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A   TREATISE  ON   THE  DISEASES  OF  THE 
NERVOTTS    SYSTEM. 


A    TEEATISE 


<» 


THE    DISEASES 


DF  THB 


NERVOUS    SYSTEM. 


•  •— .  •. 


JAMES     ROSS,    M.D., 

nmiB  or  ma  botal  oolleox  op  pbtsiouxb,  iahdoi  ; 

ABBlfiTAKT     PBTStClAK     TO    THK     HANCUCRIB     KOTAL    DTFIBIUIT; 

OOITBULTIVQ  FHTaiOIAK  TO  THB  KAXOataUB 

SOOTHKBH  HOartTAL. 


ILLUSTRATED    WITH  IITHOORAPBS,    PHOTOOJUPSS,  AND 
TWO  nOSDRED   AND  EIQHTY    WOODCUTS. 


Volume  II. 


NEW    YORK: 
WILLIAM     WOOD     AND     CO. 


I  SSI. 

3 


T?8Z. 

V.  Z.  c^l^!fP'W^  LIBRARY 

I  S8  I  2?5°''°  UNIVERSITY 

MfOICAL  CENTER 

STANFORD,  CALIF.  94305 


CONTENTS    OF    VOLUME    II. 


BOOK  II. 

SPECIAL  PATHOLOGY  OF  THE  NERVOUS  SYSTEM  (Cohtisued). 

Paut  III. 

DISEASES   OF    THE   SPINAL   COED    AND    MEDULLA 
OBLONGATA. 

PIOI. 

Chapter    T.  Anatomical  a>'D  Physiolooical  Introddctiok    ...        3 
Chapter  IL  Morbid   Anatomy    and    Clabsification    of  the 

DiBEAHEa    OF     THE    SPIMAL     CoBD     AND     UeDCLLA 

Oblongata. 

(I.)  Morbiil  Anatomy     *       64 

fll.)  Classification       100 

Chapter  IIL   System    Diseases    of   the    Spinal    Cord    and 
Medulla  Oblonuata. 

;i.)  Poliomyeloijathiea, 

\.  Poliomyelitis  Anterior  Acuta  105 

2.  Poliomyelitis  Anterior  Chronica  ...  136 

3.  Progresaivc  Muscular  Atrophy         146 

4.  Primary  Labio-glosso-Lftryugeal  Paralysis  173 

5.  Paeudo-Hypertrophic  Paralysis  ...  186 

Chaiter  IV.   System    Diseaseb    of   the    Spinal    Coed    and 
Medulla  Oblonoata  (fontinued). 
(II,)  Leucomyelopathiea. 

1.  Progressive  Locomotor  Atajy  211 

2.  Sclerosis  of  the  Columns  of  QoU  ...  249 

3.  Sclerosis  of  the  Direct  Cerebellar  Tracts    ...    250 

4.  Latoral  Sclerosia SAl 


VI  TABLB  OP  C0NTBNT8. 

PA 

CHAFTsa  T.    Mixed    Dibbasbs    op    the    Spinal    Cord    and 

USDULLA  ObLOSOATA. 

(I.)  PaxalysiB  Ascendeiis  Acuta            S 

(ii.)  Acute  Diffused  Mjelitis           1 

(in.)  Chrome  Diffused  Myelitis ! 

(IV.)  Myelomalacia      1 

Cbaftbr  VI.  Vascdlab  Disrases  of  the  Spinal  Cord  and 
Medulla  Oblosoata. 
(i.)  Anemia,  Thrombosis,  and  Embolism  of  the  Spinal  Cord 
and  Medulla  Oblongata. 

1.  Anfemia  of  the  Spinal  Cord  ...         ...         ...     > 

2.  AniEmia  of  the  Medulla  Oblongata — Throm- 

bosis and  Embohsm — Necrotic  Softening. 

(ll.)  Hy^iersomia  and  HsBmoirhage  of  the  Spinal  Cord  and 
Medulla  Oblongata. 

1.  Hypenemia  of  the  Spinal  Cord  and  its  Mem- 

branes ...        ...        ... 

2.  Hfemorrbage    into   the    substance    of    the 

Spinal  Cord 

3.  Hypencmia  and  Haemorrhage  of  the  Kledulla 

Oblongata       

Chapter  VII.  Fdmctiohal   and    Secondabt  Diseases   op  the 
Spinal  Cord  and  Meddlla  Oblongata. 

(I.)  Spinal  Irritation      

(n.)  Neurasthenia  Spinalis 

(m.)  Reflex  and  Secondary  Paraplegia 

(iv.)  Saltatory  Spaam  

{v.)  Tonic  Spasms  in  Muscles  capable  of  Voluntary  Movement 

(VI.)  Intermittent  Spinal  Paralysis       

(viL)  Toxic  Spinal  Paralysis 

(Tin.)  Hysterical  Paraplegia  

Chapter  VIII.  Tbaduatic   Diseases,   Tuuoubs,   and   Abnor- 

HAUTIE8     OF    THE     SPINAL    CORD     AND     MeDULLA 

Oblongata. 

(I.)  Wounds  of  the  Spinal  Cord  and  Medulla  OI>longata     . .. 
(lI.)  Slow   Compression  of    the    Spinal   Cord   and    Medulla 
Oblongata 

(HI.)  Hemiplegia  et  Hemiparaplegia  Spinalis        

(IT.)  Concussion  of  the  Spinal  Cord      

(v.)  Tumours  of  the  Spinal  Cord  and  Medulla  Oblongata 


^^^^^P             TABLE  OF  CONTENTS. 

^^H 

^ft  EX.  DuBJUitti  or  TaK  MtMHiuNKH  or  mg  Spikal  CoRb 

MOM.                         ^^^1 

^B               AMD  MBUUMJt   ObLOKOATA. 

^^1 

^Hl)  yoaoul&r  UImvuka  nf  the  Membraiten. 

^^1 

^H                     1.  Uyi^criCtuia  of  the^  Sptiutl  ircmbnuum 
^M                    i.  Mvtiingntl  A]i»|>texy  (HmtMtoiTbMilis)... 

^^M 
^^M 

^■l.)  PacbjrtDcningitu  Spinalis. 

^^M 

^H                     t.  Piu:lij-inralngiti«S]iioaIw  Externa 

^M                    S.  PacIi}7ucuiDgitis  Spitmlia   Intcnia   (Uypci^ 
^B                            tniUiii^a  irt  Hionutrrhngka)            

^^H 

^^M 

^BL>  LejitotiKniii^tLi  StiiiixltH. 

^^1 

^H                     1.  I>itti>ineiiiu)^tiii  Spinalis  AcuU 

^H                     S-  Leptoioeiiingitiit  Spmaliit  Clu«nica  ... 

^^H 

^^M 

^Br.)  Tutnoun  of  tKe  Spin*J  M?iiilinLii«     

^^1 

^■r,)  DefomutiM  ttt  the  Spinttl  McmbnuMM 

^^M 

H                                    Past  IT. 

^M 

■                  DISEASES  OF  TUB  ENCBPHALON. 

^^M 

Bm      I.      ASATOinuLASD  PBmOIOatCAL  IsrBODOCTtOlt    ... 

^^1 

^BB    IJ.      MOBIUD    ASaTOUV     and    CLASariCAJWlt    Q1    TBB 

^1 

^ft                     DtBBABEB  or  TnX  ESCEPIULON. 

^^H 

^H(l,)  Alorljiit  AiiiiU>iuj'  uftliP  Ruwiihalon 

^KB.)  CliMiiAciitioo  vt  tiic  DisooaM  of  tli«  EootpliAloti 

60S                 ^^M 

^■Iv   nL    OcskBAL   CoxarDKiuTiox   or   Focal    DnKjuSB, 

^H 

^B                  ACCOU'IKC  TO  THE  KaTUBB  OP  THE  Lb&IOK. 

^^1 

^B   1.  OaduaioQ  of  tbo  Intncnminl  Vuuwln 

611                   ^^M 

^H                      (o)  UccliuioD  of  tho  Oersbnil  Artorim... 

511                 ^^M 

^1                      (b)  TiuonilxMb  or  the  Cerebral  Sinuses     ... 
^1                    (e)  Ooclasioa  of  the  i.'eTebra]  Okpitbrnn 

5ia            ^^M 

^Bb   it.    Gkhsbal  Coxft[i>KiiAT(oN   or  Focal    Diskaabb, 

^H 

^m^           AocoRbmo  TO  ms  Natduc  or  thb  LKgioM  («m- 

^^H 

H                  liuued). 

^^1 

^1    S.  Intracnujiol  HtenorTliaci:        

^^M 

^1                     (a)  OerDbnU  Hnaorrbagv 

^^^^^            (k)  Haaingeal  Bonorriui^,..        

^^M 
-^^M 

^^^Bi^.       OCKKBAL     CoXHIfEKAtlo::      DP      FoCAL      DlSSAeSS, 

^H 

^^^f         Acc'OBi>t.xo  TO  THE  Katviu:  op  the  Leniox  (ton- 

^^H 

^V                  tinntti). 

