a ground upon which to simply discard it without a further hearing? Have we given up chloroform narcosis because it has now and tlien proved dangerous in the hands of the inexperienced and careless oper- ator, or have we given up the use of morphine on account of Its poisonous action when used too Irecty and for loo long a period of time? As in all other measures, wc must recognize here indications and contraindic:itions, and this c:tn be done in the majority of cases without dilhculty ; and as everything in this world, especially in the practice of medicine, even the smallest Ojwralion — that of vaccination, for example — has to be learned, so the art of hypnotizing has to be acquired, and one can expect to comprehend the subject and to have success with the pmciice of the treatment by suggestion only after careful and painstaking study.
il is very important to remember that it is never necessary to produce sleep in order I0 achieve therapeutic results, and the terms "hypnosis, hypnotizing, hypnotism." are therefore not well chosen. Only a moderate degree of bodily and men- ul fatigue suffices for the production of excellent results, aivi
6o8 DISEASES OF THE GENERAL NEHVOVS SVSTEAf. ^
it is entirely unnecessary to bring about a liypnolic cundilioB with amnesia, which, if n-ptatcd frequently, tvould unduubu edly have a bad influence upon the patient. This mild degree of fatigue is produced as fuUuws: The patient, having been placed in a conifuriahle armed chair, is asked to think of noth- ing else than of going to sleep. Wc " suggest" to him that be is beginning; to feel tired, that he is no longer able to cotn- plctcly open his eyes, which arc already beginning to close, etc. At the same time he is asked to look steadily at two fin- gers uf the hypnotizer, which at first arc held directly in front of his eyes, but arc gradually lowered, by which procedure the closing of the eyes, which wc desire, is easily accomplished. Now either a difficulty in moving the arms or legs is suggested, a loss of sensation in certain parts of the skin, or some similar idea. The tone of voice in which all this is said should not be loud, but monotonous. The same suggestions must again and again be repeated, and care must be taken that disturbing noises, the slamming of doors or the striking of clocks, and such like, be not heard, so that the mind of the patient may as much as possible be conccniralcd upon the hypnotizer. Some- times, but by no means always, the very first attempt to bring about hypnosis is successful, as I havc'scen in some of Ford's as well as We tlcrsl rand's cases, and the hypnosis may be so profound that wc can already venture to give therapeutic sug- gestions. Sometimes the first, second, and third attempts (ail completely or partially ; then wc must, if no contraindicalioiis exist, try again and again, but under no consideration shouM the individual trials be prolonged beyond two or three min- utes. Without question external circumstances are of great significance. 11 a patient who is to be hypnotized enters a room, in which eight, ten. or twelve persons are lying sound asleep stretched out on easy-chairs and sofas, and is left sitting there quietly for a quarter of an hour without any attempt to put him to sleep, his suggestibility — that is, his susceptibility— will sometimes be materially increased, and it will be a com- paratively easy matter to hypnotize him. But there arc cer. tain internal conditions also which may throw great obstacles in our way, and which must, therefore, not be overlooked. Thus, if a patient does iint believe that he can be put to slcei^ or if he makes up his mind to resist us. a certain amount uf finesse is necessary ; we have to outwit him in order to produce hypnosis without his consent or even against his will. Sudi
IJYPNOTISM.
609
exceptions, and the behavior of the physician who has to con. tend with them, can not here be treated of. Only one artifice we may mcntinn which wc have repeatedly used with very good results in pmducin); the fatigue quickly and surely. We apply a large curved sponge electrode (anode) to the forehead. a second to the neck, close the circuit and allow a very weak (constant) current, just sufficient to produce the characteristic iistc upon the tongue, to pass through the head for a few sec- onds, and then, without the knowledge of the patient, open the circuit and tell him that the electricity passing through the brain will put him to sleep, and as a matter of fact ihts "sug- gested ■' current docs so very promptly and surely. Secondly, ttie mental condition of the patient may stand in our way. It is an observation confirmed by all investigators that it is diffi- cult or impossible to hypnotize insane patients, and that hys- lertcal patients and hystero-epiteptics are the least favorable subjects. In the domain of psychiatry the treatment by sug- gestion, so far as we can judge at present, remains without signiti<:ance : on the other hand, it seems as if certain disturb- ances in nutrition — (or example, general anasmia and chlorosis — facilit.ite liypnoliotion greatly, while an absolute conTxlcncc in the physician, the absence of all attempts to analyze and to test our procedures on the part of the patient while we are trying to hypnotize him, will also materiully increase the sus- ceptibility to suggestions. If all (actors, favorable and unfa- vorable, are taken together, we may say that by far the greater numl>er of j«oplc can be hypnotized ; perhaps one might go so far as to say all, without exception, are susceptible if lime and circumstances allow sufficient repetitions of the trial. For hos- piral practice the dictum of Bernheim may for the present be
t accepted, that the physician who does not succeed in hypno- tizing eighty per cent of his patients for therapeutic purposes does not understand the method. The manner in which hypnosis comes on and the phenomena observed during this state are extremely varied. Sometimes the eyes close suddenly and the patient is .islcep at once ; more frequently this Is preceded by twilchings of (he lids and moist- ure in the eyes, which arc repeatedly closed and opened. Sometimes the lids arc shut during hypnosis, sometimes a fine tremor is noticeable in Idem : again, fibrillary twitchings in the muscles of the face may be remarked. The hypnotic influence does not always produce sleep, and, as wc have said, (his is not w
I
6lo DISEASES OF THE GENERAL XEKVOUS SYSTF.At. V
necessary for therapeutic purposes; but there are different de- grees, (rom the waking state to slight dullness of the senses and somnolence, and, hnally, deep sleep, which latter is called soni' nambultsni. Beniheim in his explanation bases his arguments upon the ideas of Luys, that the different layers o( the cortex are endowed with different functions : those nearest the surface arc supposed to serve lor the sensorium, the middle ones tor the mental faculties, and the deepest for the transference of the will. He distinguishes accordingly nine degrees of hypnosis, and characterises them in the following manner: (t) The pa- tient remains quiet with closed eyes during the suggestion, but can open them without ditTtculty when asked to do so, and claims not to have slept at all. (2) The patient is not able to open his eyes when asked. (3) The patient presents suggested catalepsy and analgt-sia, and remains in the position in which he is placed, but is able, after it has been suggested to him, to change from one position to another without assistance. (4) The patient is no longer able by himself to overcome the sug- gested catalepsy, and automatic, rotatory movements, espcciallj of the arms, can be evoked. (5) Besides the catalepsy, con- tractures can be produced which the patient himself is not able to do away with. (6) The patient presents an automatic obe- dience: he stands motionless il ordered to do so, he rises, walks, and acts, in fact, just as the hypnotizer may suggest Intelligence and the activity of the senses arc intact in these six stages. The patient on awakening remembers everything that has been done to him. (7) In the seventh stage the palieoc presents the same phenomena as in the preceding six stages, but on awakening has quite forgotten what has been going on. (8) Besides this amnesia on coming to, hallucinations can be produced during hypnosis which vanish after the return to the normal condition. (g> The suggested hallucinations persist after waking up — post-hypnolic suggestions — everything thit can be produced in a patient when in a state of hypnosis CM be brought about after he has awakened simply by suggesting to him during hypnosis that it will happen alter he has awak- ened. In this possibility, of exerting an inQucncc upon thcfio- tientfor a longer or shorter lime after he is awake, lies the whole therapeutic significance of the treatment by suggestion. This (post-hypnotic) action, which in certain cases can be obtaiixd in no other way than by suggestion, is sufficiently imporwnl to warrant and insure to hypnotism a lasting place in »cicacc.
HYPNOTISM.
6ll
H It is unnecessary to distinguish nine different stages of hyp*
f DOlism as [lernhein) di<l ; three arc quite sufficient (Ford).
The first is the stage of somnolence, corresponding to Bern.
_ heim's first stage ; the second is that ol hypotaxin (light
f sleep), embracing all the stages from the second to the sixth
of Bcrnheim ; the third is the stage of deep sleep (sonmam.
bulism), corresponding to the seventh, eighth, and ninth of
Dernhcim's classification. It is oi practical importance to
note that frequent trials usually increase the susceptibility of
the patient, and that as a result it is usually quite easy to
produce the condition of fatigue ("somnolence") necessary
■ lor therapeutic purposes. What are, then, the diseases in which we can, with good conscience and good hopes of success, venture to employ the treatment by suggestion ? Wc need hardly say that affcciionii in which we have tu deal with inHammatury processes, new growths, infections, or, in a word, with organic lesions, do not belong to this class; and, us a matter of fact, it would hardly enter any one's head to attempt to cure pneumonia, typhoid ■fever, brain tumors, syphilis, tetanus, etc., by means of hypno- tism. It is a different matter if wc arc dealing merely with cer- t.iin symptoms of such maladies — tor instance, insomnia, difli-
■ culty in breathing, or pains of the most varied kinds, not exclud* •inf; the lancinating pains ot tabes. Ilerc hypnotism should, at
least, be given a trial, yet the main field in which the treatment
■by suggestion should be employed will not be the diseases we
have mentioned, but rather all those which we have designated
and described as functional disorders of the nervous .system.
■ Here motor as well as sensory disturbances can be influenced, the latter having, caterii puribMs. a belter prognosis. Neural- gias, especially tic douloureux, arc often difficult to treat, and
Blhe migraine-like paroxysmal headaches can not always be per- manently removed. Among the general diseases of the nerv- ous system, epilepsy, the classical, hereditary migraine, and hysteria, as a whole, have a very unfavorable prognosis. On the other hand, certain individual symptoms of hysteria (the vagus- neuroses, ana:sthcsias. paralyses) arc very amenable to the treatment. Further details relating to this subject 1 have treated of in a paper read before the International Congress in [Rome (Wien med. Prcsse, 1894, 22). to which the reader is re- tlerred. I would call attention again, however, to the treatment [of alcoholism and of certain functional speech disturbances
6t3
O/SSASSS OF TUB GENERAL NERVOUS SYSTEM.
(stuttering, stammering), since my results in these conditions were especially favorable.
According to Forcl. it is possible to influence certain so. matic functions to some extent — e.g.. the menstruation :in<l digestion — in such a manner that the menses can be brought on at a certain day and a certain hour, and u regular evacuation of the bowels every day can be insured by suggestion. Al- though these accounts come from the most indubitable source, the experiments must again be tested and confirmed. They can certainly only be successful, we should think, in individuals who have been repeatedly hypnotized and are, as it were, "trained." With the treatment of alcoholism by suggestion Forcl also has had uncommonly good results in his instt. tution. The heaviest drinkers were not only for a lime, but lastinjrly cured : but no little influence certainly has here to be attributed to the temperance societies of which such individ- uals were led to become members, f have been able to obtain good results without this help. The behavior nf morphinists toward suggestion requires further study. The results so far obtained seem not to be very encouraging. The communica' tion of Wetlcrstrand (cl. lit.) thai it is possible in idiopathic epilepsy to diminish the frequency and severity of the attack; deserves to be remembered, and the procedure should be tried in cases in which bromides arc not well borne. Finally, wc would call attention to the anesthesia and analgesia which can easily be produced by suggestion, and which in surgery, as well as in obstetrics, may be very useful. I was present at Forel's clinic at the extraction of two obstinate teeth, which, after the proper hypnotization, were taken out without the slightest sign of pain on the part of the patJcnL Possibly the pains during labor may be removed by hypnotism. The ao- aesthesia of the mucous membrane of the fauces may be very valuable in making laryngoscoptcal examinations and the like.
h
/lYPXOTISM.
613
1
I
^^^^^^ LITERATURE.
I 1. H)^olistn — Treaiment by Su|^citiun (from Ibe Year 1SS7).
^B a. Gmrrml.
All th« older f«(«T«nRs han bran MUccied b; JlJtilui (cf. Schmidi's JahifaAcbcr, i8St, Od.
'»>. p. 73).
Birillon, l.a su(;:gruian el jx% apjilic.-t lions A la pf4b|fug>e. (lat. des h6pi..
1S87. 113. Biniwangcr. Dcuuclic med. Wodicnschr., 18S7, xiU, 42. (Present Sute t4
Hypnolism.) Foniaii rl S^gatd. EUmenIs de mjdecine suggtsilvc. Paris. O. Doin. 18S7. Ikmhcim. De In nuKt^tion el rfc ses applic^iiiuns & la ihtrapruiiquc. Pam,
18S8. deuutinc Mtion. B:)krUchcr. Mtinch. nicil. U'uchmschr., 18S8, ixxv, 30. KrolTi-KlHui;. Einc cxpcrimc-nirlle Stuilic auf dcm CcImc'c des llypnoiiMnut.
Slullfpin, 1S88.— EnuHsh triiniblion l>y Charlct G. Chaddock. G. P. Put- nam's Sonv TI1C KnickcrixKker Vma, 1889^ Muck. Zur EinfuliTung inriaa StudiumdeaHypnolisinusund thierachcn Mag*
tietinnui. ncrtin und Nruwicd. 18S8. SchrciMk-Noiunt;. v. Ein Ucitrag zur thcra|in](itchen Verwerlhuni; da Hy|>>
nolismus, Leipzig. Voj^tl. 188S. Seeliicnullcr Dermodcrne Dypnoiismus. Deutsche med. Woehcnichr., |8$8,
"'*■ 3'-34- SaHis. Ucbcf hypfwit, Sugg<-Mion(n. dercn Wcscn. klinbehe und simrrcchiliche
BeikulunK. Ncuwicd. 1888. Cony. UoMon Med. and SurK- Juum.. Not-embcr so, 1888, Ulx. (Tberapeuilc
Value or Hypnolism.) Forel. Schweit. Comap.-BJ.. 1888. xviii, 13. (The Value of Hypnoltsnt far the
Geflwul i'tMctilioncr) Hrncf. ItoUon Mrd. and Surg. Jtiutn.. November to. 18B8. cax. Mason. Ibid.. November. 1SS8.
benthdm. Hy|>noM: durcli Su}Xestion. WIcn. med. Pmse, 188S, uvai. a& JendrasMk. Neurol. CemrAlhl.. 18RS. 10, li. Mcynen. Ueber Ilf-pnotbmuv Wten. med. Pksm. 1888, sxi(, 14. W«1m, D. Pnger med. Wocheitichr.. 1888. xiu. k>. 11. Freud. Wiener mrd. IttHiirr, 1888, xi, }8. 39.
V. Krain-EI>ini[. Ucbi-r Ilj-pnoliimu.v DeuiKhc Med.-Zij;.. 1SS8. 16. p. I96. I><-stM)tr. BtblMgrxphie dci niodcrnen Hypnoiisnius. Ekilin, 1888. Liftieault. Du lommeii provoqu^. nruMJmc /ililion, Pativ 1889. LWgeois. De la sugijeslion el du vimnambuliimc dans kura rappons avecia
jurtfprudencc c( U niMccinc l^ale. V*t\i, Doin. 1S89. HaieriacbiBr. Die Sii)!t(rtliv iherapic and ihre Technik. Siuirfpn. 1889. Bcaunia. Le somiumlmlisme provoqui. Etudes phyaiolofiques ct ptycholo-
fique*. i3e, Paris, 1886. Binmngcr. Thera|>. Mon.ilth.. 1889, 1-4. CUka de la Tourellc. [)ct M) pnoiismut x-om Sundpunkic dcr gcrkbtL Mcdkin.
t Author. German iraniUtion, Hnmburg. IS)!?. _:
I
6l4
DiSBASES OF THE GENERAL SEftVOVS SVSTK.V.
I
Moll. Per Hypnotiimus. i. Auflngc. Berlin. 1890.
Pitrct. De la nicmoirc lUnt I'tl^pnoiiinic. (>at. mM. de Pari*. 1890, Na 47,
f'orel. Der Hypnoiismus. stinc jtsychophysiol. u. i. w. Bcdeulung und jeine
H^indh.ihung, i, AuR,. Stiiitgari, 1891, Wctierslnind. Der Hypnulismu!! und svine Anwendung in (kr prakliKhen
Mcdicin, Wirn und Ixipi'ig, 1891. Moll. Dcr Rappurl in tier Hypnoie. Untenuchungcn uber den thterischen
M.-^^etitmui. Ltipttg, 1891. Liebe:iuli. Ucr kilnslliclic Schaf und die ihm Xhnliclim ZusUtfldc. Ccmun
iran^Ution by Darnbluth. l.eipti>; imd Wirn, Dciiiickr. 189:. Btnswunger. Uebcr die Erfolgc di-r SuKgtsiivilicrapie. Wtcbl»den. 1893. Groetman. Zrilschrin Tur Hypnoiismut. Suggest ionMhcta[»e, u. x. w., 1893. iir,
Jahij;.. nctlin. Herm. BrieK'T. Hindi. SuggL-siion unci Hypnosc. Kuraes Lehrbtich far Aenie. Leipzig. Abd,
1893. Hcclcer. Ucber Autosuggestionen xwithrend (let hypnoiischcn Schlnfcs. Zciisdir.
r, Hypnoi., ii. t, t?. Kuhner. Psych (iihcrapie. Dcrprakt. Aral.. 1893, 5. V. Cor\-al. Sug^esiionstherapie. ISychoiherapie. Eulmburg's Rcal-EflCjrclo-
pttrlic. J. AuU. IIcncdicL Hyptioti.stnus unil Suggestion, Eine klinisch^psychologUche Stodk
Leipiig ui>d Wien. 1S94. Crossmann. Die Bcdruiung der hypnoiischfn Suggcilion nls FleilcnitKl
(iulachien und Hcilberichte Ucr hervomigcndslcn wisaenitctuti lichen Va-
trcter dcs Hypnoii&nius iter Gc^'cnwait. Dcutsclie AusgHbc, Itcriin. 1894.
I /, S^ia/ ( t^ariiiut Oufi tund er tnMfJ iy HyfnofU S»ggrtiimi),
Soltier. Progrfs m^d., 1887,43. (Hystcro-epileptic Attacks uid to have be«ii
cureil.) Mialeu Ca*, des hflp., 1887. t ■& (HypemnMis Gravidarum cured.) BirdMll. Bciston Med. and Surg. Joum., November 10, t88S, cxix, (Tremor.J Frey. Wien. mod. Presse. cuis. 5a %\. (Neuralipa of ihc Fifth cured.) Frty. Ibid,, xxii. ^\. (Sleeplessness cured.) Baierlachn. MunEhener med. WochenKhr., 188S, xxxr, 39, (Rejiort of
Cases.) HKckel. Die Rolle der Suggestion bei gewissen Eraclidnui^cn dci llyitcnc
und dea Hyitnoiiainus. Jcnu, 18S8. Forcl. Schwcii. Correspond, -Bl.. 1888. xviH, 6. Nonne. Neurol. Cenlr.ilbl. 18S8. vii. 7. 8. Riboi. Revue miA. de la SuiiiM rom.. Mars. 1888, i-iii. 3. {Hysterical Hmi-
plegia cured.) Scheinm.inn. Deutsche mcd. Wochenschr.. 1889, at. (Hysterical Aithonn
cured,) MichaH. Deutsche Med.Ztg,. 1889. 63. (Epilepsy Temporarily impnirw'.
Hystero-cpilepty and Hysterical Aphonia cured.) Batth. Sugf^eMiun bei Ohrenlciden. Zeil^clir. f. Ohrenlik.. 18S9. nii- X
Ladame. Internal, klin. Rundschau. 1890. zi, 31. (Cnvins for AictM cured,)
HYPNOTISM. 6lS
T. Schrenck- Not ling. Die Suggestion sthera.pie be! krankhaften Erscheinungen
dcs Geschlechtssinns. Stuttgart, 1892, Etonaih. Deutsche Zeitschr. f. Nervenhk., 1892, 2 und 3. Stembo. Die therapeutische Anwendung der pr^ypnatischen Suggestion.
Petersburger mcd. Wochenschr., 1892, 37, Hilzig. Schlafaltaken und hypnot. Suggestion. Berliner klin. Wochenschr.,
1892, 38. Grossmann. Die Erfolge der Suggestionstherapie bei Influenza. Berlin,
Briber, 1892. Schafler. Netihautreflexe wShrend der Hypnose. Neurol. Centralbl., 1893, xii,
33. 24- Talzel. Drei FSIIe von nicht hysterischen Uthmungen und deren Heilung
mittelst Suggestion. Zeitschr. f, Hypnot., 1893, ii, 1. Forel. Die Heilung der Sluhlverstopfung durch Suggestion. Eine praktische
und tlieoretische Studie. Berlin, 1894.
- "l
-^:;=5-=5 " PART 11.
DISEASES OF THE GENERAL NERVOUS SYSTEM WITH KNOWN ANATOMICAL BASIS.
The anatomical changes, which are found in the diseases belonging to this category, concern the central nervous system as well as the peripheral nerves. The former always suffers, the latter are only in certain cases affected. Whether the changes in the peripheral nerves are to be regarded as second- ary, or whether the entire nervous system becomes affected in alt its parts at the same time, so that the peripheral and the central lesions progress pari passu, can not be definitely de- cided. The nature of the anatomical changes will be discussed under the head of each individual affection. Combinations of the functional neuroses and organic diseases of the nervous system are, on the whole, rare. Such instances have been care- fully studied by Oppenheim (Neurol. Centralblatt, 1890, 16).
CHAPTER I.
MULTIPLE SCLEROSIS DISSEMINATED SCLEROSIS INSULAR SCLE- ROSIS— SCLEROSE EN PLAQUES SCLEROSIS CEREBRO-
SPINALIS DISSEMINATA S. MULTIPLEX.
Although multiple sclerosis is not one of the common affections of the nervous system, it is desirable and important for the general practitioner to possess a clear understanding of it, because the clinical appearances by which the different cases manifest themselves vary within such wide limits and rcminii us now of this, now of that spinal or cerebral affection, with- out ever completely simulating any one definite disease. The typical course given in the books is not st^ry often met with in practice. Much more commonly one or the other of the classical symptoms is not found at all, or, if present, is only vei7 slightly developed. On the other hand, symptoms are occa- 616
MULTIPLE SCLEROSIS.
617
siohally encountered which are not included in the usual de- ' scriptiuns ol the disca<tc. In a word, multiple sclcro&is is quite inconstant in its nianilestatir)ns, a circumstance which often makes the diagnosis very difficult. In the investigation into the pathology as well as the clinical aspect, Charcot has dune admirable and lasting service.
Symptoms and Course. — The course of a classical case is usually as (ollows : The patient first complains of general symp- : toms — headache, vertigo, digestive disorders— soon, also, of scn&ory disturbances in the upper and lower extremiiifs, slight weakness, and u readintss to become fatigued. These symp. toms may persist for months, yet relatively early one or several apoplcctilorm attacks may occur which sufficiently indicate the seriousness of the condiiion. It strikes the patient, as well ! as those who surround him, as a peculiar thing, that whenever
i..
'i-^..vfi-
'■-^^tr-
■-M.
»V-W
J^
-nil/
FIC. (64.— SPKctMKK nr H*if|WTMTiiw ni * Cua or UtitTirtj: Scumum*. (kh \Msm \))^Mm) H«iiriatie SMncr, Mb 48 laliic kiL Bmtau,dn igJiMi)
he attempts to pick up something with his hands, or to make any other movcniciit, a tremor appears, in exceptional cases implicating the facial muscles also (Cohn, Deutsche tncd. Wo- chenschr., l8<)0, 13), hut usu.-illy confined to the upper extremi- ties, which frustrates the intended movement more or less com- pletely. If he attempts to raiite a full glass to his mouth, he spills some of the contents. If he attempts to taxi, the food is jerked 08 his fork. etc. Co-ordinated movements, such as are required for writing or playing the piano, become difficult, the handwriting becomes almost illegible (Fig. 164), and the condi-
6i8
D/XEASES OF THE GENERAL XEXVOUS SYSTEM.
'lion is materially aggravated it the tremor is not confiiicdTo tlic upper, but if also the lower exlrcmiues. the trunk, neck, and head arc attacked, so that on voluntary movements — on attempts to walk, (ur instance — the whole body first begins to tremble, and tinally shakes so violently that the patient is forced to sit or lie down at once. This symptom, which i$*almost pathognomonic for multiple sclerosis, or at any rate most sig- nificant, is called "intention Irenior," a term which docs not. however, imply that the tremor is " intentional," but only that it appears on voluntary (" intended ") movements. During rest no trace of it is observed. When the patient lies quietly and undisturbed in bed no tremor is present, whereas, if he is spoken to, examined, made to answer questions, and the like, a tremor over the whole body develops, which, of course, pre- sents various degrees of intensity. It is most marked and characteristic if the patient is asked to bring his hand slowly to an object — for instance, to a pin laid upon the table. At first the motion is fairly good and steady, he trembles but little or not at all, but the closer he approaches to the pin the more un- steady becomes the hand and the larger become the excur- sions of the tremor, so that to grasp the pin becomes impos- sible. In some exceptional cases 1 ha%'e seen the shaking movements appear on one side only, so that the patient was capable of performing normal movements with one hand and one leg, when those of the other side had become entirely useless.
In this intention tremor the eye muscles also take part; as soon as the patient attempts to (ix a point with his eyes nystagmus appears, which, however, differs from the tremor of the other voluntary muscles, inasmuch as it docs not com- pletely disappear during rest. As a subjective symptom the very annoying sensation of giddiness must be mentioned in this connection, which leaves the patient only when he lt« quietly in bed, whereas it otherwise impedes him a good deal in his movements, especially in walking. Owing to the faulty innervation of the tongue and larynx, we meet with a peculiir speech disturbance; the patient talks slowly, in a monotonous tone, and awkwardly, and his speech is scanning, as he makes a pause after each word, almost after each syllabic, so that it takes him a much longer time to express his thoughts than a healthy man: " Yes— doctor— I— am— very — much— fa— liguH —and — worn-out." As this is spoken in the manner indicateii.
I
A
MULTIPLE SCLEROSIS.
619
\ I
I
without any change ol intonation, it is very characteristic in- deed, and it i», together with the intention tremor and the nystagmus, pathognomonic for multiple sclerosis. It impresses itself so much upon the mind that once heard it can never be iorgotten or misinterpreted.
To give a physiological explanation of the intention tremor is out of our power, and it is more especially not clear why it is so extremely common in multiple sclerosis, where we have such an irregular distribution of the anatomical lesions, where* as in most of the other cerebral affections it is absent. Whether Charcot's idea is correct, according to which the long persist- ence of the axis cylinders in the sclerotic foci has some connec- tion with the tremor, or whether we should hold with StrUm- peil that the loss of the myclinc sheaths, in consequence of which an abnormal diffusion of the ner\-c current from fibre to fibre occurs, is responsible (or this, we can not decide, nor have we any proof of the correctness of Stephana view(cl. lit.) that the existence of sclerotic foci in the thalamus gives rise to the phenomena, nor of Cramer's (cf. lit.) that the intention tremor has to be explained as analogous to the tremoi; which comes OR after hard muscular exertion.
Though we may be justified in looking upon these three symptoms as constituting in a manner the typical picture of multiple sclerosis, we must, as we have said above, at once familiarize ourselves with the fact th.it even these may not all be pronounced, or, again, that there may be others to be found in conjunction with them, developing in the course of the dis- ease. Among these latter we may mention certain spastic symptoms — rigidity of the muscles, increased tendon and sitin reflexes, the above^iescribed spastic walk — which, together, arc liable to simulate, at least fora time, the picture of spastic spin.i) paralysis. This is the more likely as there are no sensory dift. turbuices at all to be noted in multiple sclerosis: only in rare exceptions paresthesias arc obser\-ed, owing to which tabes and myelitis may be diagnosticated, especially if. as sometimes happens, bladder disorders are superadded. A careful study of the sensory changes has been made by Freund {.Arch. f. Psych., iS90-'93, p. 319). That bladder di.^ascs are by no means so rare in multiple sclerosis as was formerly supposed, has been pointed out by Erb. and after him by Oppcnheim (Deutsche Med.-Zlg.. 18S9, yi\ Glycosuria will be found asso- ciated with the disease if there arc foci situated in the Htxtr
620 O/SSASSS OF THE GENERAL KERVOUS SYSTEM.
of ihc fourih ventricle (Richardiire. Revue de mdtl., Juillct, 188;).
Participation o( the optic and other cranial nerves is not very rare, yet it is here much less importaiu for the diagnosis. and much lc») significant {or the course of ihc disease than, lor example, in tabes. Diplopia is nirely met with; and equally uncommon is the neuritis and atrophy of the optic which leads to amaurosis. Uhthoff (cf. Iit.)has pointed out. in an adminible study, that if optic atrophy occurs it is not like the primary atrophy in tabes, but that here it Is a secondary process, which follows an active increase ol the fine conneclive-tissuc elements. U is self-evident that various disorders of sight are .associated with this, yet they often present temporary improvement, and have usually a less serious issue than those of tabes. In gen- eral, it is characteristic of multiple sclerosis that its course is not uninterruptedly progressive, but that it shows remissions, during which the hopes of the patient as well as of his friends for his complete recovery are aroused. I have seen instances in which such remissions lasted for years and the symptoms disappeared to a great extent, and in which, just owing to this peculiarity in the course of the disease, the di.ignosis could be made with some certainty.
Cerebral manifestations arc not uncommon, and frequently 3 siisht degree of dementia develops, which to the patient himself makes his condition more bearable. Ii must also be regarded as a sign of beginning mental weakness, I think, that in some cases the patient frequently laughs boisterously without a cause. One of my patients had spells of loud laughter, which lasted from one to three minutes, and which appeared usually without sufficient motive. 1 have nc%*er had occasion to observe pronounced states of depression or exaltation in the course of this disease. The vertigo, which of course must also be re- garded .is a cerebral symptom, has been spoken of above. Apoplectiform attacks iu the beginning of the disease arc not rare ; epileptiform seizures may be found, if the cerebral cort« is more especially implicated.
It lias been shown by Charcot that in certain cases die development ol the symptoms appears to be abortive and ihe affection, one might almost say. remains talent and can only be recognized by the peculiar sh:iking tremor. Me proposed (of these instances Trousseau's designation, ■■/<)»■/«« /rwfrf."a'"i it seems that in multiple sclerosis such forms arc observed rcb*
^^i
MULTIPLE SCLEROSIS.
631
[tivcly frequently. Soiicqucs studied these carefully under (he Jireclion of Charcot (I'rogrfts mid., 1891, 11), As an example of [the general course which the disease may run I insert here the following history of a patient in my wards, who is still living :
I
Paul W., thirty-one years old, began to be sick ten years ago during his military service. At first, at times be could not feel his TiAe in his left arm, and then in the same year he was often conscious of a slight feeling of fatigue, which was associated with vertigo. He had a good deal of difficulty with his arms and his legs; they always felt as if they were asleep, and any muscular action necessitated the greatest exertion. He could not go through his salutes in the proper manner, and he was repeatedly punished on this account. At the s:ime time he had now and then vomiting and w<::ikness of the bladder for quite a long time, so that, on coughing, small quan* titles of urine were passed involuntarily. On examination, we are told, Romberg's sign was absent and the patellar reflexes were in- creased. A few months later, marked weakness in the right arm and the right leg became manifest, and the acutcncss of hearing became diminished on that side. The pjtttent complained of an annoying double vision. In 1879 he had some difficulty in swallowing; the bolus would Mick in his throat, so that he had to force it down. In 1880 pronounced deliberation in speaking is said to have been notice- able, and the patient at that time also complained that he could not lay his tongue upon certain words which he wished to use. The s[>ccch di«turbance soon passed off, but the patient sullcred from various troubles till January, 1884, in which month I saw him for the first time. He then presented the symptoms of an incipient tabes, but it was noted as a remarkable feature that the patellar reflexes were retained. The lancinating pains, however, the paresis of the legs, the diplopia, the paresis of the bladder, the unsteadiness which ap- peared especially in the dark, seemed sufficient to warrant the diag- nosis of tatKs., and in the out-patient department this diagnosis was made, alihotigh with some reservaiion. The patient declined to enter the hospital. He was therefore ordered galvanism, but was lost sight of in the summer of 1884. Two years later he was treated at a hoi>pital in this city for six months. Although I was unable to obtain a record of the case. I heard that the tabetic symptoms were very indistinct, and that the condition suggested rather a spastic paralysis. The patient was again lost sight of. Finally, on Janu- ary 8, 1888. he was admitted to the medical ward of the city alms- houne, where he still remains. From a note made on January to, 1&88, the following in extracted: The patient is a well>nourished man ; as he bes quietly in bed, the general aspect suggests nothing
fSSS OF THE GENERAL NERVOUS SYSTEM.
lurma]; ii, however, he is asked to perform any movement, ihe
lie body — trunk, head, and extremities — is seized with a violent
ting tremor, which makes it difficult for him to get up, and
passible for him to walk without assistance from another person.
even when supported by two canes. If he is allowed to discontinue all attempts at moving, the tremor gradually abates, and five or ten minutes later he is perfectly quiet again. The patient is unable to feed himself, and can not occupy himself with anything. The Dus- cular strength is retained everywhere. In the domain of the cranial
MULTIPLS SCLBKOSIS.
623
TVM nothing but nysta^us can be noticed, which is especially II marked on (lie right »ide. The facial, hyitoglos-sal, etc., are rmal. The tongue is protruded steadily and siraisht. Speech is ■r, although not distinctly scanning. There are no motor or &cn- 7 speech disturbances. The tendon reflexes in the upper, but
lily in the lower extremities, are increased, and the skin exes are without exception well marked. Sensory changes can irhcre be demookt rated, and the bladder disturbances, which were ■ent ofl previous occuionK, have disappeared. The spinal column (lovbert lender on pressure. Among the subjective complaints
I
^^issjISHs op the general nervous system.
of the patient the dizziness is alone to be mentioned, which, however, even if the shaking movements were not present, in itself would be sufficient to keep him from doing anything.
As a result of this examination the diagnosis of multiple sclerosis was made, and will certainly be proved to, be correct at the post-., mortem examination. It is iaterestiDg, however, that in this case the course of the disease suggested in its initial stages Thomsen's disease (although not congenital), later tabes (with retained knee- kick), then spastic spina! paralysis (conjectural diagnoEis), before the picture of insular sclerosis developed.
Diagnosis. — The diagnosis presents difficulties Id almost every case, owing to the protracted course and the changes in the picttire of the disease during the diRerent periods. Even the most careful examination will not always keep ps Jrom
MJ
^^^ /n2)
F^. 167.— SpectuEN OF Hakdwritino or a Patient (hat-uaeer) with a Hercd-
RUL TaEHOR.
errors, and we must never be surprised if the autopsy does not always confirm the diagnosis made during life. The case of Westphal, in which a multiple sclerosis was diagnosticated, but where post mortem no lesions at all were found, has been alluded to before. In another instance, reported by Frey (cf. lit,), there was found, instead cf the confidently expected foci of sclerosis, a leptomeningitis, and simitar errors would not be difficult to find on a careful perusal of the literature. The pos- sibility that we are dealing with hysteria, in a given case, must always be considered, and then, of course, great weight must be laid upon the presence of other symptoms which would indicate such a condition. The difference between intention tremor, as illustrated in Fig. 164. and other tremors, can be seen by a comparison with Figs. 165-168.
MULTIPLE SCLEROSIS.
6as
Patholog:ica] Anatomy.— The anatomical changes of muU tiple sclerosis arc t'xtrcmely characteristic. Even with the naked eye, here and there, grayish-white (oct are seen in ihe brain, in the white matter of the liemispheres. in the walls ul
the lateral ventricles, in the corpus callosum, in the pons, and on its surface, in the medulla oblongata, in the floor of the fourth ventricle, and in the spinal cord, where the white matter is decidedly more aflcclcd than the gray. The foci are distrib- uted in a very irregular manner ; somclimcs they arc more Dumerous in the brafn, sometimes they are more numerous in
626 nrSKASES OF TKF. GBt/EftAL iS'F.RVOVS SYSTEM,
the cord, often tliey are found scattered equally over tl tire central nervous syslem. If they arc situated on the sur- face, they are seen ihrouj^h the pia, and arc somewliat more prominent than the parts which surround them. They arc generally harder and firmer than the rest of llic substance, and on section they assume a light-pink color when exposed to Ihc air. If they are examined microscopically, they arc found to consist of reticulated fibrillary supportin;;^ tissue, and contain only a few intact nerve fibres ; after the death ol the mcdullarr sheaths, the axis cylinders are preserved for aii extiaordinarir length of lime (Charcot). Secondary degenerations in the spinal cord are often absent (Sirtimpell). yet they are occasion- ally seen (VV'erdnig), The vessels show an increase in the nuclei, later a thickening of their walls, and are seen as yellow dots in the sclerotic foci. Whether the disease of the vessels
Ftc. i«»— CucoifcBEirno)! THxnijoH THt CKKVicAr. EHutttaENsn OP THE Snmi Conn IK « C-UE OF Ui'i.tipli: SrLsiutKi. Iliinlimnl in ctniic add The lict-w colored arau in the white nuticr ntittwnt (he (deroiic lad, (Afiet Bramwku.)
actually {lives rise to the foci is not yet established (Fig. ifij^ Disease of the peripheral nerves has never been demonstrated in multiple sclerosis.
iEtiology. — About the xtiolngy we know practically noth- ing-. It is possible that heredity deserves some considerali<M in this connection, but there arc relatively many cases in whicli
fjtos/s.
this factor can positively be excluded. The influence of infec- tious diseases upon the development of insubr sclerosis has recently again been dwelt upon by Marie (cf. IJL). Typhoid (ever, variola (Sottas. Gaz. dcs hflp., iSgz. 44). scarlet lever, measles, whooping^oiigh, iiilluenza (Massalungo, Silvestri, Revue neurol.. 1895, i, 23). and inlerminent (ever have repeat, tfdly been known to precede the disease, although the material at our disposal is not as yet sufficient to prove a causative rela- tion between the two. With regard to syphilis the connection here is by far less definite than, for instance, in tabes (cl. the case of Buss. lit.). Age and sex seem to be of some signifi- cance, inasmuch as children and aged people seem to be ex- empt. W'estphal and others have only exceptionally seen it in children. Strflmpcll has observed it in a man of sixty. Both sexes seem lo be attacked with about the same frequency, t hiive set-n a case in which alter a severe traumatism (fait Irom a ladder) the three cardinal symptoms of multiple sclcri>sis de- velopcd ; nevertheless I am not convinced that the case was not one of traumatic neurosis. The question c:in only be settled bjf the autopsy.
Treatment. — An effectual treatment for multiple sclerosis not exist. We possess no remedy which will arrest the
Klopment of the foci. The syinplomattc treulment must always be tried, however, and the patient particularly seeks relief from the annoying tremor. For this we may administer, although without raising our expectations too high, vcrairine, physostigminc, one to three milligrammes (grs. V^-'/^) daily, in pills, or solanin, recommended by Grosset and Sar<la, and even icrmed by these authors " mfjictimf»t Ju /aistfau pyramUial" <Progr. tTv6d. 1888. 27). It may be given in doses of from two 10 three centigrammes (grs. '/j-'/,l from three to five times daily. In other respects the treatment is the same as in iiiye- l)tis(cf. page45S)■ R0V%lii (M(Nlfna). Sclcron iiiulli[iU <kl midolk) ipinalc complk^aa Mic«M.
RrSK^o Ennlia. 1S84. Mafic. P. rrogrfe mU., 1884. xii. ij, 16. iS. (Muliiple Scleroito and Inkc-
CtikciburK. N«utoI. ConlnlU., tS&4. 11.
tlitt. DiffierctiiulduKnnKr insiKlten ttysierie unO multipler Sclrtow. Bml.
InU. Zeiuchr.. 1S8}. mi. 11. tnuhoOl Uriicr Nraritis opiic.i lici ratitlipkr SckroK. lktlln«r klU. Wocbco'
tchr. iSSj, 16.
62S
DISEASES OF THE GENERAL NERVOUS SYSTEM,
KoeppeiL Arch. f. hych. u. Ncrrenlcraiikhdtai. 1886, zvS, I, p. 63. (Anv
tomical Examination.) Cramer, E. Ueber das Wesen dcs JStterns. Aus der Krankenabdieilung da
BresUuer Annenhauses. (Prof. Hirt.) Inaug.-Dissert., fireslau, 1886. Moncorva Sulla ctiologia delU aclerosi a placche mi bambini e spccialmmto
sulla influenza palogcnica della aifilida ereditaiia. Napoli, 1887. Gilbert et Lion. Contribution i I'jtude de la sclerose en plaquea 4 forme pora-
lytique de la variiij himipi^que: Arch, de phya. nonn. et palhol., 3(m
sir., Juillet, 1S87. p. 116. Unger. Ueber multiple. inselfSrm. Sclerose im Kindesalter. Ldpzig u. Wien,
1887, TiSplitz u. Deuticke. (NeuroL Centralbl., 1888, 3.) Oppenheim. Berliner klin. Wocheiuchr., 1887. 48. Stephan. Zur Genese dea Intentionnremor. Arch. f. Psych, u. NeTvaUaank-
heilen, 1886, zviii, 3 uhd 1887, su, i. (With sixty-one references.) Buss. Berliner klin. Wochenschr., 1887, sxiv, 49. (Multiple Sderosic in a
Child with Hereditary Syphilis.) Werdnip Ein fall von disseminirter Sclerose des RiickenmariEcs, Tcibundai
mit secund&ren Degenerationen. Med. Jahrb., Wien, 1889, Jahi;., S|.
Heft 7, p. 335- UhthofT. Untersuchungen liba AugenstSrungen bei multipler Herdsderost
Arch. f. Psych, u. Nervenkrankhejten, 1889, xxi, i. Charcot. Sclerose en plaques et hystirie. Gas. hebd., 1889. 2me tir., nri, 7. Buss. Deutsches Arch. f. klin. Med., 1889, 5, & Chaslln. Arch, de m£d. expfrim.. 1891, 3. Nolda. Arch. i. Psych., 1891, 3, p, $6$. Closer. Zdtschr. f. klin. Med., 1892, 3. 4.
CHAPTER II.
TABES DORSAL1S — LOCOUOTOR ATAXIA (rOSTERIOR Sf>l?<AL SCLKKOSIS — LEUCOMVKLITIS POSTERIOR CMROKICA).
TllK second of tlic diseases belonging to this group cer- tainly deserves to be considered as one of the most important of those with which we arc acquainted, not only because it is to be reckoned among the diseases of the nervous system which occur relatively Ircqucntly, and with which the general practi- tioner is not rarely brought face to face, but also because its clinical picture presents so many essential differences that it requires a large experience to fed at home with it on all occa- sions. Nr}body questions the importance of the recognition of the disease in its early stages if only on account of its bciring upon the treatment, but many do not appreciate the ditticultics which this early diagnosis entails. The more cases of tabes we sec, the more we are surprised at the protean charocter of the symptoms, and the more arc we convinced that almost every case offers some point of particular Interest, and that occasionally even an expert can be sure of the diagnosis only afler repeated examinations and long observation.
I.ITKRATirRF.
/. CfnfUi. Momogntfki, tit.
Adamklvwirf. Die Kilckcnmnrksschwindsucht. Wien. Ttfpliti a. Dcuilckc,
1888. Siriimprll, t'ehrr Wnen unil BEhandlung <lcr Tabes. MitlKh. xatA. Wo-
clicnwhr. i8go, 39. KouHiUngc. CDnlriliutinn a I'ilude <lu tatxs et <)c I'KysKric. I'htsi- dr PnTin.
1893, Minor, NpiirnI CcniralW., 1B93. M»biu». Schmiilf* JalirbuchtT. tSiM. ocxli. p. 7), (Ninth Report on Ta1>cs.)
Symptoms. — The symptomatology of tabes is so comprc. hcnsivc that in order to get a clearer idea of it we shall in our description separate the cerebral from the spinal symptoms.
The cerebral symptoms which appear in tite course ol the
6»}
630
I>ISEASKS OF THE GES'EKA!. KERVQVS SYSTEM.
disease are referable eillier to ttie craninl nerves or lo the bnio substance. When the latter is alTccted. it is sometimes the cortex, at other limes the white substance, or again the basal ganglia, which arc most deeply implicated.
In consideriitg the cranial nerves, we shall find that there ts hardly a single pair which can not be alTectcd and in which lesions have not been repeatedly described i» cases of labes. However, as we shall see later, not all of them arc implicated with the same frequency. Among them the nerves supplying the muscles of the eye arc most commonly, the facial most rarely, attacked. Between these extremes we may put in de- scending order the vagus, the optic, the fifth, the olfactory, the glosso-pharyngeal, the accessorius, the hypoglossal, and lasily the auditory. I have observed three cases in which several pairs of nerves were involved at the same time and in which the onset of the disorder was somewhat acute.
The lesions of the olfactory nerve possess no great prac- tical significance, and it is not quite certain that they arc not more frequent than is generally supposed. They consist of a weakening or even total loss of the sense of smell, or in the perception of peculiar, often disgusting odors, as we hate shown on page 26. We do not know whether these changes are due to anatomical lesions or only to some functional dis- turbances, and but little is known about the course of such dis- orders of the sense of smell. Occasionally, when examining into the condition of the sense of taste, one may accidentally discover an affeciion of the sense o( smell without being able to ascertain how long it has already existed, as it can easily have escaped the notice of the patient. Only those who uk tobacco or snufl perceive the defect very early and appeal W a physician for advice and help. Unfortunately, we can do but litilc. The treatment of these affections has been dealt with on page 27.
The roost frequent lesion of the optic nerve in tabes i* atrophy or gray degeneration. Usually both eyes become af- fected, if not simultaneously, at least within a short time of each other, and it is quite rare for one eye to be diseased while the other remains healthy for any great length of lime. The patients complain that everything seems as if covered by a gray veil. The loss of vision is particularly rapid at first : i< then becomes much slower, and the complete amaurosis occuH much later than one would have expected from the brusqi"^
■MH
TABES DO/tSAUS.
631
I
I
onset of the trouble. Along with this, a narrowing (not al- ways concentric) of the visual field appears, as the peripheral portions of the retina arc the first to become impaired in their limctlons. The perception for color may also be aSected, as wc pointed out un page 34. The order in which these changes occur is not always the same. As a rule, however, the loss of color perception and the narrowing of the visual field precede the lessening in acuteness of the central vision, and it Is excep- lional to find diminished acuteness of vision and marked dis> turbance of color sen&e combined with a normal visual field.
With regard to the frequency of the affection ol the optic nerve in tabes, the usual statements ol authors hardly give a correct idea ; the more careful our examinations are the more oJicn do wc find them. According to my experience, it may certainly be s:ud that they occur in sixty per cent of all cases (cf. the excellent piece of work of Martin, r)e Talrophie du nerf Dptique et sa valcur prognostiquc dans la scl^-rosc dcs cordons posl^rieurs de la moelle, Paris, Assclin ei Houzeau, TS90).
The ophthalmoscopic examination shows a pale gniyish white or bluish while, but not pure white, discolor.1t ion of the disk, which is thought to be produced by the obliteration of numerous fine vessels in the optic nerve. When the ambly- opia is marked, but no perceptible changes in (he disk arc found, we must think of a retrobulbar degeneration of the optic nerve. From a pathological st.indpoint we arc dealing with a degenerative atrophy, first of the medullary sheaths, and then of the axis cylinders. The theory that these changes are due to an action of the sympathetic nerves or to changes in the vaso-molor nerves brought about by the spinal disc.isc is quite untenable, (or the process is a neuritis in which we have u wasting of the nerve fibres and changes in the interstitial tis- sue, such as have been described on page 351.
For the optic atrophy the outlook is altogether unfavor- able : although a slight impro%-cment or a temporary arrest of its pnigrcss may give the patient a delusive hope of recovery, the termination is aUv.iys in total blindness. It is true that the process may take several years, during which the patient is still able to find his way about by himself with the aid of a Stick.
With such a prognosis we shall not be surprised if the treatment is without avail. The subcutaneous injections of strychnine, one milligramme (grs. 'i.) twice daily in the neigh-
6i2
DISEASES OF THE GENERAL NERVOUS SYSTEM.
bnrhond of the eye, as proposed by some, are of vatuc only because they give the patient the comforting satisfaction that something is being done for him, but they really have no cura- tive properties, and it is improbable that they even postpone the unfavorable issue.
In a few isolated cases transient lachrymation has been ob- served {Patrolacci, Thfrsc de Montpellier, 1886; K6r6, L'Enc^ pliale, 1887. vii. 4),
The nerves which supply the eye muscles— the third, the patheticus, and the abducens — the affections of which have aK ready been considered in Part II, Chapter 111, frequently be- come attacked in the course of labcs. Besides the insuffi- ciency of convergence, the central form of which may be termed motor asthenopia (Hiibscher, Deutsche mcd. Wo. chenschr., 1893, 17), one often encounters a diplopia resulting from a panilvsis of the ocular muscles. This may appear sud- denly, and after a longer or shorter duration disappear as quickly ; or, :igain, it may recur repeatedly and be a source o( great annoyance to the patient in his daily occupations. An abducens paralysis may also occur by itself, and, finding this, one should always look for a commencing tabes, for it is fre- quently the first sign of this disease in an apparently quite healthy person. If the affection remains stationary, it is to be regarded as being due to a nuclear Jesion ; the same remarks apply to a ptosis which, occurring by itself, is also a suspicious sign, and should lead us to took for tabes. In cases of oculo- motor paralysis the lesion is also relatively frequently nuclear (page 46). Waitevillc (Neurol. Centralbl.. 1887, 10) has called attention to a paralysis of the movcmcnis of convergence, espe- cially in the initial stages of tabes. Borel, in a paper published under the direction of [..andolt in Paris {.Arch, f. Ophthalm., Novembre, 1887), has dealt with the same symptoms. Several of the extrinsic eye muscles may be affected at the same timft and an ophthalmoplegia externa is not infrequently observed in the course of tabes.
The behavior of the intrinsic eye muscles is not less inter- esting, and the condition of the pupils deserves the most thor- ough examination ; they are rarely normal and of the same size in both eyes. Frequently some abnormity of reaction is de- monstrable : the marked contraction (inyosis), the difference in the size of the two pupils (anisocona), and the loss of the light reflex have already been mentioned. These changes force
{
TABSS DOJISALIS.
6J3
US ' to assume a lesion in the floor of the fourth ventricle JOuillcry).
The ophthalmoplegia interna of Hutchinson, in which be> 'sitles the loss of the li^ht rvflcx there is :i1su paralysis of the mus<:Ics of accommodation, is much rarer. The pupils of those ■alTlicted with tubes may frequently be found to dilute promptly and normally under strong and painful irritation ol the skin, as, for CTcaiitpk-, that produced with the faradic brush. B[ The rdle which the affections of the fifth nerve ptay in this disease is quite suburdinale; paralytic conditions of either it« motor or sensory branches as the result of tabes have, it seems, never been observed except in Wcstphal's case, in which there was degeneration of the ascending root of the fifth, and among the signs of irritation only the headache, tnict-ablc to the nerve endings in the dura, is occasionally met with. A certain rela- tionship is said to exiKt between tabes and genuine migraine, but in considering these cases one must make sure that the mi- B^^ine has not been inherited, and furthermore note whether ^thc attacks become more or less severe after the development of ihc tabetic symptoms. According to some observations, in such cases the headache o( the migraine becomes less and less severe, and eventually disappears, while the nausea and vomit- ing still persist, so that it is then impossible to say whether wc are dealing with a gastric crisis of tabes or with an abortive attack of migraine. In certain cases of hemicrania, il there has been, for instance, a syphilitic Infection at some previous limPt it is always well to examine carefully for any traces ol tabes, more especially for the absence of the patellar reflex. Occa- sionally one meets with parxsthesias in the face, the patient oimplaining of a sensation as if one half of the face and the lips were swollen ; this is probably also due to an affection of the ascending root of the fifth nerve.
Lesions of the facial nerve arc so rare in tabes that, when they occur, one can not help raising the question whelliiT they are not lo be regarded merely as accidental complications. Among three hundred and forty-live cases of locomotor ataxia, I have observed only two in which any of the muscles supplied by the facial were affected. H About the same may be said of the auditory nerve. There Vis no question but that lesions ol this nerve may be caused by tabes nr develop in the course of the disease, but they are very ire indeed ; ihey manifest themselves by a diminution or a
634
DISEASES OP THE GENERAL NERVOUS SYSTEM.
total loss of the power of licaring. The patients complain o( deafness, which may have developed gradually or have come (in acutely. In both cases the symptoms are due to organic disease of the nerve ; in the former we have to deal with a gradual gray degeneration of the nerve trunk, in the latter with a nuclear affection. Too few cases, however, of involve* mrnt of the atidiiory nerves in tabes have as yet been ob. served to enable us to speak with much certainty of their pa- thology (Hermct, L'Union mi^d., 1884.86: Morpurgo, Arch. I. Obrenhlk., 1S91, xsx, 26). Under what conditions the so-called Meniere's symptoms appear in the course of tabes requires to be studied more closely. I have seen them in two of my cases, but they disappeared again in a few weeks, and in these cases, unfortunately, no anatomical ex-iminalion o£ the internal ear could be made.
Functional disturbances of the nerve of taste have now and then been described in the course of tabes. In a few instances as in the case of Erbcn, which we considered on page 108. the nucleus of the glosso-pharyngeal nerve was degenerated, and during life such derangements of the sense of taste existed thai the patient was at times unable to distinguish sweet things from those which were acid or salty. To these lesions no great practical significance can be attached.
On the other hand, there is a great v.iriety of manifcsta. tions associated with tabes which are due to lesions of the vagus. In this connection wc have disturbances more gener- ally of the digestive, but also of the respiratory and circulatory organs. They occur with irregularity, and may disappear again quite suddenly. Following the suggestion of Charcot, we designate ihcm "crises." Of those affecting the digestiit system the so-called "pharyngeal crises" are relatively the rarest. These consist of paroxysmal movements of degluti- tion, which occur from twenty to twenty-four times a minute, and succeed one another in this way for ten or twenty minutes: the attacks may be associated with a noisy inspinition, and may suggest hysterical singultus : in some cases they can tw produced at will by pressure on the side of the larynx (Oppen- hcim).
The gastric crises (Charcot) are far more frequent ; they consist of paroxysmal attacks of retching and vomiting, during which the patient, without any particular exertion, may vomit lat^e quantities of strongly acid, slimy, or watery material, some-
TASES DOItSAUS.
«3S
I
I
I
jttraes of ft blackish appearance, after which he feels greatly re- lieved. These attacks arc rcjMrated (or several days, sometimes tor a week or two, once, twice, or even odener, every day, and then disappear entirely fur a longer or shorter period. In gome cases the vomiting is associated with cardialgia, but tisii- ally it is uncomplicated. It is not at all connected with the taking of food ; indeed, it not infrequently occurs early in the morning when the stomach is empty, and if the patient be a drinking man it may arouse a suspicion of the morning vomit- ing of drunkards. The diflcrrntial diagnosis is. however, not at all difficult ; if the vomiting be associated with vertigo, a sensation of anxiety, and a quickening of the pulse, It can not be considered simply as a "gastric crisis." This paroxysmal vomiting is of the greatest importance for the diagnosis of tabes. It is frequently regarded as dependent ujion some stomach trouble and treated as such lor a long period without any sign of improvement, until finally, perhaps by accident, our attention is drawn to some other symptom which places ihe diagnosis beyond doubt. If a person have paroxysmal vomiting and complain occasionally of violent rheumatoid |Kiins in the legs, we should examine most carefully for iat>es, and wc shall frequently be surprised at the case with which wc can make a diagnosis, and wonder that wc had ever been under the impression that the patient had simply " chronic gastritis " and ** rheumatism." The statement of Eckert (Die intcstinalen Erscheinungen der Tabes, Inaug.-Diss., Ilerlin, 1S87) that gas- tric crises must be divided into those of central and those of reflex origin deserves to be investigated more closely. In the central form he assumes, besides a general condition of irrita- tion in the bniin, some affection of the nucleus of Ihe vagus, in Ihe reflex form a peripher,il irritation of the vagus which, under certain circumstances, may be produced by the ingesla. He holds that in the latter cases the %-oniitlng is not associated with any distressing nausea, so that the patient suffers rela- tively little.
Sometimes intestinal dlstiirb-inces manifest themselves by intense " lightning " pains alxiut the rectum ami anus, the " anal crises ■' : in other cases by tenesmus, which forces the patient to go frequently to stool, though he is able to pass little or nothing : and [.istly by the so-called tabetic diarrhtra, about the causation of which we arc absolutely ignorant. This diarrhcea may be more or less persistent, and be followed by an equally
636 D/SBASES OF THE GENERAL NERVOUS SYSTBV. ^
protracted and obstinate constipation. Incontinence of fxces is rarely present, thougli on rectal examination we shall occa- sionally discover sensory disturbances, particularly anscsthesta of the mucous membrane. Paresthesias may also occur, and the patient may experience a sensation as if be had a foreign body En the rectum.
By "laryngeal crises" wc mean those paroxysms of dysp- na-a which may occur when the palient is lying down, or. in other cases, only when he attempts to move or walk about. Sometimes they appear in the form of peculiar suQocative at- tacks, accompanied by violent coughing, and are often pre- ceded by a sighing or whistling inspiraiion. These attacks may last several minutes, during which the suffering may be so intense that the patient gives up all hopes of recovery. Attacks of even moderate intensity, in which a long, sonorous inspiration follows several short expirations, are most disagree- able for the patient, and appear very serious: under some cir- cumstances they may be mistaken for whooping-cough. These crises arc caused by changes of temperature, speaking for a long time, or by strong odors, smoking, etc. The result of the laryngoscopic examination is freciucntly negative ; in other cases one Jinds p^iralysis of some of the laryngeal muscles; here also, in all probability, wc should distinguish a central and a reflex form.
Abductor paralysis — t. e., paralysis of the muscles that opec the glonis— sometimes occurs among the early signs of tabes, and may lead to serious danger of suffocation; but wc are unable lo say whether this should be attributed exclusively lu paralysis of the abductors, or to spasm of the adductors atone, or to both conditiims,* We may consider the condition de- scribed by t»r^y (Brain, January. 18S8). in which the voice often breaks and takes on a high falsetto, asa kind of " laryngeal ataxia."
Attacks of angina pectoris, with all its characteristic symp- toms, are rarely met with in tabes, though Vulpian, among others, has seen them (Kevue de m6d., 1885. v, i).
Lesions of the acccssorius arc considered as rarities in the course of tabes. They are occasionally found associated with a posticus paralysis when the outer branch of the spinal acces- sory is also affected ; the stcrno-clcido-mastoid and trapezius muscles then show atrophic changes. In a case observed br Martius there was an atrophic paralysis of the upper portions
TABES UOKSAUS.
6l7
\
of both trapezii, while the sterno-cleido-mastoids, which also receive fibres from the cervical plexus, were not aflccted. Whether, and if so under what circumsunces, one or both of the two nuclei of the accessory nerve are affected (the luicleiis accessorius vagi and the nucleus spinalis) wc arc absolutely ignorant. It is also uncertain whether syotptoms of irritation in the domain of the acccssorius — c. g., torticollis — ever occur in the courM; oi talH's.
Among the lesions of the hypnglossus there is one which deserves a special mention in this place— that is. the hemi- atrophy of the tongue described above, which Ballet (lit. jwigc 144) stated was relatively often observed. He even went so far as to say that, when one found this hemiatrophy, tabes
T\f. ija— ll8»iiATK)«ir or tiik Tokoub iw ak .nii:. -i;:!^ Child ipencn;^ obaerratiait>.
)-f«nxrTt.y llutTcir
should always be suspected. We can only agree with him lo a limited extent. Wc have certainly found hcmi.itrophy in cases of tabes, but one should remember that it is in ilscit a rare afTection. and that it exists more often independently than asso- ciated with tabes. In addition to the two cases mentioned on
638
D/SEASES OF THE GF.XEKAf. A'EXfOl/S SySTEif.
pagjcs 143 and 144 1 have recorded another (Fig. i;o) in which there was likewise iiu (race ol locumutor ataxia, li seems that The hypoglossal nucleus is not very liable to ihe degenerative processes of this disease.
Cerebral disturbances of the most manifold variety appear in the course of tabes, and in the first place attention must be called to the paroxysms of vertigo which come over the pa- tient when he looks up or makes quick movements ol the head, and which impel him to seize the nearest object to prevent himself from falling. There may also be found psychical de- pression and a feeling of dread and anxiety, which in some cases may be followed by well-marked psychoses. Among the not very rare forms of psychoses in this disease we may men. tion paranoia, melancholia, and simple dementia : but far more frequent and important than all these taken together is gcn^ cral paralysis, which very frequently accompanies tabes. Bui here we must try to make out which ol the two affections was ihc first to develop, (or in some instances the tabes precedes the paralysis, while in 01 hers the reverse is the case. The pn>ccss can extend from the brain to the cord or from the coni to the brain, as the case may be. and Westphal was certainly justilied in making the statement that " in certain persons there is a peculiar disposition ol the nervous system, and that this, under the influence of diflcrent e-xciting causes, the action of which we do not understand, expresses iiscti in the form o( affections either of the spinal or cerebral portion of the nervous system or o( the peripheral cranial nerves, the different aflcctions coming on in some cases nearly at the same Lime, in other cases ai varying intervals."
Epilepsy occurring in connection with tabes has already been considered in the chapter on the former disease. On this subject Schliepcr, working luider my direction, has published an article (Inaug.-Oiss., Breslan. 1884).
The cases of hemiplegia wiiich occur in the course o( tabet are mostly of the indirect variety — that is, they disappear in a shorter or longer lime — and do not owe their origin to the rupture of vessels or to lesions o( the internal capsule. The face is usually only slightly aflccted, and that only for a short time, and the extremities are not wholly paralyzed, but are only in a paretic condition, which usually disappears without any sort of treatment. I have repeatedly seen such cases oi hemiparests come on without any wanting and with only J
\ I
TAffSS JtO/tSAl/S
639
I
1^
ght disturbance of consciousness and entirely disappear ict a relatively short lime. A. IJcrnharcil (Arcliiv (. Psych, u. Nervenkrankheitcn, 1883, xiv, I) has recorded instances in which they were accompanied by aphasic conditions.
1.1TEKATUKE.
r. Tif ttrtiit anJ lAf Cntmal XrrtHi.
Ilergcr, D«* ttoublci ocuUlm ilans Ic t.ibrs. tic. Kcvue ilc m*il,. iS/ga, 3. Schultie. Arch. f. Pnych., 1889. nxt, i. (I'.-ini lysis of the Muscles of Masiica-
llon.) Cluiaigner. Dcs irouMcs auilitifs dans Ic lalin. Tti^w Ac Paris, 1889. Mati"-'*- Arch. C Pt}'ch.. 1S91, *xi, I. (Symptomi rcTeniMe lo Ihe Ear and
Minor. ZdiscKr. (. klin. Med.. 1891. y6. (H«m!|>)egla, «tc.)
Charbcrt. Cutlrubcs i, (l{-tiiit c^>hj|ique cxmcifris^ jur la Kdondo 3"*.
y-, 4-. ;- el 6** jNtiro crAniennes. Protrrb tntd., 1891, 30, uiOery. Ucbcr <tic io|>i«rlie DiagncKiik dcr PupdmrcrKbdnungen bcl der
Tabei. I)mt«chr tncd. Wochcnschr.. 1891. ji. Cliixwick. Tabciinil Bulliarsympioni*n. Newrol. C«nlni1l>l . iSyj. u. ICuti-nhurg, Uebcr <-ini^c- Faille von T.ibcs mil Dcihriliguii); (ks V'jgus und
AccMSorws. Inaug.'DiMcn., licTljn, 1893. Ilhrrg. Chufli^AniMiIen. 1893. p. J03. (AccwaorUii Para>)sis.) LaJhlle. Dn CriMs gasinque*. Cu. dct hAp., 1894. ^
B So gre.it importance has been attached to the spinal symp* toms that they ustully occupy the ^renter part ol nil dei^crip- liontt of the clinical history ol the affection, and have been allowed to predominate so far that all other symptoms have been treated of "as being of little moment, and as if the only lesion was that in (he spinal cord. And stilt, it is not rare to meet with cases in which the spinal manifestations have been for a long pcriixl of very tittle importance, and with a few in which they have never attained to any prominence, while the Ktnajority of the troublesome symptoms were due tu affections Hd( the brain and its ncrv<:s, and the lesions of the peripheral Vnervesgave rise lo more marked symptoms than those ol ihe spinal cord. Observations of this kind, the number of which will be rapidly increased by conscientious ex.-)minalions, f^> to show that the entire nervous system participates in the morbid process, and to consider this participation to be the rule is Absolutely necessary lor a correct comprehension of the pathol- ogy of this disease.
The symptoms produced by the spinal lesions concern mo- tility, sensibility, and the reflexes.
640 DlSf.ASES OF THE GENERAL NERVOUS SYSTEM.
I I
The disturbances of motility are mnnifold: tliey depend partly on a decrease in the strength of (he muscles, partly on disturbances of co-ordination. The first is not %'ery common; on the contrary, one can frequently observe that the mere _ strength in the extremilies has not been at all aflecicd, and ■ yet the motility has suffered. This condition depends, then, upon a faulty co-ordination, and is broadly deMgnatcd as •'ataxia." Movements, such as walking, writing, taking hold of an object, etc.. for the proper execution of which the simul- taneous working together of several muscles is necessary, arc designated as " co-ordinated." For such movcmeols more than a simple innervation of the muscles is requisite; it is necessary that each concerned should receive, so to speuk, the proper amount of innervation and at the proper lime, so that the contraction of the various muscles may take pluce at the right moment. It is only ivht-n all thtse various factors are pnij*- erly combined that the movement is correctly cvccutcd, and if one of them be disturbed the entire movement becomes ataxic. Even if not pathognomonic, it is certainly very characlerisiic of tubes that in the later (rarely in the earliest) stages, ccrtaia movements become ataxic, particularly those of the lower e\- trcmitics, and, above all, the gait. Such abnormities are mcl with much less frequently in the upper extremilies. and the movements necessary for writing, handling a spoon in eating. and the like, usually remain normal.
The gait of a tabetic is readily recognized even by one who has had little experience in that direction ; one notices particu- larly that the patient exerts his eyes almost as much as his fed. that he watches every step, and in passing over small obstackf. as for example a curbstone, determines exactly where he mu*I place his foot. It he ceases to use his eyes in this fashion lot any reason, even for a short time, the movements of the legs become uncertain, and he is in danger o( (ailing. But not even with the help of the eyes can he walk witliout difficulty. He does not step out in the usual way ; the legs are thrown out loosely, and in putting the feet to the ground the heels comf down first ("strutting gait"). The manner in which the feet are raised, the legs thrown out, the stamp with which the frtt touch the ground, readily enable one to diagnosticate the ta- betic gait at a distance, and we shall seldom make a mistake tl we consider a person who walks in this manner, supported on a stick or by an attendant, as affected with locomotor ataii-i'
TABES DOKSAUS.
65l
ich ns greetings and stoppir
uilk
lets of politeness.
I the street, do not afFord these persons much pleasure, for they distract their attention, which has to be kept undivided if ihey would walk in safety. The uncertainly and insufficiency of the innervation of the different groups of muscles is apparent not only in the walk. but even while the patient is standinf; still. He is nut able m stand up straight without tottering, parlicularly when he closes
■.his eye«, and he sways to and fro and (alls unless some one is at hand to sup|>ort him (■■ Romberg's sign "). The smaller the supporting basis— that is. the nearer together the fcet—llic more pronounced does the phenomenon become. In some cases it may be accompanied by irregular contractions of the call muscles.
■ The much rarer ataxia of the upper extremities produces inability to write, to play the piano, to sew. etc. With closed eyes the patient is unable to describe circles in the air wiih his
Barms, to bring the tips of the index lingers together Irom n dis- tance, or tf> touch the end of the nose quickly with his finger. All such movements are carried out with more or less irregu- larity. It is exceptional for the upper extremities to become affected at an early period or severely : as a rule, we can not detect ataxic movements in them in the earlier stages, and when
Kthey do occur they can, at least in some instances, be traced to some special cause. In the case of Bernhardt (Zcitschr. I. klin. Med., i8S8, xiv. 3. p. 289) they were due to the occupation ol
ftthe patient. Remak (Berlin, klin. Wochcnschr., iSSa 22) has also published a similar case of ataxia afleciing only the upper extrcmilics. It was associated with cphidrosisunil-iteralis. The helplessness of the patient reaches the most exircme degree when the ataxia affects all four extremities; as in the case of Fort (Hublin Journal of Medical Science. 3d s.. 1886. clxxiiiV
B But we must also distinguish between spinal and cerebral
'or the so-called cortical ataxia (page 186). A conclusion im- portant for the differential diagnosis may be drawn from
^obscr\-ing the influence which the eyes exert over the co-ordi-
"nated movements. In spinal ataxia these Ijecome belter regu- lated and more certain when they are under the control of the eyes, while in cortical ataxia this factor has no influence.
_ The physiological cause of ataxia is not as yet positively
^known. but even to-flay is a source of contention and still the object of continued investigations. While some, as IJene<likt,
4>
64=
D/SBASES OF THE GElfERAL NEfSVOUS SySTEM.
Cyon, and Jaccoud, consider that wc have to do with a disturb- ance of the reflex activity in the cord, others, with Friedreich, and after him Erb. are of the opinion that there is a disturbance in co-ordinating fibres, the course of which they confess c:>n not as yet be made out. Thirdly, others, with Lcydcn at their head, consider disturbances of sensibility to be respon- sible for the ataxia. According to these, interruption of con- duction in the sensory tracts of the gray mailer causes a brc^ik o( the reflex arc between the scnsury nerves of the muscles and the motor nerves. "Owing to this interruption, the un- conscious regulation of the movements, which adapts them to the state of coiitrnciion or relaxation of the nuisculiUure, disappears" (Wernicke), and ataxia is the result. This "sen- sory ataxia " has always had many opponents, for one was obliged to confess that ataxia often occurs when no sen. sory changes are found ; but in spile of this fact some one i$ constantly returning to this theory, which has found a strong advocate in Goldscheider. In a comprehensive article (Zeil- schr. f. klin. Med., \8S$, xv, i, 2) he subjects the meaning of the term "muscular sense" to a fresh examination, and comes to the conclusion that lour factors arc combined in the formation ol the muscular sense, viz.; (i) the sensibility to active, (2) tu passive movements, (3) the perception of position, and (4) the perception ()f weifiht and resistance, fie then states that tn all cases of ataxia in which the sensibility had been tested the examination had been imperfect in some detail ; he points out that, for example, in the otherwise admirably conducted observations of Friedreich, the examination of the sensibility to movement was omitted. According to his view, therefore, it is only necessary to perfect the eicaminntion of the sensibility in order to come to the conclusion that sensory disturbances are responsible for the ataxia.
When one considers that wc are ignorant of the origin of the normal co-ordination, and remembers that it is not congeni- tal but must be learned by practice, in which controlling and correcting influences, which arise from the periphery, come into ptav. it is not difficult to agree with .Strlitnpell. who con- siders t1i:it the ataxia takes its origin from the dit>appearance or insufficiency of those regulating influences, because "the possibility of successfully tnmsferring Ihem to the tnotor ap- paratus is removed." Wc should then have to regard the gray fiubstance and the ganglionic cells as the place where this
I
I
I
TABES DORSAUS.
«43
I
transfer probably occurs. Which of Ihc theories above tnen- lioiicd will at last be reco);iii2ed as the correct oiK. and whether or nol other factors, which have not yet been considered, pliiv a part in the prodnclionof the ataxia, it is at present impossible lu state (cf. Rutnpf, Sensibilit^tsstUrungen und Ataxie, Leipzig. Mifschwald. 1889).
Later on in Ihc course of tabes there is a diminution tn the actual strength of the voluntary muscles, particularly in those of Ihc lower extremities. This first manifests Itself by wea- riness on walking, which gradually increases, and finally ends in total panilysis (par;iplegia). The patient first notices that he has to rest in the course nf walks which he previously was in the habit of taking without any feeling o( fatigue, th.tt
»F%. «7).— Seeciars op IU»i>w«itijio in « C*»r o* Tsilimw in T»om I pcnoiul ubwraliofi).
it lakes him much longer than formerly to cover a parlicul-ir distance, and that he is in general unable to take the exercise tu which he was formerly accustomed. As the disease advances, the power of locomotion becomes more and more diminished, and llie patient is only just able to drag his legs along, and at last, becoming unable to move at all, or even stand wilhtmt help, is obliged to spend the rest of his life in the invalid's chair.
Signs of motor irritation arc rare and are limited to parox- y»mal twiichings in the fingers and toes : 5<HTietimes. however, .involunury movements occur in the limbs which the |>alient
644 f>/SEA.'iES OF THE GR.S'F.KAt. NERVOUS SYSTKM.
has absolutely no intention of moving. Stintziiig (Centr.iI Ncrvcnhcilk., 1886.9. 3), for example, observed an involuntary flexion of the hip joint when the patient coughed. SimiUr associated movements in the lingers or toes have been de- scribed by Siriinipcll (Neurol. Centralblatt, 1887, vi, 1) and Uppcnhcim (Sitzung der Charitd-GcscUschalt, 20 MUrz, 18S4).
The athetoid and choreiform movements described by Andry (Kcvuc dc mcd., 1887. 1). sometimes found in tabetics, are to be regarded as due to simultaneous disease ol the lateral columns, and accordingly rather as complications. Wc must regard the tremor as one of the signs of motor irritation, al- though wc arc at present unable to localize its anatomical scni. This symptom is sometimes observed either in the initial stjige or in the further course of the disease. If the upper extremities become aflccted by it, the handwriting is altered, in the man. ner represented in Fig. 171.
The disturbances of sensibility in tabes are either experi- enced subjectively by the patient, or can only be discovered by an objective examination. Their number is exceedingly large, and it is safe to say that in almost every case some iiUvf- esting observation of this character may be made. Symptoms of irritation alternate with those of paralysis, and one also meets with other different disturbances of sensation which be- long to neither ^f these groups, and which are more variable in tabes than in any other aflcction.
.Among the subjective symptoms we shall consider fir«l Iht symptoms of irritation, more particularly the pitins. which in the life of tabetics play such an important part. They. too. arc of a changeable nature, and vary considerably in their situation and intensity. In the first place we desire lo direct attention to the muscular pains, which, if they occur at ilHi come on very early in the course of the disease, and affect sometimes the shoulders, sometimes the legs, and recall the well-known muscular pains which follow severe exertion in the gj-mnasiuni, mountain climbing, rowing, etc. As a nile. it is true, they are not very intense, but when they come on suddenly, without any appreciable cause, the patient i> obliged lo remain perfectly quiet for several hours, for every motion is difficult lo him, and if he persists in his attempts, movement becomes impossible on account of the feeling of weakness and fatigue which at last overcomes him. Piif« calls these pains " crises dc courbalure rousculairc " (Progr.
TAfiKS DORSAUS.
645
mea!ri884. xii. 28), and considers ihat ihey arc precursors o( labes.
I We must separate from these the nervous pains of tabetics which arc dependent upon irritation ol the postcrit>r roots. They are usually situated in the lower extremities, and mani-
ficst themscUxs either as dull, boring sensations, or as sharp pains which last for hours and then disappear for a time ; they may also be (cit in the back and sacral region, and lor years be
I attributed to rheumatism, lumbago, etc. As long as only these pains exist, Ihc life of the patient is bearable, although it may tie marred and his occupation interfered with, but there is a Mcond class of nervous pains which, appearing and disappear- ing like lightning, arc known as shooting or lancinating pains. '• douUvn fMlguruHles." It is these that make the existence ol the tabetic most miserable, and make him wish that he were dead ; it is these, again, that can reach an intensity which causes the most resolute stiHerer to lose his energy, and con-
'%'erts him into a complaining and whining weakling. They also occur paroxysmally, and may continue for minutes, hours, or even days, and then di&appcar (or variable periods, some- limes for months. In many cases they recur often, some- limes every week, but they then usually only last for a few moments.
In some cases, in connection with these attacks, cutaneous ecchymoses may develop, which are to be noted in the por- tions of Ihe body subjected to the pain, and may attain a considerable size, so that one who docs not know their sig- nilicance. on examining the patient, may come lo the conclu- sion that he has been injured by a blow or a fall. In still rarer instances swellings have liccn observed instead of the ecchymoses, which in the same manner as the latter di&appcar in a few days.
Along with these pains the patient may suHcr wilh hyper- .-tsihcsias of Ihe skin to such an extent that in certain parts ol the botly— very frequently, for Instance, on ihe back— he can not bear the slightest pressure, and even his clothes will be a source ol annoyance to him. These cutaneous hyperarsthcsias may persist for months unchanged without being affected tn the least by Ihe paroxysmal pains.
Among the symptoms of sensory irritation the 80.called girdle sensation may also be reckoned. This likewise occurs paroxysmally, at which times the patient exjiericnces a feeling
6146
X>/SEMS£S Of THE GEKEkAL NERVOUS SYSTEM.
as if n belt were being drnu-n Around his chest and abdomen, which iiUcrJcrcs with his breathing.