^1     3.  ItitrKCBuiutl  Tomoun         

^^M 

till  TABLE  OP  CONTENTS. 

FA 

Chaptbb    VI.     Sfscul    Conbidkbation    of    Focal    Diseases, 

ACCOBDING  TO  THB  LOCAU8ATION  OF  THE  LeSIOS. 

1.  Affections  of  the  PeduDcular  Fibres  and  Internal  Capsule. 

a.  Affections  of  the  Pyramidal  Tract. 

(L)  Hemiplegia S 

(ii.)  HemiBpaam       B 

6.  Affections  of  the  Sensory  Peduncular  Tract. 
Hemiattsestheaia         B 

Chapter  VII.    Special    Conbidbeatios    op    Focal    Diseases, 

ACCOBDIBQ   TO    THE    LoCAUBATIOIt    OF  THE  LeSIOS 

{cotitinued), 

2.  Cortical  Lesions. 

a.  Lesions  in  the  Area  of  the  Middle  Cerebral 

Artery, 
(i.)  Uono8i)a8ins  and  Unilateral  Convul- 
sions        6 

(ii.)  Cortical  Paralyses  and  Monoplegite  ...     S 
(iii.)  Affections    of    Speech    from    Cortical 

Disease  6 

b.  Lesions  in  the  Area  of  the  Posterior  Cere- 

bral Artery        .,,        ...        ...         ...     6 

c.  Lesions  in  the  Area  of  the  Anterior  Cere- 

bral Artery       6 

Chapteb  VIII.    Special    Consideration    of    Focal    Diseases, 

ACCOKDINQ   TO    THE    LOCALISATION  OF  THE   LeSION 

(caHlinited), 

3.  Lesions  of  the  Basal  Ganglia,  External  Cniisulc,   and 

Claustrum. 

(a)  Lesions  of  the  Lenticular  Nucleus 6 

(6)  Lesions  of  the  Caudate  Nucleus  ...  6 

(c)  Lesions  of  the  Optic  Thalamus        6 

(d)  Lesions  of  the  Corpora  Quadrigemina  ...  6 
(«)  Lesions  of   the   Claustrum   and   External 

Capside 6 

(/)  Lesions  of  the  Base  of  the  Skull. 

(i.)  Lesions  of  the  Anterior  Fossa;  of  thi> 

Skull      6 

(ii.)  Lesions  of  the  Middle  Fossa;  of  the 

SkuU      6 

(iii.)  Hiemorrhage  into  the    Lateral  Ven- 
tricles          6 

(iv.)  Tumoura  in  the  neighbourhood  of  the 
Pituitary  Body 6 


TABLE  or  COMTBMTa  IX 

PlOB. 

lAPTBB     IX.      SpXOIAI.      COSSIDBIUTION      or      FOOAL      DlSIABSa, 
AcCOBDntO  TO   THE   LOOAUSATIOIT  OF  THE  LsfllOH 

4.  Lesioas  localised  is  the  Stnicturea  situated  below  the 
Tentorium. 

a,  LeaioDB  in  the  Pons  and  Peduucleaof  the 

Cerebrum  881 

b.  Lesions  in  the  Peduncles  of  the  Cerebellum    870 
e.  LeaioiiB  in  the  Cerebellum 671 


lAPTEB       X.     DiFFDBBD  DISEASES  OP  THE  ENCEFBALOH. 

(i.)  Antemia  and  Hypenemia  of  the  Brain, 

(i)  Antemia  of  the  Brain  88B 

(ii.)  Hfpenemia  of  the  Brain  693 

lAPTSB  XI.     DlFTUSBD     DlBEASBB     OF     THE     EnCBPEALOII     (COTI- 

timud). 
(n.)  Atrophy  and  Hypertrophy  of  the  Brain. 

(i.)  Atrophy  of  the  Brain  703 

(iL)  Hypertrophy  of  the  Brain  706 

lAPTKE    XII.    DlFFCBKD    DISEASES    OP    THE    EnCKPHA1X)N     {con- 

linved). 
(in.)  Shock  and  Concussion. 

(i.)  Shock 710 

(ii.)  Concussion  716 


BAPTBE  XIII.   DlFPUSED     DI8EA8B8     OP   THE    EnCEPHALON    ((»»- 

tinued). 
(it.)  Encephalitis. 

1.  Diffused  or  Oeoeral  Encephalitis      724 

2.  Partial  or  Local  Encephalitis      734 

a.  Acute  Encephalitis  complicating  affections 

of  the  Bonea  of  the  Skull       727 

b.  Acute  Pyeeniic  Encephalitis      728 

c  Encephalitis  around  pre-eziating  Lesions  in 

the  Brain  7S8 

d.  Chronic  Abscess  of  the  Brain 731 


X  TABLE  OF  CONTESTS. 

ChaPTKR   XIV.    biSEASEB  07  THE    MeUBRAN'ES  OF  THE   BbaIN'. 

(l.j  Diseaites  uf  the  Dura  Mater. 

(i.)  Estvroal  PachjiaeiiiDgitui        

(ii.)  Internal  Uromorrhugic  PachTmeniiigitis 

Chapter  XV.  Diseases  of  the  Mehbrasks  of  the  Bhain  (i^oi 
tinned). 

(II.)  Ducaxes  of  the  Pia  Matcr. 

1.  Leiitomeiuiigitis  Infaiitiiuu 

2.  Tu)>crGular  MeiiingitLs      

Chronic  Hjdrocei)halii.s 

3.  Ba:iilar  Meningitis  

4.  MeuingitiH  of  the  Oouvesity  of  the  Brain 

G.  Metoittatic  MeningitiH 

8.  Traumatic  Meningitis  

Part  V. 
DISEASES  OF  THE  ENCEPHALO-SPIXAL  SYSTESI. 

Chapter  I.  Paralvkis  Agitans,  akd  Multiple  Sclkrosis. 

(i.)  Paralyms  Agitana 

(ll.)  Multiple  Sclerosis  

Chaitsr  II.  Chorea,  and  Memeke's  Disease. 

(i.)  Chorea  

(ii.)  Mtinitire'B  Dirwa.se  

Chapter  III.   Epideuic  Csrkmho-kpibal  Mesisgitis,  Tetasls, 

AND  HtDROPHOBIA. 

{[.)  Epidemic  Cere bro-.-ipi mil  Menin^ptis        

(ii.)  Tetanus 

(Ill,)  Hydrophohia  

Chapter  ly.  Htbtebia      

Chai-ter  V.   Catalepsy,  Trance,  Ecstasy,  axd  other  Allied 

COMDITtONf). 

(I.)  Catale[>sy      

(n.)  Trance 

!  (in.)  Eestaay         

(it.)  Somnambulism  and  Hypnutism  


TABLE  OF  CONTENTS.  xi 

CHArnS  VI.   £PILSF8T  AHD  ECLUfTBU. 

(l)  Epilepsy        913 

(n.)  EclAmpeia           946 

Chaftkb  VII.  Toxic,  aitd  Fbbbilb  ahd  Pobt-fbbbilk  Nbrtodb 

DiaOBDEBS. 

(I.)  Alcoholic  Nerrous  Diseases           963 

(II.)  S&turniae  Nen'oua  Diseases 966 

(m.)  Mercuri&l  Nervoua  Diseases       .   ...        901 

(TV.)  Syphilitic  Nervous  Diseases 962 

(v.)  Febrile  and  Post-Febrile  Nervous  Diseases        97B 


BOOK    II. 
iPECIAL  PATHOLOGY  OF  THE  NERVOUS  SYSTEM. 


4  AKATOmCAL  XKD  PHT3IOL0GICAL  INTRODUCTIO 

iimer  surface  of  which  is  oovered  by  a  single  layer] 
Uietial  plates. 