Manifestations of sensory pitralysis may also be subjectively perceived by the patient. Not infrcqucnily he will say Uiat he docs not Icel the contact of the cluihing on certain pohiuiis of the body, or thai the soles of the feet are without sensatiun. In n case under my ubservaiiun the patient complained ol a widespread loss of sensation in the perineal region, which on objective e?camination proved to be ana-slhetic as well as the inner surfaces of both thighs. To the anaesthesias, which are particularly unpleasant to the patient, belong those affecting the mucous membranes — as, lor example, that of the rectum — owing to which the bowel may empty itself without the patient being conscious of it. Again, there may be an».*slhesia of the testicle, often associated with atrophy (Pitres), and loss of sen- sation in the mucous membrane of the sexual organs — as o( Ihc vagina, for example — owing to which the j>lcasunible sensa- tions attending coitus arc either absent or greatly diminished.
Among the perverted sensations which arc cxi>crienceti subjectively may be mentioned the alterations of feeling in the soles ol the feet, owing to which it appears lo the patient that he is not walking upon solid ground, but rather upon a suit yielding surface, such as moss, cotton, etc. To these may be added the sensation as of ants crawling over the skin, a feetinR ol numbness, which usually appears in the lower cxlreniitiw, but sometimes also in the hands. In the latter case it tiuy become impossible for the person lo write, sew. etc.. in spite of the fact that he may be suflcring from no disturbance of motility whatsoever.
Many anomalies of sensation in labes can only lie discov- ered by means of objective examination. They constitute the second group of sensory disturbances to which we rcfencd above.
We would here insist upon the necessity of making the examination as carefully as possible, and of remembering i« the first place that when the patient is repeatedly examined he ceases to give us his attention and makes careless answers 1" the inquiries made of him ; and in the second place that ihert arc certain sensations, the so-called spontaneous sensatiunii which the patient experiences without any external irritation whatever. Rosenhach (Deutsche med, Wochenschr., 18S9, ij) holds that accumulations ol weak sensory stimuli occur, tlte
TABES DOKSAU&
647
ft
ntcrvals between which vary according to the strength of ihc stimuli anil the better or worse condition of the ))alienl. If one remembers this and the fact that the so called aftcr-sensn^ tions must also be taken into account when miiking the test, one will be able to avoid gross errors, B. Stern (Arch, (. Psych, und Nervcnkrankhcitcn, 1S86, xvii. 2) has not been able to cunhrni the sintenient of Belmont (Gax. m^., 1877, 19) that points of predilection exist lor the disturbances of sensation in tabetics, as, fur example, in the soles of the feet, the areas about tlie malleoli, and the lower cxtremiiies in general. Were it true, it might constitute a new source o( error in the cxamina* lion of the anomalies of sens^ition. The methods of examina- tion arc as simple as possible, and the necessary instruments are an induction appaniius. Weber's arsthesiomeler, needles, mounted brushes, and test tubes tilled with hot and cold water. With these one is able in most cases to obtain all the necessary information.
Among the symptoms of irritation, hypcnesihesias. as we ilatcd above, arc not of very frequent occurrence, but when they do occur they can very easily be recognized. They are frequently quite transient, so that a point, which yesterday was sensitive to the slightest touch, presents to-day a perfectly normal condition. The exaggerated sensitiveness is probably always conhncd to the perception ol pain, but Is not found associated with the other qualities of sensation. We recognize another symptom of irritation in the so-called double percep- tion of painful impressions, polvivsthcsiii (Fischer), by which is meant that from one external irritation, as the prick o( a needle, the patient experiences two painful sensations in suc- cession.
In the objective examination of the sensibility the symptoms of paralysis play, without doubt, the more important r^e. In the fin-t place there arc the anaesthesias, which may afTecl all (pialities of sensation, the sense ol pain, touch, and temperature. The most interesting is an analgesia, to which Bergcr first directed altrntinn. who demonstrated that while the patients reacted normally to slight stimuli, they scarcely did so at all to stronger ones. We must consider it as an anomalous analgesia, when a patient experiences only one kind of p.Tin in response to the most varied kinds o( painful stimuli. It sometimes hap{iens that the tabetic can not tell the difference between the action oi the thcrmo-caulery, the simple prick of a needle, or a violent
64&
DISEASJiS OF THE CEXERAL NERVOUS SYSTEM.
pinch, and desiKnatcs the pain produced by these various agents as simply a burning one. The painful sensation on electrical stimulation mav also become abolished, so that wc can apply the strongest currents or the (aradic brush to Hie most sensitive parts, such as the inner surfaces of the thighs, the perinKum, or the scrotum, and the patient not gi%'e the slightest evidence of pain.
Lastly, delayed sensation is to be considered as a syoiplotn of a paralytic nature. In these cases, when the patient is pricked with a needle, he docs not experience pain until one, two, or three seconds later. Goldschcidcr has attempted a physiological explanation of these phenomena (Deutsche Med.- Ztg,, 1S90, 43, p. 484). The delay of perception may vary for the dilTerent qualities of sensation — for example, for touch and pain — as OsthofI and Rcmak have pointed out.
We must attribute to disturbances of the muscular sense, which we alluded to in discussing the cause of ataxia, tJie (act that the patient with his eyes closed is unable to state accu- rately in what position his extremities arc, and if one, lor ia- stance, changes the position of a limb, he is not at all certain into what position it has been put. He is unable to estimate the weight of an object placed in his hands, and so forth. All these conditions are to be remembered when one is testing the muscular sense, and at the examination one will have to ascer- tain what is the minimum change of position which can still recognized by the patient.
I.ITERATfRK. 3. The Spirml Cord. a. Mftifr anil Sniioty Ditsrdtrt, Runipf. SFn9lbiliiaiis«>t>rungen und Ataxic. Dcuischcs Arch. f. kEn-
|8«9. t. (lolilicheitlcr. Ilcrlincr klin. Wochcnschr., 1890. 46. Uinswangrr. Ihiil.. 1890, 3i, 32.
Quinrkc. Zeilschr. f. klin. Med.. 1890^ 5. (Auocialei! ScnsaiiotM, etc) Wngncr. K. Ucbrr die BcMthuiiKcn iIlt Bewc^un|fM:m|>lin<lvng tut Auxk U>
Tabikrrn. Inaug.-Dlwcrt,. nrrtin, 1891, Runuwikl. Vewutli. ilie Unache der Ataxic bci Tabea zu erkllren. Itiitnui
klin. Rundsirhau. 1S91. 17. (Tl)is xuli^or optnins aiaxin by a difflbulic"
in the cxcii.-ibiliiy .ind conduciiviiy of Ihc motor nerve*,} Dubuc. Ua douleurs rulHur^intn laMiiqucs. T)i^ de Bordeaux, 1S99. Gmssei. Du vrriige dcF aiaxiques (signc de Romberg). Arch, de Noirti.
1893. 73. 74-
i
TABES />ORSAlJS.
649
Of the disturbances of the reflexes, lltose conitcctcd with the lUcin interest us less than those connected with the tendons: o( the latter, the patellar reflex is the most important, the ana- lumical localization fur which is in the so-called root zone (Weslphal). This xoiie is siiiiuled at ihe Junction of the
■ lower dorsal portion of the cord with the lumbar enlargement at llie level ol exit of the second, third, and fourth lumbar nerves (cf. page 422), and constitutes the area which the roots entering to the median side of the posterior horn must traverse in order to reach the substantia gelatinosa of the pos- terior horn. If this field is degenerated the patella tendon
A.
H FIC. i7«.- Tw-o Cjikti nr Tahch. i ARet WtarniAL.)
^LJ. Thr linrt 4 A Oiow lb* limit* ot llic hi-ciIImI " roM inn* " Thr d(K*npratliui t* (irncMW- ^B tax 'n»n viUiin (iioinl Ibcm. bul onlji rtathci Ihe bcmlet linv. The pwdlw nOcm ^B «<tr Rtkintd until death.
^p'#. Tfcc dcfCMnUcni ti prnpmlni; from *lllila cnuwiRt, *nil hii< ciiuMlid far Inui iha V " rodl MNW." The pauUu nduo were toM Ave yean bcf on dMiK
rcflcx disappears, but if it is normal, the reflex is preserved icf. Fig. i;:. \ and H). The rare cases in which it remains preserved on one side also confirm the localization assumed by Weslphal : at the autopsy it has been repeatedly noted (cf. IJcrlin. klin. W'ochcnschr., 1887, 31, p. 586) that there was a degeneration of the posterior columns and of the " root zone " on the affected side, while this zone on the healthy side w.i9 intact.
The disappearance of llic patellar reflex, " Westphal's sign," was formerly considered as pathognomonic of tabes, and when- ever the knee jerk could not be obtained, the diagnosis was made wiihout hesitation. This was the standpoint taken in the earlier works ol Wcstphal. Krb, and others, and it must be confessed that " Westphal's sign " is observed in by far the jfTeatcr number of cases of tabes, and usually early in the [Course. However, it began to be doubted that the rule was
650
D/SEAS£S Of THE GENERAL NERVOUS SYSTEM.
without exceptions, and toward the end of the seventies sev- eral undoubted cases of tabes were reported (Berger. Foumier) ill which the patellar reflex was retained to the end of life, and, since then, other similar cases have been added. \Vcslph.il himself pointed out that the Icnee phenomenon might persist with degeneration of the posterior columns (Arch, f. Psych. «nd Nervenkrankh., 18S6, 17, 2), and preci>ely at this time I myself reported two such instances (Berlin, klin. Wocheoschr., 1886, to). Accordingly, it is an undeniable fact, and one which, aniilomically. can be readily explained, that under cer- tain circumstances — that is, whenever the " root zone " remains free from degeneration — the patellar reflex may continue to be present during the entire course of the disease. By repeated and accurate examination, in which Jcndra&sik's tnclhod ol re-en force me nt should not be forgotten, one is sometimes able to follow up the gradual disappearance of this rcllex, and to observe that the time of its diminution and final disappearance may diller in the two legs — for example, the reflex may still be well marked on one side, alter it has completely disappeared on the other. Among others, Goldflam has reported observa- tions on this point (.Neurol. Ccntralblatt, 1888. 19), and has su|>- pusfd th.Tt iiitcrlerence with conduction, produced by p:nh(i- logical changes in the peripheral nerves, may also be the cause. Eichliorst has reported a case in which, although the patellnr rcllex had been absent, the autopsy revealed no changes in the rout zone, but a parenchymatous neuritis of both cniral nerves. The patellar reflex which has once disappeared in the course of tabes can never reappear, since destruction of the correspond- ing portions of the cord has taken place, but in trauniattc MU- roses this may very well happen, and in doubtful instances it may become an important point in the diHcrential diagnosis. The patellar reflex can only be increased in tabes when there is a coincident degeneration of the lateral columns.
While, then, for the reasons we have given, " Westphal's sign" can not be regarded as pathognomonic, there are sitll others which should warn us against laying too much stress on the condition of the patellar reflex in the diagnosis of tabes. Unquestionably it may also disappear under certain circum- stances in the course of other affections — as, for example, to certain diseases of the brain — if the muscular tone necessary to its production has been lost; also in neuritis, poliomyelitis, diabetes, chronic alcoholism, and in aflections of the knee joint
I
I
TABES DOJtSALlS.
6si
I
when llie movements of the Icndon arc interfered with. When wc add that it can not be deinunstmted in all healthy persons — a small number being entirely without it, as IJcrger and others have stated — and moreover consider the fact that in old age and in conditions o( marked nervous exhaustion it may entirely disappear without any apparent reason, perhaps from a diminished lone in the muscles, we shall have sufficient grounds (or not overestimating its significance, important as it may still be for the recognition of tabes. The measure- ments of its strength, which have lately been made a good deal of. may for the present be omitted in practice without dtsadvanlagc for the diagnosis.
l.lTERATt'RE. 3. Spinal Coftl.
RoKTohcim. Arch. C I*«)-Gh. u. N«Tvmlch., 1884. xr, 1. (Eipcrimcnul Studies
on the " Trn<IoN<|>h«nunieiM."l Z«nitcr. The Kncc-|>)iciioniniMi in l^Komotor AlaiiiK. JtMim. of Nvrv, anil
Mern. DitcJixc, N. S., April. 1884. », 1. Delpiai. Nettrrld. TijilKhr. vmr Genccskumle. lt86, Jl. (Three Ca*ra of
II at>n iti which the fdlclUr Reflex peruttcd uniil Mtlhin a Few Huurs bc- Tiirc l)e3ih.) Wruptial. L^cbcr I'ond.iurr <lc« Ki<irplilEnninms bc< Urt^ncration iter 1linier> UifriKe. Anh. f. lH)cl>. u, N<r*cnkh,. 1886. xvii. j. klitchelL ^Vet^, und Morris, Tei^ilon-jirrk and MuHi:te-jerh in Dinrnsei. expeciiilly will) KcfTrcncc lo I'wicnur Sclcrusis of the Spinal ConJ. New Yurk NteiL Rccont, 1SB6. %\\. I. Kr4UM, E. ttciinii; lur Localiuilon dea PUclbrrclleKea bel T«bes u. s. w.
Neurol. Crntrnlhl.. 188A. r. 10. Ilirt. Uelwr TibcK mil eriutleneii PatellaTrertexen. Berliner klin, WocbenKhr. ■ S86. Xtiii. lu
tWmptiat. Zwri ntHe von Tubes mit erhaltrncm Knieph&nontcn. Berliner klin. WotlirriMhr.. 1S87. xxiv. 5. Minor. Zur Frjgp iihi-r die l.ocAliMtton des Palrllanrltcxcs bel I'ahei. Ccn-
tlralhL t Nrrvpnhk.. 1H87, «, 6. XVe&i|>luL Aniitoniischcr iJefuivd hci etnsciligem KnicphXnamen. Arrh. t
I'Sjrch. u. Nervcnkh.. 1S87. xvilt. 1. CoUftim. UelwT die t'ngleichheil dct Kniephlnomeoi bci der Tatm. NeuroL
Ccntralbl, iltSti. vii, 19^ la Warren. Hyniton. I.onilMird, The Variations of the Normal Knee-jerk and
their KrI.iliun 1A ihr Activity of the Central Nervous SyMcm. Anier.
Jogrrv. o* I-sjehol.. 1887.!. 1. Mcfcr. Barftncr klin. WochcnKhr.. 1SS8. 3. (InAwnce of Phjrsoiligmine on
Ibe Tendon KcHexes.)
653
D/SEASBS OF TI/E GSX&JtAl XEKVOUS SVSTnU.
Uenedikc. Qualluttve Verlndenin^n (lc» Ki)iejihSni>ineos. NcuroL Cenlnilbl.,
1S89. 17, Ivichhontt. Virchow's Arch., 1891. cxiv, I. [ralellar Reflex in Cenictl
Tabes.) (iolJRam. Berliner klin. \Vochcntchr„ 1891. 8. (Reappeanncc of ihc pAidLr
KcflM.) Vucctic. M^ric. )naug.-Dit»cn., Wicn, 1893.
The reflex centres for the functions ol the bladder, rectum, and scxn.1l apparatus, which arc situated in the lumbar portion ut the cord, are naturally also greatly disturbed in the course of tabes. The reflex processes, which come into action here, are but little understood, but Ihcir pathological condition has been studied with great care. Mucli attention has been directed toward the bladder troubles of tabetics, and attempts have been made to distinguish between the dillcrcnt kinds of aflcc. tions. They are mutor or sensory, or both, according as only the one or the other or both centres have been destroyed by the degenerative process in the cord.
Among the motor disturbances there are symptoms of irri- tation as well as of paralysis, which may affect equally the sphincter and the detnisnr. so that the will may have but little inHuenue over them, or finally none at all. According as one or the other condition is the more prominent, the complaints ot the patient differ : sometimes he is obliged to strain for a long lime before the bladder will begin to empty itself, and even then the stream is often interrupted ; sometimes he is unable to urinate at all in the erect posture, but must squat down or sit on the closet to bring the abdominal muscles into action in order to expel even a few drops of urine, and the act of micturition may take so long that the patient feels ashamed to use the public conveniences. In other cases, where there i^ not only paresis of the detrusor, but at the same time a spasm ol the sphincter, the patient can not urinate at all. and the re- tention must be relieved by means of the catheter; in other instances, again, where there is a paresis of the sphincter, be has to urinate very frequently. Long before the bladder is full— every hour or two — he (eels an irresistible desire to empty it, which he must satisfy or run the risk of an in%'oltintary pas- sage ot urine. He is unwilling to underlake railroad journeys, to go into society, to lectures, or to the theatre, for fear that he will not be able to reach a convenient place in time where he can urinate in peace. Paresis of the sphincter is often «
I
I
I I
TABES DOHSALIS.
n why the patient sleeps poorly, because he has to get up and if he sleeps soundly he docs not apprc-
Sftcn to
IE pa;
male
When
cotighs or sneezes the under-^rments arc moistened wiih
urine, and, despite his utmost efforts, he is unable to prevent
In the more marked degrees of weakness of the sphincter
'there i<> an involuntary trickling or aii occasional discharge of
Murine, which (he patient is unable to predict ; this necessitates the constant wearing of some sort of receptacle ; otherwise the patient is surrounded by such an ainmoniacal odor that the ^incontinence is recognizable without any examination. If there a combination of retention and incontinence, it manifests it> elf in the following manner: After long slr.iining the urtnc is Ppassed in a moderately strong stream, but this suddenly ceases, and can only be started again after renewed eflorts. Some- times, after the patient has strained in vain for a long lime and has given it up in despair, the urine is passed involuntarily. These and many other facts of the same description are only
tto be discovered after careful and repeated questionings and txa mi lint ions. Sensory disturbances may manifest themselves (i) by more or less intense pain before and during the act of micturition, which may distress tlic patient greatly and make him dread to relieve his bladder (the "crises t'/suaUs'' of Charcot). The |>ain maybe situated either in the hypogastric region or ex- tend down into the urethra {crises x-fiico-urilhraUs). Painful strangury, forcing the patient to urinate every hall hour, when ic only passes a few drops, has also been observed. On the ther hand, (3) there may be a diminution in Sensibility, su in consci|uence of the antcsthesia of the mucous mem- ine of the bla<idcr and urethra, the flow of urine is not no> ticed, and the p;iiienis. especially when there is a weakness of the sphincter at the same time, do not know whether they are urinating or not, and only become aware of the fact when they feel the chilly sensation proceeding from the damp clothes. A rather rare manifestation, which may be observed after violent bladder crises, is the appearance of hai^maturia, which must be attributed to capillary ha-morrhagcs into the bladder or ure- thra: the bloody character of the urine may be a source of new anxiety and worry to the unfortunate patient, already greatly bmken down by the agonixing pains. These htcmor* rhages may be considered as an.ilngous (o the ccchymoses in
6s4
DISEASES OF THE CENEkAL SERVQUS SYSTEM.
Ihu skin occurring; after the intense lancinating pains, whf wc mciUioiied above on pag« 64;.
The most troublesome rectal symptom is the very obstinate constipation. Incontinentia alvi and an.'csthesta of the rectal
Fie. t7J— A Cask or Ckamcot^ Joun- m a TAsmi: (pcraatui obsemliaaV
mucous membrane, in consequence of which the patient is not aware o( the act of defecation, and so soils himself unoon- SCtously, arc among the rarer occurrences.
The centre for the sexual functions, the scat of which is also in the lumbar enlarfjement, is under the control not oolj' of rcHex but ahc> of cerebral influences. If the palh coming from the psychical centres is interrupted, the performance ol the function is faulty ; if the path from the inhibitory centres is disturbed, the sexual reflex activity is increased and priapi?ni may occur. Pitrcs (Progr. ined., 1884. xii. J7), under the name of " crisfs cliloridieanfs" has described in women conditions
i
^^^^^^^^"^ TABUS DOSSAUS. ^^^ 655
which consisted of periods of voluptuous excitement accom- paiiied by secretion, .niialogous; to the violent erections and
■ spermatorrhoea (ound in men in the initial stages ol mbes. Such cases arc, however, at least in Gcrmanv, exceptional. Not infrequently tabetics have been knuwn to preserve their
■virility, and even after the beginning of the disease to beget one or even several heiilihy children. Only later does the sexual power, and with it the desire, become diminished, and
I Coitus lose its charm, so that it is undertaken more rarely, the act being s^imelinies incomplete. A normal condition of the nerves necessary for the erection of the penis, associated with > paraly&is of those going to the ejaculntor seminis, so that while coitus and orgasm are normal, the semen is not emitted till later, and then very slowly— a condition which Bernhardt has oiKierved after injury (Deulsch. Med.-Ztg., 1888,48)— has H been known to occur also in the course of tabes. B T'>c vaso-motor and trophic centres in must cases are not afTecled. In the majority of instances, symptoms of this char, ncter are entirely absent during the whole course. In some, however, peculiar symptoms attract our attention, as, for ex- ample, a local hypcridrosis. which Ollivier (Gaz. hebdom., tScptemhre 7, 1883. xxx, 36). I^aymond and Arlbaud (Revue de med., 1884. 4. j), and others have obscr^'cd on the hands and (ect. In a case of tabes we have also seen the sweat secretion on the hands so increased that wc were able to note the forma- tion of small drops and walch them unite to form a steady dripping. In another case there was unilateral sweating, the hyperidrosis appearing after every meal on the lek half of the head, (ace, and neck. I do not care to risk an opinion as to how far an assumption of an affection of the sympathetic would _ here be justifiable.
f Greater practical importance must be attributed to the changes which are observed in the nails and teeth of those affected with tabes. The nails are either deformed, becoming twiste<l or marked by deep furrows, or fall out entirely from the fingers as well as from the toes, as JofTroy (L'lJnion. 1883. 106), Bonieux (Th^e dc Paris. 1883, No. 237), Hay-Margiran> diirc (Thise de Paris, 1883, No, 75I, and others have observed. The loss of the nails (" la chuU ihs ongiti ") is (mt rare in tabes,
»anri is in some cases to be attributed lo the temporary cessa* tion of growth of the nnil matrix. In others an ccchymosis uoder itte tiail may be the exciting cause. Under certain cir-
6;6
DtSEASES OF THE GENERAL XEXl'OUS SYSTEU.
\
cumstances llic nail of Ihe great toe falls off allt^cthcr, wilfiowt pain, with only a slight itching scnsuliun, and the newly lormcd nail, which is often rough and irregular, soon shares the fate ol its predecessor.
It iii occasionally observed that the teeth become loosened without any pain and (all out without the :ippcarance of any symptoms ol inHanimalinn, Ihe tooth iiscll being intact. This arises from some disturbance in the nutrition of the jaw, a rare- fying ostitis which is connected with a lesion of the nucleus of ■ ihc trigeminus (Vallin and Demange). In this way the patient may lose all hh teeth in a few months. It is very inlcrcsiing to note that this may be connected with laryngeal crises, a fact which would indicate that there may be some truth in the view advanced by Buzzard (British Med. Journal, February ii^ 1886), according to which the centre lor bone nutrition lies quite close to that of the vagus.
The so-called wrt//rr/i>rfln/(/«/>tVrf (perforating ulcer), which begins with the formation of a bleb and leads to abscess forma- tion and necrosis of the tendinous and bony portions ol the feet, is due to snme trophic disturbance, and may become a source of great discomfort to the p.iticnl.
Affections n[ the bones and joints, which arc also of trophic origiji. belong to the more Irequcnt complications of tabes.
Flu. 174- Fie- »7S.
Fi|E. J74.— Crmiiw op ni8 I-litAi) or thk KvMEitm ik TAhes Dokmlu Pif. ■f^' Ndrmal HuMKKua. (Alter Charcot,}
The bones become extraordinarily brittle and fractures fre- quently occur without pain, and one could almost say wilhuol (he knowledge of the patient. The seat of such fractures is most commonly in tlie femur, and, more especially in old
I
TABES DOftSAllS.
657
I
I
women, in the neck o( that bone. This remarkable fragility is of especial mo- ment when it occurs, us it sometimes does, in the bones of the spinal column, and particularly in its inmbar portion, and gives rise to spondy- lolisthesis without it being pa<:siblc to de- cide whether or not the cartilages and ligaments were first afTccled and the dis> case of the bones was only secondary (Krocnig, Xcitschr. I klin. Med.. 1888, 3ctv, r, 2).
Among the joint affections which arc not essentially differ- ent from those pro- duced by arthritis deformans, the "rtf. tkropatkie d(s ataxia y«rt " or " Charcot's joint," because it was first described by him, deserves par- ticular mention. Ac- cording to his de- scription, there dc vclops in the course of one night, with' out any appreciable cause and without pain or febrile move- ment, a swelling of a
4>
Fie. il^i— SKKLRTOif OF ji T*BKTtr FnoT. (AflarCMAa- OfT.i (The ur%4nal (i tn ihc pallMUii(ka) mummib of CtumM^ dsfiuisieM la Ihc &U|»<uMn ht Pwia.) 1-5. ntKUtanal boaea. t, InWnul o«iKtr«f« booc t- ■"■■1* lUt cunelfonn bone. 8. fragBtM of the Mmt*! «ni*l' ■nm bone. 9. <ubo4d bnat. ic uid ii, IracntMt lA th* tcafkoM boM, ta and ij, (krc tmnfim. 14. ih« cacaloiMUM.
6s8 DISEASES OF THE GENERAL NERVOUS SYSTEM.
Joint— for instance, the knee, shoulder, elbow, or hip. In the course of a few days there is noted a collection of fluid in the joint and in the periarticular bursre, and on puncture a lemon- yellowish transparent serum can be withdrawn. In one or two weeks later one is able to make out more or less well-marked crepitation, due to changes in the joint surfaces. The joint becomes extraordinarily movable, and luxations frequently occur, especially when the ends of the bone are worn away (Figs. 174 and 175).
Occasionally the tarsus is affected by the process. In such cases a marked swelling of the foot occurs in a relatively short time, the joints become affected in the way stated above, and at the post-mortem examination the tarsal bones are found to be altered in the manner represented in Fig. 176 ("tabetic foot").
The real cause of the affection is not vet known. While Charcot considered it due to an atrophy of the anterior gan- glionic cells in the cord, Virchow pointed out that it might be due to a state of lowered nutrition of the bone following a disturbance of nerve influence. Oppenheim and Sjemerling demonstrated a degeneration in the peripheral nerves, and ac- cording to Volkmann the analgesia produced by tabes creates a predisposition to the occurrence of the joint affection which he attributes to disturbances in the cartihges. Rotter divides the cases into three groups — true arthritidcs deformantes. primary fractures of the joints, and a third class in which there are most pronounced changes, but in which we are unable to determine whether they arc due to an arthritis or a primarv fracture.
We may add th.Tt arthrcctomy has lately been performed several times for tabetic affections of the knee joiiit. and has been followed by success (Wolff. Sitzung der Berliner nicd. Gcsellsch., 7. Miir-z, 1888, Deutsche Mcd.-Zlg., iSSS. 22. p. 26S1.
LITKRATURE.
3. Spinal Cord.
e. Vasomolor and Tivphk Cha<igi-s.
Porliiher. These de P;iris, 1884. (Trophic Changes in the Preaia\ic SPS"
of TabL-s.) Russolvmmo. Arch, f. Psych, u. Ncrveiikh., 1884, \v, 3. (Trophic Changes in
the Skin.)
TABES DOSSAUS.
659
I
jAHOWsky. Wilier mcd. Pm«c. iS8s,uvl,S, (On EiianllMinaious Eniplioiu
in Talieiici.)
Koflhiani). Hcrtiner kiln. Wochcnschr.. i8Sj. iili. 13. Drownc aiMl d'Arc}- Powrr. St. Buiholomcw's HosfHUl Reports. 18S6; xviil.
(" Mai iKifunnt du pied."] Cilipp^. Cak (h-K Mp.. 1886. 5lt. (AffiKiions ofihe Tecih.) Knxii);. Wirbckrkrankungcri <kr Tabikcr. Ueutichc Med.-Ztg.. 1886, tU,
101. HiiMc Da.H llaniiifjcctchwiir unil "cin VcihUlniu lur Tsbcs. Si. PMcnburgcr
incd. Wothrtisthr. N. h.. 1886. iii, 16-38. M^nitrier. Annal. de dermal, ct 6}'ph., 1S86. vii. 1. (Mai Pcrforanl affecting
the Hands.) MollM«. Lyon m«l.. iSS?, Iv. p. 377. (Onset of Tabo with Trophfc
ChangM^) Suckling. Urii. Med. Joum., April 6. tSSj. (Pcrfotaiir^; Ulccf u the Fir«t
Syinptum of T^bcs.) Marshall, J. G. L.mcci. Januan-, t8$5, i. t, Joffroy. Cjt. dcs hAp.. 1885. 133. (Tal.eik Fool.) KtcKanlifrtt. Revue de inM.. Vivr. 3. 1S86, ri. (AnhropUhy in l1»e Fingcr-
JointM.) Andmon, J. WsILkc. Brain. 1S861 KKHtv, p. 114. (Anhropaihy.) Ko«inti>w. Med. Ohserv., 1S86. 17.
LrtwcnfcUL AIuiKh. m«L WuchcnKhr^ 1887. xxxir, 20, (Anhropathy.) Kuiter. Arch. f. klin. Cliir. 1887. xx»vi. 1. (Anhrupiiihy erf Tabes,) Kramrr. fragitr med. Woclipnsihf,, 1887. xii. 33, (Tnlwttc Foot.) Kahldcn. VirchoM's Archiv, 1887. ci(. 1. (Arthrop;iihy.) fdricr. New York Mctl. Ki-L-ord. Octolx-r. 1V87. txiii. iS. (Anhrapalhy.) Dana. Elation Mrd. and Surg. Jnum.. Octnhcf 17, 1887, cxvil. (Anhropathy.) Paolidt*. I>M anliTi>|)allties iaUli<|un du pied. Nouv. Ironogr. lie la Salpttr.,
IS88.4.5- Collier and Hit. Traniuicttnnii of the Pathol. Sockly. 18S8, xxsii. p. 31.
(Charc«4'« Joint in lite Knee.) Kmt«l. Die Anhn>|wihim und Spoctianfmciurcn bri Tabes. \'iitkRiann't
Samml. klin. Vortr.. 18S8. 309, Chir, Nr. I>rjerine. Surl'nlropliic muiculaire des alaxiijuct. I'arb. l88^ Sucktins, {Int. Med. Juurn,. lS6'}. p. 1009. (Muscular Alraphy.) VemruU. Hull. mM.. 1S90. 76. (I'alhologica) Fractufca.) KOnig. Progr. mM.. 1891, 44- Roain. Zur Lchrct-ondenlrophiKhrn KklererkrankunKtntKtTaliet. t>cutKhe
Zcitschr. r. Nervrnkh., l8^i. $. <^. Slrnir. Afihro|h)ihia uhidonim, Inaug-Divierl., tlerlin, 1S91. Coblacheider. Atiuphiuhe Lfihinung bci T.-itio. Zcitschr. f. klifl. Med.,
1891.S.6. Croue. Ueber Mutliebirophie bei Tabes. Inaujt.-niwert . Ilrtlm. iSqi. Xipkau. Airophische Lihmungen bei Tabes. Inau^.-Uisscit.. [kilin, l8g).
For (he last few years only we have known that the pcriph- |«ral nerves play a lar^c and important part in tabes: previous \%o (his Tiirck und later Friedreich had reported alterations
66o DISEASES OF THE GENERAL NERVOUS SYSTEM.
in the mixed nerves, but we were ignorant of their character until the pubtication of the work of Westphal (1878), which was soon followed by other articles, among them those of Dejerine, Pitres and Vaillard, Oppenheim and Siemerling, Sakaky and Pierret. The results of their work showed that the peripheral nerves suffer a parenchymatous degeneration, a destructive process, which, being associated with an increase of the peri- neurium, a proliferation of the nuclei, and extensive connective- tissue formation, leads to a final atrophy of the nerve elements. This peripheral neuritis is not necessarily followed by marked symptoms, but, according to our views, it is the main factor in the production of the analgesias which are often observed so early in the course of tabes, and to which O. Berger has already directed attention. Under certain circumstances this neuritis may produce deformities; thus if it involve the nerves which supply the muscles of the plantar surface of the foot these latter atrophy. The muscles concerned are those of the inner surface of the foot affecting the great toe, those of the outer surface to the little toe, the flexor brevis communis, and the interossei; the plantar aponeurosis retracts, and the toes be- come flexed and immovable (Fig, 177),
If larger nerves be affected by the process, the symptoms, which are characteristic of neuritis, and which have been de- scribed on p^ge 386, make their appearance. They are chieflv pains, motor disturbances, and muscular atrophies. To this class belong the musculo-spiral paralyses caused by tabes, de- scribed by Striimpcll (Berl. klin. Wochenschr., 1886, xxiii, 37). lesions of the median, described by Remak (ibid., 1887, xxiv, 26), and lastly, lesions of the peroneus loni;us. as described bv Joffroy (Gaz. hebdom., 1883, xxxii, 48). Lately Dejerine has described a widespread muscular almphy in tabetics, which has its origin in a peripheral neuritis (Neurite motrice peri- ph^riquc dt's ataxiqucs, Revue de m^d., 18S9, 2). The obser- vations of Rcmak seem to indicate that the muscles which are subjected to an unusual strain in the patient's occupniinn are particular ly prone to become atrophied. In confirmnlion of this I can add two cases of my own : (0 In a cigar-maker. who exerted particularly the first three fingers nf the riirht hand in making the cigar-tips, atrophy developed in the muscles of the bal! of the thumb supplied bv the median. (2) A den- tist with tabes, who overexerted the musculature of the hand in filling teeth and in other manipulations, came under my obser-
TABSS DOSSAUS.
661
vation on account of an atrophy of the hypothenar muscles supplied by the ulnar. Similar cases arc not uncommon.
I
Pis- 177.— PUMTAB Fluiq)* or Tus Tou ta thr Covrb or Tams rpenuiuU otwervauoa).
It is not at all rare in the course of tabes for the peripheral nerves to be attacked by neuralgias: the sciatic nerve calls for first mention, as it is usually affected early in the disease and very severely. Wc have already stated on page 372 that double sciatica is more particularly a frequent accompaniment of tabes. Bnuiches of the pudic nerve may also be aflcctcd, and often rcclo-vcsical neuralgia may be a source of great trouble (Xcftcl, Arch. f. Psych, und Ncrvenkrankheitcn, 1880^ to): in this the patients complain ol a painful burning sensa- tion in the rectum after each defecation, which is often fol- lowed by marked depression of spirits, and the longer the in- terval between the acts of defecation and the firmer the con< sistcncc of the stool, the more intense becomes the sulTering. After all, it is not easy to distinj^uish the peripheral Irum the above-described central afleclion, which may run a similar course.
I.ITKRATl'BE.
4. Tkt Ptriflurtl Xtrvei.
Sakatcy. Arch. f. Pij-ch. uihI Nen-cnkh., 16S4. iv. 1. (tV^ncraiion of the
. PrriphrraJ Nefvc«.) Stem. Uolktv, \\m\.. ivii. y (Anomalie* nf Senutlon.)
UjiiHrnhrim umt Siemirling, AkH. f. I^ych. u. Ntrvrtlkh,. 1887. «vlH. a. {SU fcciMtis of the I'chphcral Nervex.)
662
DfSF.ASF.S OF T/IE GEh'ERAL KERVOVS SYSTEM.
Dcjcrine. Gw. dc Parin, 188B. 10. 1 1. 12.
Dcjeriiie. Revue ile in^., 1 889. ix. j, 3. 4,
Dtjtnne « Sollier. Areh, iJc mid. cipirimcnt., 1889, f. »,
DcJL-rinc. K-KlinliiilSlimunK bci Taba. UcuIm-Hc Mcil.-Ztg.. tSgoi so. ]>. 331,
UieniackL Aiulgc&ic dcs Ulnanuummcs. NcuruL Ccu[r.ilb4.. 1S94. ?•
We will now attempt to say something as to the relative
frequency i)f the symptoms and the lime of their occurrence,
Itit, of course, such statements can not lay claim to accuracy,
'and tan only serve to give an approximale idea concerning Ihc
points in question.
Among the most frequent symptoms belonging to the brain, arc, as wc have already shown, lesions of the cranial nerves, and particularly of the oculomotorius. by which transient diplo- pia and irregularities in the condition of the pupils (anisocoria, myosis) are produced ; next come lesions of the abducens. Almost as frequently will one recognize disturbances of the vagus, amoiifj which the gastric crises deserve particular men- tion. Among the .<ipinal .symptoms belonging to this category the first to be mentioned are the maniluld disturbance of sensi- bility, among ihcin cutaneous analgesias, particularly in the lower extremities, then, the paresthesias and the lancinating pains which occur more particularly in the legs : how far these symptoms in a given case are due to disease (irritation) of the posterior spinal niots or to lesions of the peripheral nerves can only be determined by microscopic examination. At all events, degeneration of the peripheral nerves in the most varied cuta- neous areas is to be classed among the regular occurrences in tabes. The disappearance of the patellar reflex and some form of the various bladder troubles are almost constant accompani- ments oi the aflcctinn, and tliesc, taken in connection with the symptoms just mentioned, must be considered as the founda- tion for the diagnosis.
Lesions, particularly atrophy, o( the optic nerve, symptomi of irritation and paralysis in the domain of the fifth nerve, and ataxia of the lower extremities, are frequent but less rcgulnr occurrences.
Less frequently met with arc the laryngeal crises, due tn lesions of the vagus, and affections of the nerves ol taste and of the acccssorius ; the same may be said of the psychoses, hemiplegias, and atlacics of epilepsy observed in the course of tabes. Certain disturbances of sensibility, the so-called recta! crises, cutaneous hyperacslhesias, neuralgias of the peripheral
TABES DOSSAUS.
66l
spinal nerves, paraplegia of the leps, the tremor, and disturt>>
aiiccs in the sexual functions also belong to this category. The
k trophic disturbances, the muscular atrophy, the falling out ol
' the nails and hair, the " tnal perforant du pied'' and Charcot's
disease of the joints arc aho comparatively rare.
To the symptoms which occur only seldom, one might almost say exceptionally, belong those referable to the hypo- glossal, the auditory, and the facial nerves; among the motor disturbances of spinal origin, the so-Called associated move- ments and ataxia of the upper cxircmitics, among the sensory disturbances, the so-called polyxsthesias, double sensations, and delayed sensations belong to this class ; marked diminution in the muscular strength is also exceptional.
As to the lime at which these various symptoms severally arise, it is even more difficult lo give reliable data, since there exists no uniformity ; still, one can state with some amount of certainty that next to a feeling of slight weariness, particularly in the legs, the lesions of the oculo-motor and abduccns are often the first to make their appearance ; the disturbances of sensibility, particularly analgesia and panesthesia. as a rule Lalso occur early, while lancinating pains make their appear- ' ancc at a later period. The gastric crises are observed rel;u tively early, and bladder troubles are among the more frequent occurrences before the disease has advanced very far. The dis:tppcarance of the patellar reflex, as it usually constitutes one of the initial symptoms of the disease, ptays an imfK>rtant part in the diagnosis, as we have already shown. Pronounced motor disturbances, particul;irly ataxia of the lower extremi- Xiici, are often not observed until later in the disease, often only alter years : and paraplegia of the legs, when it occurs at all. characterizes the last siages of the disease. Optic atrophy sometimes makes its appearance relatively early ; in other in* stances it occurs only at a late period and comes on very grad- ually. For the time of its occurrence no definite rules can be laid down. Hemiplegias, epileptic attacks, and psychical dis- turbances, if ihcy occur at all. manifest themselves sometimes earlier, sometimes later. As far as our own observations go. the trophic disturbances mentioned above, particularly the muscular atrophies and Charcot's joint aflcctiun, usually belong lo the later stages.
The course of tabes is rarely markedly influenced by com- iplicatlons, but such may nevertheless occur. Lesions of the
664 -DISBASBS or TBS GBIfBSAL HSMVOUS SYSTEM.
pyramidal tracts iii the spinal cord (Eulenbur^f, Deutsche med Wochenschr., 1887, 3$), valvular diseases <A tiie heart, espe- ' daily aortic -insufficiency, Gnves* disease, peroicious aiuemia, diabetes, general paralysis, and bulbar paralysis are to be re- garded as complications. Coexisting hysterical symptoms we may at times not be aUe to distinguish from those arising from the tabetic changes.
* LITERATURE.
Oppcnhcim. Beriiner Icfin. Wodteiachr, iSft4. zzi, 381 (HenicraiiiK aad
Tabes.) LeicbtenstNi). Deutsche med. Wocfaemchr.. 1884. x, ja. (PemidooB Anarais
and Tabes.) Oppenhein). BerUner Idio. Wochenschr., 1885. ufi, 49. (Diabates conplkal-
ing Tabes.) Reumont Ibid.. 1885, sxUi, 13. (Diabetes with T^xs.) Grasset Arch, de NeuroL, JuUlet. 1886, tL rucber. CentralbL t Ncrveokh. a. P^chiatr., 1886, ix, 18. (Diabetes whfa
Tabes.) Leyden. CentralbL f. klin. Hed., 18B7, viii, i. (CanBac Afiectioos widi
Tabes.) Eulenburg. Deutsche med. Wochenschr., xiti, 35. (Tdxs comlMiied with
Motor System Disease of the Spinal Cord.) Croedel. Deuische med. Wochenschr., 188S, xiv, 25. (Cardiac AfTeciions
with Tabes.) Stransky. Prager med. Wochenschr. 1888. xiii, 25. (Tabes with Muscular
Atrophy.) Lichtheim. Deutsche Med.-Ztg., 1890, 16. p. 187. (Tabes and Pernicious
Anxmja.) Jolly. Miinch. med. Wochenschr., 1891, 23. p. 406. (Tabes with Hemiatrophja
Faciei.) Kuh. Sidney, Arch. f. Psychiat. u. Ner\enkh.. 1891, xxii. 3. (Comphcation with
Meningitis Cerebro-spinalis.) Souchay. Tabes mit HenafTeclionen complicirt. Charit£-Annaten, 1893. xviiL Marie et Marinesco. Revue neuroi., 1893, la (Tabes with Graves' Disease.)
Course. — About the general course of the disease the fol- lowing remarks will hold good in a large number of cases : A middle-aged person who has become infected with syphilis some years previously, usually from eight to fifteen years be- fore, begins to complain of slight fatigue on walking and occa- sional pains in the lower extremities. In spite of all treatment the pains continue to be troublesome, and occasionally become so severe that they disturb the patient's rest at night or even
TABES DOXSA/./S.
«5
I
I
I
render sleep impossible. At the same time it appears to him that his vision is becoming affected, and he complains particu- larly that he sees double, and in consequence suffers from ver- tigo. The diplopia may last only lor a few moments at a time. The vertigo, which at the onset ol the trouble was insignifi- cant, becomes more and more pronounced, more especially in the dark, so much so that it is almost impossible for the patient to pass through a dark room without help. He also discovers that he staggers or falls to one side in the morning when in washing he covers his face with the towel, and only regains his equilibrium when his eyes are free again. Only rarely do dis- orders in the innervaliim of the larynx occur in the incipient stage ol the affection, but an abductor paralysis may b« found very early (Grabower, Deutsche mod. Wochcnschr., 1893, 18), and the laryngeal examinalion should therefore never be omitted in suspicious cases. Finally, he complains that he is obliged to pass water more often than usual, and that he con- sumes more time and must exert himself more when urinating than previousiy. The objective examination shows thai there is widespread ana»thirsia, particularly analgesic areas, about the lower extremities, and a loss of the patellar reflex. He may be inconvenienced in this way for years without his cun* dition becoming serious. He suffers more or less all the time, sometimes quite severely, but, on the whole, his existence is quite bearable. The state of his mind is hopeful, lor the diiily occupation has not yet been interfered with by the disease.
The aspect of affairs is quite different when the patient suf- fers from gastric disturlKinccs. The appetite becomes poor, and occasionally — sometimes lor weeks at a time— there is morn- ing vomiting, which is quite profuse and occurs as soon as the patient awakes, when, without effort, watery, slimy masses are discharged. After lasting for a longer or shorter time this ceases, probably only to return later on. The appearance of the patient, which was previously natural, now becomes al- tered (or the worse. The skin becomes yellow and wrinkled, and his friends and acquaintances, who have not seen him for some time, begin to inquire about his health. At the same time a new symptiim makes its appearance, and he notices that his gait is becoming uncertain and that in walking he must invoke his eyes to aid his legs, which, instead of carrying out the movements he intends, are thrown out in a peculiar aimless manner, so that if he be not led or supported he runs the risk of
666
OISEASES OF THE GENERAL NERVOUS SVSTEM.
tumbling down. This trouble in walking, which is associatcft, perhaps, with occasional gastric and more rarely with larvn- {;eal crises, may likewise continue lur yenrs ; but if tbe ataxia implicates the upper extrcmilics, as happens in a small propor> tiun of the cases, it may so interfere with the patient's occup- tinn that he may be unable to ccmtinue it. In the meanwhile the bladder symptums become more prominent and are aggra- vated to such an extent that it becomes necessary lor the patient to wear some sort o( receptacle, while the marked con- traction or inequality of the pupils is apparent even to the layman.
Gradually another change for the worse in the gait comes on. The legs, which, although thrown out in the characteristic manlier, in other respects performed their duty and even en- abled the patient to cover considerable distances, begin to be fatigued on the slightest exertion : ihey become heavier and heavier, and it becomes more and more diflicuil. and ai last needs the greatest effort, ti> walk at all. The legs arc so weak that they arc no longer able to support their owner, who is forced to take to the invalid's chair, and in this he ends an existence, the last years of which arc as wretched as could be imagined, especially if atrophy of the nplic nerve has robbed him of sight and the lancinating pains make his days and nights miserable. When the disease progresses in this or a similar manner its duration varies from tctt. fifteen, even to twenty years or more. It can, however, be considerably shorter. I have seen cases in which only from three to five months elapsed between the beginning of the alTection, from the first appearance of the disturbances in the movements of conver- gence of the eyes, to the appearance of well-marked paralysb of the legs.
On the other hand, there are cases in which the course may extend over a space of thirty or more years ; in these paralytic symptoms may not come on at all, and the ataxia m.\v continue to the end. There arc tabetics who during their entire illness arc hardly prevented at all from carrying on their work : they are always able to be up and about, and it appears as if the different symptoms never attained iheir full development. These arc the so-called " formes frusUs " of the French, analo- gous to those with which we have already become ac<|uaintcd in Graves' disease and in multiple sclerosis. Again, in other cases, tabes sets in with brusque symptoms, such as apoplcctt-
rASSS DORSAUS.
667
form attacks, disturbances of speech, anri lesions of the oplic
(nerve, and then pursues a mild course for a long period — vio-
hcnl symptoms, such as laryngeal crises, intense ncur,ilf;ias,
fete, only occurring occasionally ; ihcie are the so-called alyp.
ical lorms of the authors.
Proni what has been said it is evident how ditficult it is
make a positive statement concerning the general course of the ftfTection. Scarcely one case follows (he same course as
>ther, and it often requires a great amount o( caution and friencc to enable one to take a correct view of all that
:urs.
Just as much uncertainty exists about the prog-ntwis, which H% influenced by various (actors. One most important question is, of how long standing Es the disease, for in recent cases in which there are no other symptoms than dtsturtinnccs of sen- sibility and absence ol the knee jerks, and the course of which has not as yet exceeded three or lour months, and in which (here is no ataxia, the prognosis is not at all unfavorable, and the disease is under some conditions curable. Advanced cases of tabes in which there are numerous spinal and cerebral symp- toms oflcr a much more scrinns prognosis, but even here the possibility of cure is not excluded, though the highest percent- age of recoveries is estim.-ited at one per cent lEulenburg). Ol course, one can not expect thai the anatomical changes will disappear, and at the autopsy a widespread dcgcneralion of Uhe posterior columns has been found in cases 'in vrhich during life all symptoms had practically disappeared. In the majority of the soculled recoveries from tabes one is led to believe that there was a misLnkc in the diagnosis, and that these were cases of chronic nicotine poisoning, peripheral neuritis, hysteria, neurasthenia, etc. The prognosis of old cases with [>;iraplcgia of the legs, paralysis of the bladder, and so forth. \s altogether unfavorable, and anv attempts at cure are not only useless, but may even interfere with the comfort of the {mttent.
It is a matter of indifference, so far as the pn>gnosis is con- cerned, whether one is able to dcmonstnitc that the patient has at one time or other been infected with syphilis or not : a so< called specific or luetic tabes, especially when the infection has taken place ten or twenty years previously, dtKS not afford a belter outlook than the more rare idiopathic affection.
It is clear, then, th,al one must be very cautious in prcdicl- ,ing the duration of the disease ; one can nut say delinitely how
668 DISEASES OF THE GEXEftAL AESrOt/S sySTEV.
many years a tabetic patient has to live, and just as little should one attempt to make a positive statement as to how long the patient will be able to work. The condition may remain quite endurable (or months or even years, and the outlook may ap- pear quite hopeful, particularly in regard to the capacity (or work, and yet suddenly a marked change may take place ; pro. nounced ataxia, cerebral symptoms, or the like may mani(est themselves, which render the patient incapable of (oUowing any occupation. The more cases one sees, the more cautious docs one become in givinjr a prognosis, and the more distrust- ful of the reports of so*caIlcd cures— at least when old cases are concerned.
Diagnosis. — As one can readily see from what has been said, the diagnosis of tabes is sometimes one ut the simplest possible tasks for the physician : in other instances it can not be made with certainty for a long time. Thus it may under certain circumsUnces be very difficult to differentiate between the disease under consideration and complicated cases of syph- ilis of the brain and spinal cord. diabetes, or hysteria. ]t seems perfectly possible (or one to consider a severe case of neuras* thenia for a long time as one of tabes, but the further course and fin.il success of therapeutic measures will demonstrate the error. When in the course of tabes the sensory and bladder disturbances are only sli|;htly marked, there may be question of the existence of a chronic anterior poliomyelitis, but usually the lancinating pains, the para'sthesias. the affection of the eye muscles, and the mere fact that bladder symptoms exist at all. afford sufficient grounds on which to base a diagnosis. In dis- eases of the vertebral column, in the course of which lancinat- ing pains, " Westplial's sign." and bladder symptoms may be (ound, an examination will reveal that the vertebral column itseU is affected, and the spinous processes are pain(ul on pres- sure— a condition which is sufTicicnl to settle the diagnosis. The mistake of considering a tabophobe, or a person who im- agines he has tabes, as a real tabetic, can only occur when a careful examination is neglected, and the physician is afraid to adopt any energetic, psychical as well as somatic, treatment. As soon as this is instituted the tabetic symptoms will turn out to be mere hypochondriacal notions, and recovery will quickly follow.
It is of practical importance to note that the various symp- toms occurring in tabes arc also observed in other affections.
I I
4
i
19ES rWRSAUS.
669
I
I
In these cases there is much room for errors in diagnosis, the most important of which wc wish to bring to the reader's attention.
Paralysis of ihe eye muscles and pupillary symptoms are, as wc ha%'c remarked, very common in the course of tabes. Another affection in which they also occur is multiple sclerosis. Here, however, diplopia as well as strabismus arc rare, white, on the other hand, nystagmus is very frequent, and the pupil- lary reaction to light is preserved. Myosis occurs in thisaffec tion as well as in tahcs. but whereas in the former the pupils contract still more under the influence of light, in tabes they usually remain immobile under the same circumstances.
Symptoms referable to the optic nerve — amblyopia, for in. Stance— arc also observed as the effect of different poisons (page 39). In such cases the history will be of great assistance to us in making the diagnosis. Amblyopia developing in the course of multiple sclerosis is not accompanied, as in tabes, by a contraction of the fitltl of vision, nor docs it steadily grow worse; but remissions occur, and the impro%*emenl may even list for a considerable time. It has already been shown on page 620 that the opiic atrophy of multiple sclerosis differs in important points from that occurring in tabes. It should also be remembered that there is an optic atrophy in which the morbid process is confined to the optic nerve, and in which it is impossible to demonstrate any general nervous disease.
The various visceral "crises," in which tabes abounds, can likewise be produced by independent affections of the vagus. Here one must rely upon the more characteristic symptoms of tabes, particularly Wc^lphal's and Romberg's signs. That "gastric crises " alone can not enable one to make the dJag* nosis is all the more to be insisted upon since l.)cbove has observed them in neurasthenics (Soc. dcs h(»p., stance 1888, xij. 28).
The motor disturt>ances which we find here, and of which the most important is the ataxia of the lower extremities, ap- pear not only in the course of tabes, but also in other <liseases in which one is unable sometimes to ascertain their anatomical basts. This is more es|iecially true of the so-called (unctinnnl Ataxias (Gallard. Jaccoud). which develop sometimes wiih. sometimes without, sensory disturbances, and arc associated with no other symptoms. .Itasia has likewise been observed developing slowly or quickly after diphtheria <Berl, klin.
6;o
I>/S£ASES OF TUB GENERAL NERVOUS SYSTEM.
Wocheiischr.. 18R7, 49, p. 930). after quickly succeeding pr«__ nancies, and in the course u( diabetes; and the (Question ntust remain undecided whether it is to be cunsidercd as the expres* sion of a se\'cre jjcneral aflection. of a faulty composition of the blood iiiid an imperfect innervation dependent upon it. or as the result of a peripheral neuritis developing under the influence of an infectious agent. However, it can not be diffi- cult in a given case to determine whether the ataxia is to be regarded as of spina! or tabetic, or as of functional or of in< (cctious origin. In cases of hys-teria the differential diagnosis, as has been already pointed out, may present very great diffi- culties (Pseudo-tabes hysidriquc, Gaz. m&J. de Paris. Sepiembrc 20, rSgo).
The lancinating pains occur also in affections of the verte- bral column, e. g., in Pott's disease, when the posterior roots are irritated, but the deformity and the tenderness of the vcr. tebrx upon pressure will make the diagnosis clear.
Other pains, following the course of various larger nerves, which can last for weeks or months without marked exacerba- tions, and be accumpaniijd by par»:sthcsi.-is, formication, numb- ness, etc., are observed not only in tabes, but also in peripheral neuritis, following, for example, the abuse of alcohol. If to these a temporary loss of the patellar reflex be added, we have the picture of what is called pseudo-tabes, and a cautious and often -repeated examination is necessary in order to make the differential diagnosis. The history and the further course of the disease, which in alcoholic neuritis m.iy become favorable after the removal of the cause, should always be taken into consideration (Higicr, Deutsche mcd. Wochenschr, 1891,34; Fournicr, Miinchener med. Wochenschr,. 1892. 10).
\Vc have already pointed out on page 6jo the circumstances under which VV'estphars sign may be present, and we can not insist too strongly that it is an error, or at least a too ha^ty conclusion, to think only of tabes whenever the patellar reflex is absent. On the other hand, we must not imagine that its presence puts tabes out of the qiieBtion, foi the possibility of ihc existence of this disease is not at all excluded when the reflex is found to be normal.
Pathological Anatomy. — Considered from the palhologieal standpoint, tabes represents a degenerative process in which the entire nervous system takes part. The reason that we have been unable to demonstrate in all cases the participation ol all
I
I
I
T^BES DOflSAUS.
67 1
nerves — that in many cases, (or example, the cord seems to the part most involved while i)ie brain and its nerves appear less affected — lies in the (act that we have been accustomed to examine ilic cord with the greatest accuracy, while the brain and peripheral nerves were considered only of secondary im- portance; and. secondly, in the fact that many cases are ter> niinaied by intercurrent diseases before the degenerative process has had time to develop in all directions.
This degeneration, which consists principally in the death of the nerve elements and an increase ol the supporting tissue <L.eyden), presupposes a certain change in the nervous system. the nature of which we do nut as yet know, and which is peculiar to the individual cither as the result ol hereditary influences or which has been acriuircd later through syphilitic infection. The congeniul predisposition is not suflicient to prfKluce an outbreak of the disease. For this some one of cer- tain exciting causes, of which wc shall speak Liter, is needed. Oti the other hand, the changes produced in the nervous sys- tem by a syphilitic infection are able of themselves to lead to the production of tabes. As to the manner in which heredity works in the production of these changes, wc are not in a posi- tion even to hazard a conjecture, nor are we by any means cer- tain of the precise mode of action of syphilis. In this latter , however, it is, according to our idea, most probable that he changes are a result of a syphilitic affection ol the blood- vessels. It is, in our opinion, less likely that a poison (" toxlne "), which affects the nervous system, is developed secondarily, in which case tabes would have to be regarded as a post-syphilitic allection, just as paralysis of the solt palate is a post-diphtbe- riiic affection (Strllmpcll): and it would be still harder to im- agine that the syphilitic virus becomes localized in the nervous system, and, as stich, later produces the disease (Rumpf). One could in the last case not help but ask how it is possible for ten. fifteen, or more years to cLipsc between the syphilitic infection and the appearance of the ftrst tabetic symptoms, a circumstance which, on the other hand, could be easily ex- plainefl by .issuming the existence of anatomical changes which arc due to a diminution in the blood supply and require a rela* lively long time for iheir development.
The degeneration begins probably always in the peripheral nerve.s. The terminations of the cutaneous sensory nerves may be the first to become affected. The admirable researches of
A
6;i
D/SEAS£S OF TUB GBXEXAL NERVOUS SYSTEX.
Dcjcrinc, Oppenhcim. Sicmerling, and others, have clearly dcmuti<>i rated itic participation of the peripheral nerves in the tabetic process, and there is no doubt but that they appear just as much dej^eneralcd as the posterior roots, in which the atro- phy was shown to be most marked between the spinal g'anglia and the cord, while the peripheral portion was often relatively quite free (Dcjcrine. Compt. rend, dc la Soc. dc biol., 1883, p. 215). The defcrce to which the several cutaneous nerves arc attacked varies. Those of the legs arc usually more affected than those of the upper extremities. No delinite rule can be said to exist. Somclinics, and this often happens, the pcriph. era! ends of certain of the cranial nerves arc the first to be- come diseased— c. g., those of the optic, the oculo-moior, and the abduccns — and then the symptoms described above appear ill the initial stage. .\\. any rate, the first symptoms develop in consequence of lesions of peripheral end organs.
The degenerative process in the cord, which occurs later, is the most prominent pathological feature at the autopsy, and formerly was considered the only, or at least the only charac- teristic, lesion. This explains why tabes was and is still con- sidered, by the majority of authors, as a disease of the spinal cord. According to our idea this is not true. It is rather an affection of the entire nervous system, in which the cord (s not even the first part to become affected, but later is altered in such a characteristic and striking manner that we cannot be surprised if the other, less marked, conditions were over- looked, Though the changes in the cord have long been rec- ognised, the views as to their origin arc still conflicting and the most varied interpretations have been put forward. We do not care to enter into an account of ihc controversies, but will only bring before our readers succinily the conclusions arrived at as to the nature of the affection. It consists prob- ably of a primary degenerative atrophy of the nerve fibres, which is followed by a secondary increase of the supporting tissue. As the degeneration takes place slowly, few compound granular corpuscles arc found, and only in older cases can cor- pora araylacca be demonstrated. The grayish discoloration of the posterior columns depends upon the destruction of lite medullary sheaths. A marked degree of atrophy is to be no- ticed in the posterior columns, and in advanced cases the entire cord appears narrower and thinner than is normal. On cross-section it is readily demonstrable that besides the
I
TAlfES DOKSAIIS.
6;3
posterior columns the posterior gray bonis and the posterior ruoiit also become atrophied. The condition ol the i>osicriur roots has been carefully studied by Leydcn, who noted the (rcqiicnt atrophy in Ihem ; according to his conception, the changes in the posterior columns arc a result of the chiingcs in the posterior roots, so that we have " a progressing affection ol ihc sensory portions of the spinal cord," This view is still upheld by leydcn. in spite of various objections which have been raised against it (Kediich, Marie, and others ; sec the latest article of Leydcn in the ifeilschr. f. klin. Med., 1S94. xxv. 1, 2). Moreover, it is of interest to note that certain portions of the cord seem, .is a rule, to be spared, while others are almost always involved in the degeneration which affects both sides of the cord symmetrically. The lesion is of the character which we have learned to recognize in the so-called " combined system diseases " — thai is, certain systems of fibres which have certain anatomical and physiological relations to one another become diseased, while others are unaffected. It is also seen that not all portions of the posterior columns are implicated equally (Strtimpcll). but that ihe extent of the lesion differs according lo its situation. For example, it is most severe in the lumbar region, in which only the nnierior part is left intact, the middle and posterior portions being dc- i-v ■]&
*
Fit. «». Ffc. iHo.
FV. lift— SBCTKMr -nitiovoii tii* CcHvrCAL Oorb m a Cam or Cnnimncvita X\wr». He. in-— ^'K'^O'' niRoktiii niR LlMua Cciiid ih Tam*. V\t. tfa—Sn^fm niantT.ii THt C»vic*i. Cou> id a Cam op AinrAlnclti TAau. (Afi*r Sthlm-
jjenerated. In the cervical region there are to be distinguished (our fields on cither side, of which, two. GoU's columns and a pan of nurdach*s columns, the so-called lateral root fields (into which direct fibres enter from the posterior nerve roots), appear 43
674
DISEASES OF TffS GENERAL NERVOUS SYSTEM.
degenerated, while two others, one anterior and lateral, the other posterior and external (the posterior outer fields of Sirtlmpell), appear normal (Figs. 178, 179, and 180). Such a distribution ol the lesion is frequently observed, but naturally not found in all cases. Wc have already mentioned that the posterior gray matter is involved in the process. Lissauer deserves credit for having demonstrated (Arch. f. Psych, und Nerveiikrankheiten, 18S6, xvii, p. y}<i) that here the affection of the fibres in Cbrlce's columns should be distinguished from (hat of the fine and large root fibres in the posterior horns. _ Physiologically this discovery can not as yet be utilized. f
O! the lesions in the medulla oblongata and the brain, pro- duced by tabes, the former affect the cranial nerves at their nuclei or in their peripheral course. Uf the manifold $ymp< toms produced thereby wc have spoken before. On the other hand, we may have lesions of the cortex, an implication of which in many cases can not be called into question. We also said that some of the nuclei, particularly those of the eye mus- cles, of the vagus, and of the hypoglossus, are affected more often and more severely than others, while, for instance, the facial, the auditory, and the glossopharyngeal remain as a rule intact, a fact for which we have no explanation. According to Jendrassik's conception (Deutsches Arch. f. klin. Med.. 18S&, xliii, 6), the brain is the primary scat ol the tabetic process, so that the sensory disturbances and the ataxia are to be consid- ered as of cortical origin, and the degeneration in the posterior coliimns.and perhaps those of the direct cerebellar tracts, as secondary processes. Until the cortex has been examined mi- croscopically in the initial stages of the affection, and some constant changes have been demonstrated in it after dt-alh. this theory, like all the others, will remain nothing more than a bare hypothesis, and can be neither contradicted nor yet accepted. Such a pathogenesis, hnwever, is not impossible, though it is not dilTicult to bring forward objections to it.
La.stly, it should be mentioned that Basso (Ann. univers. <li med. et chin, June, 1886) considers tabes to be an affection o( the sympathetic system, under the inlhience ol which the cerc- bro-spiiial lesions develop. He thinks that the anatomical changes in the nervous system arc al first caused by functional, and later by organic disease of the blood vessels, and holds that when taken in lime tabes is curable.
I
,1
i
TABKS DOSSAirS.
675
LITERATI! KE. 6. P-tlM--j;it.tl Atohtmy,
A(toint:i«wici. Die AnatomUchen Vcrilndcningcn bd Tabes. Congr. Inlmutt.
de Copeiiluituif. 1886. Pick. Arch, f, Psych, u. Nrnenkh , 1SS9. 3. (Anatomical Condition tn a Cue
with Alwenrc tit one Knet-JiTk.) Flcduig. 1st die Tubes tine Syslemeikr.inkung ? Neurot. CeniralM., 18S9. 1. Schmkia. DeuiKhc» Arch. (. klin. Metl., :Six>, ilvi. (ln){>lical)on of the Ljlcral
Cdiunn*.) lUj-mond. Coniribuiion A ranaiomic piliologique <lu tabes, etc. Rcrue de
m^l.. 1891, 1. Brutolo. Suite locaJiuuioni anatomo-piatolofpclie c suUa jutogcncsi delta talx
donali. tiull. d. Kicnie mud.. April. 1S91. Ilcft 4, p. 1S7. ofl. VirclMiw's Anhiv, 1893, cxTviit. i. (The Degeneration of (be Posterior
Colamns fonncrly rcj-ariM as characteristic of Tabes b oLm IouimI in
Lepra Ana:siheiic.>.) \Vollcnbcri[. Arch. f. t'*j-ch. w. Ncn*nkli., 1891, jtii*. 3. hNonnc. Ibid., p^ jt6; ^Krauts. E. Ilnd.. ttXn, 3. 3. Rcillich. Wiener Jahrt). t. Pt)-ch., 1891, t, 3. (Condition of the Posterior
Rool^> Leyden. Dctilfche Med.-Zlg., 1893. 96, p. tool. Lcyden, NfuioI. CcninlbL. 1894. 1. a. Marie. P. £iude compdrjiivc An Miionf mf<lotliure3 dans U jtaralysie gfainA^
el dam Ir t.-i)i». C.a/. des h/lp.. Jnnr. 16. 1894. l.cyden. Zt'itschr. f klin. Med., 1894, ixv. t, j,
Etiology. — In spcnking of the sctiotogy of tabes, one must constantly distinf^uish, as is evident frani the views expressed above, between the non-syphiliiic and the syphilitic affection. In the first case one should above all take into contudcration the hereditary conditions in order to comprehend the congcrv- ital predisposition which is necessary for the production o( the dtsease. By this u*c do not mean to class tabes among the hereditary diseases in the ordinary sense of the word, for it certainly can not come in this category ; on the contrary, we are jusliAed in assuming that direct inheritance of it is quite rare. By heredity in this connection we mean a general neu^ >3thic inherited tendency, or, in other words, that in the (imily of the patient all kinds of neuroses, not excluding psy. choses. have occurred repeatedly. Not only the parents, but also more diMant rcLitivcs. e. g., aunts, uncles, or grandparents, rinay hare suffered with general paralysis, epilepsy, melancho- lia, hysteria, migraine, etc., and it is just this heredity whicn iti the presence of exciting causes is sufficient to open the
676 DiSBASES OF THE GENERAL NF.RVOVS SYSTEM.
door to the tabetic process. The labors of Charcot (Arch. ^hw^T. de m^d., Sept., 1SS3) and the comprehensive statistics ol Ballet and Landouzy (Arch, de neurol., 1886, vii. 20) have thrown an interesting light upon this subject, and have bril- liantly substantiated the view which Trousseau expressed at an eiirlier period, th»t ta[)cs was (in the sense of the word as expressed above) hereditary. Among the German authors Mubiits has occupied himself particularly with this subject (Allg. Zcitschr. f. Psych.. 1S83. xl, 1, 2).
The exciting causes which relatively Ircquently lead to the development oj tabes (in those with hereditary tendencies) con. sist (d) in exposure to cold and wet, to sudden changes of tem- perature, and to prolonged living in damp lodgings ; (^) in traumatic influences; (r) in certain (actors due to the daily oc- cupation, the most important of which is overexertion. The opinion th:it sexual excesses may lead to tabes, which has been expressed by vaiious authors, must be given up as without proof.
1 have n?ver questioned but that exposure to cold, sudden changes of temperature, and. particularly, severe wettings, may play an important part in the xliology of the affection ; still, to me the following case was particularly convincing 1 The pa- tient, a general agent for several hail-insurance companies, fifty- eight years old. had h;id syphilis thirty-nine vears before, since which lime he had been perfectly well. In ,\ugust. 1885, while estimating the damage caused by a hullstorra, he was drenched to the skin, and was obliged to spend several hours in his wet boots. Three months later the first tabetic symptoms made their appe-irancc— paresthesia and anaesthesia of the tegs, loss of the pntctlar reflexes, etc, ; by Christmas, 1885. he was mark- edly ataxic, and in the spring of 1SS6 he was unable to pursue his calling. In the summer of 1886 he suffered with intestinal crises and intense lancinating pains, and eighteen months from the beginning o( the afTcction he had paraplegia of both legs. In the early p,-trt of 1887 he died from an intercurrent attack of pneumonia. When tabes develops in one well on in the fif- ties, there must be some particular cause for it. and in this case it was, without doubt, the wetting. Similar cases can easily be found if the history be careTully taken.
The r6U' which traumatic influences play in the production 01 the affection is just as certain. In r)ne of my cases, a gov-
I
I
I
crnment official of
high position,
who had been affected with
rjiS£S DOKSAUS.
677
syphilis twenty-nine years before, met with an accident on a glacier in the summer of 1884. He Icll and slid some distance on a snow field with great rapidity, but no bones were broken and no dislocation occurred. A few months later the lirst tabetic symptoms made ihcir appearance, and now the disease is well developed. Again, a fall from a height may be the cause (Oppenhcim) : Strauss reports numerous traumatic cases <Faits pour scrvir k litudc dc8 rapports dc traiimatisme avec le ubes. Arch, de phys., Nuvembre, 1886). From his com- munication it is npp.ircnt (1) that years may elapse after (he accident before the disease makes lis appearance, and (2) that the traumatism may have an influence in determining the scat ol the early symptoms, particularly of the lancinating pains, so that, lor example, after a fracture ol the lower part ol the left leg the pains will first make their appearance at that point, and so forth. In an article by Spillman and Parisot (Traumatisme p^riph^rique ei tabes. Revue de m^d., 1888, 3) there is a table which gives the different forms of injury which have been followed by tabes. Of great interest also is a case reported by Blocq and OnanofI (Arch, dc m£d. cxp. et d'Anat. pathol., p. 387. 1892) in which there was a combination of tabes and Irau- matic neurosis.
I have already jwiinted out, in my book on diseases ol the laboring classes, that the occupation is not without importance, and more especially overexertion — (or instance, at the sewinj; machine — or hard bodily labor in general may be the cause o( the outbreak <>( the disease in those who are predisposed 10 It. However, the percentage of such cases is not large. Hof- mann gives an instance which may be classed partly with those cases in which the occupation, partly with those iti which trau- matism, is the exciting cause. The patient was a laborer en- gaged in cutting tin plates, and in the course of his work his body was shaken from six to ten thousand times daily : under the influence of these shocks the disease developed (Arch. 1. Psych, und Nervenkrankhciten, 1S8S, xvlii, 2. 439).
Concerning the syphiUlic tabes, which has been studied with the greatest care by Fournier and Erb, it is an undoubted fact that syphilis by itself is usually a suflicient cause for the disease, and that no other exciting factor Is needed for its de- velopment.
\Vc do not know what percentage of persons who have had syphilis become tabetic, but wc do know lor certain that the
A
6;S DISEASES OP TUB CENEftAL NERVOUS SYSTEM.
great majority of tabetics have had syphElis at some time or other — according to Erb, sixty per cent ; according to Foumicr, ninety per cent. Syphilis is more (rcquetitly followed by tubes than hereditary and exciting causes put together. Out ol three hundred and (orty-five cases of tnbcs which I have seen in the last few years of my practice, in sixty-six a syphilitic history was not obtained, while in the other two hundred and seventy- nine cases it was demonstrated with certainty, so that my figures, although they do not quite correspond to those of Fournier, give eighty per cent. Minor points out in his statis- tics (Wyestnik psychiatri i nervipaioiogii, i88i!, vi) that tabes is much rarer in Russia among the Jews than among the other Russians, which is simply due to the fact that the former are less frequently syphilitic. The communication of N^cl also deserves consideration. He found in M03 cases of tabes forty-six per cent of syphilitics, and out of 1,450 other pa- tients only nine and one hall per cent. The time which elapses between the infection and the first appearance of tabes varies from a few months to one. two. live, fifteen years or more. The severity of the syphilis docs not ap- pear to stand in any relation to the severity of the tabes; for one can observe very pronounced tabetic symptoms alter an apparently trivial and quickly healed primary sore, whereas sometimes alter the most severe type of syphilis the general affection of the nervous system only appears in its mildest form.
The influence which age and sex exert in the production o( the disease can only be considered in the non-specific cases. It is, however, only of slight importance: for, although It is true that males arc far more frequently aflected than females (the proporliim being seven tp two), and although most ol the patients arc middle-aged, these facts can very well be accounted for by the nature of the several exciting causes, which make it comprehensible why men in the prime of tile furnish rela- tively the greatest contingent of cases. For the special con- ditions under which the disease may occur in childhood, and the peculiarities presented by tabes in children, the reader is referred to the articles mentioned on page 679.
Lastly, it must be confessed that in a lew cases, which, however, form an exceedingly small fraction of the whole num- ber, no xtiologicnl factor can be made out — neither hcrediLiry predisposition, nor exciting causes, nor syphilitic infection, .^t
I
4
TABES DORSAUS.
679
present u'c can only acknowledge our ignorance of their palho* genesis. '
^^^ LITCRATURe.
^^^P ;, /Etiottgy (Afi. Sex, M-.J.
^Pnincc. Jnum. nf N«rv. and Mrni. ni^ra^rs, 18S9, xill. (Malniia » Causr.l H Cuiiibault vi It^llcl. Arcb. de mcd. ex|>cnin.. cic, 18^9^ j. (On»c( U the Age H of Seven.)
V Qernhnnli. Neurol. CcntralbL, 1890. 13. (Work with the Sewing -machine.) KlFn>|Krcr. Anivkng von Frerichi und Leyden. 1S90, iviti, i. Tick. ?M> Ixhrevon den Tabcsformcn im Kindculier. Zeitschr. f HeiHtaBde,
iSyi.ni. Hi1dirtw«ndi. Liebcr Ta)>ts in <Ien Kinclerjnhrcn. liuug.-K^KTt.. Berlin, 1893. [ Krh. I>jc Actiologie iter T^bcs. VnUinanit't Samml. klin. Vnrir., 1891. 53. iFnedncliMO. Tal>es bein n-ciblichcn GcKhlccliL lnaug.-Ui»sc(1., BerliB, >893-
Prognosis. — From what has been said, wc may infer what j the prognosis will be. Thoufjh il is not absolutely unfavorable \ fUMui vititm. inasmuch as the p-tlicnt may linger on for year;:, land sometimes tens of years, one should not forget that in Igeiicral the course is unfavorable, that the patient will suffer greatly at times, and that the linul lot of the t.ibctic is almnst always a total inability to work or gain a living. In discuss- ing the prognosis as to complete recovery, the question arises. Is tabes ever curable, nr is there even a possibility of cure? This qtiesiion is, with the proper restriciiuns, tu be answered ■in the affirmative; it is possible to cure tabes, but only fresh cases o( luetic origin. Advanced cases. In which degeneration in the cord has taken place, are incurable ; we possess no means of bringing the lesion to a standstill or causing it to disappear. Il is evident that the chances for the successful treatment of recent cases are incre.isL-d the younger the i>;itient and the better his general conslilulion. The prognosis is. cfr/cm />«/-i:. ^ns. less favorable in individuals with a neuropathic tendency, in whom the disease breaks out in consequence of* some ex-
I citing cause, than in fresh specific cases. Treatment. — In taking charge of a case of labcs wc roust first see that we ourselves, as well as ihe patient, clearly under- stand how much can be expected from any treatment. 1( his • is one of those exceptional cases in which the prognosis is relatively favorable, we m.-iy tell him so: but in most instances it will be our painful duly to make hira acquainted with the seriousness of the situation, of which he will often be entirely
68o DISEASES OF THE GENERAL NERVOUS SYSTEM,
ignorant. We must tell him with gentleness that a complete recovel'y can not be hoped for, and that all that it is possible to accomplish is to relieve some of his symptoms and to keep him in such a condition that he can as long as possible carry on his occupation. There is no disease in which it is more out of place to arouse in the patient vain hopes of recovery than in tabes.
The choice of the therapeutic measures themselves depends upon the stage of the disease in which we find the patient — that is, upon how long he has been sick. In old cases the greatest caution ought to be observed, and one should not forget that rash therapeutic interference may do more harm to the patient than good. The value of a treatment is often quite problematical ; its harmfulness is too often quite evident. Hygienic and dietetic measures, conscientious nursing and cleanliness, injections of morphine in severe attacks of pain, occasional cool baths, ever-repeated kindly encouragement, these constitute — if we leave out the suspension method, of which we shall speak later — the only treatment which old cases of tabes need, or, for that matter, can stand. But the recent cases also demand a great deal of care and forethought. In view of the duration of the treatment, protracted as it will probably be, all circumstances have to be taken into account— the constitution, the age, the occupation, and, above all, the pecuniary situalion of the patient.
As syphilis is at the bottom of so many instances of tabes, the question whether we are justified in expecting anything from an antisyphilitic trealmcnt should be mooted, but only in exceptional cases can we have such a hope — that is, only when either signs of syphilis arc still present, or when the time that has elapsed since their disappearance is relatively short (not longer than a few months or at most a year). Such cases are very rare; generally years, perhaps twenty years, will have gone by during which the patient has been apparently per- fectly well, and then the antisyphilitic treatment is of no avail. If, however, wc wish to institute it for any reason, possibly be- cause the patient himself insists upon it, bold doses ought to be given, (our, six, even eight grammes ( 3 j- 2 ij) of potassium iodide a day, and from three to si\ grammes (grs. xlv- " jss.)ol mercurial ointment rubbed in daily. In all, two or three hun- dred grammes (;vj-5i'i) of potassium iodide and the same amount of mercurial oiiitment ought to be used. Recently
TABES nOXSAL/S.
681
»
^ ^
^
^inkier, in Erb's clinic, has made careful observations with re- ^j^rd to the influence and the justilicaliun of the treatment by mercurial inunctions (Berliner klin. W'ochenschr.. 1893, 15, 16); he comes to the conclusion that in hlty-eighl out o( seventy- one cases — i. e., in about eighty percent — one or several symp- toms were improved by the treatment.