(3)    The  Ilia  inaier  consists   of  an  ©iternal  and 
portion.      The  former  is  composed  of  longitudinal  bu 
connective-tissue  iibreB,  and  its  external  surface  is  co^ 
HD  endotheUal  layer  (Kieia).    The  intenuil  portion,  or  int 

Fio.  loa 


Fli;.  lOD  lAftur  K«r  txA  R«Iihm>.    Tranrreitt  Heetitm  '/  ihe 

upper  dor-M/  rtt/i"'*.  viM  it*  membrma,  — CtoM  oa  lb«  [uurri  .  .  _ 
{A|  lie*  tilt  ■ctictnuiil  (B).  vbicb  U  thr«wii  into  luDiiitudiakl  tMt  Kt 
In  tba  posterior  mbwihnioidkl  bjikm  (the  put  behind  Ute  liganimi 
1i^  (ii.  tba  Hptnm  iHMt-icum  (C)  mav  b«  obwrvMl  in  Ui*  ndddit 
nomerou*  pkrliuoim,  aIhuk  with  tho«uD»r»cliiiMd*l  iiiacn  vUob  tb 
Tb»  »«|iliim  haoninM  ii.utlr  Mtkclivd  to  tba  wubnotd  MUmtXty,  1 
Blireailii  litlrtiLi!yi.<VBrt!i«'iiiiii>iBurtiiC(Mif  tMtDHmhnuw(D).  Tlje*«|iti 
intcttiiLEly  uvv r  Ibe  yna}  alic»l1t  u  tbo  viiip)^  •ubftnohnoiiuil  tiva*  (I 
Bnituroiu  wurkU  <p««Mi.  Two  va^wla  laikf  he  olmrvtil  in  thin  a|n| 
f ,  tba  pottarior  narvo  raota,  mtnoitiidcii  hy  tho  Ri]tiampliii'<i>l*l  tn 
TlM  iraoB  (II  between  ths  iaAltr  mL-iutirMK<«  And  the  iKiittiiu  pcMld 

TUwbu)  depth.  K  ia  th*  Mpnos  brtHrnrii  tbr  [HHitvrioc  Ortrr  nxit*, 
BiRDliHUlai,  Mid  Uw  linitiFatum  dpalii^ulntiiu  :  Iliin  wimca  being 
membmrin  tbroufhoat  toe  riaurc  length  ai  the  cord,  \b«  9\ii»neira 
&»d>  k  itt^riiaiiMmtff  thioiiRb  it  thtn  lhruu]{lx  ui)'  othtr  iwrt  of  thi 
•nbkrftohiioldAl  a[«M>  Aiit«rior  ti>  tbe  lljfunentft  dBnticoJoUk  \,G\,  tl 
(ubtuaclm-uidol  Kpaoo  nuy  be  obacrved  free  tram  mombnac.  H,  II 
Den's  icoU. 

FlO.  101. 


Fin.  101  (From  Key  aad  lUMat)'    l>iaorvm  «j  a  TVanrvn-K  Sirfioa  q/ 


AKATOiaciX  ASD  PHTSTOLOOICAL  INTHODtTCnON. 

■  a  metbwork  of  bundlea  of  conDecdve-tissue  ftbres,  its  inner 
surface  beiog  lined  by  a  layer  of  endothelial  celk  The  pia 
nntOT  coDtains  numerous  blood-vessels,  which  lie  between  the 
ectersal  and  internal  layers,  whence  tbey  penetrate  into  the 
Kibstaace  of  tlie  cord  being  surrouni]ed  by  a  prolongation  of  the 
pial  shtiaih. 

TV  auibaTacknoieUd  titsue  consists  of  a  plexus  of  irabeciUft; 
of  fibrous  coDDeetive  tissue  ensheatbcd  in  endothelium  andcon- 
taiiuag  a  few  elastic  Bbres,  It  forms  a  spongy  ti^ue  between 
Ibo  uaobooidal  and  pial  fiheaths,  and  subdivides  the  subarach- 
noidal space  into  oumcrous  minute  lacuotc.  It  \»  a  prolongation 
of  the  inner  portion  of  the  arachnoid,  and  its  trabecala-  contain 
brjger  and  smaller  bluod-vesaela; 

XAgamentum  denticuiatwin  stretches  like  a  diaphragm 
between  the  arachnoid  and  pial  sheaths  on  each,  side  of  the 
eon),  from  the  foromeD  ovale  magnum  down  to  the  fillum  ter- 
mlnale^  between  tlio  anterior  aud  posterior  uervo  roots.  The 
flubaiBclinoiiJal  space  is  coiiKei{iientty  divided  into  an  anterior 
and  posterior  chamber.  The  ligamentum  deoticnlatiim  consists 
of  tiabecaloi  of  oonnective-titaue  bundles,  the  trabecule  being 
eovered  with  endotheliucn.  The  tistiue  passes  into  the  externa) 
layer  of  the  pia  mater  (Klein). 

laolaliid  conooctivc-tiiauu  trabecular  also  extend  between  the 
dura  mat^and  arachnoid;  they  are  eoabeathod  in  endothelium, 
white  blood-veesels  and  nerves  paes  from  the  one  membrane  to 
the  other.  These  irabcculut  are  most  numerous  in  the  posterior 
partfl  of  the  cord. 

Between  the  dura  mater  and  arachnoid  is  the  subdural,  and 
botwMD  the  umdinoid  and  pia  mater  is  the  subarachnoidal 
lymph  spaoa  Neither  of  these  spaces  form  one  open  and  free 
cavity,  inasmuch  as  numeroas  oonnective-tissae  trabcenloj  pass 
between  tbo  dara  mater  and  arachnoid,  and  betweoo  the  latter 
■ad  pia  mater.  The  two  spaces  do  not,  however,  communicate 
with  one  another. 

The  nerre  roots  receive  a  prolongation  from  both  tbe 
aiachnoidal  and  dural  sheatlis,  and  consequently  the  lymph 
cpaoes  of  the  peripheral  nerves  and  their  ganglia  have  been 
iojeeted  from  the  Bubarachnoidal  and  subdural  spaces  re- 
iptctivdy  ^Key  and  Bet^iat). 


AKlTOinCA.L  AND  PBTSIOLOGICAL  INTRODUCTION. 


m.)-9TBUCTUllB   OF 


THK   8PINAX, 
OBLONGATA. 


OOED  AND 


The  spinal  cord  coDsists  of  a  framework,  with  gre;  aiKT 
niAtt«T  embedded  ia  it. 

§  350.  The /ramework  consints  of  tbe  fullowing  part«T 

(1)  Qmneative-timiu:  Proceamis. — ProcesBes  of  filiroui 
nectivo  tissue  pass  from  the  intima  pim  into  the  ai 
Ji&Bitre,  and  at  difibrcnt  points  of  the  circumfereoce  h 
cord,  where  the;  form  septa,  which  divide  the  white  eoim 
tbo  cord  into  acgmeota.  The'so  pioluDgatioDS  of  tba  i 
pis  cany  blood-vcai&els  into  the  cerU.  ■ 

(2)  AVuropZio. — The  chief  part  of  the  framework  coM 
a  semi-lluid  substance  named   the  ncurvglia-matriii:. 
substance  prewnta  a  granular  aspect  under  certain  rea 
but  \a  homogeneous  in  the  fresh  condition.     Numerous  d 
fibriK  which   auastomoae  with  one  another  in  a  neti 


Flu. 


1.  tlM  dm  atUttt  7.  Uw  uaOiauM,  sad  {Si  U»  pU  lokUr:  4,  tin 
lajer  of  the  nniraslu. 


ANATOXICja   AND  PHYSIOLOGICAL   INTRODUCTION.  7 

ombeddetl  ia  Uiis  rabstancc.  Tbuse  fibriU  have  a  loDgitudioal 
direction,  except  in  the  septa,  where  they  foroo  iraosverao  net- 
works, and  in  the  grey  suhatanoo,  where  Ibuy  oxtend  uniformly 
.all  directions  (Ivlein).  Flat,  brancbed,  nucleated  coDoootive- 
16  corpuscJM  are  found  in  connection  with  the  network  of 
Hid  neuroglia  fibriU  The  neuroglia,  therefore,  is  oompoBeil  of 
neuroglia-matrix,  neurogtia  fibrils,  and  bracched  cells,  the  latter 
bvin^  named  Deiier's  eelU  {Fig.  103). 

rio.  103L 


.    \ 


V 


/ 


Wlf.  103  (nnn  Bait't  AattieuH-    Della't  <kUi. 


IMtAuHv*  6/ At  yeurogtia.—The  nturoglU  U  abiuidatit  io  tb«  fol- 
iMrtng  ptrt*  :— 

(«)  On  the  eztsrnfcl  mrfnet  of  th«  cord,  where  it  fornu  k  ))«ri|>b*rtl 
cruab  bcoeatJi  the  iotinia  pUe,  tb«  latter  being  eosilj  ao]»ntO(l  from  tb« 
fonatf. 

(&)  la  the  MpU  which  paw  brtwooo  difbnoi  aMtioos  of  tho  whit« 
matter  ;  the  t>n"terior  &asan  btnog,  indeed,  odIj  a  Mptum  of  this  kiud 
(KlatD). 

(e)  It  famu  ttis  ground  sabstanoe  of  the  anterior  and  poeteriar  nerve 
raola. 

fit)  A  Ujner  of  oturoslia  of  ooneidcnlilc  tbickooBs  s'lrrounds  tb«  cpi- 
thduU  Ufllitg  of  the  oeutral  canal,  named  the  etntral  irr«y  ntulmu  of 
KSUUtor. 

(f )  A  peculiar  form  of  DenrogUa  U  found  in  the  postariur  portion  of  the 
jioatcrior-sre;  horm  fonolog  the  mibitatUia  gelatinoia  of  Itelaado. 

The  tMVWgUa  ia  always  moro  abandaat  n«*r  tba  grey  nutter  and  in 
Uw  prrliibanl  cniat  tlum  to  the  parts  between  tbera. 