If we have resolved to try internal medicines, knowing, of course, that there is none which acts favorably upon the dis- eased nerve elements, we may bc^in with silver nitrate in doses ol one centi|;ramme (gr. '/,) in pill form three times a day tor four or six weeks, after which time it may be combined with ergotin (arR. nitr., 0.3 (grs. ivss.); exir. secal. com.. 3. (grs. ilv): pulv. et cxtr. quass.. q. s. ut f. pil. no. 30), of which also one pill is to be taken three limes a day. Finally, a trbl may be made with the salicylate of physost limine, of which one milli- gramme <nr. ■/«) in pill form may be jjiven three times a day (or a month, as recommended by Meyer in his paper on the Influence of Physostigmine upon the Patellar Reflex (Berlin, klin. Wochcnschr., 1888, 2). With these drugs we may be (airly confldent that we are doing no harm, and often wc may per- ceive a distinct improvement in the condition ol the pntirnt, although we <ire, of course, not able to dclinitcly decide whether this is actually to be attributed to the medicine or not. We would recommend these remedies more warmlv than any other, even Ihan slrychuinc. which has been administered subcuiane- ously in doses of from three to five milligrammes (gr'/^-'/n), gradu.illy increased to one centigramme (gr. '/,) in twenty-four hours, (or repeatedly after these injections we have observed the occurrence of pains which had not been present for months. In the treatment of the individual symptoms we must resort to the same measures ih.tt we should adopt when these appear in Ihc course ol other diseases nr by themselves; (or instance, fur the lancinating pains, as in other neunilgias, we shall be obliged to give antipyrine and aniifebrinc, which have recently been recommended by lupine, Suckling, Germain 8^e. G. Fischer, and others, but wc shall be driven to Ihc conclusion finally, that for the relief of these pains there exists only one drug by Ihc help of which the patient's painful existence may be ren- dered at all bearable — viz.. morphine, which here more than in any other disease wc are justified in using in large amounts. The application of a tight bandage to the limb in which the lancinating pains are present, as ndvoc-ited by LcidylMcd.
683
DISEASES OF TUE GEJiTB/tAL NEJtVOUS SYSTBAf.
News. August, 1891, 29), 1 have repealedly Tound efficacioti the combination of pressure and warmth seems so beneficial to many cases. Gastric and laryngeal crises, headache, etc., are to be treated symptomaiicalty.
In addition to the internal medication, it is the electrical treatment which deserves special consideratiun. This, if used at a period early enough, may be followed by excellent results, and may alone sometimes be capable o( effecting a cure or aa arrest of the morbid process. On the other hand, if we do not select our cases properly — lor example, if we treat old cases like recent ones — we may do more harm than good with it. It may give rise to severe pains, and make the patients, who until they were treated by electricity were in a fair condition, begin to suffer terribly and soon lose confidence in the physi* cian. Electricity m.iy also prove successful against the motor disturbances, nut so much against the ataxia as against the wcikness in the legs ; also in combating anaesthesias and par- fcslhesias in the hands and feet it may have some eflect, whereas it is usually of little avail against the lancinating and rheuma- toid pains. How to use the electricity, whether in the form irf the faradic or the galvanic current, it is impossible to say in a few words. Every one forms for himself, in the course of years of practice, his own technique, and gives preference to this or that method ; the one prefers the galvanic, another the (aradic ; again one will recommend the ascending, another the descend- ing current through the spinal cord ; the one believes in moist, the other in dry electrodes, especially the brush. Among all the dilTerenl methods, besides the excellent general faradization advised by Dcard and Rockwell, the faradic brush applied 10 the back, as recommended by Rumpf. has perhaps met with a more favorable reception than any other pniclice, and justly so. We prefer it, so far as electrical treatment goes, to all other modes. Details on the subject may be found in my text-book on Electro-diagnosis and Electro-therapeutics, in which all the points necessary for the practitioner to know are discussed.
In a large number of cases the cold-water treatment has been found to be extremely beneficial. The action of the water on the peripheral nerve endings, the influence which a>ld douches, wet packs, moist (" Pricssnitz's ") abdominal bandages, cool baths, etc., exert upon the circulation in the vessels of the skin, and thus upon the terminal nerve twigs, is often so favor able that marked improvement during and after a stay in »
I
I
I I
i
TABES DOSSAUS,
683
I
I
hydrothcrapciitic establishment is not rarely seen. Even in cases in which sensury and motor disturbances have attained to such a degree that but little can be hoped for. a carefully conducted cold-water treatment may be quite beneficial in improving the general condition of the paiicnt imd raising his spirits.
On the other hand, we would emphatically warn against the use of warm or hot as well as steam and sweat bitths. As a rule Ihey are ol no avail, but often evoke the lancinating pains. Unfortunately, the physician is not always in a position to prevent (his. since the patients, who believe implicitly in the rheumatic nature of their pains, use them at random with- out his orders often lor months and years. There are a great many tabetics who during the course nf their disease have taken many hundreds ol steam baths without perceiving ihe slightest benclit therefrom.
From the springs we can, on the whole, expect but little, and especially old cases with paraplegia and severe bladder troubles should be spared the trial. The disadvantages, the overexertion attendant upon the journey, and the Lick of home comforts, in the case of these patients especially, will far out- weigh any good results obtained from the baths; nor should we. as we said above. leave out of sight the necessary cost which, even with the most modest pretensions, is not incon- siderable. One should never forget that the disease is likely to last a very long time, that the patient will soon be unable lo earn any irtoney, and that lor him there can be no greater misfortune than lo find that, heedlessly or yielding to over, persuasion, he has spent all his worldly gmids ol which now he stands in the greatest need, There exist not a lew of such helpless patients in whose caM^s just this ]x>int was overlooked. and it is especially our younger colleagues who seem rather too prone to disregard it. Ksuchandolhcr objections do not exist, it is most advi<iablc to recommend places where warm brine baths can be taken, as in Kehme-Oeynhauseit, this place having become famous for the treatment of tabes especially, though it is my experience that patients get along there no better and no worse than at other springs of the same kind — e. g., Nauheim — and it only deserves to be warmly recommended owing lo the excellent arrangements which we there find, particularly the facilities for moving helpless invalids from place lo place. Chloridc'.of-sodiuin springs containing iodine and bromine —
684 ^/SEASES OF THE GENERAL NERVOUS SVSTEAf.
for instance, K5nigsdorf-Jastrzemb, Kreuznach, Goczalkowitz, Krankenheil — may be tried without fear of doing any harm ; while the nonmedicated hot springs of Gastein, Teplitz, Johan- nisbad, VVarmbrunn, PfaSers, and the hot snlphur springs of Landeck, Aachen, Trentschin, Pistydn, Baden near Vienna, and Baden in Switzerland should be prescribed only with great caution, and the baths should never be taken too warm, never above a temperature of 80" to 90° F. Among the chalybeate springs, first Cudowa, then Pyrmont, Flinsberg, Schwalbach, and St, Moritz (Engadine) deserve to be tried.
The results of massage in the treatment of tabes are not sat- isfactory. There is no objection to giving massage in a care- ful manner 50 as to improve the nutrition of the muscles and to stimulate metabolism, especially in cases of young, compar- atively robust patients ; but we are hardly justified in building much upon such a procedure and in expecting to bring about a lasting improvement in the sensory or motor disturbances. I have known instances in which the general condition of the patient was influenced for the worse by massage, and in which certain symptoms, especially the lancinating pains, appeared to be aggravated after its use.
Of only historical interest is the operation of nerve stretch- ing, which, in the first half of the eighties, was by some claimed to be an excellent me.nns in the treatment of tabes, the sciatic nerves being usually chosen for this operation. They were laid bare bv cutting through the gluteal muscles and "stretched" according to different methods. The result was in many cases at first very striking. Pains, bladder disorders, and anxsthe- sias vanished, and the operation was undertaken comparatively frcquentlv. Soon, however, it was found that what had been regarded as a success was of no long duration, and that the old troubles returned, and, finally, after it had been repeatedly demonstrated at the autopsy (Striimpell, Rosenstein) that the elongation of the nerves not only had not exerted the slightest benehcial effect upon the morbid process in the spinal cord, but that several times at the place where the nerve had been stretched a neuritis had developed and extended to the sub- stance of the spinal cord, giving rise to a myelitis, the praclice was given up, and can be looked upon to-day as having been definitely discarded.
Finally, various other modes of treatment should be men- tioned which we m.iy collectively call the mechanical methods.
TABES DOKSALfS.
685
Graduated exercises consisting in the execution first of sim- pl<: muscular movements, later of simple co-ordinated, .ind finally of cuniplex co-urdinaied movements (Frenkel. Miln- ctiencr mcd. Wochenschr.. 1S90, 52), it is claimed, bring nliotit a decided improvement in the ataxia. Again we have the treatment acconliiig to the method of Messing, by which a permanent support ot the spinal column is attempted : the patient is provided with a corset made of cloth which he has to wear for years day and night, and which transfers the weight of the body to the pelvis and relieves the fpinat column. Certain clinicians, among them Jiirgcnscn (cf. lit.) have spoken favorably of this procedure, while MUller, o( Stuttgart, would prefer another form of apparatus, since he considers llessing's corset inefficient (Mcd. Cor- respondenzbl.. d. WUrtemb. iirzll.Landesvcreins. 1890. 15). Frequent extension of the spinal column is attempted in the method by suspension first advocated by Motschu- Itowsky (Wratsch, iHSj, 17- 21) and later by Charcot. The results obtained with this mode of treatment in the Salfitltriire were favora^ ble enough to induce many clinicians in Germany, Eng- land, and America to m.ike
further iiial of it, and at present we possess quite an imposing array ol articles treating of the " suspension method " and the re:9ults obtained by it. According to some authors the cere, bral, according to others the spinal symptoms are improved by it. The procedure is &aid to be without danger, but in one instance the immediate consequences were fatal ; it should l>c said, however, 1h.1I in this case the suspension was undertaken I without the physician's supervision (Gorccki. Lyon mid.. i8)f(), I 20). Allhaus (cf. lit.) has attempted to give an explanation of
Fig. tgi.— Sv«r(n»o9i App«m*m vhd in T>iE Trkatmcmt <>r Taimk
686 DISEASES OF THE GENERAL NERVOUS SYSTEM.
the mode of action of this treatment. According to his opinion, the meningitic adhesions over the posterior columns are loos- ened, so that the nerve fibres, especially the superficial ones, gain in power of conduction, the sclerosed, thickened neuroglia becomes looser, and the pressure upon the nerve tubes is thus diminished. He also thinks that suspension should only be used in older cases, because in recent ones it might lead to inflammatory conditions. The possibility that this loosening does take place, as Althaus claims, can not be disproved, but this much is certain, that for those instances in which improve- ment is said to have shown itself after only one, two, three, or ten suspensions, this theory affords no explanation.
The results which I have seen from the method by sus- pension both in my clinic and in private practice are by no means encouraging. Outside of an improvement in vision, which I have been able to note and which Bechterew (Neurol. Centralbl., 1893, iS) also observed, I have not in a single in- stance been able to persuade myself that any marked or lasting improvement took place. The account which intelligent and unprejudiced patients gave of themselves after the thirtieth, fiftieth, and eightieth suspension corresponded almost exactly to that which they had given prior to the institution of the treatment. In opposition to Althaus, then, it is my conviction that anatomical changes are not produced by suspensionTbut that the transient improvement has to be referred to the influ- ence of suggestion. The patients hear of a new treatment for their incurable disease, they subject themselves to it with much pleasure and confidence, and by autosuggestion produce an improvement in some functional impediment (for example, in the ataxia), which may be quite marked, but which is never lasting. Four times during the act of suspension I myself met with rather unpleasant accidents: in two cases the patients lost consciousness and had to be rapidly taken down, and were only then with some difficulty recalled to life; in two other instances severe laryngeal crises appeared, so that the pro- cedure had at once to be stopped. Such accidents, of course, make a very bad impression upon the patient, and bring the results, which are in any case doubtful, still more into ques- tion. Careful examination is necessary before the suspension is used, and if there exists a disease of the heart or of the ves- sels it should under no consideration be undertaken. We need, of course, hardly add that while the patient is suspended he
TABBS 130/tSAUS. 687
should be carefully watched. Benuzzi has recently attempted to replace the suspeiisioti by simple sirclcliitig. and claims that with his method the spinal curd is extended much more de- cidedly. The legs arc held at the ankle joints with a towel and are pulled over the head until the knees touch the lore- head. Hencdikt has seen good results from this method in a number of cases (Wiener med. I'resse, 1892, i). I myscU soon abandoned the procedure, owing to the (act that it is s^ry dis- agreeable to most patients. 1 must admit, however, that it is deserving of further trial in suitable cases.
LITERATURE.
8. Ttatmeul.
JtirgcnMn. Ueber die roechanische B«hanillun|; dcr Tatxs nacK dcm System
Hewing. Druuchc Tncil. Wuiilictisciir.. 18S9, 40. Lcydra. Berliner Uiii. Worhftivhr,. 1S94, 17. 18. L^tde. Du ir.tiicnicni ^lccln((u<: Uu (aba. TbiM dc Bordeaux, 1893.
TrraMfiH tf "SMiffMnim.''
Charcot. Dc la suBprn&ion <Ui>t le tnuicmeni dc t'aiaxic locomolrice pragma live ct dc quclquea aulrea maladie* du systime ncmvx. Progris m^.
1889.). Wiir MiiehHI. Med. Nrw«, April 13. 1889. Cberncl. ^^'ienc^ mttl. BISlier. i88y. lii, 5. Dana. New York Medkal Record. April 1 $, iSSjK nmr. Cillrc 4k la Tourcttr. Prugris mid.. 1SS9, xvit, S. <T«chiiii)iM of Stitpciunn.) MoTlun. New York Med. Record. April 15. 1S89, mmv. Aliliaut. Lancet. A|>rll 13. t889. p. i6ol Watiewinc. On ihc TreaimfW by Sutpeniion or l.ocomotor Ataxy. Loiwtoti.
1S88. V. Opcnchowdii. German iransbtlonofMotihukowski'ilBvcstipatloivt. Ikrlincf
Itlin. WochenMhr. 1889. 1^ Itcneaikt. Wiciier meet. WochtMChr.. 1889. 45. 46. Hauvtuliet d Adam. >*To];rii mM., tiitf. 44. Ctllet lie la Tourette. Arck lie Neurol., Juillet. 1889. xviil, No. 5). Pinehcrli. Rituta vencta dl Klenic med., 1889^ Otiobrc. Ro»enb<tuiD. Deulxbe Med-Zig., 1890. 39^ p. 444. LcAnuinn. Iliid.. 1890.69. CMgftty. Liuic«l, January 18, 1890.
CHAPTER 111.
DEMENTIA PARALYTICA PROGRESSIVA — GENERAL PARALYSIS OF THE INSANE — GENERAL PARESIS — SOFTENING OF THE BRAIN.
While in tabes we have learned to recognize a disease of the general nervous system, in which the spinal cord chiefly is the affected portion, we find that in dementia paralytica, on the other hand, ihe brain is pre-eminently the part attacked, whereas the spinal cord and the peripheral nerves do not suffer so regu- larly nor to so marked a degree. In its distribution the lesion of the cord is either diffuse or, as in tabes, confined to the pos- terior columns. With regard to the affections of the spinal nerves a more careful study is still necessary, and more espe- cially this question needs to be answered whether here, as seems indeed very probable, primary degenerative processes, analogous to those of tabes, can also be demonstrated.
jCtiology.^The manilold points of resemblance between general paralysis and tabes, to some of which we have drawn attention above, are found first in the tetiology of the two dis- eases. In the former as well as in the latter hereditary tenden- cies are of much significance. A person belonging to a familv in which nervous diseases of any kind have been prevalent is more prone to develop general paralysis than a member of a healthy family. However, this factor is in the majority of in- stances not suflicicnt in itself to bring about the disease, certain exciting causes being also necessary, and experience has taught us that it is chiefly overstrain of the nervous system, and more especially of the brain, which favors its development. Such e.xcessive demands which arc made upon the brain are numer- ous. Chief among them is mental overstrain, caused by loo close attenticm to work and worrying over business — too much scheming, calculating, etc. — so that we are not surprised that bookkeepers, accountants, bankers, Stock brokers, authors, actors, etc., form the relatively largest contingent of cases. Besides this, deep emotions, repeated or long-lasting sorrows or care, the struggle (or existence, disappointed hopes, baffied
69S
DEMENTIA PARALYTICA.
6S9
ambitlnns, and fright, may attain an xtiotogical importance. On hearing the history of a general paralytic, one at least ol theKC factors will hardly ever be absent. Bodily overstrain, forced marches, excesses rt Ventre and the like, can be made responsible to a less extent. Excesses in JiacJio, tlic habitual abuse of alcohol, only rarely lead to general paralysis, but sometimes a condition is produced by such excesses, the " pseudo- paralysis a potu," which resembles general paralysis, but which is quite distinct from it. and belongs to chronic alcoholism. There is no question but that the occupation may furnish causes (or the disease ; thus, those which cnt.-iil at once bodily and mental work, or those in which the workers must (or a long time remain in very hot rooms, and again working in poisons, especially in lead (Snell, Vogel, and others), are par- ticularly dangerous. 0( great interest, finally, is the (act that, like tabes, general pandysis may be caused by trauniiiiisnt either to the head or the back, so that wc have a traumatic progressive paralysis which is quite analogous to the traumatic tabes. In this latter category we must also place the insolation, (sunstroke, licit stroke) wluch has been known to lead to gen. eral paralysis (Bonnet and Paris, Ann. m£d.-psych., Novcmbre, 1834, 6,5. 12).
Besides the congenital, however, there exists also an ao> quired predisposition, which differs (rom the former, inasmuch as no other exciting causes arc needed (or the production o( the disease, since, just as is the case in tabes, it atone is suffi- cient to bring about general paralysis. We refer, of course, to syphilis. The same highly important rJle which it plays in tabes it plays here too. An individual who has had syphilis has much greater cause to (ear general par.alysis than one who has never been inlected. According to the statistics of Rieger (cf. lit.), the one is sixteen or seventeen times as liable to the disease as the other. These figures correspond very closely with those founded on my own experience. Out of two hun- dred and fifty-seven paralytics a hundred and seventy-one had been syphilitic, and out of two hundred and sixty patients with other diseases only fourteen. Heredity and all the exciting causes taken tf^cther do not give rise to as many cases of pa- ralysis as does syphilis alone : but here again, as in talKS. we must leave the question open as to how syphilis acts, whether. as I myself am inclined to think, the syphilitic .irterial disease is responsible, or whether we arc dealing with a toxic action 44
690
DISEASES OF THE GENERAL NERVOUS SYSTEM.
SO that general paralysis has to be regarded as a post-syphititie affection. Whatever our decision on this point, the fact that general paralysis may be the result of syphilis is universally acknowledged, and the numerous writings which we possess on the subject are all without exception in favor of this view.
The influence which has been ascribed to age and sex can usually be explained by that of syphilis. Males are more fre- quently attacked than females, the ratio being seven men to two women. Those in the prime of life furnish the largest contingent.
Symptoms. — The symptoms of the disease are partly psy- chical, partly somatic, and this will not surprise us when we learn that the seat of the affection is preferably in the brain, and more particularly in the psycho-raotor region of the cere- bral cortex. The psychical manifestations differ very greatly, and it is more especially in the prodromal stage that these variations are most noticeable. This is a feature equally well marked here as in tabes, and the main difference between the two consists in the fact that in general paralysis the clinical picture of the prodromal stage is dominated by the psychical manifestations. The patient becomes unabie to concentrate his mind for any length of time. He gets easily fatigued when he has exerted himself mentally, he becomes forgetful, and is no longer able to comprehend and deal with matters which he previously understood perfectly. He is found to be indifferent in the performance of his duties and careless in keeping his ap- pointments ; he becomes unreliable and absent-minded. When writing, he makes mistakes in spelling, and presents a slowness in thinking and a general dullness of intellect which are quite foreign to him. At the same time his disposition presents alterations. Previously tolerant and kind, he becomes now ill- humored, moody, and irritable ; on the slightest provocation he loses his temper and may even be inclined to violence. His character is not the same as it was; his will power becomes weak : he loses his energy and his moral individuality ; he allows himself to be influenced and overpersuaded by anybody, and even thus early does things for which he can give no clear motive ; he gradually loses all consideration for others in his social intercourse; he neglects his appearance, his dress looks untidy, he becomes indecent, commits nuisances on the open streets, tells obscene stories before his children, and so forth.
DF.MEXT/A PAKALYTtCA.
In exceptional cases the paticnl hiinseK is to a ccrtnin extent conscious of these changes which arc going on in him. They Burprise him, and he speaks about them to his most intimate friends and expresses a (car that some serious disease is coming on ; but in the great majority of cases, he does nut in the lea&t fipprcciate his condition, which worries and troubles his family so much. Months, even years, may thus pass and no new mani- festations make their ap|>c3rance. It is only the occurrence of certain somatic symptoms which gives to the clinical picture a different aspect. Among these latter, besides a very trouble* some ophthalmic migraine, which is frequently observed, there are especially two on accountof which the physician is consulted, namely, insomnia and the alteration in speech. The former is all the more striking because the patients often by day and at their work are overpowered by sleep, while at night they lie awake fur hours without being able to rest. The latter manifests itseU by a difDcully in pronouncing certain words. The patient stutters, misplaces letters and syllables, leaves syU lableii out; in a word, presents the group of symptoms known as "syllable stumbling " (Sylbrnslo/pfm). At the same time the voice loses ils usual timbre ; it becomes harsh and its former modulation is gone.
For the examining physician, the associated movements fn the facial muscles, the fibrillary tremor and twitching of the tips, and the trcmulousness of the protruded tongue arc suffi- cient to lead him to the diagnosis, and the inequality of the pupils which may appear at this stage is an important sign. Ballet has shown that other ocular symptoms m:iy be utilized (Progrfes m^.. 1 893, 33 : cf. also Oebcckc, Allgcm. Zeitschr.. f. Psych., 1S93. lleft 1, 2. p. 169). The motor dislurbances (Le^ moinc et Lccordonnier, tiaz. mdd. dc F'aris, 1889, November 2) further manifest themselves in a change in the handwriting and in the gait. The writing shows uncertainty and irregularity ; the letters, which are usually larger and written more awk- wardly than before, become tremulous; the paper is covered with blots: the words arc incorrectly written, inasmuch as letters or entire syllables arc omitted or misplaced. The gait becomes awkward and clumsy and the patient " shuffles .ilong " ; he is one-sided, and small obstacles in his path arc apt to cause him to fall.
This initial stage, which in its duration varies from a few months to one, even two or three years, is followed by a stage
6^2 DISEASES OF THE GENERAL NERVOUS SYSTEM.
which is generally characterized by a rapid increase in the psychical excitement (" maniacal exaltation "). The patient — previously quiet, sullen, apparently occupied with his own thoughts — now becomes noisy, talkative, all the time restless and in a state of excitement ; without noticing his surround- ings and his friends, he lives with a sense of perfect comfort; he is young, handsome, extremely strong, and immensely rich ; he has studied all sciences ; he occupies himself with absolutely preposterous but to him feasible "schemes; he is going to dry up the Atlantic Ocean, he is the Emperor of China, he is Na- poleon, Christ, he is the chief among the gods, etc. In the dreamlike play of his imagination all these fantasies arise, but the patient is not able to give them any logical connection. Without critical faculty he stands out a pitiable victim o( the most bizarre delusions of grandeur. At the same time his memory rapidly fails him, especially for recent events ; what he did to-day, yesterday, the last visit of the physician, etc., he does not remember, whereas the reminiscences of long-past years can still be called up. He does not know the day of the week or even the name of the month and the season in which he is at present. People with whom he used to deal in busi- ness he no longer recognizes ; he confounds them with other persons, etc. The lack of judgment of the patient has, of course, a decided influence upon his actions ; he buys things recklessly, squanders his money in a most foolish manner, he makes debts, commits easily discoverable frauds, which he de- nies with the utmost calmness when he is found out. Assaults of which he may be guilty, misdemeanors against the public order, offenses against the public morals, etc., not infrequently lead to trouble with the authorities and to the arrest of the patient.
In by far the smaller number of cases the above-described initial stage is followed, instead of b)' the maniacal exaltation, by a stage of depression. The patient believes himself perse- cuted by everybody, and his life menaced ; he hears voices, and he is always troubled with a presentiment that something ter. ribic is going to happen. He cries, laments, begs for help, and so forth. In other instances hypochondriacal delusions gain the upper hand. The patient imagines that he is made oi glass, that he can not eat, that he is unable to urinate, that he has no head, and the like. The lack of all power of criticism in these delusions, and the inability to systematically elaborate
^^^^^^^^™^ DEU£STIA PARALYTICA. ^^^^693
^n>em, and the usually rapid course o( this stage, distinguish the
■ general paralytic from the paranoiac. Quite gradually in the course of time the general aspect chansjfs, the exciietncnt abates and disappears, and the intel- lectual impotency increases. The paliccit spends his days with, out a thought or care, writing and reading become to him lost arts, he forgets his own name, and his social position, he be- comes oblivious of his family, and in general takes no interest whatever tn the outside world. This is the stage of dementia, lie becomes uncleanly in his habils. hts eating and drinking must be watched, and step by step the psychical life approaches more and more its extinction ; the patient no longer lives, he
ITCgetates. It is of great practical importance and interest to study the somatic disturbances which occur in the course of the dis- ease associated with the psychical ones, and which arc caused by the simultaneous affection of the spinal cord (and periph- eral nerves). The diminution of sensibility, that of the skin as well as of the nerves of special sense, particularly of the opticus, the absolute inactivity of the pupils, the decrease in the per- ception of pain, the changes in the electrical excitability of the muscles, which.at first is increased, later diminished, the (not regular) loss of the tendon reflexes, the appearance of trophic Bdisturbances (ichthyosis, F6r£), the tendency to bedsores, the perforating ulcer of the fool (««/ jHrforanl tiu firti, cf. page 6f;/i), all point to a participation of the spinal cord in the mor< bid process. Sometimes, tiuiie early, peculiar attacks occur,
■ which, associated with loss of consciousness, are cither accom- panied by transient hemiplegias or convulsive movements, and which therefore either deserve the name of apoplectiform or epileptiform seizures. They are designated as " paralytic at- tacks." Under ccrt-iin circumstances they appear very fre- quently, from ten to fifty limes in one day, and they may then keep the patient in an almost constant condition of uncon- sciousness. The elevation of temperature which accompanies these attacks is not considerable, the occurrence of albumin in the urine not constant. Among the alTeclions of the cranial nerves which have been but little studied In their connec-
■ lion with general paralysis may be mentioned more particu- larly the optic atrophy, which is seen in ten per cent oi all cases. The nerves of the ocular muscles also frequently be- come involved, the Implication of the trigeminus and of the
694
DISEASES OF THE GENERAL NERVOUS SYSTEM,
facial being less common. Of the nuclear aflections of the vagus coming on in the course of this paralysis nothing defi- nite is known.
The duration of the disease varies much. In the " galloping form," in which, owing to the sleeplessness and inability to take sufficient food, the strength rapidly fails, it may require only a few months to bring about a fatal issue. At other times the disease may last two, three, five, or even more years, out of which no small proportion is liable to be spent in an asylum, as it is out of the question to keep the patient at home, in spite of all the care and devotion possible on the part of the family.
Pathological Anatomy. — The questions as to the anatom- ical nature of the disease have unfortunately not been as yet answered satisfactorily, and there is still a great deal of diver- sity of opinion among the authorities on this point, although the macroscopical appearances are usually very characteristic, the atrophy of the brain, especially in the anterior regions, being very striking. Although no one can doubt that the con- volutions are diminished in size, that the frontal and the parie- tal lobes weigh less than in a normal brain, yet the precise mode in which this atrophy comes about, what are the micro- scopical changes in the nerve elements of the cortex, and what is the primary process in all this, are not as yet decided, but re- main the subject of much controversy. According to Tuczek, there is a marked primary atrophy of the fine medullated nerve fibres, particularly in the outer layers of the cortex, in the tangential " association " fibres, which run parallel to the sur- face. The gyrus rectus is said to be relatively the earliest attacked, later, the remaining frontal brain and the island of Keil, then the temporal, but the occipital lobes never. This view, according to which the atrophy is the primary process. is in all probability correct, although it is still combated bv some authorities (Mendel), who look upon the death of the nerve fibres as the secondary, upon the increase of the in- terstitial tissue, the thickening of the vessel walls, and the ap- pearance of spider cells, as the primary process ("encephalitis interslitialis ").
Analogous changes in the ganglionic cells have frequently been noted (Binswanger. Mendci, Gudden) ; a peculiar aggre- gation of nuclei associated with disease of the vessels, degener- ation of the capillaries (Kronthal, Neurol. Centralbl., 1890, 22),
DEMENTIA PARALYTICA,
695
changes in the bodies of the cells in the large pyramids of the paracentral lobule, changes in the nucleoli and nuclei, and sclerous and atrophy of the cells are not uncommonly found in this connection.
But, besides the cortex, the deeper regions also arc the seat of alterations, and the manifold changes which the white matter of the hemispheres may undergo, have been studied amoi^ others by Fricdmann. He describes four different forms o( atrophy of the fibres of the while matter, the number of the fibres diminishing in a manner analogous to that which has been shown by Tuczcit to be true for the cortex. The central ganglia of the brain do nut remain cscmpL Lissaucr describes a degeneration extending from behind forward, by which the pulvinar Is often only partially implicated, the in- ternal geniculate body sometimes, the external geniculate body never; he is of opinion that this degeneration is pres* cnt in cases in which well-marked sensory focal symptoms accompany the paralytic attacks, but admits that these changes in the thalamus are by no means constant. Wcstphal has shown that the pyramidal tracts or the posterior columns of the spinal cord are also often affected, a fact which prob- ably accounts fur a not inconsiderable part of the motor disturl>anccs.
The condition of the pia varies. Frequently it is adherent over large areas of the underlying cortex, so that it can not be stripped oS without luss of substance (" decortication "). In rare instances, although it is nowhere adherent, in places it is thickened, of greater consistence than normal, and contains variable nmuunts o( fluid in its meshes. Whether the latter condition is only a later stage of the former — that is. whether adhesions only exist at first, but later disappear — is not defi- nitely known.
A case reported by Rey (cf. lit) shows that exceptionally all the symptoms of progressive panitysis of the insane may be observed during life, and yet at the autopsy nu change be fuund. The same thing, as we have mentioned, has been known to occur in connection with multiple sclerosis.
Diagnosis. — The diagnosis may present some difliculty, inas- much as in certain forms of chronic alcoholism the egoism may be exaggerated as in general paralysis, and inasmuch as cere- bral syphilis, brain tumor, senile dementia, finally, chronic meningitis, especially the diUuse syphilitic basal form (Oppen-
696 DISEASES OF THE GENERAL NERVOUS SVSTEAf.
heim), and multiple sclerosis, may more or less resemble gen- eral paralysis in their course and their symptoms. In alcohol- ism the hallucinations are wont to be a prominent feature, the speech disturbances are less marked, and the ideas are worked out in a more connected manner. The tremor and the history in cases of chronic alcoholism wilt also assist ns in our diagnosis. In cerebral syphilis also the history as well as the age of the patient (who is, as a rule, younger than the paralytic) must be taken into consideration. Brain tumors present a similarly progressive course, but the stage of exaltation is absent and the characteristic delusions of grandeur do not occur; in place of them we have stupor and somnolence. Senile de- mentia, of course, occurs in people of advanced age, and is characterized by a tendency of the process to remain stationary for some time.
In meningitis we have febrile symptoms ; the choked disks, which are found comparatively frequently here, and the de- lirium which occurs early will guard us against errors. In multiple sclerosis, finally, we have the scanning speech and the intention tremor, and when the disease is well developed, it can not be mistaken for general paralysis. In certain forms, however, the differentiation may be impossible. The most im- portant points to be remembered in the diagnosis of general paralysis are, then, the following: The pronounced psychical weakness, which even in the initial stages is the most promi- nent feature of the disease ; the constantly progressive course ; the motor as well as the sensory changes, the former of which give rise to more or less marked alterations in the speech, the handwriting, and the walk, the latter to changes in the im. pressionabiiily to external stimuli and to marked interference with the functions of the nerves of special sense — the cutaneous sensibility, the sense of taste, hearing, and smell. With this in mind we shall make a correct diagnosis at least in a good many cases; to avoid errors completely will be impossible even to the most experienced.
Prognosis.— We need hardly say much about the prognosis. From the above description we can welt infer how unfavorable it must be. Almost all cases prove fatal in a few years, and the outlook for complete recovery is worse here than in tabes. To be sure, it has been claimed that such may occur in pro- gressive paralysis (Wendt, Voisin), but, in the instances in which it was observed, the possibility that the case was not
DEMENTIA PARALYTICA.
697
Dne oi dementia paralytica, but nttlier one of the so-called seu(lQ-paruly!>c<i, such as are known to occur alter the abuse of alcohol, can not be excluded with certaintjr.
Treatment. — In the treatment of the disease we must chiefly endeavor to keep away all excitement from the patient, and, since this is best and most easily accomplished in an asylum, it is the first duty of the physician, after he has once made the diagnosis definitely, to urge the family to transfer the patient to some such institution. Only then is it possible to guard the patient as well as the family against all the accidents and fatali- ties to which he is otherwise necessarily exposed. This step must be taken as early as possible, not with the idea that the patient will be cured, but with the conviction that only in an institution is he safe, and that there alone it will be possible to secure for him the proper care and nursing so necessary for one in his condition. Where there is a history of syphilis, the treatment with inunctions must of necessity be given a trial, however slight may be the prospect of success. Once decided upon, let the antisyphititic treatment be pursued with vigor: at least three to four hundred grammes ( 5 ix- 5 xij) 'of mer. curial ointment should be used altogether, to which must be added from two to three gnimmes (grs. xxx-xlv) oi the iodide of potassium daily for a good while. The chloride of gold and sodium, a remedy which years ago was highly esteemed for its antisyphilitic action, has again been brought back from oblivion and used in cases of general paralysis (Boubila, Hadjcs. and Cossa. Annal. mid.-psych., 1892, 1, 2) ; the results arc not better than those obtained with any other drug. To meet the out- breaks of exaltation and the insomnia the usual hypnotics, which are. however, of little avail, should be tried. Sulphonal in doses ol two or three grammes (grs. xxx-xlv). methylal in doses of from five to eight grammes (grs. lxxv-3ij), by the mnuth (Mairct and Combemale). morphine, from one and a half to three ccntignimmes (grs. '/,-'/>) hypodermically, chloral, paraldehyde, possibly also hyoscynmine. should be tried in turn. The cold-water treatment and baths, .ilso galvanism [o Ihc brain, are decidedly contramdicatcd. .Ml such pnnrcdures are likely only to increase the excitability of the patient, to give him all kinds of unpleasant sensations, and to make his troubles worse, without being in any way of benefit to him or relieving his condition.
6g8 DISEASES OP TOE GENEgAt tfEXVOUS SYSTEM.
LITERATURE. .
. ,0. ^mptpmt.
StrilmpelL Neurolog; CentralbUtt. i8S8, 5. (General Paral^ combined .with
Tabes in a Child aft^ Syphilii.of the Father.) Jelly. Boston Med. and Surg. Joupt. July 3, 1888. cxix. 0>nadon of Ten
Years.) Rottenbiller. Centralbl. T. Herfenheitkunde, 1889. in, i. (Observations on the
Temperature.) Buchholz. Das Verhaltender^I^nbd Dementia paralytica. Inaiic.<DiaMfU
Breslau, 1889. WendL Allgem. Zeitachrift f. Psych.. 1S89, xlvi i; {Recovery.) Voisin. Bull de thtoipeut, Mai 15, 1889. (CurabilUy of General Paralyais.) Gerlach. Arch, t Psych, u. Nervehlch., 1889, xk, 3. (Changoi in the Galvanic
ExciUbility.)_ Ascher. Allgem. Zeitschr. f. Psych., 1S89, slvi, i. (Course and Etiology oT
General Paralyus.) GodeV Revue miA. de la Suisse rom., April. 18S9, u. 4. (Paeudo-paraJysis
caused by Alcoholic Excesses.) Ueycr und Weber. Peptonurie bei allgemeiner Paralyse. Bericht tiber die If-
lenanstalt. Basel, 1889. Blocq. Arch, de Neurol., November, 1889^
Ascher. Aphasie bei allgemeiner Paralyse. Allg. Zeitschr. C Psych.. 1893, 1. x Redlich. Zur Charakteristik der reflecfotiachen PiiiHllenstarre bei pr(q;res5tver
Paralyse. Neurol. Centralbl.. 1893, la NScke. Allg. Zeitschr. f. Psych,, 1S92, i, 2, (Kalalonic Symptoms.) Kiinig. Ibid., 1892, i, 2. (Transient Speech Uisiurbances.) Neisser. Ibid., 1S92, 3. (Combination of General Paralysis and Progressive
Muscular Atrophy.) Raymond. F. Semaine med., 1892, 25. (Relation of General Paralysis to
Tabes.) Rendu, lliid,. 1892, 31. Pierret. Ibid,, 1892, 41.
Nageoite. Tabes et paralysie gfn^rale. Paris, 1893, Steinheil. Marie, P. Extr.liis des Bulletins de la Soc. mfd. des hflp. de Paris. Stance du
12 Janv. 189;.
*. Pathological Analoity.
Tuezek. Beilrag jur pathologischen Anatomic und Paiholc^e der Paraiysf'
Berlin. Hirschwald, 1884, Zaeher, Arch. f. Psych, u, Nervenkh., 1884, xv, 2. Savage. Jouni. of Menial Sc, January, 1884, xxix. (Pachymeningitis and
Paralysis.) Camuset. Annal, mfdieo-psychol,, Novembre, 1884, 6me sir,, xii. (Changw
of the Dura Mater in General Parai_vsis.) Mendel. Allgem. Zeitschr. f. Psych., 1885, xli, 4. j. (The Ganghonic Ccllsof
Ihe Brain Cortex in Genpral Paralysis.) Baillarger. Ann. med.-psychol., 1886. xliv, 1. (Diminution in Weight of il*
Cerebrum.)
DEMENTIA PARALYTICA.
699
I
I
I
Mr)'ncn, Vom Mechaiiismus ikr ]>rofres»iv«n Paralyse. Wiener med. Dlatlcr,
1887. X. 17, 18. ZAcher. Da& VcThaltnidcr marlch.-iIiiKen Neneofajwrn u.s.w. Arch. (. PE}ch.
u. Xcrvcrkh.. 1887, xvii), 1. Zaclwr. Acch. f. Pqrch. u. Ncnenkh., 1888, xtx, 3. (General Pjiraty&ls bsw-
datcd with Focal Lesioiu in the loienul Ca|>sule.) Rejr. Ann. in^,-p»ych.. Mars, 1689, ymc iit., ix. i. (During Life Sj-mpioms
of General I'valysiv^ al the Autopsy no ChAitKcs Touml.) Bin«wangcr. Ahg. Zrilschr. f. Ps)xh.. 18S6. xlil. 4. (Pjlhotogical HiM<ila|nr.> CoielU, Roaolino. Le alterailoni dei nervi penfenci netk parnlisi gmttak |>io-
grcuiva in tappurtu con i loio nuclei central! di ot^iiH:. AtiniiJi iti Nc^ro>
V'f,\*. Num-a iicria, 1891, ix. Hochc. Beiliitf^e tur Kcnnintu des anatoiniKhen Wrhallcns dcr mcRfchlichm
Riickenniarluwuriteln bci dcr Ucnicntia paralytica. Hcidellxn;. Homuig,
1891. JofTroy. Contribution A rAnatomie patliolo£H)ue dc la Paral)-s)e gisiit. Arch.
de mM. cxp. et d'Anat. pathol., 1893, ]>. 841.
t. .-F-titlefy ami Otewrrttmte.
ThomMn. Die praktiiche Bedcutunt; der S)'|>luli«-l'aral)-sefra|fe. AUg. ZeitKhr.
i. Pij-ch., 1890. xKi, J, Rouchaud. Annal. mM. psychol., 1891, 7 %b, xiii. 3. Mvilhon. Ibid., r89t. Uonnri. KappoHs dc la Syphilb et de la Paraljrnc g£f>tnde. Tbtee dc Paris.
1S91. Charcot cl Itlocq. Paralysle gcntralc chci I'adotesocnt. Scmaiiw mtA„
1891.6. K^gii. Syphilis cl paratysie ([^ncrale. Arch, cllniqucn de Itoid,, 1892, i, J, 8. Orlwkc. Zur Actiologic dcr Paralyse. Allg. Zciischr. f. IS)ch., 189:. 1. 3. IVrson. neiichl ubcrdic Priiathcilnntlalt u. ». w. lu Pitna, Drcvlcn, i%^y Mivcl- Laval liJe. Kcvue de mtA., t893. I. (S}'philiK and Gcncr.il I'arjilyw.) Niconleau. Annal. med.-ps)'ch,. 1893. 7. 8. (Catiscx of General Para)yxi«.> Wi);1eMK<orth. liritish Med. Joum., Marclk r893, 15. (General I'aralywk <lur<
mg Puberty.) FMmkr. Syphilis cl parahste g^n^rale. Re^uc nevrol., 1893. lo> Wesiphal, A. Charity- .A nnalcn. i8'>3. p. 719. (Genernt Paraty^ntn Women,) Oiaitton. I^ssai sur Ics tjpports dc In pat.ity&ic gfn^rale cl Syphilis. '1 Mk
4k I'ariii, 1893.
CHAPTER IV. SYPHILIS or THZ GENERAL HBBTOUS SYSTEM.
'In different places in our book, in the chapters oa diseases of the brain as well as in those treating of affections of the spinal cord, we have had occasion to point out the rSU which syphilis plays as an setiological factor in various diseases. We have also shown that tabes and the progressive paralysis of the insane are to be regarded as the main representative of affec- tions of the general nervous system depending upon syphilitic infection. It only remains, therefore, in the present chapter to add some general remarks %0\ what has already been stated.
No part of the nervous system, whether of the brain or of the spinal cord, is exempt from the chance of becoming impli- cated in the syphilitic infection, and remembering how the blood-vessels are affected by syphilis this is easily understood. Clinically, it is especially interesting if we are able to recognize diseases of the cerebral cortex and symptoms — e, g., monople- gias— resulting therefrom, as syphilitic, but the corona radiata and the basal ganglia, the pons, the medulla oblongata, and the cerebellum, all may become the seat of syphilis, and syphilitic affections of the base of the brain are relatively common. In many cases it is difficult to make a certain diagnosis, especially if the patient denies the primary sore and no trace of it can be found, for the clinical symptoms, of course, are the same, whether the brain lesion depends upon syphilis or not.
Symptoms. — Among the manifold symptoms which occur in brain syphilis we may mention polyuria and polydipsia, which have been subjected to careful study (cf. lit.). If focal symptoms are present it is easier to make a diagnosis than in their absence. In the latter case it may sometimes be impos- sible to decide upon the diagnosi9»of brain syphilis; we may be dealing with a case of cerebral neurasthenia.
With reference to the spinal cord the matter is somewhat more simple, because syphilitic disease here, which does not implicate also the brain, as in tabes and general paralysis, is 700
SYPHILIS OF THE GENERAL NERVOUS SYSTEM.
TOl
rather rare. It is nnt a common thing to find disease o( one system of tibres or discnse u( sever»l systems combined de* pending upon syphilis, and the cases in which lateral sclerosis, for example, was attributed to tliis have been published as rarities. It is of pathological interest to note that the rout bundles usually present a marked and extensive participation in the process. In a case reported by Siemcrling(cf. lit.) there were gummatous growths o( the pia. which, although they had extended into the substance of the cord, had not attacked any "system " in its whole extent, so thai, as is often the case, the spinal symptoms here also were not at all prominent.
We can not assume that the spinal nerves, cither motor or sensory, ever become diseased alone, but we must rather look upon their implication as a partial manifestation of a general affection. If in exceptional cases we find a neuritis of the sciatic or of the muscuto-spiral nerve, etc., which we have to regard as of syphilitic origin, perhaps because it rapidly passes off under antisyphilitic treatment, the manifestations of cerebral and spinal syphilis have either existed previously and have not been recognized or their presence later has to be l<H)kcd for.
Diag^nosis. — The diagnosis is based first upon the history of the patient and the presence of signs of the primary sore. If ihese are established, it is relatively easy ; if not, we must look for other signs to help us. Secondly, the other organs— for instance, the skin, the visible mucous membranes — all must be examined for the possible existence of syphilitic lesions. Re- peated and careful search may sometimes clear up much that is obscure, although the p;itient"s account may be imperfect. Thirdly, it must be remembered that the symptoms of cerebral syphilis are extremely changeable, and are rarely ever of long duration. To^ay, matters may look as if the patient's life were in danger, while to-morrow he is apparently perfectly fe again. The rapidity with which the changes in the con- ■ tfition follow each other, just as in hysteria, the extraordinary circumstance that apoplectiform att-icks occur in younger and epileptiform attacks in older persons, in doubtful cases are in favor of the dingnosis of syphilis of the nervous system. In every instance we shall do w*ll to pay careful attention to the condition o( the eye-muscles (Uhlhoff, Arch. f. Ophthalm., 1893, I) and the pupillary reaction ; the latter may temporarily dis- appear and reappear: the same peculiarity may be found in the condition of the patellar reflexes, an anatomical explanation
\1
^02 DISEASES OP TMS GElfESAL IfEXVOUS SYSTEM.
for which has thus far not been arrived at. Finally, the thera- .peutic test is of some value, inasmuch as the successful ami- syphilitic treatment makes the existence of syphilis almost certain, although a failure does not warrant the contrary con- clusion.
Prognosis. — The prognosis must, above all, be influenced by the time which has elapsed since the primary infection and.be- fore the first appearance of the nervous symptoms. The longer this period of incubation the worse is the prognosis. Accord- ing to my own experience, from 6ve to nine years is the most common time. Occasionally the infection of the nervous sys- tem manifests itself earlier, and in quite exceptional instances two years, or even one year, after the primary lesion ; but often the interval which elapses is longer than the time above given. Cases in which the spinal or cerebral symptoms did not appear till after twenty or twenty-five years I have never seen get well. The second question of importance is, how long the nervous symptoms have existed before energetic antisyphilitic treatment was commenced. Often as it remains without effect, a trial of it is still indicated if not more than two or four months have elapsed after their appearance. If they have existed for half a year or longer, nothing can be expected from any such treatment, and it need not, therefore, be begun. In such cases the prognosis, of course, is worse than in the others. Thirdly, a good deal depends upon the kind of symptoms by which the infection of the nervous system manifests itself. General symptoms, headache, vertigo, epileptiform attacks, allow, ctEteris paribus, of a more favorable prognosis than focal symptoms, such as monoplegias, hemiplegias, and paralyses of certain nerves. The worst outlook is afforded by those in- stances in which the brain and the spinal cord are equally severely attacked, as in tabes and progressive paralysis of the insane.
Treatment. — The manner in which the treatment is to be conducted must be made to depend upon the individual case, the age, the nutrition of the patient, and so forth, and no rule applicable to all cases can be laid down. Only one remark, which has repeatedly been made* before in this book, we wish here again to emphasize, namely, that if we have once decided upon adopting the antisyphilitic treatment we must do so energetically, giving iodide of potassium, one to six or eight grammes (grs. xv-3 jss.-3 ij) daily, in one or two doses in hot
SYPIllUS OF TUB GENERAL NERVOUS SYSTEM.
703
mitk. continued for from six to ten weeks, and inunclions of blue ointment, (rom three to five grammes (grs. xlv-Ixxv) a day. continued for from four to six weeks. All necessary pre- c:iiitions arc self-evident. Finally, we should not neglect to lamiliari^c ourselves with the progress which lias been made in the modern ircalment of syphilis, and consider whether lite subcutaneous use of mercury is advisable, and, if so. what the exact mode of its administration should be.
LITERATURE.
ipenheim. Zur KetintnUt d« lyphJIii. Erknithtingen <lc£ Ccntr4lnef\'eti-
sysicni*. BerlliKr khn. WocheniKhr., 18S9, 48. Zi«iit«n. Syphilis <lcs Nctvcn^yycinB, Klin, VoOt.. iv, November 3. 1S88, Warrirt. Britiili Mvii. Joutn. Srptcmlwr. 18S8. (Two Cuct of tlr.un-Sjiihilis
in Onr Family.) JurKciM. Uerltncr klJD. Wochtiischr.. 188S. »xv, 33. (Sjrphilis of the Spinal
Cn«l.) Oppcnhclm. Berliner kl in. Wochenschr. 18S8. 53. Sicm«rling. Arch. T. l*»>Yh, u. Scrvcnkh.. 1888, xx. I. (CoDgcniial Syphilis of
the Uraia ;)n<l Sjiitiul Cuid.) Naun>n. Miiihcilungcn £U» iler mediciiiischco Ktiitlk lu KMi|;)tKfg. Lcipui.
VoKcl. 1888. Siemcrting. Atch. f. Pt)Th.. 1890. 1. 1. Nounyn. Die Progmisi- der «yphilit. Ericnnkucigen ilct Nerreiiiyucmt, XIII.
Wxnilervcnuimmtung iler (UflwcU<lcut*chcn Ncuiolufcn, Arch. f. l'»fch.
U. Ncrvenlih.. 18S9L xx. 1. SKiigcr. Zur Kcnniniss dcr Ncrvenrrkrtnkungefl (n (I«r Fr(lht>erio(le <lcf Syphl-
lit. Jahrb. cl. Hamburger !Jt.-iatsitniMkcnjnM.ilicii. II. J.-ihrj;,, 189a Sachs. B. New York Med. joutn,. Sept, 19, 1891. HtitchiiiMn, Jr. Syphiliiic Disease of the OccijMlAl Lotie wiib I'crforalion of
Cranium. British Med. Joura., Miin-h 11, 1S91. Joflroy ei Leii«nn«. ConlrDniiiuti i I'^iikIc <Ic la syphitls cMIWiilc. Afch. do
meil. expcrim. M d'anai. pathol., 1891, 3, Schulf. K. NniTol. Cmlrnlbt., 1891. 19. G<^lflam. Riick<'nnMrks)|>liilis. Wiener Klintk. 3. 93. Cowers. Syplulb und Ncnciuysicm. German b)- LehfeUlt. Dcrlin. Karser,
1 89 J. Cnopf (Niirnberg). Munch, mrd. Wochcnschr.. 18913. 11. (Cue of Ccrtbnl
Syphilis, t Picic Zur KennlnHft der ccrebro-S|>iiMkn Sypliilis. Zeitschr. f. HriUiunile.
1891. 4- >■ Nonne. Ikitifii[c tw Kennlniss <Ict syphilit Erkninkunscn dcs Rdckenmarks.
Hamburg. 1893. Obermrier. Deutsche Z«-iischr. f. Ncrrcnhk-, 1893. iii. 1-3. (Two Cases of
Gummaiou* Mcnintiio* ) Ca)kiew)cji (WnrMw). Svphilis du sy»tfmc ncrvctix. Paris, Dailliirc, 1893. Kowalcwsky. Arch. f. Dermal, u. Syph.. 1S93.
INDEX.
n
Abducens, analomjf of, 44 ; paralysis of, 49 ; paralysis of. in Ubes, 63a ; pkralysis of. in brain tumor, 39B.
Abduclor, paralysis of, 113 ; paralysis of, in tabes, 636.
Abscess, of the brain, 360; of the spinal cord. 465.
Accnsorius. anMomy of, 136; lesions of, in labes, 636 ; paralysis of, 138 ; spasm of, 137.
Accommodation, errors of, as a cause of headacfae. 65.
Acromegaly, 512.
Adam^^tokes disease, 730.
Adductor spasm, 114.
A|«pusia, loS.
Agraphia. 176.
Agrypnia, 510,
Akinesia algera, 464.
Alalia, 153.
Alcoholic neuritis, 3153.
Alcoholism, treatment of, by suggestion, 611.
Alexia, 176.
Amaurosis in brain tumor, si/b,
Amaucosis, epilepliform, 33. ,
Amaurosis, epilcpiiform, in brain tumor, 397.
Amaurosis partialis fugai, 38.
Amblyopia, alcoholic, 39 ; lead, y) ; to- bacco, 39.
Amblyopia, central, 3a.
Amyotrophic lateral xclerosii. 447.
Anxmia, cercl)ral. 254 ; spinal, 4I11.
Anxslhesia of blaildcr, 378.
Anxsthesia, doll's head, 5(12 ; gustaloria,
lo3; hysterical, 551, 557; laryngeal,
m ; in transverse myelitis, 4;) ; in tabes,
646 : in traumatic Deuroses, 56a ; of
45
trigeminus, 73 ; in unilatenl cord lesions, 456.
Analgesia, in synngomyclia. 471 ; in tabes, 647.
Anarthria, 153.
Aneurisms, of cerebral arteries, ajj ; mil- iary, 314 : of spinal arteries, 462.
Angina pectoris. 113.
Angio-neurotic a-dcma, 133, 359.
Angiomata of spinal cord, 46S.
Anidrosis, 399.
Anisocoria, 48 ; in general paralysis, 691 ; in neurasthenia, 532 ; in tabes, 632.
Ankle clonus, 433.
Anlipyrine as a cause of epilepsy, ;73.
Anosmia, 36.
Ape-hand, 435.
Aphasia, amnesic. 177 ; in children, tSl ; conduction, 176, 179 ; diaf^osis of, 177 : Grashey's, i3i ; motor, 176. 179; total, 176 ; refl". 182 ; sensory. 176, 179.
Aphonia, hysterical, 542.
Apoplectic. e(|uivalenis, 321 ; stroke, 3tS.
Apoplectiform attacks, in general paraly- sis. 693 ; in hiemaloma dur.r malris, 6.
ApoplCKie foudroyantc, 219.
Apoplenies. capillar^', 214.
Apopleiy, cerebral. 313; hysierical, 545 ; menial condition in, 32S ; pn>gTe--sive. 6 ; sensibility in. 234. 33B ; spinal, 4$^ : spinal-men ingeal, 336 ; trophic changes in, 231.
Arai:hnoid, anatomy of, 3.
Aran-Duchenne type of progressive mus- cular atrophy, 434.
Argyll Kobcnson pupil, 48 ; in tabes, see loss of light reflex, 633, 669.
Arsenic, as a cause of multiple netuitts 389.
7o6
INDEX.
Arriifthmk cordb, tjo.
Aitcrica, cerebral, 309 ; diloulion of, 353 ; embolism and Ihrombotit of, 344 ; nen- roM* of, as4.
Arteries, qiioal, 458 ; dilatation of, 463 ; embolism oad (hromboiiii of, 460 ; neu- roses of 46s.
Aileiy of cerebral beemonhage, 313.
Arthropathy in Ubes, 657.
Aspermatism, jji.
Asphyxia, local, 401.
Aspiration pneumonia in bulbar paralyiia, 156.
Associated movements, 339.
Associated movements in tabet, 644.
Astasia abasia, 54S.
Aslbma, bronchial, tiS; cardiac, 139; hysterical, I3o. 543 \ saturnine, 131 ; ihjmicum, 114.
Ataxia, cortical, t86 ; in diabctea, 670 ; after diphtheria, 669 ; functional, 669 ; hereditary, 443 ; locomotor, 639 ; after pregnancy, 670 ; in tabes, 640.
Atheimd movements in tabes, 644.
Athetosis, 3B4: bilateral, 359.
Atrophy, mnscukr, congenital, 413 ; in hemiplegia, 333 ; hysterical, 546 ; myo- pathio, 406.
Atrophy, muscular, pn^ressive spinal, 434.
Atrophy, optic, 33; congenital, 34; in general paralysis, 693 : in multiple sckrosis, 630 ; in tabes, 630.
Attncii, apoplectic, 21B ; Bpopl eel i form , in general paralysis, 693 ; apoplectiform, in hoimaloma durx oniric. 6 ; epileptic, S7S ; hysterical 553 ; hystero-epileptic, 600.
Auditory nerve, analomy of, 95 ; hyper- itslhesia of. 97 : paralysis of, 97 ; paraly- sis, rheumatic, 1)7 ; in tabes, G63.
Aura, epileptic, 575.
Automatism in hypnotism, 603.
Basal gtuiglia, anatomy of, 19S ; lesions
of. 193. Basedow's disease, 518. Uedsore, acute, malignant. 331. Beri beri, 331. Birth patsy, 354. Bladder, an:esthesia of, 37S ; disturbances
of. in myelitis, 4;z ; disturbances of, in
tabes. 652. Elepharoptosis cerebral is. 46.
Blepharospasm, 7^
Btachta] pleaus, anatomy of, 334 ; diaeata
of, 3*X Bradycardia, 139, Brain abscen, 460 ; Mtiology of^ s6t ;
dii^nosis oE; 364 ; prognosis of, 36j ;
symptoms of, 361. Brain syphilb, 700. Biain tumor, 3E9 ; Ktidogy oi, 393,
choked disc in, 396 \ diagnoda of^ 399 ;
epileptiform cimvuLuiHis in, 394 ; focal
symptoms in, 397 ; mental change* in,
S94 ; nature of, 303 ; Mkt of^ 301 ;
symptoms of, 393. Breast, irritable, 365. Bromides in epilepqr, J90. Brown-Stqnard's paialyus, 456. Bulbar paraly^ 159. Burdacb's columns, 43(X
Cacbexie eaophthahaiqae, JiS.
Cachexie pachydeimique, 535.
Cadaveric position of vocal cords, 116.
Capsule, internal, anatomy ot, 190; le- sions of, 199.
Carcinoma of brain, ago ; of coid, 468 ; of Tcrtebite. 453.
Cardiac branches of vagus, 133.
Cardialgia, 131.
Caries of the spine, diseases of the cord la, 453 ; pachymeningitis spinalis due to, 316.
Catalepsy, 602.
Cauda equina, tumors of. 469.
Cavity formation in cord, 471.
Centrum ovale, 1S9.
Centrum ovale, lesions of, 19J.
Cephalalgia,;/. Headiche.
Cephalocelc, 313.
Cerebcllai, abscess, 263, 265 ; ataxia, tj- Equilibrium, loss of, in diseases of tie cerebellum ; peduncles, lesions of. 206 ; tract, direct, 430.
Cerebellum, lesions of. 305-
Cerebral lesions, pathological diagnosis oT. 309 : topical diagnosis of, 163.
Cerebral palsy of children, 268,
Charcot's joint, 657.
Cheyne-Slokcs breathing in apoplcit.
320.
Chiasm, optic, anatomy of. 39 ; lesions of,
34- Choked disc, </. Papillitis.
|
^^^^^^^^^^^^^^ ^^^^^^^^^^^^^^^^H |
|
|
CholettcsMnu of brdn, 2^. |
byitcria, S4I ; in tab«*, Ajo; nultiple ^^ |
|
Chorda lympuii, l«nom of. i%. |
affectioint of, 147. |
|
CKore*. 4S1 ; conj[GiiiIat, 4B8 ; hcndiinrj. |
Crcmailcric rcHci^ 411. |
|
4^; ltunIiIl|;Ion'^, 4S3 ; imluiotia. |
Ciim, anal, in tabes I^S ', triaet, (aa- |
|
4SS ; major ind minor. 4S1 ; in pr«g- |
trie, 6>4; laiyuccal, 63b: phoiyncoal, |
|
1 nancy, 4^3 ; vcnilc, 46S ; Sjnlsnhaiii'i, |
6J*. |
|
481. |
Crura cerebri, sol. |
|
; CirdeofWillii. llo. |
Cmlch paliy. ^4;. |
|
Ciratmflci nerve. p>irJy>ii of, }}}. |
Cryini; liti in hysitria, ^3. |
|
CUw-tumd, Jix ^yy |
Cyil. apoplectic. 3I4< ^^^M |
|
Ctonni. anVle. 4>3- |
CyuiccKiu. of biinjn, yt; ; ot tpinal cord, ^^^^| |
|
Clowkixm, but. |
^^H |
|
Chib fool, pwaljttic, 438. |
^^^^1 |
|
Cocaine at a cause of qnlepxy, }7J. |
DaiiTmalil'i craatp. 3S7. ^^^^H |
|
Coccygeal acrvei, aniiom)' of, j;o. |
DcafncM bi hytietl^ M< i •■> nwitagtata, ^^^^| |
|
Coccyeodyaia. 3S0. |
10; ia label, 6)4; ■onl. tjb. ^^^^| |
|
Colcl-wnicr ireilmcnl in hj-*icria, j68. |
Oegenentioo, of i>f rvn. 333 ; rvaclioa <it, ^^^^| |
|
CoIm vUioD. diilurbincct i>f. in papillilit. |
4t ; wooiHlaf)', 44s : »iett* of, in tpttty- ^^^H |
|
JJ ; in (ntm. 6)1 ; in hyitcri&. 541. |
ilct, 584. ^^^1 |
|
Coma, iB ccr«liral iMmorrhai:*. no ; dif- |
l>r|;l«(ilKin paraljils hyilcrical, S44. ^^^" |
|
ferekilil ilia|[B(iws oif. ajj ; cpllc|iiic. |
l>(nic>iiU in btatii tuuiui. 395. |
|
353 ■ in I'achyincnintiitLi inlorna turmur- |
Iktmenlla potBlytkn. tM. |
|
rlu|[lca. (i. |
l>epRttloa la (cnrmi paralyiii, Oya. ^^^. |
|
CoMbiMd yfuem MtetM, 443. |
l>cvUltun, conjii|[ile, 51. ^^^^^| |
|
ComIKMbIdd myclliU, 45) |
UcviaiHD ol cyct. primary, ji ; wttiHMlafy, ^^^^| |
|
CottCMHion, fplnaL e/. 'I'raatnallc nearo- |
^^^1 |
|
M*. |
Diabdo, hncc-jctk is, 650; niallipk nn,- ^^^^| |
|
Coajogato deviation of rye 3m. |
rilli (nllawlnit. ytS; aiaala foUowtnK, ^ |
|
C'lMlncluita In liifaiilik ccrcUtal palkle*. |
67a. _^^^^ri |
|
s;3 : in *pina1 pamlyili, 41H ; In heml- |
]>iaplirn|[Tn, piralyut of, 336, ipMOi oF. ^^^^| |
|
lileula. 23b; In hylcla, sjo. 556. |
^^M |
|
Couvcrijiacw, tiunflicicncy of, in (iravct' |
DianliiEa, ta Ubes, 63s. ^^^^H |
|
' diuoiic. JM. |
Dlfuw tdeniHi, ccrehtal, (67. ^^^^H |
|
COavotiiliaini of ibc btain, 167. |
DiffniMM decttodc. 71. ^^^H |
|
CoovDldoni, cpilepiiforai. In brain ittmot. |
Dlceilivc dtMntbaneet In alTNIioiU tt ibc ^^^H |
|
399 : in cetcbral paUln of children. |
ngni, 130. ^^^^1 |
|
371 ; u f cnenti ponlyiU. 6g]. |
DIpktheria, ataxia foUowtni;, 6^91 hmil> ^^^^| |
|
C<>iml>iani,hyiienM:pilep(ic.6oo: infan- |
pkc>i faUo«in|£. 117 : laryniceal jiataly- ^^H| |
|
lile. 1/. Edimpiia ; puerpcnl. $95 ; in |
■inMloHtnf. 113; UryncMl aaa^iheiia ^^^^ |
|
ipiaal pi[»|ir*ii afcluMrca. 417. |
folhmuiit iij: pbuyncral ptniy*h ^ |
|
1 Co-onUoMicMk, ditturtiancct of, tn tnbea^ |
foUowlntt. 149: neu rill* follow 1^, jU: ^^HH |
|
1 640. |
ocnlu-nvolor paralyMt lollou-liif . 4(h ^^^^^| |
|
1 Comn Amnionii in rpilepiy, s8;. |
Diplegia, cerebral, ail ; facial, »6. ^^^^ |
|
1 Corpora albicanlij, toy |
DI|lopia. cmited. 51 ; boimnf-niou, ji j ^^^^J |
|
C^rpont^aaingemma. 199: teiiiMuof.ioo. |
■UHMCslat, 46 ; in laliet, ftja. ^^^^| |
|
Ca(p<tt callMun, abwnce of. 313- |
Donal nervo, 363. ^^^^H |
|
C«1x*l, aMNb,t66; cpilrp«T> >^ : <^>or |
Douhk tmagM, eiantlaatlon fur. JI. ^^^^H |
|
dtoariwacw. 18] ; Mwoiy diiliubaiKOa |
Double riiMin. t/. Diplopia. ^^^^H |
|
iSK. |
Dnchenne'i ducakc, ija. ^^M |
|
Co«cli. tt]r4i«rieal. nj. |
Dura mater, cercbnL 3 ; fploal. jiA^ ^H |
|
Conilh, Ingcnitnal. yd. |
Dyipepsia. nerreai. 133. |
|
Cnnial imtw, dii«atn of. 14 : in apo> |
Dyipbai^ia, spoimodie. 1 34. |
|
pleay, m : In brain tumor. 398 ; in |
Dyiliophy, pngnaaiTc mutcular. 406. |
7o8
INDEX.
Eu- ditcMC, in brdo i&scets, 361 ; snd
meningUU, 10. EcdirinoMi, cntaneotts, in Uba, 645. Echinococcut, of bnin, 307 ; of ipinal
cord, 470, EclampEia, 594.
Embolism, cerebral, 344 ; i^nil, 460. Encepbalitii, non-mppurative, 166 ; puru- lent, 360. Encephalocele, 313. Enccphalomalacia, 344. Encepbalopatbj, utumine. 3{J. Enchoadroma of brain, 390. Endaiterids, cerebralia iTpluIitica, 353;
spinalb iTphilitica, 461. Endocarditis and chorea, 485. EnvKHt noctonia, 379. Epilepsia, acetonica, 586 ; ptocnnlra, 583. Epilepsy, cortical, 1S6 ; and tieait diieaee,
$86 ; Jacksonian, 1S6 ; reflex, 574 ;
■atumine, 5S7 ; and STphilis, 573 ; Iran-
matic. 573. Epileptic, abwDce, $81 ; attack, J75 ; aura,
575 ; equivalents, 583, insanity, 5B3 ;
Tertigo, s8i. Erector spiue, paialysu of, 365. Erythema nodosum, 399. Erythromelslgii, 398. El her, subcutaneous inject ion of, as a Cause
of musculoE-piral paralysis. 347, E<(uilibriuni, loss of, in diseases of the
cerebellum, 205. Equivalent, apoplectic, zzi ; epileptic,
582 ; hemicranic, 509. Ex ophthalmic goitre, 51B. Eye muscles, paralysis of, 4g ; in btain
tumor, izqS ; in mcninigiiis I3, t6 ; in
Inbes, 631.
Facial nerve, anatomy of, 77 ; in labes. 633.
Fnctal paialysis, bulbar, 84 ; electrical re- actions in, 91 ; movements of expression in, 83 ; peripheral, 87 ; pontine, 84, 85 ; prognosis in, 91 ; rheumatic, 89.
Facial spasm. 78.
Facio-lingual monoplegia, 84.
Fce<ling system (Weir Mitchell), 567.
Fifth nerve, if. Trigeminus.
Fi>BUTes of brain. 16S.
Flexibitilas cerea, 603.
Klexor contractures in meningitis, 14.
Foot-clonus, (/. Clonus.
Forced,, movements, 306 ; positions, 306.
Fonnes frasies, in Gravci' dbeie, 539 ; in multiple sclerodi, 6ai> ; in tabes, UA. Fothergill's faceache, 6S. Fourth nerve, tf. Patheliciu. Fractures in tabes, 656. Friedreich's disease, 44a. Front tap, 433.
r
Gait, in multiple neuritis, 393 ; in paeado-
hypeitn^hy, 36;; in qtailtc pMaljsii,
44a ; in tabes, 64a Gangrene, qrmmetriol, 401. Gasserian gan^ion, j6. Gsslralgia, 131.
Gastric branches of vagus, 130. Gastric crises, 634 ; vertigo, lOt. Gastrodynia, 133. General paralysis, 688 ; teticdogy of, 688 ;
pathological anatomy of, 694 ; and tabe^
638 ; treatment of, 697, Gerlier's disease, loi. Giddiness, tf. Vertigo. GiUes de la Tourette's ditease, tf. Haladie
des tics conralsifi. Girdle sensation in labca, 645. Glioma of the brain, sSg ; of the qiiiud
cord, 467. Gliosis in syringomyelia, 471. Globus hystericus. 544. Glossopharyngeal nerve, anatomy of, 107;
lesions of. 108. "Glossy skin," 400. I Glottis, spasm of, 114; hysterical, 542. Gluteal reflex, 431. Goitre, exophthalmic, jlB. GoH's columns, 420.
Graefe's symptom in Graves' disease, W- Grand mal, 581. Graphospasm, 356. Graves' disease. 518. Gray matter of spinal cord, diseases of,jl5- Gubler's tumor, cf. Tenosynovitis. Gyri, cerebral. 167.
Ilxmaloma duis mains, 4.
H^matomyelia, 458.
Himalorrbachis, tf. Meningeal hatnW'
rhogc, 326. Hematuria in tabes, 653. HiBmorrhagc, cerebral, 213 ; spinal, 45*'
spinal-meningeal. 316. Hair, falling out of, in Craves' disease. S'l- I Hallucinations in hysteria, 541.
|
^^^^^V 1 |
|
|
llcoilache, zlioloQr of. 6,1; uiatomkal |
HypcriUrcwit, 399; of th« face, 6q: I« ^I |
|
MAI of, Ai ; in brain i^phitii. 703 : m |
Uk\bH parolyus. 9a ^^^^H |
|
brain tumor, Z93: in pachymeniniiitii. |
Hypcriuntxii (ordii, ia6>. ^^^^^| |
|
6 ; trcatmcill of. fj. |
Hypeiir«[iJi<r of niiatdet, 41a. ^^^^^^H |
|
Ileatmi;, rfiilutbane** of, t/,tilao Andilrny |
Hypnoliim, ftott, ^^^^^^H |
|
Dcrvc, 9S ; in ni|[iu<:m>. i)S ; In facial |
Hypogloual nerve, aaalomy of, 140: in ^^^^^^ |
|
paralftii, a. |
hcnuplcgin, aa) : panlfiii of, 141 ; ^^^^| |
|
Hurt. •JTcciioiu of. in v^ia letloiw, tS] ; |
q>aHn uf. 144 ; in lali«>, 637. ^^^^| |
|
in Cravti' diKosc, jtS. |
llytleria, S39. ^^^H |
|
Hurt diicuc anil chi>i«i,4ft3; and est- |
Hyueria, aorlic. S43 : in ">« nule, |J4. ^^^ |
|
tcJiun, 144. |
Hytlorical, aphooid. $41 ; Btthwa, 343 ; ^^^^| |
|
I Icmiaamlhoia, in ilitc»«t of ih< Inlcr- |
cnnmUioni, 353: bcmknntlKctM. 345; ^^^^| |
|
nol cnpculc, 199, aa; : lij*ici4c«l. S45 • |
boniipleKia, 343; bdwria, 339; nrar>l- ^^^^H |
|
in lyringooijclia. 471. |
Kla. )}t : panlyib. 548 ; vonltinc. 3M- ^^^| |
|
Hcmianopia, 34 ; in c«Kbr«l typhilK 36 ; |
Hy»tcr<X|ii)rpty, 600. ^^^^^^^ |
|
eumioaticin for, 36 ; oKilloUiig. )6. |
Hytterogtsic toitet, S3t. ^^^^^^| |
|
Itcmianupic pujtillajr ttaclloa, 35. |
^^^^^H |
|
Mcmiataxia, 3>q. |
|
|
Keaiathctotit, 1.^, |
Imilntion cpilepoy, 374. ^^| |
|
KcMiatruphia, facUlIt, 403; lUiEiMln, |
lncc|ualil]r of pupih. </. Aniueonl, 4B. ^^| |
|
144. 637- |
Infantile, cerebral paIiy,tAS: <ianvml>ia«M. ^H |
|
II«atichot«a, 481 ; pMt hcmiplcgk. nS : |
</. Eclunpua, 3<h ; hcinii>Usia, 171 ; ^H |
|
prtk(rmtplr|;i<. llS. |
spinal polty. 4t6. ^H |
|
Ilcaiicnnia. )u;. |
Infeclidiu ditcoies and ni»inGiiii, 1 1. ^H |
|
Hcmiopia, 34. |
lnf(«aibi(al neuralgia, 69. ^H |
|
Il«npl«pa, 914; kltcmatinc. 95, M4; |
Inuinity, post-epileptic, 378; pivefiilF]*- ^H |
|
MnbnL *a4 ; direct, 21} : in gcnoial |
373- ^1 |
|
|M)aJyilii,6Qj; hjiMcrkiU, 545 ; indirvct. |
InMtmnia. trcaIiM«t of, 310, ^^| |
|
aat; lafaalib tfUMlIc, 371 ; (xM-iliph- |
Intula, 1/. Island of Rcil. ^^| |
|
Ihtrtlto, SI? : tpuul. 4S7 : in labn. |
Iniulu iclcrinis. if. Multiple uleiowh ^^^^H |
|
639- |
Intention trcmar, 61B. ^^^^H |
|
llcaiiparcil*, 3x4. |
IntcicfHtal Bcnrolgia, 363. ^^^^H |
|
llcniMciioa ofilM ifilwtl mnl, 4$& |
Internal cipaule, 190 : l«MiMn of, I99. ^^^^| |
|
H««iit|>MM, ilouo-Uiial. 81. |
tnlcmal popliteal nerve, 3S1. ^^^^| |
|
lltfMUlgta. 1)1. |
Involuntary sioveiucnii in tabes, 643, (44, ^^| |
|
D HwcillMiy auii*. 44S> 1 tlttadliarr chofM. 43S. Hcipci, lahlAli*. in nenfngllU. 18 ; CMlcr, |
Iiritllion. ipinul, 4^3. ^^| |
|
Island of Reil. 171. ^^| |
|
|
Ischuria, byitciieal, %%% ^^^^H |
|
|
364. 400, |
^^^^1 |
|
Hip mukclei, ijMum «f, 38}. |
Joctuonian epilepty. 136. ^^^^| |
|
Mvitllnglon't. chorea. 4^!^ |
Jaw-jcifc. 447- ^^^H |
|
llfilrviliiiMl), 4001 |
Jdnt, CharcoiV byi : hyKtcrita), jji. ^^^^^H |
|
llrilToc«|ihtli», yA. |
Javenile nuiiculai atro|>h)>, 406. ^^^^^^H |
|
WyAmmytSXit, 471. |
^^^^H |
|
llTdnvrhachli, 471. |
KakJie, Jji. ^1 |
|
Ilfpencuils In facial pmljnii, Sq. |
Kakosoiia. jCl ^H |
|
1 H]rpccrinla, DtrthraL, 1(4 ; iprn*). 4fiS. |
Kn<<r<JDtk, 413; crntrv for, 491; in ^^^^| |
|
Il]r7>er«ubc«l*. of audiioiy Mno. gfa ; tn |
ditonic ■looholiin^ byt; in dlabefe^ ^^^^| |
|
BrownJiAiiianJ't |Mnlir^i«, 457 ; hjrt- |
630; <«lieaiipU|pa.M7.93i; in b(rt4i- ^^^H |
|
ivrieaJ, jji, JJ7 ; larynccat. iij: in |
ury uaxia, 441; tn wulllplo tclcrmls, ^^^^| |
|
menlsgllU, is; plantar, 377 1 In tabo. |
bI9: in neurlllt, 391; 650; la lalie^ ^^^^| |
|
6*S- |
^^M |
|
Kyphmla, 365. ^^^^^^^ |
7IO
IND£X.
lAlma-f^txxa-Uxjagtil paraljnii, 151.
LachtytnatioD, iiaDsient, in label, 633.
Landnatiiig p«iiu in labci, 645.
Luidiy's panlysU, 466.
Laryngeal anKitheiia, iij.
Laryngeal ataxia in tabei, 636 ; Iiypcr-
anlheiia, 115. Laiyogeal moides, paisly^ of, 113, 116 ;
ipasm of, 114. Laiynglsmiu itiiduliu, 114, Latenl uJeroda, 440. Lateial icleiosii, amyotnqiliic, 447- Laughing fits in hyiteria, 543. I. cad palsy, 347. Lenticulo-oplic aiteiy, lis. Lenticalo-striale arteiy, aia. Leptomeningitis, cerebral, S ; qtinal, 3aa. Lethargy in hypnotism, 603. Lencomyeliiis, 439.
Levator patpebne, paralyni of, tf. Ptosis. Lightning, neurawt caused by, 565. Lipoma of brain, 390. Localisation, cerebral, 163, i6s, 171 ; of
spinal-cord lesions, 433. Locomotor ataxia, 619. Lumbago, 415, Lumbar cord, lesions of, 435. Lumbar nerves, 366. l.umbo-abdominal neuralgia, 369.
Mnl pcrTorant du pic<^, 656.
Maladie des licii convul^ifs, 549.
Malum Cotunnii, 371.
Maniacal exaltation in general paralysis, 693.
Mankopfs symptom. 563.
Massage in hysteria, 56S.
Maslication, paralysis of muscles of, 59,
Mastication, spasm of niusL-les of, 58.
Maslodynia. 36 j.
Mastoid disease and meningitis, 10.
Median nerve. 349; paralysis of, 350; sensory alfections of, 352.