AKATOHICAL  AKD  PHTStOLOQICAI,  IKTBOOCCTIO: 


TIOI^^ 


§  351.  Tk6  grey  wurtiw  occupies  the  central  parts  of  tbe  < 
Id  the  well-kcowD  shape  of  aa  H.   The  medi&a  part  contAina. 
ccDtral  cftnal,  and  tbe  "  ecotrat  grey  ducIcus  "  of  KblUker  ^ 
aDt«rior  ^y  and  white  commisiiurcs  \y'\n%  ia  front  and  the  j 
terior  commtBsure  behind  it.    The  lateral  parts  or  columns  ^ 
BLSt  of  on  anterior,  middle,  and  posterior  part ;  tlie  first  of  i 
repnseotiog  the  anterior,  and   the  last  the  •posterior 
horn;  while  the  middle  portion  on  each  side  of  the  cc 
canal  consists  of  the  vesicular  coluntn  of  Clarke,  and  what 
he  called  tlie  central  column.      The  central  grey  nucleus 
Kblliker  may  indeed  be  regarded  as  a  portion  of  the  c«n^ 
coluiuQ. 

The  grey  matter  consists  of  a  (I)  matrix  of  neuroglia, 
ganglion  cella,  and  (3)  nerve  fibres. 

(1)  The  neitroglla.  of  the  grey  matter  is  similar  to  that' 
the  white.     It  \v>  looner  in  texture  and  more  spongy  in 
central  grey  column  than  in  either  the  anterior  or 
horns,  and  in  tliia  situaUon  it  also  contains  a  relatively 
number  of  Dcitt-r'scclU, 

(2)  The  (faitglion  eeUs  of  the  anterior  horns  are  relatii 
large,  brajiched  cells,  containing  in  seme  aQimals  maaaeaj 
jeliow  pigment  {§  13).  These  cells  are  surrounded  bi 
lympb  upoce,  through  which  the  processes  of  the  cell 
The  gaogliOQ  colls  of  the  posterior  boms  are  much  smaller 
less  branched  tban  those  of  the  anterior  homa.  Some  of  the 
latter  appear  spiodlc-sliapod,  but  each  citremity  is  branched 
into  BeTexal  procoesea.  ^B 

(3)  Tlie  nerve  jihres  of  the  grey  matter  are  of  different  kinda? 
The  great  bulk  of  the  grey  matter  is  composed  of  a  minute  and 
dense  network  of  fine  fibrils,  named  Gerlach's  nerve  network. 
The  nerve  network  surrounding  the  central  grey  nucleus  of 
Kotliker  is  less  dense  tban  in  other  parts.  The  branched  pro> 
cesses  of  the  ganglion  cell  attach  themselves  to  Oerlach's  nenre 
network;  while  the  unbraoched  processes  pass  into  a  medal- 
lated  ncTTc  fibre  of  the  anterior  root.  The  cells  of  the  pos- 
terior horns  are  not  directly  connected  with  any  nerVe  fibrw, 
but  anastomose  with  them  indirectly  through  Qerlacb'a  nerve 
network  (Klein). 


AKATOUICAL  AlTD  PHYSIOLOOICAL   IXTBODUCTION. 


9 


§  332.  Tht  t^Ue  mailer  ia  composed  of  modultated  noire 
6bres,  by  far  tbe  greater  number  being  arraogecl  in  a  longitudinal 
direction.  A  vertical  section  of  the  apioal  cord  is  represented  in 
n^.  lOi,  showing  Uic  loogitudinal  disposition  of  tbe  fibrea  in 
tbe  outerioc  and  lateral  columns.  Each  aervc  Gbro  poasesseB 
aa  axii  cylinder,  and  a  medullary  ahcath,  but  there  is  no  definite 
•videnco  of  tbe  presence  of  a  sheath  of  Schwann,  or  of  nerve 
corpuaclaa,  as  in  tbe  mcdulktod  Bbrcs  of  tbe  cerDbro-spina) 
oerroa  The  ocrrc  fibres  are  ombeddod  in  neuroglia  as  pre- 
TMiuly  described  ;  tb«y  vary  mncb  in  size,  aomd  being  brood, 
•raw  of  medium  size,  while  others  arc  very  fina 


Fio.  lot. 


Jl. 


CM 


r* 


c. 


w?? 


Kg.  101  [Ftwb  Bvnia'i  AnAtiMiu«>,-Fl  AaUfior  ooJonin  ;  Ogk,  Anterior  sr*; 
lUnv  ¥»;  iMntX  ooliumi ;  Ca,  PcaUrior  gnj  ban. 

Tbe  while  matter  also  coulaina  nerve  Bbres  that  hare 
an  oblique  or  hoiixontal  direction.  Tbe  following  may  be 
dtstioguished : — 

())  Tb*  fibna  of  tli«  posterior  roota  pan  into  (be  eny  nutber  of  tbe 
j/ovtmiar  boro«  m  li<>riB«it*l  films.  Then  fibrM  on  aot*riDg  the  cord 
Ipraul  out  Uterall;  in  Hue  form  of  a  fan,  ao  Uut  aa  external  fonciculun,  no 
iaUrnal  fMoieuItu,  osd  a  mediui  portion  may  be  ilutiDguulmd.  Tli« 
Afccm  of  tbm  rxUTTial/iuciettlut  -wiuA  farwmida  round  tho  oxtonul  nurgio 
al  tb*  fomttrioi  bora,  uid  »X  I«ut  «ome  of  them  pa»  forwards  through 
tba  anterior  floranUaaure,  a  few  orcn  puidng  betvMO  ths  longitadinal 
fibiM  of  tJw  ut«iior  fwinmn,  m  u  to  nacb  the  intenul  and  ant«rior 
gnm^a  of  guglioQ  oeUa  of  ths  aaterior  g^vj  boru  of  the  oppont*  atdt 


ANATOMICAL  AND  PHYSIOI-OGICAL  INTRODUCTJOH. 


(Fiy.  134,  p').  TliB  fibres  of  tbo  inUntal  /iwejcKfu*  pau  betweoo  I 
InDgitiiiUtial  fibnsfi  <if  the  [)CHt«rJ<>r  Taoi-raao  to  )^iii  tlio  [KMt«Hor  bt 
(/^c.7.  l^-i.  pf ).  SoiDo  cf  iliom  tiioD  wind  round  tbo  TosicitUr  column 
CUrke,  but  it  m  tiat  kitown  whether  they  uv  coDauctod  with  the  cells 
Uikt  oolums,  A  fvnr  of  tbeao  ftbras  appear  to  paw  bohiad  the  vestciL 
calumn  of  Clarke  and  to  decuBsate  with  the  correeponding  BbrM  of  t 
oppMit«  Hide  in  the  poeterior  ooaimUaure.  The  wWiaii  porHon  of  tl 
pruttcrior  root  entere  the  nbite  matter  of  the  poaterior  column,  and  i 
fibre*  pMK  for  a  longer  or  ehort«r  diatftuce  iu  a  Ic-agitudiiial  diroctio 
either  upwards  or  downwarda,  before  joluing  the  posterior  grey  honuL 

I  (S)  Th«  ntedullated  nerve  fibres  of  tbe  aQt«ri»r  nerro  root*  p«M  in  I 

oblique  direction  from  the  grey  matter  ot  the  auterior  boTOB  through  tl 

I        white  matter. 

'  (3)  The  EDtcrior  commimurs  in  uud  by  Qerlaab  to  be  oompoaed 

m«dullatMl  uervo  fibres  that  pu*  from  the  grey  matter  of  the  aittor 
bora  of  one  »ifIo  into  the  whito  mkttrr  of  the  niit«riiir  tract  of  tho  q% 
site  aide.    Someof  thofibns,  homror,  pass  from  tho  anterior  horu  of  i 
aide  to  the  pyramidal  tract  of  tho  opposite  irido,  while  obberai  as 
described,  paiw  from  tho  intertiAl  fasciculus  of  Ui«  poaterior  roots  of 

■  ■r  idde  tti  the  auturior  groy  bom  of  the  opposite  aide. 

^m      (4)  Mediillatud  tiurve  fibrea  emerge  from  the  aides  of  the  grey  mat 
of  the  autorior  boms,  and  after  a  short  oourac  enter  the  white  matter  i 
the  latend  tnwtB  (Klein). 

(5)  NoTo  tibres  emerge  ft-om  tbo  posterior  grey  horns,  and  after 
loiifjirr  i>r  shorter  horizontal  course  eater  the  whito  matter  of  the  poateria 
column  (Gcrlaoh).    It  In  probable  that  tliey  leave  the  pceterior  tract*  ago 
as  the  nerve  (Ifcriw  of  tlie  pufttcrior  ronta  (Klein). 

I  (6)  ribreavmergafrom  tho  cells  of  tho  \'»it.'ul&r  column  of  Clarke,  vbk 

piM  obljiiuely  oiitwiinii  a:nl  iipvfiu'd'i  to  «iit«r  Iho  direct  cerebeUar 
(Flechaig),    Theac  fibrw  f&rm  roaad  bundUsi  at  the  junction  of  the 

I       aabatAnce  and  the  lat«ml  column,   and  are  cut  triuiaversely  in 

'       tootal  Hfrctiona.     Thoeo  bundles  am  rcproMnt^id  in  fi^o.  13-t  to  140 
dark  round  »pot»  near  tho/ormafio  trtic'dans  (fr). 