Medulla oblongata, 206 ; lesions of, 307.
Meniere's disease. 99, 103.
Meningitis, epidemic, symptoms of, 13 ; diagnosis of, IS.
Meningitis, gummatous. 9 ; idiopathic purulent, is; pscudo-. hysterical, 19; serous. iS ; tuberculous. 10 ; in adults, 16 : tuberculous, in children, 15; spi- nal. 311.
Mercurial tremor, 624.
Merycism, 131.
Mesmerism, 604.
MetaUnalgia, 377.
Meteorism, S44.
Meteoroli^lical condition and mcnli^Ittt,
II. Middle cerebral artery, an. Higiaine, 507 \ ofdittudBiic 508. Miliary aneurianu, 314. Mimic facial spasm, 78. Mind-blindneis, 176. Mind.dcafne*s, tf. Word-deafiies, 176. Miners' nystagmnt, 53. Mogigraphia, 35*- Honocontracttue, 186. Monoparesis, tBs- f
MoQopt^lia, cortical, tSj ; fiicial, 84. Monoplegia, facio-lingaal, 84. Motor centres, 184.
Motor disturbances in Graves* disease. 511. Motor-ocali, tf. Ocolo-motorioi, 43. Motor point*, of arm, 347, 350^ 351 ; o(
bee and neck, 93, 3SS : of leg, 381,383. Multiple neuritia, 387. Hnltiple iderosis, G16. Mnscular atrophy, juvenile, 408 ; pragtci'
sive. 434-
Muscular rheumatism, 414.
Muscular sense in tabes. 641.
Musculo-cutaneous nerve, lesions of, 353.
Musculo-spiral nerve, paralysis of, 344: in lead poisoning, 347 ; paralysis due to snbcuianeous injeciion of ether, 347.
Musculo-spiral nerve, spasm of, 34S.
Mutism, hysterica], 543.
Myalgia, 414.
Myelitis, acute, 465 ; cervical, 4Z4 ; chron- ic, 467 ; dorsal. 424 ; lumbar. 42S ; purulent, 46; ; transverse. 450 ; Irans- veise syphilitic, 44I.
Myelomalacia, 460.
Myoclonia congenita, 549.
Myoclonus mulliplex. 549.
Myopathy, progressive, atrophic, 411.
Myosis. spinal, 46 ; in tabes, 633.
Myotonia congenita, 497.
Myxoedema. 525.
Nails, falling nut of, in tabe«, 655. Nasal disease and asthma, 119. Nerve -si retching in tabes, 684. Neuralgia, cervico-oceipital. 338 ; cceli"* 132 1 crura], 369 ; of external genitiii<
7"
377 ; hr»lef Icil, 5S7 ; iorra-oiUiat, 69 ; inicroottal, ]6 J ; lumbo-abdominAl.jbij: o( pKHlitc, 37s : qiermatic. J6q ; mpnr Mbiial, 69 ; iriccmiiul. CS : of imthra, J78.
N curat! lien in, js^.
Ncurllik, 331 ; dne to aloohol. jgl ; due to umte, 389 : mfe<tioa>. jSd ; tnicraia. I )]i : nodou. 331 ; maltiplc ^7 ; mill*
^^_ •» a idiucnce of olba disruci, i$$ ; ^B afHic, •/. PapiliitU ; puiulcDt, 331 ; ^^^ iclro-bulbar, 39. I Ncuro-filiroma plciironiie, 333. Neuromii, 331. Neuroici. coiucd bjr lightiUDg, 565 ;
tnoMalic, jbi. Niraiine pononioj;, isS. Nigin fokj, 400.
N7«ugnMi, 53;. in Friedmch's dbcaie, 441 : ill inultipk tckraiu, 618 ; oxciUa- totini, S3-
NUbti
Obtanuor nerve, panljnit of. jOi).
ipitol. lobe, loiont of, 17s, 176; ncu- nlgia. jjS. Onlar ttmgp, 48, too. Oculo-moaot Merve. anatumy of. 41. Ocalo-niMur parklvui. cctilral. 46 : a>iii< jikto, 47: ctiilical. 46; pciipheral. 4S : rhounialic, 4;. CKcuiMilio* ii«iirow*, 3J(iL (KdcMia, ■ngioacuiottc, 133, 319^ (K>v(ihai;itaiu>, 134. CK*upliai;iit, tpahni of, 134. LHfaciory, o«ittte, 35 ; ncivn. anatomy ol, >5 ; »erve, li}|icrmili<h>i ol. 17 ; nerve, cealral I«>i1im» of. 3; ; netve. perl|iheMl lotion* olt 37 ; ncf vr. In tabc*. frja 0|ili:halinla paralytica, 74. c^ililhalmnfilqtU. cxietna,5o;lnteRU,so: pnvrc«*ii^ iSt. y l>plk-. atrophy. 1/. At mfiliy. optic, 33 : cen- I m. )o : chiaim. sg. 34 ; nrrvc, «nal-
I uniy of, 19 ; ncnc, diicaw* of. jo :
I neiiriik ■"/. Papillitii ; neurltt*. rtlru.
^^ bulliar, 33: raidulioo, anaiomy of, 30; ^^m niliatian.knontof, 35; lhalamui,1etion* j^V <rf. I9t ; Incl. 34.
Otlta^Komi of brain, 39a. Oklao-arlhropaihy, jib. L>tiii> mcilia. Bi a cause of brain abtccn, abi ; w a cause ol meningiiii, 10.
OvariAn hypetxitlieua, i%T. Oiqracoia, 97.
Pachymrninciiu. cerebral, 4; oervicalla hypcciiuphica. 317 : intetiu hxmur- rhagio. 4 ; tpiaalit, 316.
FAiDi, lanciMliof, ta labe^ &ts.
Palate, innervation <rf, I4S.
Talpitaiiun ol the heaif. 196.
Paby, canibi]ieil*lioalikr4rtn.3Ss: niBhi,
Papilliiii. 30; in brtia abtcev, fl6a ; ia brain mmor, )■ ; in mcotnitiii*, 13 ; la nenropalliic Jnilividuali, 33.
Papillu-reliniiifc 3a,
ParacuHi Williui. i>S.
Paraituxical coniraction- 433.
Pinritlmia in ttbtf. tub.
Parageviia. 10^
Paralyiii, acute a.<ic«tiitiiag, 466 ; ■£■!«■•, 500; BrowB-Sequaid't, 41^: boUiar, ■ 53; ONlital. 185: glono-labloUotyn* seat, l$i: |[l<M>»iab*i>>fdiat7n|;ea an- b«»l>i. 350; hyvlencal, {48; tnraiitll* ipiul, 4x6; Laniliy'i, 466; |M»i-dlph- Ihetilic, 146 ; pteudi>b«lbar, ayi, paeudowliyperirophic, 419; i|iMlic tfi- nd, 44'.
Paramyocloout Muttiplea. 544.
Panplaeia, alailc. 443.
I'aiatitta of bnln, >>$.
I'anaiim of oonl, 470.
Patkttt lobc^ 168.
ParkbiMti't dliw«ie, ^oo.
Patellar relict. ■*/. Knee-jerk.
Palheiknv aniiony of. 43 : kriont of. 4i>
Peduncle*, of cetebclliani, 9o6 : of crrr- brum. 301.
I'erf'iratlni; nicer of ihe fooU 6j6.
PcrUttciili*, 313.
Perimoiiic eaamlnalioa. jH.
rcroiicaJ panlyiia, t/. PopUteal ntrvs. external, pantytia <rf.
relit Mai, jBi.
Itiaryiii. paralyii* of. 14S.
riKink (laralytit, 116^
Itirenk nerve, noralcla oC, 337 : ptnly- ui of, 3)6 : >pawn uT, 3361
Pla matrr, cvreiml, 3: tplnol, 315.
PliM«l ^and, tuaior of, aqft-
PiirebKottinaccI MctianK 194.
Piiuliaiy body, tumor of. 997, sgB.
Plaque* janneh 346.
713
INDEX.
Plexus, bntchial, letiooi of, 340.
Plexus, cervical, mnatomy of, 331 ; lesions of, 336.
PlcEus, lumbar, lenoni, sfifi.
Hexus, sacnl, lesioni of, 37a
Pneumogastric nerve, r/. Vagoi.
Points, lender, in inleicoital nearalgi*, 364 ; in sciatica, 373 ; Id trigemiiial neunlgia, 6S.
Pcdio-encepha]itis(Strtmpell},i68; (Wer- nicke), 150.
PoUomydilis, anteiior acuta, 416 ; chron- ica. 43a.
PotyKsthesia in tabes, 647.
Polydipsia in brain syphilis, 700.
Polyneuritis, cf. Mnlti[de neuritis, 3S7.
Polyuria, in brain iy]^ilis, 700; in hys- teria, sja ; in neningitii, 14.
Pons, 204.
Pt^iteal nerve, external, paralysis of, 381.
Popliteal nerve, internal, paralysis of, 381.
Porencephaly, 367, 319.
pMt-diiJitheritic paralysis, 14S.
Post-epileptic phenomena, 57B.
Posterior fossa, tumor of, 399.
Pott's disease, 453-
Pre-epilcptic insanity, 575.
Pregnancy, ataxia ful lowing, 670.
Pressure myclilis, 453.
Professional spasms, 356.
Progressive, bulbar paralysis, 152 ; muscu- lar atrophy. 434 ; ophthalmoplegia. 15 1 ; paralysis of the insane, 6SB.
1'rosopatgia, 6S.
Propulsion, J04.
Psammoma of brain. 290.
I'seudo-apoplcxy. 321.
Pseudo-bulbar paralysis. 15S, 250.
Pseudo-hypertrophy of muscles, 366, 412.
Pseudo-meningitis, hysterical, 19.
Pseudo-tabes peripherica, 388.
Psychical blindness, 176; deafness, 176; condition, after apoplexy, 228 ; in brain tumor, 295.
Psychoses in tabes, 63S.
Ptosis 47 ; in tabes, 632.
Puerpcml, convulsions, 594 ; eclampsia,
S94- Pulmonary branches of vagus, I18. Pulse, In brain lumnr, 29; : in menitijfitis,
la ; slowing of, in lesions of cervical
cord, 414.
Pnlvinar, 30^ 35, 198. Pupil, Argyll Robertson, 48. Pu[h1, inequality of, cf. AniMCoria. Pupillary reaction, 48 ; hemianopic, 33. Pyramidal tract, anatomy of, 4aa
Qoadnttus lumboium, spasm of; 385. Quadrigeminal bodies, anatomy of, 199 \
lesions of, aoa Quinine as a cause of amblyOfHt, 40. Quinine in H<ni^'s disease, loj.
Radial paraljtu, ef. Musculo-ipiral peral-
rsb,344.
Railway ipine, s6i,
Raynaud's disease, 4DI.
Reaction of degeneration, 91.
Rectal symptoms in tabes, 651.
Recton, centre for, 413.
Recurrent laiyngeal paralynt, I13.
Reflex, abdominal, 431 ; arc, 431 ; cre- masteric, 421 ; gluteal, 431 ; patellar, cf. Knee-jeik, 421; periosteal, 447; plantar, 431 ; pupillaiy, rf. Pupiltaiy reaction ; tendo Achilles, 433.
Reflexes, deep and EupeiAdal, 431 : in ^loplexy, 335, aa7 ; in epUep^. 547.
Relation of cortex to skull, 169.
Respiratoiy organs, diseases of, in vsgus affeclions, llS ; nerves of, 118.
Rest cure, 567.
RetropuUion, 504.
Rheumatic, acusticus paralysis, 97 ; oculo- motor paralysis, 45 ; facial panlysii, B9.
Rheumatism, and chorea, 4S4 ; muscular, 414.
Rickets and laryngismus stridulus. 114.
Rigidity of muscles in paralysis agitans, 502.
Rigidity of neck'in meningitis, 13.
Rinne's lest, 104.
Romberg's sign, (m.
Root zone. 420, 649.
Ructus hystericus, 544.
Sacral nerves, 37a
Salivary secretion in facial paralysis. Si;
in bulbar paralysis, 155. Saltatory spasm, 386. Sarcoma, of brain. 390 ; of cord, 467. Scanning speech. 6r8. Scar, apoplectic, 215.
|
^^^^^^^^^P ;i] ^^^1 |
|
|
Scailel Errrr, iniit[i|ilc neudii* (i>I1owIb(, |
Speech, centre fw. 179; la doncalia ^^^^H |
|
368. |
pouljiicB, &i)i dl*iiutiai>i,'e( of, r/. ^^^^^M |
|
Sdaiica. 3?>- |
Aphakia ; is Filedrcivh't diiicaae, 443 ; ^^^^^| |
|
Sciatic HMvr. jiaralyili of, 389. |
in ibuIii|>1k itrlerw^it, t)l9, ^^^^^M |
|
ScltmdNCtyif . 401. |
SpliiiKtcr^ dl>turlMiicck of, la cunt <li>- ^^^^| |
|
Scicrodcmi*, ^as. |
ca»ct, 4S1 ; in uUa, 652. ^^^H |
|
HeUtv^ sn |>tiu|uc». 616 |
Spmk Iiiridn, 473. ^^^^M |
|
Sclcrorit, unyotrophic Uteml, 447; com- |
Spinal, npoplcky, 458 ; bcfnipltgia, 457 ; ^^^^| |
|
hhied potterior and lilcial, 441 : diflnte |
irriutiuu. 4(13: Icplomcnincitu. 3x1: ^^^^H |
|
ccf^ral.tt?: cliM('mlni(cd.6l6; Uteiat. |
inuKiildrBliophy.431 ; pocliymeniaitMis ^^^^^| |
|
^^-.lohat.tttj: n)u[tlpie,6i6; poilcrioi |
316; p«ndy>i\ acote aKcu<lln|[. M*>: ^^^^| |
|
i|Hnal, Ai<^ |
panlpii, tlrofa-SM|uanl'», 436; |iat»- ^^^^| |
|
^H SeoliMls 30j. |
iyiii in cbildiea, 496 ; parajyua, tfiuiic, ^^^^| |
|
^KSooUmIi In KUtlca, 373. |
^^^1 |
|
^^Kfiooioma, ccMnl. 39: AiliioE. 3S ; Mmple. |
Spinal (onl, aJnccHi of. 46S ; oaalomy ot, ^^^^| |
|
m ^ |
4lS; UwhI 9iipj<)xof.4sS; ooinprewjoa ^^^^| |
|
f Sclmrihfca. 399. |
0^. 43} ; coDciuuoa, 1/. Trau*aiic aoi* ^^^^H |
|
' Sccielion, anotnalio of, in hytteria. |
loict; oongcnilal diseaan of. 471 ; ^^^^H |
|
iM- |
kicmorttiagc inlu, 4S9 ; paramci of, ^^^^^| |
|
470; wftcningof, 4601 ijplilla uf. 461 , ^^^^^| |
|
|
Senile, ehorea. 4SH ; lorteninif, Z46 ; tic- |
lutnort 467. ^^^^1 |
|
moF. S06, 61 ]. |
Spondyloithtoorc. 4S3< ^^^^| |
|
Scnun}', ■phi'-ia. 17b, 179 ; oonducilon in |
Spondylitic luhcrcnUr, 4S3. ^^^^H |
|
coid, 430; crou-vty. 199 ; diiturbaocn |
StMui epikpliciu, $93 ^^^^M |
|
» apopldy, 337, 3iS ; diilnrbance*, cgt- |
Siell'Tig'i tymptocn, 519. ^^^^H |
|
(ical. tM; dliiuibiuicu in neurnilhcnu. |
SlcnMBidia. 133. ^^^^H |
|
S3o; diriorbiuicci in peripheral nerTc |
Surao-ckido-auitokl, paralytb of, ijB; ^^^^| |
|
l««ioni. 334 ; in loho, (^s. |
ipaam of, 137. ^^^^H |
|
Semilui. p«ralyiii of, 34a. |
Strabtiniut, 47. ^^^^^| |
|
Senal fiutclJoni, diilurbuicci of, ik imii- |
SIriic alro^icc. 40OL ^^^^| |
|
mlbcni*, $30 1 in tabes. 634. |
Stroke, apoplecllc. aiS : tn Mrclxil ctn- ^^^^| |
|
Shaking paUy. s°^ |
bollun, 347. ^^^^H |
|
Shoulilct-aim |KiralyiiB, 3^4. |
SueK^lion, liy|iaollc A04. ^^^^H |
|
ShoultltT muuloi. pxralyiii of. 13^ iji); |
Superior ol>11c]nc niawlc, t'h ^^^^| |
|
tpoKni of. i]S. |
Surglctkl treaiiumt. of alitcew, 163 ; of ^^^^| |
|
SlnuUliun in epitcpty, iij. |
tumor, 3n). ^^^^^M |
|
Singulla*. 337 ; in hyileria, 344. |
Snipeniilon tmimcnt in taltct. U5. ^^^^^| |
|
^^L Sinmt ifaramtMMh, i;S>. ^^P Stnntn, cctpbral. l$j. |
Sydenham'^ ilitca'c. t/. CliorCB. ^^^^^| |
|
Sylloble-iiluintilin);. 6qi. ^^^^H |
|
|
Stilh nerve, r/. ralhelicvs. |
Syncope and apopleiy, 333. ^^^^H |
|
SUb ffn^lons in meningitw, 14, 18. |
Syphilid, and dcmcalia paralyllca, 6^ ; of ^^^^| |
|
SIcKp, kyuartnl. 34(h |
the ncrroui. lyUcm. 700 ; of the >|Naal ^^^^| |
|
SlecMMby. Mb. |
conl, 461 ; and labci. 677, ^^^^M |
|
SIceplcHDrw, ;io. |
Syphilitic bull i»cnin^ti>. % ^^^^M |
|
Sincll, ccnirr for, ti ; diitarb*ncM of, 16 1 |
^phikinu ol ktaia, tqix. ^^^^M |
|
etaminaltou ei, 3^. |
^pbitoiMi of cord. 468. ^^^^1 |
|
Snheniag, cercbnl, </. EncaphalonulMi*, |
^ringomy«)ia, 471. 473 ^^^H |
|
144: "tutllpic foci of, 349; tplfiol, «/. |
SyMem tliieaH*. cembiatd, 44a. ^^^^| |
|
Spiot) myelomkUiel*, 46a |
Sytf «n diteaHt of the ipiaal cwd, 44U ^^^H |
|
Somnaaibnliun, 6ot. |
^^^^M |
|
Spasm, bronchial, iiS: at giMiK 114; |
Tab««. «Ad alMhotltM. 3Q> ; donallt, taq : ^^^| |
|
whniory, 3*6. |
|M(«(lo-,3M. ^^^H |
|
^^^&MMn« ntfliuiu, 79. |
Tabetic foot. AjL ^^^H |
714
INDEX.
Tachei cMbmle*, 15.
Tachfcaidia, 137.
TRcbjrurdia itnimosa eK^tlulmiM, 518.
Tiiloi'i cramp, 357.
lulipet, in infantile patsjr, tf. Clnb foot,
43B ; in external popliteal paraljnii, 3S1. Tmtc, examination of, loS ; diiordei* of,
106 ; disordenof, in ladal paralalia, 88. Teeth, Uling out of, in tabei, 656. Tegmentam, 303. Telegraphen' ciamp, 357. Temporal lobe, 169. . Tendon reflexes, tf. Reflexea, 431. Tensor fascise lotie, ipasm of, 385. Tenosynovitii hypeitiophica in wriit-
drop, 346. Terminal arteries, 91 1. Tettlcle, irritable, 369. Tetaoilla, 493- Tetastu intenaitteiis, 493. Tetany, 493-
Thalamnv optic, 30, 35, 198. Third nerre, cf. Oenlo-motorina. Thomsen's diseaw, 496. .
Thoracic nerve, anterior, 343 ; posterior,
340. Thrombosii, cerebral, 245 ; hdiu, 958 ;
spinal, 460 ; venous, 356. Thyroid gland, in Graves' disease, 518 ; in
myxixdcma. 515. Thyroid treatment of myxoedema, 527. Tibia! nerve, ef. Internal poplileal. Tic, convulsif, 78 ; douloureun, 63 ; rola-
toire, 137. Tinnitus aurium, 97. Tobacco amblyopia. 39. Tongue, alrophy of, 144 : hemiatrophy of,
144. C37 1 paralysis of, 144 ; spasm of,
144-
TorUcottis, 137 ; rheumatic, 414.
Tracts, of cord, 430
Trapezius, paralysis of, 13S ; spasm of,
137-
Traumatic, neuroses, 5G1 ; objective symp- toms of. 563 ; reaction of mu!,cles, 563.
Traumatism, in meningitis, 10 ; in tabes, 676.
Tremor, alcoholic, fifi ; in Graves' dis- ease, 531; in hemiple(;ia, Z30; hyster- ical, 557; intention, 6l3; in multiple sclerosis. 61S ; senile, 633 ; in tabes, 643, 644.
Trigeminal, cough, 76 ; neuralgia, 68.
TrigemioDt, anatomy of, $6; aacitbetia of, 73) central leiiaat a( 58; cstr*- ctsnial lesioiu of, 68 ; Intn-cnnlal levoDa of, 61 ; peripheral leiioiu 0^ to ; nudei of, 56 ; panlyni at, 73,
Triamiu, 58.
TroddeaiU, tf. Pathetkna.
TrojAic distnibancei, in apopte^, 931 ; 1b choica, 485; in hyateia, 553; U •yrinpnnyelia, 473 ; in tabes, 655,
Trophic uetrei, 397; genna] aSectioos in which they are chiefly implicated, 51a.
Trouswau'i dgn in tetany, 493,
Tubercle, of brain, 390 ; of cord, 468.
Tubercular disease of the spine, 453.
Tabercuhir meniDgitis, 9.
Tumor, ceiebral, 389 ; spinal, 467 ; of spinal meiiii^[eal, 398.
Twitdilngt, fibrillaiy, in dutmic mnacnlar atrophy, 437 ; in neniastlieniB, 533.
Ulcer, perforating, 656.
Ulnar nerve. 349 ; panly^ of, 351 ; sen-
soty afliections oC 353. Uppei-atm type of paby, 431. Urtemia and apoplexy, 334.
Vagns, anatomy of, no ; lesions of, in.
Valleix's points, 68.
Variola, multiple neuritis following, 3S8 ; myelitis following, 453.
Vaso-molor changes in labes. 655.
Vaso-motor oervea, 397.
Veins, cerebral, 257 ; spinal, 45S.
Venesection in apoplexy, 23S.
Vermiform process of tlie cerebcHum, 205.
Vertebral artery, aneurism of, 353.
Vertigo, 99 ; epileptic, 581 ; laryngeal, 101 ; Minitre'a, 99, 103 ; in multiple sclerosis, 620 ; nasal, 76 ; ocular, 48, 100 : paralyzing. lOt ; a stomacho livso, 101.
Visual centre, 30.
Visual Helil, contraction of, in hysteria, S41 ; contraction of, in tabes, 631 ; con- traction of, in traumatic neuroses, 563 ; erroneous projection of, 48 ; examina- tion of, 36 ; sectorial defects of, 33,
Vocal cords, paralysis of, 113; spasm of,
114- Voice in paralysis agitans, 503. Vomiting, in brain tumor, 39b ; cerebellar.
INDEX.
;'s
ao6 ; cerebral, i! ; in Graves' disease, Sai ; hysterical, 5-14,
Weir Mitchell trealmenl, 567. Westphal's sign in tabes, 650. While substance of card, 439. Willis, circle of, no,
Wor l-blindnes-s, (y. Psychical blindness, 170.
Word-deafness, 176. Wrist-drop, 344. Writer's cramp, 356. Writing, disturbance:! of, 176. Wry-neck, 137.
Zones, hysterogenic, 5JI.
Zoslcr, herpes. 364, 400. Zoster ophlhaiiiiicus, 69.
THE END.
A TEXT-BOOK OF GENERAL SURGERY.
Br DR. IIEKMANn'tILLMANNS,
PnunMua m tiia I HivaaairT or Laovc.
VOLUME I.
7'A< Prineipk* of Surgertf atit Surffiral Pathology. Orttrnd #«/<■ gnverMiitg Ofentliaiu u/id Ihf Ap/ilifiili-m of tfrrtuiitjf. TraxMlatciJ fmai the ifaini (l«miuii i-rllil'in by Joay Ituotiw, Jl. D., and Bvua*ui T. Tiutiw, U. D. Wtlh Ul JUMtrali««*.
VOLfME II.
Itftjional Surijfry. Tnuislal«i1 from the fooHh Oomian mlltlMi by IlKMiatii T. TlUIoN. M. I).. N«« Ynrk. With flT lUutlrxiliM: VA^icA hj Uwu X. Snxxm. U. I).. Protmwr of Siincvry Id ihn N«« Vtifk I'niivnliy.
VOI.rMK 111.
Tifffi'initl Suri/fri/. Trannlntnl tmin ihc frairth Orniun nIIU'W iif [lltitJ tmx 1'. Til.T>>,v, M. P.. Xcir Ynrk. ITt'A Xf' llliMralion*. VMtnl by Lkwin A. Vnuwai, M. D., Prottwwr o( Siirgrcy in llm Sew York Cnlnnitr.
Cloib, S5.00; e<beep, 80.00 por volumo. SOLD OXLY BY SCBSCRUTIOS.
I^N. lltKNAjia TiLtDAkvo, l*rDK«Mr oT Si(f|t*rr tu ihv l^eiwttliy nf Ldpaki, | m iwdin IhuM nro qualltla nioh Mut4« Mm la iutnM tr>a aluliM. «■■> b^ ••(«•, Inctiurinc b} th* hiyl^c or ■ Snn, tootd Ibqnalution. npoo whlcb U bMlll th« mM •ur)[ii«l •mirtim. U WW nn Kcouni uT IhcM uocFtlan*! ^uMlUioi of tbamtbor Iha bU work ownholMlHiti* Iml l>>r UiB UM of MKilciiti, >nil at Uw miiw ttno wiU liitiitnl In tb« iietd* if ibr jr^ctitliinan
S^'wimiT, w pmcDtB) In lh« pnaent roJamc^ b » truulaUoa vf bb worko "n 'luiaaM,
tnu ToluiiUM. lb* Kvnml uf aliicli aill bkiii ba en |'n>«.
V>itB>a I, llivnui. (InsbNar ar> tlrmicju. PAtuoumc, 1« lupcly ibratMl latW Mtv- ■tiln*) iif til* »«cMi*l ntiMiplai wbloh vuilnrUe • mIUI aunrlol •tnivluN Tbb >|>|-aK ih4 miIt b< bmmmI Riirjkal <^r*liniiii. Iiul *)*o to all aunriaal OMKlitinM. The nnrk eMsn ih* •nllf* riuM iir Arnsnl lurifpry and of ■nralcal ill>«ai*i, 4ailliiK iwl ■» nnrb «lih oiitvlal DIvMloiu M vnli lb* oniiilllVni obldi i>hnutd goirBrn thcw • niunl •IbvHiam *<« iliatr larttmiaara. aft*r-lra*UiiMit, and the Miolnirj. ratbtJugy, aii<l tniiliiMll or the vukua auritifal dbwi>.
VuLniB II, KbtKiKit Hi-aanr, it <l>vol*il to th« mirxri nrtbo baad, *>>rb, ibioai, aHd
•fiiM* aad fflnal 'IitiI ; liioluilitif In (boj(r4 JtrMas tiijurin aiiil <U-«wrW «< Iha xalp, lYllta anaial ■■«», ■( iIm brain ai^ iu adnota. of th« IWv. ■>f (ho ikv* (mI iib*! Ki*^, >■! tlw >a««, of iha MmDh, Ani«H, and pharriH.of the (ar, anil nf iIhi <*)lrif7 ilaiHl*. Tbo ■*■■■< MHtitn iMdiMlaa U^hutai anil mirflal JbMMm tiT the m<k, of lb* b^iu mi tnobaa, aM of Ih* nwfibaCtt*. Tta /AirJ iJinnm ptnr* ti^iBtta mmI JUpmm iif ih* lh»W Mii) of tba hMni aoil t\>r/.n\HS dirirmn tnat> nf tin tiiiyvry of llig*|>iio alid •{anal oc4il, iMhidIm tl*fiirUiitio>. lYaiiirn, ^mhi* Injur!**. lumoriL, etc.
Tb» IM of MliiaMa b m Aill rhal it lnrliul« f*vn ll>i> (nal wntol nridH. bihI tin ■iifrtpU'O' aiT -wafclwrtlyyHnt^fte bxavatheruibrrnw ir« wnwiMj af aaBtalihn ntliai wiuka M obui* Uio fenoiaMcv ocmanaiy (o oBdentaMl annl l» tnwL
D. APPLETON AND COMPANY, NEW YORK.
THE PRINCIPLES AND PRACTICE OF MEDICINE.
Designed for the Use of Pivetitiojters and Studentt nf Medidne.
By WILLIAM OSLER, M. D.,
Pdlnrsf ibeRoyilCotlinof PbyridaB*, LaWloe; PnfMWt of Uedicne m ds JobM Bnlom Onha-
•in', ud Phyudin-in-Cbicfof nu Jolmi Hopkiu HiMfriad, Buliiaar*; fccmcrif Fnicaior tf
iheluiitiiiasf UcdiciBa. UcCaiUBlmi^.Haiiind: and Pnfcvor (f Ctiakd
llediciii* in Bk UnraittT iif riiiinjliHiii. naMMpbih
Second Edition. SOLD ONLY BY SUBSCRIPTION.
87a Cloth, $e.50; ahaap, SeJBO; halt moroceo. $7.00.
" The appcRrance of the seconit ediEJon of th!* now dauical tezl-book hu called forth renewed expressions of the approval which followed itt first puhlicatioa. Tltere w probably no medical work in the English langnige more widely and conttant^ con- lulled, and certainly none to which the physician and alodent may refer with tnort conHdence. It must indeed be gratifying to the author to know that his work bat been adopted ai the standard text-book in the principal medical schoola of Americftaad Great Britain, and it is no exaggeration to asmme that its translation would meet irith equal appreciation in the medical centers of Europe." — Montreal Mtdical Jaunuil.
" Professor Osier's work stands at the very beginning of the list of authoritative text-books in this country, I'here are many reasons for lis holding so high aposition. These pertain, on the one hand, to the lecogniied ability of the author, and on the other to the intrinsic worth of the work itself Dr. Oster has for a long lime com- manded the esteem of the profession, both as a teacher and as a writer, but his greatest ability is in the latter field. The work is admirably arranged, the diseases being scien- tifically dassilied ; the text is lucid, positive, and concise. . . . The improvements in this second edition refer chiefly to a general revision of the entire text, with especial attention to typhoid fever, malaria, diphtheria, septicsemia, py;emia, cholera, syphilis tuberculosis, diabetes, and a number of Other affections. The work has thus the ad- vantage of being Ibe latest. It is in every respect one of the most excellent." — OAia MtdUal Jeurnal-
" The success of the first edition of this work was most pronounced, and deservedly so, for It was not merely a r/ium/ of current literature, but an exposition of medical science based upon the extensive and carefully recorded clinical experience of a mas- ter in the profession. In the present edition the admirable arrangement of the original work has not been changed, but sixtyfour pages of new matter have been added to the text, and a number of new illustrations have been introduced. . . ■ Nearly every pagt shows the evidence of a thorough and careful revision, and those who consult this late edition will surely find the best that can be written at the present time upon the sub- ject of internal medicine." — Univirtity Mtdical Magatine.
D. APPLETON AND COMPANV, NEW YORK.
M-EDICAL GYNECOLOGY:
.
A TREATISR ON THE DISKAStS OH WOMEN FROM THI= STANUfOlNT OF THE PHYSICIAN.
By Alexander J. C. Skene, M. D.,
of CynttcAogy in Ihc Lona Itlmd CqIIck^ Hn>piU!. B'ooklyn, N Y. ; (v- ktnotly Plotts^at ot r.yiicii>bgy m Ihc New York I'otl-r.ijJiud MciIkjI School ; Cynevologitl lo llie Long ItUnd Coll(];c KutpiUl, etc*
fiw, 5_jtf pages. If //A /Uuslratrons. CMIi, tf.oo.
" The lUrecilun of mad«rn fyat<oiogj hu I)c«n almW enCrvl; wiuicRl, ■»•! I< tt r«a]U nfmhine ti> 0[>cn ■ lioo£ of tbii. dekcrl[i(io«i. The <li>l!ne«i>Md anihor h<> fillM « imich.Mt nni In )>l^i<ie ihlt valamc bohin ihv pcMfrstioa. . . , Ur. Skmc huemtreJ iin almoii iiiimnUcii Kraiinil, (he greii hnpoiikiicc of which n* imi be Ion hiKlily apptcciaictl. riiit work coinmendi iitcll nol ouly in (lie gcnen] mm- litioiier bul to the ipctiilisl a> well, who will had in lt> p^a niwcb LmportaBt imdc- tnilMiL*' — Aanah t/ Gyiutelf^ ainf Pjtiiatry.
" tf by the publicnllon of (hii book Dr. Skene BceompIii)iM,iK> flloK thoa lo dlrKt •ItmtliMi to iIk pouiMltiict of ihe niolKal iteatnient of synccolagiloil OMn. ftnil lo divert Ihe tninili a\ imi-liliiuien. e>|>eclatl]r llie j-ououor onn. troM tlw Mm Ihil oiily from «U8«Tr <• reli«f in lh«io oMoi to tio IimAciI tor, h« will do IW pmrcMJo* anJ the (Mblk kn ine<iiiai1ilc lerrioe. We pKdic: hx ibc Ti^lume « tordiai rec«^'llon oa Ihe |M(i uT ihc pmrcxiDD whcrci^er ilt tnerili ue known, for lb«i« b no oihet buik of tcv-.'iit dale wlii,:li man tlieis tubjecu in Ihe uae prKlkiJ Mid oanunva-wxc niJiiaoi." — BraikljrH .\Mital Jimnul.
"Thlo h not • leii-boiik. hut better than • (eti-book lo ihc ptvcliliaiiM, It It the nmril of a rijie nii-irKnce. nnd |-fvei inuijr iixAi. am! nlh •llmtlon l» Mutny comU- Itoiii llui lli< mere ti-it-b-KAii of (lie tlaj' cui nol itaicll. In >hof1< if it a book llitl nusht tu lie tcul by th; pnuiiiianei. and then there will be the need of many refcN cnee* to lu page* lo refieUi memory."— I'iipma A/eJkal Attnlhfy.
" In lh« npid >ln*clo|>ineni of evnecolo^^y duilng recent yean, the Mrsical nde of the xobicti hnt received the Ur);cr tnxo »f itlcniloa, thuh in ■ ntcaMrc leadiw lo ttt ncKlevI from « mcilud) tUnil|Kiitit. Thi* ctccllmt aildilion to the tilemurE (if meJ- lc«i Sf^rttiktgi will aid in cnirecltng; thi< tendency and maintainlc^ a jatt ImImic* between the Diodicil ind lurKical phatci of ihitdepuimcTit of our art. . . ■ The wnik i* an ahlr and wcll-writicn |>rewnt.itioii ai the uibjccl, and will no doubt be ncoii^ wllh iIk l)i|th degiee of Uv <r neorded lo llie variant conliibulionn of ibe astli-w lu (HISlell iQfnetolojy."— .W*(w/'i-» Affiti^al MtmlAly.
" We h*<rc BC*«r tead a mcire cnlvrliiaing and ptt>6l»ble book. The pDf|>at« o( In popular an I bar la eonlrihniing ihi» liii l.iieii volume on gynoMlogyli tooulllMt
I Ihe |>u rely medical aipeci of thciubjotl. and eYeciallrtodraw the line dearly bclwe«H meilical and lurxical indication* for treatment. . . . The ):«»cral pnncipks UMlcriytnK heredity, lexuil typci. and functionn are dtMiibed al Icngttt All ibc (anciloaial a«i9 oricanic dttorden peculiar lo women are dlicuueil In an cKC^ptlonatlf rational anl pncilcal niaDiici. 'I hniuijliont ihe paeo of ihc book byclcne and pt«|>byla«la tn
IClven (pecial aiicaiiim. 1 he bo -k it Jlogdher valuable and de«ir«Ut. andouglil u be rtaJ liy ei«ry ntodical slndenl and pnclitionci, patticularly Ihe lallei.' — Omvir
D. APPLETON AND COMPANY, NEW YORK.
THE DISEASES OF • INFANCY AND CHILDHOOD.
For the U.te of StiuienU and Practitionere of Medicine. By L. EMMETT HOLT, A. M., M. D.,
Pro/aior of Diieatet of CAildnn in rh4 AVw Tort AlyeKaie ; Atttnditig J^j/ntian to
ti4 SakM HoipUal and to tki Suntry and CiiUet Ho^Uat, JV>» York;
CentuUing l^yiieiaa to Ikd Aia York Infant Atftwt, and In tk*
Hotpital for Supturtd and Vrippltd.
With 7 fall-page Colored PUtes and 303 IllDstratioiu. Cloth, ^.00 ^ ■beep, $7.00 ; half morocco, $7.50.
SOLD ONLY BV SXJBBCHIPTION-.
Amtriemn iledioa-Saegieml BuUeOa:
" Thii work u in every aen^ of the vord s new book ; for, vbila tin beat work oT other ■uthoiB in this and oilier cJuotriu hu been dnwo upon. e>peciallf thU m the fonn of ii]v>D'>)|T*pb9 Mid in tbe Ulea oV padutric lilemturc, the nujorit]' is dFiiFed Horn tbe ■uthor'i own alinii!il obaemtioiu. Ubaotelo dicta huided down from Isit-book to text-book in here ci>nspieuou9lv abKent. uiil aotbin^ hu been locepted whzoh hu not been 0711011} le:r>ted. ... It is not Tcnturinii too uiucb. after ■ carefiil perusd of these pages, to predict lor tlib volume a |>re-eiuinent and la*tln ■ podtioa anionK the treiliaci upon this iiubJHt. Wc lit-irtitj rti>>iiiiu;'nil Ihut it find a pla™ not only in the librarr of even phjsician. but >i'i'io '^]\-ii M Uii" v'll-'w oi' ovtry Hiuii ^vho do^irvs to d<-al iiitellifcentlv iviih tlie pn>l>lcmi ail >')i wiiI^'iK him in I'l.f trLjIuit'iit <>!' iiilUuts otid otkiUrvu iDtrual«<l Id Uid can:."
Nishville Journal of M»dieiao :
^' TKis ni;i;niti<vTit wrrk i- otk' of ilie m-'r^t vahxabk rewQt contributions to niedioil tit^^r- aturi'. It will rapi'Uy win its wny t" a fmiu r.uib tritb I'tlivT st^uidird w ■rt-. upon kindn-d :«iihjivtf. It is UP Dearly i^>iii|'!i-ie aa ii trv^atL^.: u|koij thb subjrct cao be."