^m    §  353.  Didrihution  of  the  Veaadt  of  the  Spinal  C/yrdt 
^H  Malidla  ObtovgaUt,  and  Pon«. 

^^     73w  rerfe&m/  artery  is  the  first  and  lnrgl^st  braiioli  "f  the  euhdavti 
artery.    It  ariaea  firom  tho  poatorior  aspect  of  the  trunk,  and  aaaend 
through  the  foramina  in  the  tranaverw)  proccaaea  of  all  tho  ccn'ical  vei 
biv,  except  the  luit.    It  winds  backwards  around  tho  artioulating  ] 
of  the  abloa,  piercen  the  dura  mater,  entcra  tho  nkull  through  the  forame 
magDum,  and  terminates  at  the  tower  border  of  tho  pom*  Varolii  by  uniting* 
with  the  corroaponding  veaeel  of  the  oppoote  side  to  form  the  bofUar  arttry. 
Jlu  batSar  arttiy  runa  forward  in  the  grooro  mi  the  aiuturinr  surface  of 
th«  poaa  VkroU),  and  diridea  at  the  anterior  border  of  the  poua  iuto  two 
t«rmitial  brancbn,  one  to  cither  aide. 


12 


AKATOMICAI.  AKD  PUVSIOLOQICAL  INTBODUCTIO.V. 


7^  taUral  ijtinal  brandui  tnter  tho   iutorvcrtcbml   foramiDA, 
t&ldng  tlio  courao  of  the  roots  of  tha  s[ntiAl  nerces,  nra  dtatribut 
tbo  spiDol  cord  and  vortgbns.     Wbore  tbo  vortebral  artocy  coma 
ths  ortiaiilar  process  of  tha  atlas,  it  givea  ofiT  several  mutaidar  bnac 

Thi  fx/sttricnf  vKnin^ad  arltr'nn  aro  am&U  bmnchas  wbiob  Btlt«r  i 
cnnium  through  the  forumen  mnsuum,  to  be  dlatribated  to  tbs  dn 
caaUir  of  tli*  cerebellar  foaeis,  aud  to  th«  faU  cer«b«UL 

FiOl  100. 


7(11.  106 {After  Durol).    ArUria  <^  Oie  Pon*  aiti  Mti^la. 

1 1',  Auterior  aiiinal  artvry,  the  bulbar 
branch  to. 

2  2*  S',  lofcriiar  utari«a  of  tlio  posa. 

3  3*.  MfdUii  ait*rtM  of  tin  pona. 
4.  batniiar  anvrles  of  (ha  poiUk 
6i  Pcatcriiir    (iniuJ    arlvnia,     nwdian 

bnuulira. 


A,  L*(t  vvrtcbnJ  aa-taty. 

B,  lUailar  aiterr. 

C,  Blidilla  earfWIIu'  artfry. 
T>,  Kap«r)or  ocrabeilar  uti;tf.j 
£,  PotLcfior  GCRfanl  utery. 


AlfATOMtCAI.  AND  PUYSIOLOGICIL  IHTBODUCTIOH. 


13 


71b  oMcrior  ^'nof  arUry  la  a.  small  branch  which  iiiut«a  TJth  Ua 
follow  of  th«  oppoaito  ai»,  oa  Um  frant  of  Uio  moduUa  obloagsta.  The 
artor;  tanaitA  by  Um  odjod  of  Ihcuw  two  vhuqLs  drac«od8  along  the 
Mtltrior  wpoci  of  tbe  apuul  cord,  to  which  it  distnUitw  braocbes,  Mi<t 
n>n)M  the  ooaomenccinent  of  the  anterior  median  artery. 

1^  poitmor  ipimti  artery  wtuda  arouad  the  iMdulla  obloogaU  to 
raach  the  pcwteiior  aaiMct  of  the  cord,  aitd  dosccmbt  on  either  aide  to 
tbe  canda  eqaiaa.  li  comrauniotai  rvrj  fnwl/  with  tha  tqiUtal  bnuiobM 
of  tbe  InterooKtal  and  lumW  arteriea^  and  near  its  origin  Moda  a  hraooh 
apwda  to  tbe  foortb  Tenthcle. 

nU  inferior  «ra6«Uar  arUria  wind  aroQiid  the  upper  port  of  tbe 
tMduIlA  ^loogaU  to  reach  the  nader  aurfooo  of  tbe  cerehoUum,  to  which 
they  are  diibibuted.  Tbe;  paaa  betweoo  the  filnmontB  of  origin  of  tbe 
bjTpoglMMl  nerre  in  their  eourae,  and  auastomoao  with  the  superior 
oerebellar  arteries.  Small  liraucbea  derived  fttim  tbetw  tnmks  paan  to 
the  choroid  plexus  of  the  fonrth  Tentricle. 

Tta.  107. 


<^ 


fiu 


f  r 


rn  Iff  (After  Dtmt).    Dittriiitba  tf  Om  AiUriu  <,t  liu  PU<^  ef  l^  Fimiih 

A  A',  Pcstoior  nnaal  srlerr, 

B  B*.  Ik  wnunkfaa  baaebM. 

CCCtr,  Bawtcaue  of  tbe  ai«diu  artrriu. 

t>  ir,  Cienid  pIsMne  drawn  M  om  m<1«.    (Tvo  or  tliree  artnlce  nuy  be  ten 


to ennse  Inxn  IL) 
HKV  E".  ArtHica  of   tk* 
ewehtHsr  artwy 


leaUTona   IxkUcs  eaaing  from  the  inferior 


14 


AKATOMICAL  AXD  PHTSIOLOCICAL  INTKODnCTIOX. 


Tk*tnaurtnt  brandies  of  Um  buUar  arterj  upplj  Uie  pool. 
Mad  adjacent  porta  of  the  bmo. 

Ttte  mitUtc  cnvfreOnr  artrry  arina  tram  Uie  tniak  of  the 
ita  middle^  It  miu  paraU«l  to  the  tranavcne  bmnehea,  and  paaMa : 
the  middle  jietlaDcIc  to  be  distributed  to  tbc  sntocior  port  of  tlio  i 
•urfooo  of  tbu  oerobellum.  It  gires  off  a  small  branch,  aiviitira  inl 
wUtoh  aoconpanica  the  auditoo"  ■k-tvo  tuto  the  meatus  auditohus  int* 
and  to  tlw  labyrinth  of  the  ear.  The  auditory  broach  U  fioqiwDtli 
riv*d  dirocti;  frain  tbe  baailar. 

Tit  tttperior  eerd/eUar  arifrif*  wind  around  tbeonta  cerebri  on 
vide,  \j\a%  ill  rcUtioa  with  the  fourth  ucrro,  aud  are  diatribat«d  t< 

Fia.  106. 


/^ 


^ 


X. 


Fl9.  10fi[A!kTi!ur,:l). 


Jrteria  o/  the  /\trt«rJor  Pari  ef  lAe  lltdatta  and  t 

CrrtUltum. 


A.  Cbnrrid  pleani.  B,  Choroid  velnm.  C.  Poateriort.  _ 

fonoinK  a  coummniotivii  Ixtwcvn  the  fuurlh  vcntride  uul 
poat«ri«r  ntwracbBDid  tp*ict.  U,  Porteriot  pyrunid. 

t,  lufdliir  oFn-tirllu  artMT. 

2  •',  Arl-r)-  of  ibc  clortiid  ]>It;<u«. 

8  :i  3  3,  Anerii-a  nl  thn  oh»r<ii(l  v^lmo.    Bob*  prM««d  to  tb»  floor  of  | 
fonrtli  v«iitn«ie ;  tliey  tn  cat^tltn'. 

ft,  PoiUrior  tylual  wl^ry, 

4,  tU  MmcdiDg  or  pjnLmidkl  branch. 

T,  Lla  dnveiuling  bruic^ 

6,  Ita  ffiediaa  bntodi. 


ASATOlIICAL  A.VD  PHYSIOIOOICAL  I>"TaODUCnON.  IS 

wiitMx  at  the  oenbdluin  uutomosii^  witli  the  inferior  oersbsUir. 
BrudtM  of  th«  su{>«rit>r  oarvbdlw  arteriee  run  inwsnU  to  tnip})]/  Um 
nlTfl  of  VwuMena  «od  tbe  posterior  put  of  tbo  velum. 

TV  ateending  Mrmol  braneh  of  the  toferior  thyroid  utotr  giTM  off 
oov  or  two  bnnchm  (ipiiml  brawi\e*)  which  eat«r  Iba  iDt«rvertebnU 
tonusink  ftloDg  with  tbo  Mtrtoiil  noma,  uti  Mslrt  ia  suppljrinc  the  bodiM 
of  ti>o  rartebnn  oaA  the  iptDal  cord  unA  its  mmmbrutoa. 

TA'  rpxtuU  bntn^Ku  of  1A4  aortic  int^reMtnl  drturU*  fruter  the  iuler- 
Tartcbn)  fanuaioA  of  the  doraol  region,  and  supply  thu  Teittibroe,  spiual 
(onl,  uul  mcmbnuMe. 

7%«  upMMil  bmncArt  of  tke  Iiuniar,  itK)-(ttm6ar,  and  taleral  tacnil  arttriu 
mter  the  spinal  csdbI  throngh  the  iatwvertebml  foramioa ;  they  are  dia- 
iribut«l  Uka  the  other  spioal  arUries,  and  aoaatooioae  with  Iham. 

g  3di.  The  folIon-iDg  orteriea  are  distributod  to  Uio  medulla 
oblOCgata  aiiii  pons  : — 

1.  Tke  Root  AjnsRiu. — Theee  arteriM  are  direct«l  Utonlly  towatda 
Utk  TV*a  of  the  uervm,  which  th«y  peoetrato  aoar  th«ir  point  of  tmorgence. 
Thcf  aobdivide  into  an  <uc«iuh'nir  branch,  which  is  dirootod  towwda  the 

McUi  of  orijia  of  the  uervea,  and  a  dttetindiny  branoh  wbioh  deee»iida 

lowndi  the  peripherj. 

{•)4^l*rior  Boot  ArtttM  {Fig.  109,  ar). 

f  1]  Um  artenea  of  the  hypoj^loaBal  oerva  ara  ilortvod  from  both 

tliD  anterior  spinal  and  Tertabral  arterida. 
(3)  Tbe  arteriee  of  the  uixth  iKrve  are  dorived  from  tba  baaiiar. 
(3)  Tbe  artvricB  of  tbe  third  imtto  aro  derired  from  tlw  trtuik 

of  tlie  tmulur  near  it*  lerminattou. 

M  foNrof  Bool  ArUriet  {Pi^.  109,  W). 

(1}  The  aiivriea  of  th«  «piDal  aooMoory  nerre  are  derived  from 

tlie  ittrnnor  ovrebaUar  and  vertebml  arteriea. 
(K)  The  artoriM  of   the  pneumogiLrtrio  and  gloeao-phnryneeal 

uurriM  arise  frocn  the  vertebral  art«ry. 

(3)  The  arteries  of  the  auditory,  facial,  aod  portio  intcrmedM 

(nerre  of  Wrisberg)  are  deriroJ  from  the  mrtcbnl  a  little 
before  ite  temiinntiuii,  and  froia  a  hmiich  of  tba  bMUar, 
Braaehea  may  uLmi  deeoeiid  perpendicularly  from  the  middle 
Mrebtllai  artery. 

(4)  The  artery  of  the  trlgvmlnua  is  compuutirely  lar^  and 

oooNtiuil,  and  ia  derived  directly  from  the  iMisilar  about  its 
middlo.  Auobbor  brooch  ia  dcrirod  from  the  midJIo 
cerebellar  artery. 
<5)  The  fourth  nerve,  aa  well  as  the  optic  and  olfactoty  oerrra, 
r«c«ive«  ita  arterial  aupply  from  the  branobea  of  the  otrcie 
of  WilUa. 


ANATOHICU.  AND   PHTSrOLOGrCAl   INTRODUtTIOK. 


17 


8.  AWMBB  or  rBs  Uei>ias  Bju-b£  (f^.  109,  B). 

(a}Bulbtf  iirt<<ri<»derir«<lfri>iDtli«*Dt«rMr«^alartei7(^.  lOOilV 
(6)  Inferior  utonai  of  Uw  poiui  derived  ftora  the  loirer  n»d  of  Ihe 

buiUr  [fil^.  10^  S  2'  2*). 
(e)  ll«djui  aiitriat  of  the  poos,  dvrired  firom  the  trunk  oT  tbe 

l>Matt(f>>.  106,3  3-). 
(d)  Superior  utcnn  ot  Uie  pon^  derived  from  the  superior  end  of 

th»  bwikr  (;^'^.  10«,  4). 

The  tnoexed  dikgrun  [Fiy.  110)  ehowH  that  a  doable  row  of  vesHto 
inter  the  Bapbdl,  Um  tdomU  oq  caoh  aide  of  the  middle  line  enU^nug  at 
lifienot  levela.  A.  rerUea]  aection  of  tbo  ohvarjr  bod;  afcow*  that  tbo 
rtadasalerUie  hilici  in  a  siinilar  macnur;  so  that  the  brarichcei  from 
lie  Ulterior  n>ot  artvrjr  and  the  nrt«i7  of  the  Kapbii  an  nerer  aeeii  in  the 
■ae  boriaootal  koUou  aa  icprawntod  io  Ft^.  100. 

3    Tns  IiATBBAb  Abtskibs  or  tbt:  ManotXA  OiitoxaaTA, 

Id)  Anit'ior  tatt:ral  arUrg  (Ft^.  109,  oJa)  pWHce  into  the  mibetaOM  of 
I       the  medulla  behind  tbo  olirarjr  bodjr.    It  gives  toanchm  to  tbe 
h.  Tke  antnler  bttnal  ertcrr  ef   Ike  nedBlIa  obloanta.      It  icpiiliN 
branebn  to  Ihe  (oniwUo  ntknlMU.  olivwy  lw(l>',  xntninr   inidnia 
of  tba  lateral  coliuna  ta^h  aad  tcrtninMca  ia  brui«htB  to  tbo  birp^ 
(iluMil  awloiM. 
aifa,  Th«    BikMIe  latwal  artery   of  the  awdnlla  ohloanta.      It  mppHM 

■  Ltaachee  ta  tbe  fermaHa  nticmJaru,  the  poaUnor  nucteui  ul  tbe 

latMal    mJwbd  (ftlr),    aad  larminahM    in   cnui«l)M  which  kn  iti*- 
trilioted  to  the  extenftl  ecwnry  anclaat  o(  tbe  faohU  \tfi. 
ptM.  The  inMcrioi  Uicnl  arttvke  of  tbe  UKdulIa  oUongala.    Xber  mpply 
ill*  tMlifnna  bo4i««. 
_',  Cntn)  artery. 

.1  S  y,  BraiMlini  to  tbe  bjpogloBel  and  extmial  Beermotj  fetikl  nnclri, 
my,  U«*UatijHiMtrwrart«rv. 

4  4'  I',  Rnncbee  to  the  ntcmal   acoetey  luiii  ud  pnftiinnfutric 

aadn. 
Kstamal  iKjetcrinr  aittij.     IteuppUce  braacbea  to  tlie  Intemal  divittaa 
ol  tbe  iaferiiv  |Mdanda  of  Um  oenbeUwa  aad  mitifdvni  body. 
lateraal  iniapol  eella  ol  tlie  hjrpoKltMeal  aacieiu. 
Aaleny-lalMal        „  „ 

feeteio-Uteial        „  „ 

■  andose  ^  tbe  latnal  colnma. 
■""*  •>  II 

, ■  portlna  of  the  poeterior  tntdiea  atxMHtle  nadeu. 

K  bIsBal  eBBWiij  laoal  nnciln. 
ff,  Kaleraal  uuivmnf  fecial  nnelcna. 
/.  Fwcu-tiltu  rtilaadn*. 

li.  ColnmiefUolL 

pr.  PHterior  raot-xrae.     Tba  direct  oerelienar  tract  fatnia  a  tliin  bend  lying  ci* 
tnaal  to  tbe  coIuihd  vl  QoU  aad  poeterior  reet-eeae. 
re.  Claval*  Baei«va 
(a,  Triaarnlar  nactaiia 
•t  OUvMTbody. 

pa,  PMnUrMy  bckdy. 
. .  Undfrn  of  the  jiyramtd 
jM,  Kulrai  o(  tbe  tnatana  thit*. 


18 


ANjLTOMICAL  AKD  PHTSIOLOGICAL  ISTRODUCTK 


oliTarylwd^itbe  anterior  lateral  DncleuB,  and  tamiiE 
UiB  groupo  of  {aiiKUou  c«lla  «f  tba  liJi>agU»sal  i 

(6}  Middle  laUral  arttry  {Fig.  lOD,  tnta)  pasBes  into  Lb 

tiM  luedulU  ii)  Front  qS  ibo  rwtifurm  body.  It  gircd  bi 
to  the  |>ost«!rior  latoml  nuclau*,  and  t«riiiinatmb«twMiiUH 
of  oello,  vltich  give  oiigiD  to  Uic  latoral  miicd  itysUiit  oC  a 

(c)  Tii»  potleriar  lateral  arleria  (f'iff.  I  OS ,  j>ia)  suter  th«  aubtti 
tberentifono  kodj  behind  Uiorootoof  origiaof  tb«tiuz«d 
qntcm  of  tiervn. 