Virpaia XediCAl Semi-ttoatlily :
'- WIkii I'oi; n.\-ji!r ir»- itMi'liinpi oi' a dniid.> ■■r tw,. aif"^ snd pimparts the inculcati'ini ot' tc-il;iv, he i\.u M.ii!\T'y lulp rix^^yrniiiiij tliut ■ ■>'.il IbitL,-^ hav# p«MAJ away, and all tl;iiLj> lull- (■■■■■'Til' mn.' T\v v.>liiiih> Ivlorv it' L- pnt'tieally the ris>ird ••( infomiati.in oK-..t;ii.J '>> lUe a.i:h •! I'rotii eiiton vear* ■■!* sivi.il fruJy and pFaotiw. ?o that nearly eitrj' J .i>jt.t i- |rv-.:;:..l fnii, rh ■ -iaiid|i.>!in oi iviv.i-i»l .^K-en-fltion and eipericnee. TJjf iiif-Tiiin'i ■!! .-ii,-'i •' tli.n-fTi- rv!i.il>',e. 1"t |ir. U-''X i' a >-l>>*e oliwrier and a careful jtudenl of 111-, div t ^'1,"^' "1 V , - . l:i ^ln'rt. '"ri!^ S-'l: .ipT'car. ti^ u* t'' Iv the U-ii all-r*'und. up-ln- ,irti- !■-■» lor i'rj.,':iti ■iK-ri ai;.l siuJiuti 'f^'LilJ^;!'* iii-ca.-i.'s ib»t wc ku-'W olV
MedicnJ Progress:
" Tho Wi.^rk ^vT^'-re ".:* N ."'nf' TiTu.-h rv:!e\':* _"^ir er^ili* u-^^n tb^* dttininiished aullThf. Pr. ll^"'^: !::»* l-'-ir 'ki.!i k!i^«!i ;u a ni *^t :n-i;>'rl 115 ii;d ni:;i-:akiQi7 invft.iii.'aT.jr. an<t in 'i:i^ vo/jiiie hi' 5':#'.jl:i- :i a: r<-p:itLiii''D. Thv w-Tt. we may say in a a'nleniV. i& fully up to -.tv rr i,;!tvn;i;;r* ■ ( i'..< :;ii.<-i. an I ihen. :? r. ■ advicce bn-wn t> f*diattii3 nhieli iias ■.■A 'riiii t_l:>- dealt »;'.h a,v-rd;:ij !■■ :;? n!.-r.:-i."
D. APPLETOS AND COMPANY. NEW YORK.
April, m».
^iEDI
AWD
HYGIElSriO WORKS
D. APPI.E70N AND COMPANY. 72 Fifth Atrnnr. Nem York.
ACl.DE (JOEIN). Tilt' Fockct Phkmacy, wllb Tli^mitfutk loihx. A rUvmt of ibo Clinical A|>iillc-*tloua of liritwdko ni)np(i<l lo ()>r I'lKkrl-raw, fur tli« TrnatuieDt of fUiiergracien aDtl Ami? liti<«»«ii. ISmo. Clotli, |2.0i>.
KARKKIt (FORDYCE). On ::»<ui-8)vknow. A PopuUr Tnclia* l»r Tnt>»lor* ■nd tl'i.- Guoural RwuU-r. Siiull Itino. Clotli, TS cent*.
HAKKLIi (FUKDYCK). On Puurporal DiMwa. Olinica) I^lorM d«liv»r«d It B«t)rt ue llcw)>iul. A Couna tit Lecture* rn]uabl« alik« lo tli« 8udwt ud tll« f rnofitiutiiT. Tbiri] MliliiMl. Svo. Clutb, f^.OU i thi^ti, $C.(W.
UAKTHOLUW (RIlIIEItTS). A TimIIm oo MaUriit Uttlicn iml Tl<er»|mHin Mfllh fdlllM. Rifti^cil, enUrirad, and adajiUdlo "Tli«Ncw I'lurmBCOpob. 8»o. Cloih, in.iHi; dIm'p, |il,DO.
BAKTIIOI-OW (rtOBKI{T8>. A Truitiw on t(.« rrttclioe .>f MmJIoIb.. fur Ibo Uiir [>f Hliidi'nU luicl I'mi^titioner*. tetMlb HIHm, rnvixil and riiUrgad evi>. Clulh, in.UCt; Khecp, (o.oa
BAKTIIULUW (ROBI^:i{TS). Oii tU ADbiKtinUiii IwtwMn ll»dIoln«« «»•! U- I«r««i) I{«iuv<liri> anil Diiciuu'i. Uciog the C'Hrtvflght L«rtur«a for Um Yoar imo. Svo. Ululh. il.ii.
BAOTIAS III. I-'IIAKLTOX}. i'anilin*: CccebrBl, Biilliftr. idiI Spinal. A MhouhI uI' I>in|;uu-i« tor Stwlvnli and PraolltiMicro. With ISS [llii>lrM- IMDH. Sinall Avo, STl |<aitc*. Clulli, (1.041.
BA&TIAN' (II. C-1IARI.TOX). ParalrsU frtun Hrain Dimam in ita CoianKb Kmhih. With lllnnlrHtioiM. ISmu, S40 |>airr«. Oolh, $1.79.
BILLKUTII (THKOIlOlii. Cmwrnl Sargiea) Palliolw and Tberapomlri. A T«xt-Buok for Siodcnta and l*h7«lciuH. TrtMlatad bvn lb* t«iitli iirmian e<]lt>ua. bv ^|>l^cin) piriiiiiBioa of th« iinthor, bjr Chtrl<« E. llftokU;, U. I>. nru Imritaa *dlU«*. r*>lw4 ant falannd. «vo. Clulli, 9A.00; atiwfi, (COO.
ROYCE (ItlRKItT). A r«i(-Book ot Morbkl lll.ioWv. For Madeota and I'rartitioncrs. Wiib 1:m Culurul IUittiraii<iB«. Ctulh, |T.AO.
IIRAUWKU. IRVROM). Dt««««a of lb« Heart ami Tbonrk Aorla. Illu<» iratcd wiih -.■><! Wool-Enffrariiig* and 69 Utboarapb PUto— aliowiiiic 01 rtgur«»— in all. SIT lllnatrallon*. »ro. Clirtb. I9.U0: alMep, Itf.VO.
KKYANT (JOSEPH D.l. A Uanaal of OprraiiT* Sarirrrr. Km lAOaa. mlir< aad»lancf4. TM lllualntion^. Hvn. CloUs lA.OO ; tliMp, |«.M.
BtntT ISTEi'liEN S.y Exptoratioa of th« riif.i in )l(«lih ami 1Mww«l •«•, SIO paiRs. With llln>trn(ion*. Clolh, (LAO.
CAUPBEI.L(F. R.J. Thi- UnRuaRc of Mnlirin*'. A Uabual irl ring tlia Oriel a. KtvtnotoKT. PrunuucinlJon, nnd MiniiiDi; of tli« Yeiliiiical Temil funad la Ucttical CtMfBturo. 8vu. C]o|b, fS.W.
OABMIOHAEL (JAHEB). DImms io Obfldre^ A Haand for Btadento ami PractitioDen. Ilinstnited wtth Thtrt;-oM Cbarta. 12mo, BVl pagw. (SfCDUiTa' Sune.} Olotb, tS.OO.
CHAUVEATJ (A.). The Companitive AaaXomj of tlie DranMtlcatod Animab. ReTiwd and eDluged, witL the co-operalion of 8. Arlolng, Diraetor of tiM Ljons Veterinarr Bcbool. Beoond KdrII*)! edition. TraaNated and adited b; George Fleioinp, O.B^ LL.D., F.R.O.T.S., late Prbu^ Taterinar? Bargeoo of the British Ann;; Foreign OorreepondiDg Member of the 8ooi6t£ Boyale de Hidedoe, tai of the Bod&fi Rorale da HMedne Fnb- liqne, of Belginm, etc. Hto, lOSi pages, with 580 lUanrationa. Cloth, $7.00.
OORNIXQ (J. L.}. Brain ExbauatJMt, wHh iocdo Prettmloai? Conilderatioiif on Uerebral Djnaotica. Grown 8ro. Ctbtb, (9.01).
OOBNINO (J. L.). Local Anmtlieda in General Medlcineand Bormn. Baioft the Fractica] Application of the Aittbm''a Keoent IHsoonriBa. With lilna- trationa. SmaU 8to. Cloth, $1.86.
CmtBIEG (ANDREW FO- Tlie Menopauae. A Ooasldaratioti of tha Phe- nomeoa which ooonr to Women at the Close of the Ohfjd-bearing Period, with Incidental AIIobIodb to their Relationship to Heaatmatlon. ' Also a Particular Conaiileratioa of tlie Premature (especisllj the ArtifitAsl) Hcno- psnse. ISmo, asi pages. OloUi, |8.00.
TtATIDSON (ANDREW). Geograpbioal Pathologj: Aa Inqniry into the
Geographical Distribatlim of Inactive and Climatio Dissasn. S vols.
Svo. Cloth, $7.00. DEHOH (£. B.). DiMuses of tbe Ear. A Text-Book for Praotltfoaara and
StndeDta of Hedidqe. With 8 Colored Plates and IBS lUoatratioas fn the
text 8to. Ctoib, tO.O0; sheep, (6.00.
DEXTER (FRANKLIN). Tbe Anstomy of the Peritonanun. ISno. With 89 culored UluiiraUons. Oloth, |1.S0.
DOTY (ALVAII II.). A Muoaal of loBtruciiun in the Principlea of Prompt Aid to tbe li^urcd. IneludiDit a Chapter on Hygiene and the Drill Regala- lions for the llo8[)ital Corija, C. S. A. Designed for Uilitar; and Civil Dst. Second cdiUsB, reiteed Hd eilirged. 121 I Hast rations. t2aio. 01otU,¥1.50.
ELLIOT (GEORGE T.). Ohstttric Clinic : A Practical Contribution to theStndir ot ObatetricB nud the Dijeaaes of Women and Children, 8»o. Cloth, t4.6tf.
EVANS (GEORGE A.). Hand-Book of Bistorical and Geographical Phthisi-
ology. With Special Reference to the Distrihation of CcmanmpUon in tbe
United Stalea, 8»o. Cloth, |2.00. EWALD (0. A.). Lectures on the DiBeasea of the Stomaoh. B7 Dr. 0. A.
Ewald, Professor of Pathology and Therapeutics in the Cniveraiij of Berlin,
etc. Translated from the German by special permipsion oF tbe antlior, b;
Morria Manges. A.M., M.D. Sttend mUUm, rcfbed uul narfasgc4. Cloth,
$5.00; ahoep, t'l.OO. {Sold only by »vh»criplioa.) FLINT (AUSTIN). Medical Ethics and Etiqaette. Commentaries on tbt
National Code oF Ethics. ISino. CJoth, 60 cents.
FIJNT (AUSTIN). Medicine of the Future. An Address prepared for the Annual Meeting of tbe British Medical As^ciation in 188G. With Portrtii of Dr. Flint. J2mo. Clolh, $1.00.
FLINT (AUSTIN, Jb.). Teit-Book ot Human PhjMologj; designed for the Use of Practiticnera and Ktudents of Medicine. Illustrated with three hnndred and sixteen Woodcuta and Two Plates. Fearth Miltlaa. nTlK<> iKperisI Svo. Cloth. $6.00 ; sheep, $7.00.
FLINT (AUSTIN, Jr.). The Physiological Effects of Severe and Protracted Muscular Exercise; with tipecial Relcrence to its Inflaenoe npon the Excre- tion of Nitrogen. 12mp. Ulolh, $1.00,
3
FLINT (AtlSTiy. Jh.). The S<Mir«e of MiiMutar Power. Afv-umt'iiU tad Ooa* (Jdwook drawn frara ObMrvattoo np<ia tli« lluriiaii SiiliJ«ci itDiUr CuodiUan* ol ]to*t and of Muooular Ex«ralw. ISmo. Clolb, tl.iKl.
F14NT (AUirriN, Jr.). PbjaloloKy of Uaii. D«^)[B«d lo re|ir«MBt 111* Eilil- iogSlatoof Flijni>loai«il8cHiiMa»a|iplMd U> Uw PaDcliunaof Iho Iliunna Hndy. CoRipl«t« in S vol*., tlva. I'«r vol., eiolh. |4Jl>; abaop, fa.DO. *,* Vota. 1 >oi) 11 can be liad in diitli an'l ulit^p tiiiidin]! ; Vol. Ill in alit^p onlf. Tol. IV Is mt |>r<MDt out of print.
FUMT (ADSTIN, Jr.). UbhiuI of Cbominl Eiuniauiou of the Urine III DIlMii; villi Uriel Direction* fur tlia KxoinlDadon of tlw roost Com nou TaHMlM of llrinarr Calculi. ICevWd «ditloii. Uino. Ooth, $l.0<>.
I-'USTER (FRANK P.). IllgalniUd Eii<'7duf>icJi« Uedlcal Dlviioiiar; : lhln< » IHutionarT o{ Iba Tecbnini T«rtiia ni>«J hj Wrilara ixi Mnlivino ani) lti« Collalvrnl .'^cifiiroi in the l^tin, EnglUli, FroitcK, aixl (irmitn ljuiKiia|t«a. Th« work i.on«i>t> of Four Volnmvn, and i* hiIiI la Part*; TtirM' Pari* 10 a VolaiBO. {Sold #nfy by nib*eriplion,i
FOSI'ER (FKANK P.). A KcfrrcncrUo'ik of Prw'ti.al TherapMlica, bj tarluu* writers. In Two Vulacnc^. Eilitvd liy Frank P. Fo>l«r, H. D^ EdlMf at TIk- N«»r York U«(licnl Joiironl. Ctotli. i& >V ; tfacep, t«M9; lialf morocco. t<.5(i, <'aoh vutume. (.SdM ottlp Ay mbterij'tic*.)
FOtlRNlER (ALFRED). Svpbllia aixl UarrlaM Tran«lal«l b? P. Albwi Morrow. U. D. 8vo. Ulotfa, $S.OD; Bti««]>, fSM.
FKIKDLAN'liKK (CAUL). Tb« V-* of il.o HW<3M0|)« In Clnictl and Patbo- Ii>i(ic«l Euminnlitx)*. Hecood tolilion, «nlnn{«] and inprovod. with ■ Uliroiuulilliufiruph Plui«. Trnn<liit(4l, »itb lh« ponniaMOU of tli« Kulbor, by Henry C. tVw, M. D. Stv. CU.lli. f 1.00.
CUCIIS (ERNEST). Tcxt-ltuok of Oi-Mbalniolofcy. By I>t. Krn«M Fuolu, Proftwor of Oiihtlialniolofcv iu tlic I'liivcraity of Vienna. With 178 Wood- cola, Aolhomcd iraniilalioo froni the Mooud ^nlar^ed and linproTcd Ger- I edition, by A. Duan«, U. I>. Clulb, in.Uii; eUvtp. $0.00.
QARMANY (JASPER J.I. Op6raiit« Miiriwry on the Cadavff. Wilb Ttro Color»d Diairraiiia »bowlDg Ibe Collawral Circalatlon after IJ^turM of Arteripa of .\rni, Abdoinm. and Lowor Extrvmily. Stnall 8*0. Clolb, 9S.00.
UERSTER (ARI'AI) <!,). Tb» Rnl«> of Amtptio anil Antbcf>(lc Sursory. A Praotitwl TrMiliM f»r (lifi r«e of t*tudeot* and lUo (ieiMtral PnudtloMr. UlnatrM«sl wilb uwr two liundro) 1I110 En|:ravitt)!B. 8vo. Clolb, fO.OO; ifa««1S tS.DO.
UIBSON-RrsSELL. Ph>MPaI Dlagoofis: A Cable to Uptbod>of CMsImI la- *«atifntion. Uy O. A.Ulbf^in, M. I>.. ad4 ffltUaoi Riiawll. )l. l>. H'itb lot llIiMtratioii*. I4mn. (STiii>ii.vi^'.>iR>ini.) Clolb, |d. 00.
HOrLET (JOHN W. S.). IHmmmoI U.o TrlMry AppBratn^ Part L Pbla*. maaie Afle«tion*. Hoine n Serira of Tw«'lvi> [.•■cturf* dolircrvd ilarlDfftiM aotnnifi of ISSI. With mi Addrnduin on RplaniKW ttt Drtne from no- ■Ulle Obatmetion in fcldcrly .M«o, Clolb. |I.M.
GROSS rSAUUF.L MfX \ PnoUral TrMliw on Tnmon of tke UUBiaaiT UUnd. Illii*trat*d. Sro. ClolK $3.ni>.
ORrBER (JOSEF). A T«i:-Book ..f ilio hWoFH-- »r ibe Ear. Trvndalwd fraiB Ibe *fyM>tii1 (li'tiunn nlittim l>v >Tipoial pcrisMslon of tlia aiitbor. and •■lllvd by l%d<>'iir.l Uw. M. I>., mid CoWman Jewrit, U. I>. With IAS llliu- tratiiKia and 70 C<>)i>rv<l Ki^'irv* tin Two LitbograpMo Ptatirm 8vo. Olotli. |4.ftO : «litte]>, $1.M.
a^KUOKt) (V, A.). A TmtiM on DiNnw Of tli« Karvom Bjttaa. Vltb tbft OoUamwatlon of Orawie Vi Hammond, K. D, WttJ^ono hiadnd and okhteen inaatrattoDS. Sktk tdUn, with comodoBB imil addillmu. iwn. (Ml),$5.00; aliaep,t6.00.
HAMMOND (W. A.). A Treatbs on Iiuanitjr, tn Itt Maffloal BdaUoBi. 8*0. Olotb, 95.00; ibnp, |8.00.
HAMMOND (W. A.). Olinioal Leetaraa on DlaiMna of tha Nanooi Qraton. DoliTDred at Beltenio Hospital Mo^oal Ooll^. Edltod hj T. M. K. Oroaa, M. D. Bto. Oloth, $8.60.
HIBT (LUDWIG). The Diseae^B of the Nervous S^steiii. A Teit-liooh for Pbjridana and Btodcnta. Transkleil, witli permission of the AiithiT, by AtignirtHooh, M.D,, aasiateil by Fnink R. Smiih, A.M. (Cantab.). M. D., Aaaittant Phjdriana to the JoIids Hopkins Tlo^pital. With on lotroditv- lion hj William Osier, M. D., F. K. V. P., Professor of Medicine in the Jobna Hunkins Dnivt-rsItT, and Pb^Bicinn-io-Chiel' to the John^ Hopkins HdaiiitaJ, BuMmore. 8to, 671 pBgea. With 1T8 lllastrations. Clotb, $.1.00 ; sheep,
'HOFFHANN-ETLTZaCANH. Aaal^U of tbo [Trioe, v^ Sp«dal Batonn to DiaesMB of tha ITrinarj Apparataa. Bj M. B. HoffnMm, Frofcaaor in the Uulfanltj of Qrita, and S. UHanun, Tatar in tha UalTWii^ of Tienoa. TIM aAllM, miMl ui tUMftL Sro, Olott, >9.0b.
HOLT (L. EMUETT). Tha DiMBsn of Tofanor and Childhood. Bro. Oloth, 9«.00 ; aheep, $7.00 ; half moraooo, |7.60. (Sold tnlf ty mOKriptiom.)
HOLT (L. EMMETT). The Oara aod Faediog of Ohadren. A Catoobiam for the Uie of Motbera and Ohlldran'a Nnrara, Iflmo. Goth, SO eeitta,
HOWE (JOBEPB W.). Emei^ndei, and how to treat tfaem. Foortb editioo, reiised. 8vo. Clotb, 99.S0.
HOWE (JOSEPH W.). The Breath, and the Diaeasea nbioh give it a Fetid Odor. Witb Direotions for Treatmeni:. Hecead cdHleB, revised and corrected. 12mo. Olotb, tl.OO.
eOEPPE (FERDINAND). Tbe Uetbode of Bacteriological Inveatigation. Written at tbe reqneat of Dr. Robert Eoob. Tranalated bj Hermana H. Biggs, M. D. Illastrated. 8vo. Oloth, fS.GO.
JAOOOUD (S.). The Curability and Treatment of Pulmonary PhtbUis. Trana- lated and edited by Montagu Labbook, H. D. Svo. Oloth, |t.O0.
KEYES (E. L.). A Practical Treatise oa Genito-Urinary Diseasea, inclading Syphilis. Being a new edition of a work with the aame title by Van Baren and EeyeB. Almost entirely rewritten. Witli Illnstratione. Sto. Olotb, $S.OO; sheep, tS.OO.
EETES (E. L.). The Tonic Treatment of Syphilia, including Looal Treatment of Lesions. 8eMBd edlUto, 8to. Olotb, $1.00.
LEGG (J. WIOKHAM). On the Bile, Jaundice, and Bilious Diaeoaes. Witb Illustrations in Ohromolithograph;. Svo. Clotb, $6.00; aheep, $7.00.
LOBING (EDWARD G.). A Teit-Book of Ophthalmoscopy.
Part 1. Tbe Normal Eye, Dotermination of Refraction, and Diseases of the Media. With 131 JHustratious and 4 Chromolithographs. Svo. Buck- ram. $6.00.
LllRlNO {KDWARIi G.)- A T«xt-Hook of OfilitbnlinoMOpr.
Pan II. IiWsM-^ i>l ilin ItplJna, Optic Nrrv«, ud Choroid: tbeir Vuli> (^« ottd Oiinplioationii. Tliv iiiaiiaMTipl <>l llii* trolnmr, whkb ihe aathor HnNbvd jiisl |>ri<ir to liii ilrAtb. Iiu lw«n thoraaff My edited antl rsTiaei] bj I'. B. Luriuji, M. U., of WaaliingUw, D. <X, vid U bow ImwmI in lli« «aiiie t'ljlu ai tlie Drat valaaic rroftiMly UluMnud. Put ]l. baoknm, f^.OO. Two Parta, buckniu, 110.00.
LUSK (WILLIAM T). Tb« ScImm sikJ Art of Mldwlfwr. V||b 94< llliiatra- Uoiia. I'Mrtli Mllt«a, rrilttd and faUnpA. 8to. Ctirth. $0.00; abtvp, tS.OO.
UAKCY (lll^NKY O.). T)ie Aontotii; m<l Sureir^l Ticatwi-nt of lUrsLa. 4to, witti nbixit alil7 fall-pngo llftllvl;|i« and LltljO(;r«|iliic KeprKxIiKiiitifiB from tlt9 Ulil Uaatcra, and nnnteroa* lilaslratkmii iu ih« Teil, (SrU «nlf
MATHEWS (JOSEPH U.). A TreUUe on DlaeMfa of tbe B«rliiiii. Aon*. and ^igcnoiil FI«xaro, Hvn, WItK *\x OliroraollthoKranha, juiil IMnatra- tliiD* lu the tvxu SrtMd r^ltlM. {S^d mljf ly lU^HptUn.)
UILLR (WESLEY). A Tvit-Hook a( Animal VUjtMogj. wHh Inlnxliietor; ObaplM* on (ientral Hiologf uitl a full TreMOMBt i^ RapriMlBCtlMi for 0tM«iU of Honian and Oo(ii]Mmive HadMiiew Wu. With BD6 Iltsitn- lian*. CloU), tS.OO; stieep, fl.OO.
HILLS (WKSLEY). A T»l-BM>k of Compniniive l>bTrii>|pirr. For SndaBia and PrBctitioom «( VetvrlDarj- MmIIoIbo. Soutll Svo, (^^olll, $8.00.
MUKKOVr' (PKIN'Ce A.). A Ajiu>m of (lenilo- Urinary DI*«mm, HrpIitMoffv, and Ilcnnulolog;. Bv ywioiM AutlK>n. Id Three Volume*, lieauliAiliv Uttturai«l. VuJ. I. UenlhKBiiBBrjr Dlteatw^ Vol 11. iffiibllographr. Vol. III. I)ennBUil..|ir. (StIJ »»tg if ni*erlftta».)
THE NEW YOItK MEDICAL JODRSAL (Weekly). E<lited l.j Frank P. Fo««r, H. D. TertDt, $J(.OI> per aaoDPn. BiattlOi Caae*. ctotb, 60 centa each.
"Seir-Rlndcr" (Uim U uMd for umporary btBillng only), 90 centi^ OnuAL iKbsx.rrom Apr4l,l8U,toJtiBo, l8;S(t$Tala.). 8ro. Cloth, 10 eta.
NIEMEY'ER (FEMX VOX). A Text-Book of PrM)tl«Bl Ifedkla*, with partlon- lar rcfercoca to PItTiioIoify noi) rmholnnical Anatomy, OoBtatnlng nil Ibi Bntbor'a Additiunii aud Kwii'iDiis in tli« eifthth aail laet Oernu etillMk. Traaatattd by Ue»nt« II. llDoipbruya. M. U., and Cbarl«B E. Rarkl^y, IL P. Irol*. Bro. Cloth. )».00; ilieep, ttl.OO.
IflGUTINOALE (FIX>RENCE>. Note* on NnrMng. lino. CSolh, 70 cent*.
OSLER (WILI.IA M). Leolore* on Aofint Pertorii and AIIM Sutei^ Smnll Bvo. lUiialntiMl. Clotk, |l JO.
OSLER (VILLIAM). Ixetnrt* imi the DlaicBoehi ot Abdonlnal Tamon, Small Svn. lllnUmtriL OUith, $I.AO.
08I.KR (WILLIAM), The Prinnple* nnd Pr»rti«e of HodloiBe. DeeiKoed for tl>« t;*n of rrnrtiiionor* nnd Htodrnl* »r Medirioe. fcnK (dlUaa, retlxd aU nlanifd. Clolh, «5.»l ; tbrep, tS.&O ; lialf moroccO, $7.00. {S«U tmlp
PELLEW (0. E.). A Uanaal ot Practical Uedlcd a>«mUlry. IIbio. With inuatratlon*. Cloth, $1.00.
•
e
PnELPS (CHARLES). Tnninetic lojaries of iht Brain aod its Uembranes. With a Special Sta<l; of Piatol-Sbot Woanda of ibe Head id tbeir Medico- Legal and Snrftical Relations. 8vo, 6S9 pase». With fortj-nioe lUnstr«- tioDS. Clotb, $5.00. {Sold only (y tubteription.)
PIFPABD (DENRT G.). A Practical Treatjae od Diseases of tbe Skin. By Hear; 6. PifTard, A. M., M. O., bmUM hj Robert U. Fuller, M. D. With flft; fbll-page Original Plate* ud thirt;-three Illiutrationa in the Text. 4to. {SM only by Mt&fcrtptiM.)
POMEROY (OREN B,). Tbe Diagoori* and Treatment of Diieaaes of the Ear. With One Honclred lIlnatratioDB. NetMi etllUa, revised and enlarged. 8to. Olotb, (8.00.
POORE (O.T.). Onteotomj and OBteoolosls, for tbe Correction of Deformitier of tba Lower Limb*. GO lUnBiration*. 6to. Clotb, $2.S0.
QTIAIN (RlCnARD). A Dictionarj of Uedicine, inclnding General Pathologj, General Therapeo tic*, H^ene, and tbe Diseases peouliar to Women and Children. By Various Writers. Edit«d by Sir Riobard QnatD, Bart., H. D., LL. D., eta Assisted by Frederick 1 humas Boberts, M. D., B. Sc., and J. Hit«hell Brnoe, U. A., U. D. With an American Appendix by Bamnet Treat Armstrong, Ph. D., M. D. In two Tolumes. {Sold only by luiteription.)
RANNEY (AMBROSE L.). Applied Anatomy of tbe Nervous System, being ■ Study of this Portion of tbe Haman Body from a Standpoint of its General Interest and Practical Utility, designed for Cse as a Text-Book and as a Work of Reference. Sewi edttiM, reTtoei ut NlUKCd. Profnsely [[Instnited. Svo. Cloth, |S.OO; sheep, $6.00.
ROBINSON (A. R.). A Manual of Dermatology. Revised and corrected. 6vo. Olotb, »6.00.
BOSOOE-SCHORLEMMER. Treatise on Cbemistrj. Vol. 1. Non-Metallic Elements. 9vo. Cioib, $5.00. Vol. 2. Part I. Metals. 8to. Cloth, $3.00. Vol. 2. Part 11. Metals. 8vo. Cloth, $3.00.
Vol. 3. Part I. The Chemistry ot the Hydrocarbons snd their Deri.-utivei'. 8vo. Clotb, $6.00.
To). 3. Part II. TbeChetuistrjof the Hydrocarbons sod their DerivaiiveB.
8io. Cloth, $5.00. Vol. 8. Partlll. The Chemistry of tbe Hvdroearbons and their Derivu-
tivBB. 8vo. Clotb, $3.00. Vol. 8. Part IV. The Chemistry of the Hydrocarbons and t'loir Derivn-
tives. 8vo. Cloth, $3.00. Vol. S, Part V. The Chemittry of the Hydrooarbons and their Ueriva-
lives. 8vo. Clotii, $3.00.
ROSENTHAL (1.). General Phjainlosy of Musclesiind Nerves. With 75 Wood- cuts. 12mo. Clotb, $1.50.
8A YRE (LEWIS A.). Practical Manual of tlie Treatment of Club-Fout. Fenrtk edlUei, eaJineil aad terrettN. 12mu. Cloth, $1.25.
8ATRE (LEWIS A.). I-ectures on Orthopedic Surgery and Diseases of the Joints, delivered at Bellevne lIo»pita! Medical College. New cdltlMi, illus- trated with »ii Engravings on Wood. 8vo. Clotb, $5.00 ; sheep, $G.OO.
SCUULTZE (B. S.). TLo PalliotO);? and TreeuacDi of UhplxMBnU ol ll>* llleru*. TrstteUttd from ih« tioriiian b; JatiiMoii J. llwnB, N. A., el«.; ajul edil«l by Aitliiir V. Mmciiii, M. ti., «lr. With one buixImJ and imeutj lUtimriilioni'. Dvo. Clotli, (8.30.
SHIELD (A. MAl{UAr>ITKK). »atg\eiii Anau-wj tor titndcDta. JZno. (MroKXTH' Suuu.) Cloili. tl.Tlk
SHOEMAKKK (JOHN V.). A T«)i-l)o»k uf (>i>r»vo of lU fiklo. Bli UhrotnuliihoLTaiili* aiid nuiiiiTtiun KngraTing*. Tlijnl nliUoii, rerlsetl iu>il enlitrgciL t>vu. I'lotb, tS.UD; thetf, t^.OO.
mUVSOS (JAUESY.). ScUctixl Work*: AnMthm.u. DiMuei ol WonvD. 3 voU. 8vi>. Per vt>lam«, clotli. $8.00; nboep, $4.00.
SIUK (J. UAlCIUSj. Tbe f^tory <>1 no IJrc. &lil*d Iijr liU Sou, U. llan«D. tsiiu*. it. If. Willi Portnut. laniu. Cloib, (l.&U.
aKEN£ (AI.EXA.N]>EK J. 0.). A T*il-Uook on Um IHmmc* of Waa,«it. l)ltMtrat«<i witb two liundrod ui<l tltly-laur lllimtratkiat, of wbicit u«* liunitrcd aod nixtj-livo eru uri^lual, hhJ uioe rhramaiitbagraiiba, Herooid mUImmi. 8vu. (.ieU okI]/ bf lubterijrtioii.t
3KENr. (AI.IuXANDI:K .1. O. Ifvdiual G^necoliM?. A TfMtlM on U.« UiaeaMtt of Wotii^ii Iruin tbo &uoJ[>oiBt ul Ui« Vhrtioian. Vi-i>. With
UlllltlrBllUDB. Cluth, $&.O0.
8T£INE[t <JOUANXV. Compaoilliim orui.lldreb'a OiMaM*. A llaiid-thK-k (or rraclltioMn and Stod«nla. TranslaliKl trum ihit •ocuad UonnaB editkMi. bj LawMMi Talc 8to. Clnth, $8.Au ; (Ji««>p, $4.A<),
8TEVEKS (OEOItOE T.) Funrtluiial Nervou* Dia«eM»: Tbsir CauM* anil ibeir Traainiont. Mnixrir for tli« CoiKWraaof 1081-1^83. Ai:ail#iiil» liajti d« M4d«ci&« do ltdjiiquo. Willi a HvpidaniMl, on ilia Aiiumiliv* iri He- ryactioBaiKl A(«i>Diiuiidati<to i>f tlie Ejt, andol ibetlmUr MumIc*. 8mall DtO. Wttb UK l'bulo|;ra|>liic PlalM nliO larira IlluslntiKU. Chili, tS.blK
STONE (K. KItENOII). Clwuentatfr Uodcra MoliiiiK-. iacNidlii( Piiix-ipln u( Palboluj.7 and ot TliMvpeatloa, witb taaiij' IVfiil Memoranda aud ^'alnabla Tat)l«« i>( Ktffrr«iiL'(>. Aooomjianled hj fockvl F«vrr Lliarla. I>«al«ii«d for Ui« (.'lu d Siiid«iit» and I'racUtlvner* ul M«<lk-in«. la irall«(-bow form. • lib jiockolH oD each eoiar for Ifemoranda, Tecnperatora Charts ale* Kuan, tork, t^ AO.
STRECKF.R (ADOU'II). Shi>ft Ti-xi-ltook q( OrRaiiii; Cbwniairy. Bj Dr. Joliannr* WlaliMiiiia. Trnti»lat«d and r<]|[«d, with ExIvimI** AdililiiMii^ b* W. U. llo>lf;kiJi»uti Hud A. J. Urerotiwajr. 6iOl Clolb. $a.Oa
SntCUPELI. (ADnT.PII). A Taxt-Bot^ of Mfdk.-iti«^ ri>r Stiidaat* and Trac- litioiwrs. Tr^iialntiMl, l>v i.vrmiMoti. from lb« *>aili (iuraaJD cdltlua iij Hcrmaii K. Vickrrjt, A. B.. M. )>., iBKmfitir iu Cliiiirnl ModMnc, Uar- Tiril Ui-ilit^ itehool, etr., and Pliilip Cvumlin Kiia|>|i. l'li;ni(4iB toUol* ratMiUlA wiUi DLH««ea oflbu Nvrvonn Sju«ii), livMvtt City llaa|>ltal, «(c With E4Utor{al Not«a bj Fmlorick l\ tUiattnck. A. U., H. If., Jackton E'ri>- faaaor of Ullnloal Uedliriii*. Itiu van) 3J«Jical School, pU. 8«ooim1 Amavicaii (dUioo. WiUi 111 lllmtiration*. Sto, 961 pacaa. (Tlotb, M-00; •been, 17.00,
THAYER (WIU.IAU HYDNKY). Lcaurt* on tli* Ualarial Fema. With iLiMC«oB Clurl* HDd ihrcv Litbograpbh) Plaloa «ho«bif tbe Panuilo of ToniNB, Onotidiao, aiKl .EHlivu-AuUBinal Fevora, Sanfll 8r», USA lutcctL Cloth, W.00. '^^
TBOJIAB JL flAnijAEn).
TBOMFBCnr (W. GIUCAKJ. ftaalfcj PMilK wllh
TBCniSOV (I. AKIBCB).^ OidfaMa tf ZBBla^^ WU Oftrtj^n
TILLMAHire (HXHXAIO). A Ttet-Book of 8«|nt. V«l. L TteMi.
BBr(M7 MS wugluM FlAafa0> ftio. ,
|tat^-«M UartratiaM. TJoirtai lyJoto B^»rfc M.D- mat B«Ai»h T^TDtai^ M.D. TU. II. BiflMranRnx via l£ ksini mi MWtiw UhMbalku. TrwJMri bj Ba^taidB T. TfHoa, 11.1)1. KiA
OLTZMASN (BOBKBI). ftwia, or Ph ia O* Cita^ «d fa _ _ _ TnMbMl^P«BMaa,VrDr.iri)iarB.PIttt. Ukwk OleA,«Lao.
TAV BDBEK (W. H.). I— law ^on Mumm of At Baatw. — d Oc &«^ fM7 of th> L»w«r Bvwcl, Mhcnd >t Bdton* Boalullbdfaa] CbDat. fclilllW,nHitM*i^Wpi. Bra. Olotk, «UN}; riNap, ILOO.
VAH BUBEK (W. H.). Lmlww-o A* PrfMiplM nd PnotlM of Smmr. IMInndaBdIvrMHMpltdlMUOoUtca. Edtted br Lawto A. 8ll» ■OD,]LD. Bto. OIoO, tkOS; dwip, tB.00.
VOGEL (A.). A Pnctieal Tr««tiM on the I>tMa«ea of ChUdreo. Tmialatad and edited b; H. Raphul, 1L1>. ThM 1m»Im frNi the i%fen Strmm («- UN, RTtnl ■■< Mlut*^ Dliutrated b; nz Utbo^npfaio Pktw. 8*d. aoth, t4J>0 ; «he«p, 16.50.
VON ZEI8SL (DERUANN). Outlines of the Patholog? and Treatment of g^philis and Allied Venereal Diaeaaea. SccMd ctfllaa, reviaed t^ ilaiiml)- ian von ZelM. Anthorized edition. Tranilsted, with ^otea, bj B. ha- pliael, H. D. Svo. Oloth, fi-OO; sheep, $0.00.
WEBBER (8. ti.). A Treatise on Netroos Diaeaaes: Their Symptoms and Traatment. A Text-Book for Stodenta and Practitiunara. 8vo. ci(^, (B.OO.
WEEKa-SHAW (CLAKA B.). A Text-Book uf ^larfdog. For the Dae of TnuDiDg-Sohools, Families, and PrJTate Stadents. Hecond edition, rvTieed nnd eola^ed. 19ido. With Illustrations, Qoeations for Beriew and Ex- amioation, and VooabnlaiT of Medical Teniia. ISino. Cloth, %l.7S.
WELLS (T. SPENCEB). DiiraxM of the Overiea. 8vo. Cloth, $4.60.
WOKCESTEB (A.). Honthl; KoraiDg. Setairi edldaa, retlied. Oloth, $1.38.
WTBTH {JOHN A.). A Tert-Book on Sargerj: General, Operati»e, and Ha- ehanlcal. Frofnaelj iUnatrated. lUH e4ltt««, ntImA ni Wlarged. Sto. ^Sfl4 mlf If tuiMi^f van,)
LANE MEDICAL UBRARY
To avoid fine, this book should be returned on or before the date lut itamped below.
|
H67h Xhe diseases or ztie i loU9 nttr^ous systeui. | |
||
|
Hua |
MTE !«■ --I |
|
|
t |
||
|
I |
||
|
\ |
||
|
r |
||
|
A |
||
|
_^ |
||
|
__^M |
||
|
:j^M |
||
|
;^^M |
||
|
/ |
^^H |
|
|
/ |
1 |
|
|
y |
||
|
/^ |
||
|
X |
||
|
y |
||
i
.'A
1
1 I I
1