4.  Tub  CeKtral  AntElir  {Fig.  109,  c)  of  the  medulU  oUonga) 
oontiriuation  of  the  central  arl«rj  or  Ll:e  Bpiiifll  cord.  It  aubdividi 
internal,  middla,  and  ut«nul  bnuohea  {Ft's-  1W>  3  $'  3"}i  ^bK 
diitribut«d  botveea  th«  groujn  of  uUs  of  the  hypoghiaaal  uucleiu. 

6.  Tbk  UzDtav  PoSTEERlOB  AitTEBT  {Fig.  109,  mp)  entore  th< 
stancse  of  tho  medulla  oblongata  oii  tbn  floor  of  tbe  fourth  v«nLr]cla. 
probably  dsrivod  from  the  choroid  plexua.  ft  ia  tn&inly  dlttribn 
the  froupa  of  cells  which  ^ive  origin  to  tbe  nerrni  of  tbe  lateral 
«jst«m. 

8.  Tub  Sxtebmal  Posterior  AnTSRV  (Fty.  100,  ep)  anteiB  thi| 
atoned  of  tbu  medulla  at  the  juuction  of  the  gre;  sabotaiim  wit 
reatifarm  bodjr. 

PjallO. 


Ft*.  IM  iFrom  H«tiU'»  Aaktomie).    TfrtiW  Strlion  o)  JUfki  oj  0>* 
(Woaffata,  ihaainff  U<  trntrmun  ef  Hit  ntmit. 


4XJIT0MICAL  AND   PUVSI0U10[CAL  UJTBODCCTIOS.         19 

§  355.  Arteries  of  tits  Spinal  Coi-d. 
TIU  anitrior  mtdian  artery  giroi  off  a.  aeries  of  anull  brenohM,  vfaicfa  pan 
bwkvkrds  ia  tin  uit«rior  modiaa  fiwuK,  and  reacli  tbe  aoiUrior  coramui- 
som,  bcnca  Uiom  reneb  v»y  be  called  the  arteries  of  the  anUrior  modian 
fiseure  {fiy.  \\\,»f).  EMhof  tbcdeveewlaoaniohingitlieuiteriorccia- 
miaKin  dirides  into  two  maio  Iranlm,  wbich  enter  the  grey  aulnUnon  of 
tbe  anterior  horna  ;  these  ma;  b«  c*U«d  the  krt«riei  of  the  ftctohor  4ota- 
taimnj9{Fi$.  Ill,  ac). 

Fio.  lit. 


ac 


Wir" 


"TJ. 


/ii 


V, 


vc 


nip" 


A 


*^. 


Anlerior  BWiliaa  artwr. 
^,  AfUfiM  cf  iha  atitarfof  ■•dlaii 
tbaiu  II. 


t,  AaMrtorlniKh. 
RUeaiaabMSt 


■bnaok. 

L  AaiaiMr  tmndk 
r.  UadiaabMBah. 
r.  rMteriur  tmadt. 
J  Pii^iriiw  w«<  arterie*. 

r,  AilariM  of  poitciior  bomt. 
•  lataaaal  aaUridrraot  artrnr. 
M,  Kvtarsal  aatortor  tooV  arlrry 
Sy^  taMraat  and  •atweal  br*scli- 


ar,  AaUro-lakni  btancli, 

4,  AaUder  branefa. 
f.  Median  bnoch. 
r,  PMtcriocWwcli. 
Mr,  Hcdiao  lat«t«l  a«t«t]r. 

ft  B" ,  Aatarior  and  poalerior  liniiahta^ 
pr.  F<Mltfi«i  lalwal  aM«r(««. 
if,  iBtenulpiMtarinrart^ry. 
nfi,  Kxtemal  inateilor  arwrjr. 

01  ArtcfWB  «f  tke  ooUunn  c4  GaU. 
fM^  Ait*tT<<thapMU«ii>«iauDiHar«. 
te,  Tailcalar  ootonn  of  Ctarfce. 
i,  iDternal  Kitaip  of  ovIU. 
«,  Anterior  group. 
Antaro-Ularal  tn^titi. 
;  P4}at«tV'Utenl  gnrap. 
c,  CWetnl  cmuft. 
■,  Uedlauana. 


a 


20         ANATOMICAL  ASB  PnYfilOlOQICAL  ISTHODDCTIC 


The  arltrif  of  th«  awtoriw  WHimtHun  mihtWviits  into 
wbicb,  fmni   tb«ir  posJUon,  aiftj  mpcctit-ely  1m  luuiteil  tba 
{Fiy.  Ill,  1),  m-fiiiMiFig.  HI,  !>,  wid  po«t«Tior  {%.  Ill,  1')  U 
The  Anterior  branch  cunrca  furwordn,  Ktid  in  dintiibuted  totho 
nnd  iiiUsmal  iturlion  af  th«  groy  sulMliLncA ;  th*  nadUii  is  diatrib 
the  lateral  ixirtion  ot  the  antmior  bora,  whilo  the  poeterior  is  i 
bookvMda  to  the  posterior  hem.  ^ 

T^4:  crntral  arf'-ry  alao  givea  off  an  anterior  (/'t'?.  111.  41 
(ft)?.  Ill,  2'^  and  paat«riar  {Fig.  Ill,  fi")  branch,  which  are  dU 
rospecUvol;  to  the  aulvrior,  latdr&I,  and  (xuiUiriur  |iMiioui>  of  t 
tubatanc«.  Th4  tnodiui  bruichu  of  tho  two  maiu  vMMlii^  badd 
pljiog  tho  gnj  mibsfaitcs,  ars  aloo  diatributod  to  the  [)yrainidal 
the  Ubaral  caiumn. 

The  fioataior  tpinal  ioUrji  {F'v/j.  Ill,  pa)  givos  off  branches 
pasa  bj  the  side  of  tho  poxtorior  nioU  tu  «itvr  tho  grejr  substasoi 
poatorior  honiH,  nhcro  thcf  •abdivide  into  a  variable  aumbcr  o 
braochei  (Z*):?.  llliOCQ'),  vrhich  may  bo  csIImI  art«rioa  of  the  pi 
borua.  lu  aildiUou  to  tho  vosaolsjuat  dosoribodjalaigeaiiiaberpa 
the  (lia  mater  into  the  subeUuce  of  the  oard,  and  some  of  thea 
\ax%e  aud  bo  ouuotaut  as  to  doa«rve  apocial  mouttou ;  two  nut  bj  t 
of  tha  InuidlM  of  fibm  whi^h  cuiiHtituta  the  anterior  ruutt  of  tlw 
bctico  tbo;  ma;  be  caUed  the  autGrior  root  art«ri«B.  Tho  hmaoli  i 
the  Diediaa  &ti<ure  may  be  c^ed  the  internal  anterior  root  (^t^.  1 
and  the  otbn-  tho  external  anterior  root  [Fig.  lU,  «*)  artery. 

The  I'jittmal  auttrior  root  artery  (/%,  til,  to),  on  entering  U 
■ubatancv,  j>»ina  Uio  outoricr  braucbM  of  the  &nt  aubdivisioa  of  the 
of  tho  aiit«ri(ir  median  fiunre  aiid  of  the  cootisl  artery. 

TA>  fxtfftwil  anltrlor  roirl  artery  {Fig.  Ill,  '«),  on  entering  Ui 
substance,  subdirldeH  into  tno  branches,  the  inner  {Fig.  1 1 1,  3)  o( 
t*  dintributed  along  with  the  veasela  juat  meDtioned ;  while  the 
bcAQcb  (Fig.  Ill,  3'J  pauea  between  what  we  laikj  call  the  autsro- 
{Fiij.  Ill,  a/)  and  central  graupa  {Fig.  Ill,  c)  of  uella, 

A  very  constant  veaael  paaeaa  to  the  grey  an  balance  f^m  ibe  pia 
at  the  point  of  junction  of  tbe  anterior  and  Uteral  columna  of  tbi 
and  it  may  thiirufore  ha  called  the  an(CTW<i(>-nf  I  art<Ty  (Kjf.  111.  ar' 
reaching  the  gr«y  mibMtanea  it  frequastly  divid»  into  tliroo  hra&dM 
ofviiichpaMOB  in  front  (f^r.  lll,(ir,4  4'4"),  another  behind,  andai 
into  tbe  subat&nuo  of  the  antoni-Iateral  group  of  cells.  Another  oo 
tbbbbI  {Fiij.  Ill,  mr)  puatea  fn>ni  the  lateral  aspect  of  Uie  curd,  ai 
reaching  tbe  grey  tnibatanoc  it  ^mlxlividint  iiito  two  bnncbes,  tbe  \ 
which  pawes  iu  front  and  the  other  behind  tho  poatcro- lateral  gri 
eells  (Fvj.  i\\,pt),  and  this  vnsel  may  from  itM  positioa  be  c^ 
utedivn-lilKTtd  artery.  Small  branoboa  (/Vj.  Ill,^r)  paaa  at  short' 
vaht  through  the  posterior  part  of  the  lateral  rolumn,  and,  togetha 
tli«  loodiau  Irancbes  of  tbe  first  subdirision  of  the  art«ry  of  tbe  \ 
median  fbrnir*,  and  of  the  central  arteries,  anpply  tbe  jioatarior 


ASXJOmClL  XSD  PRTSIOLOQICAI.  [KTKODtrcnOK. 


21 


Um  Utuil  eolntBiu ;  beaob  Hum  tvatelfl  nu;  bo  eaUtd  j»tttHor  letUr«t 
mritriM. 

Two  TMwla  p«M  from  tbo  pb  maUr  iuto  Um  uibrtancc  af  tb«  postoiop 
Doluinoi  Uw  on«  newest  Uio  puetwior  nieili«n  Assure,  ami  w^ii^  may 
Uiinlbi*  b«  «iUm1  tho  intoiwiJ  piMlerit>r  ort^  {Fig.  Ill,  t/i),  paaaM 
batwwp  tba  wlumn  of  OotI  and  tbe  paeteritir  root-sMie ;  ami  After  punng 
thnotgb  about  two-thirds  of  t]>o  depth  of  tbe  |meterior  column,  11  ounw 
oulwMitls  to  rMtfli  tbe  posterior  frejr  horu.  Tii«  oilier  vewiel  (Day  bo 
Bmmed  ibie€si0^\al  or  nudian  poaltrior  artery  £/V'  '^'t  *"/>}  :  >L  )<aMN 
Into  tbe  suWtaQM  of  the  postehor  coluinu  ut  the  mid<ilQ  of  tbe  |K«t«r!or 
foot-Miiic,  and  on  rraidiiiig  about  oo&-thiril  the  depth  of  the  [loiaterior 
ooliuiin,  it  cur>-M  outwanla  to  raKh  the  posterior  grey  horn,  wbera 
II  twrmiiistoa.  Smalt  TaiuHtl*  (Fig.  Ill,  g)  pnwi  from  th»  )>ia  mater  of 
Um  poetenor  raodiaa  ftuure  ioto  tb«  eubotauoe  of  thv  column  of  OolL 
AnoUwr  venel,  whkli  ma;  be  called  tbe  artery  ■>/  lit  poUfrior  commiuurt 
(^^lllipc),  pawca  from  tbe  pia  mater  aloog  tbe  poeterior  margin  of  tho 
poatarior  cocnmiasun,  aud  wituls  backwards  a.Iong  tbe  internal  edge  of  tbe 
foaterior  boFO. 

8  556.  QroHXiinij  of  the  Ganglion  CelU. — The  ganglion  cells 

of  tbo  ftQterior  boms  are  arrftoged  in  groups  which  are  pretty 

coQsUDt  for  the  same  portions   of  tb«  cord,  allbough  tbe 

umq^emeDt  varies  considerably    «bca   aeclions  at  iliOorent 

dendona  aro  compared.    A   digram   of   the  topographical 

tlUtributioD  of  tbeae  groups  is  given  in  Fig.  111.     BegiaoiDg 

U  tbo   po<t«rioi   and   Intend   aspect  of  tbe  anterior  born, 

^  {roup  is  observed  vbtch  from  its  position  is  called   tbe 

fott»n>-iateral  yroup  {pi).    It  ia  bounded  behind  by  tlio  poii- 

t«ior  and  in  front  by  the  anterior  twig  of  the  mediao  branch 

rf  the  central  arl«ry  ;  while  oo  iU  extorual  aspect  it  receives 

btsochea  frum  tbo  median  lateral  artery,  one  of  which  paioes 

Iwbind  and  another  in  front  of  it.     Anterior  to  this  group  is 

uoiber,  which  from  its  position  is  called  the  anterolateral 

group  (at).    On  itH  external  aspect  the  group  recetrea  branches 

(rom  tbe  anterior  lateral  art«ry,  one  of  tbe»e  passing  behind 

ud  another  in  front  of  it,  while  a  median  branch  of  tbe  artery 

aaj  often  be  n'ea  tu  pass  into  itH  mibstanoc.     A  branch  from 

tbe  external  anterior  root  artery  winds  round  ita  inner  border 

10  pun  the  potitcrior  a«poct ;  while  the  anterior  bhincb  of  tbs 

central  artery  passes  along  its  internal  and  anterior  aspeete. 

U  haa  already  buen  meotiuned  that  tbe  intemiU  and  external 
Ulterior  root  arteries,  on  reaching  the  grey  aubatance,  divide 


22         ANATOMICAL  AXD  PHTSIOLOOlCAl  ISTBODUCTK 

into  two  branckefl ;  aod  the  external  branck  of 
internal  of  the  latter  converge  so  as  to  meet  at  a  point  Li 
Vimha  of  the  letter  V.    Id  the  small  area  of  grey  matter 
Iteti  bctwoea  tbcao  tcsmIs  several  diatinot  cells  mo  bo  oon 
observed  as  to  deserro  a  q>ocial  Dam«.    These  cells  mb 
their  position  be  called  tie  niUerior  grcu.p  (a).    Another 
of  Inrgc  celta,  which  may  lie  calleil  the  iitlemal  fffoi^ 
bounded  anteriorly  and  internnlly  by  wbiw  substance,  i 
the  external  aspect  by  the  anterior  branch  of  the  first  gtibd 
of  the  nrtery  of  the  noterior  median  fissQr&     Another  gl 
cells  may  be  observed  towards  the  centre  of  the  anteric 
and  it  may  therefore  ba  termed  the  cerUi-al  group  (aji 
hounded  in  front  and  on  its  int«mal  and  external 
the  external  and  internal  brauches  of  the  external  ai 
root  artery;  and  behind  and  also  on  its  internal  border  ' 
median  nud  anterior  branches  of  the  central  artery.     J 
important  area  ties  between  the  iuternol  group  on  tl 
hand  and  the  antero-latoral  and  central  groups  on   the 
while  the  anterior  group  passes  into  Ita  anterior  hordei 
H  small  wedge,  so  as  to  divide  it  into  the  form  of  the  let 
Tbo  cells  of  this  median  area  (m)  are  much  smaller  dian 
of  the  other  groups,  and  the  area  itself  is  cxcccdinglj  nt 
being  supplied  hy  the  two  anterior  root  arteries,  tbo  40 
bmnch  of  tlie'tirHt  division  of  the  artery  of  the  anterior  u 
fissure,  and  the  anterior  bmnch  of  the  central  artery.     A 
group  of  eslls  Ueii  near  the  internal  border  of  the  pos 
groy  horo  near  the  posterior  coramissuro  called  the  vee 
column  of  Clarke  (oc).    We  must  again  direct  attention  1 
fmclthnt. Fig.  Ill  is  only  a  diagram;  and  although  it  is  mof 
the  upper  part  of  the  lumbar  and  lower  portion  of  the  ce. 
enlargements  than  any  other  part  of  the  cord,  yet  it  » 
strictly  accurate  representation  of  any  one  section.     Th« 
tribution  of  these  groups  at  various  elevations  of  the  core 
be  bettor  understood  after  the  history  of  the  developm^ 
the  grey  substance  has  been  sketched. 


f  Sa".  jDa>eU>fy>nent  of  lAe  Cnttral  Ony  ThUa 

Ttie  partj  nhich  snhseqiieatly  cMresiKmd  to  tha  tnterior  grty 
M«  tbe  first  portioos  of  tha  oonl  to  bt  develo^ied.    TheM  ar«  soot 


ASATOMICAL  AND  PHYSIOLOGICAL   INTRODUCTION. 


S3 


CMdad  b;  UUial  mmmmi,  lod  wioiewhat  Met  ty  the  |>o«t«rior  horns.  Th« 
Mit«(ic>r  gr*j  oDQuuMun  ta  Umo  fonood,  and  tliii  U  •oon  foUoiroil  by  the 
(l«Ta!opm«iit  of  tbo  poaterior  commusiire,  and  it  in  only  at  a  conaidsrablj 
l»t<rr  i'rn<Kl  thAl  the  wtiite  commiasun  i4i[)esn.  When  the  tub*  which 
f-^mu  the  mdiment  of  the  oord  has  oloaed,  it  in  kmr  to  be  aDiii«whjit  aval 
im  secttio,  and  at  Uua  period  itooasutealnMnbinitiroIr  of  gref  aubetanoeL 
The  gray  aafaaUooe  i«  at  Gnt  compoeed  (rf  Bmall  round  celb,  not 
nocb  lugn  than  lymphoi*!  oorpnecloa,  nith  a  distiikct  Docleus,  and  uo 
■CffiavBoacaQ  bedetectiHl  between  one  portion  and  another;  the  vhoU 
ia  ainfile  aad  iitdeHoite  iu  ita  st.rui;ture.  A  aecttou  of  the  conl  at  the 
tyid  mcmtii  of  enbiyouio  life  (P^j.  1 12J  oliotni  that  the  oentnL  canal  haa 
eecilnMt«<l  to  a  anall  oral  upeotug,  covered  by  colamaar  epitLtlium,  while 
thegi^  eabitance  baH  anumed  the  general  outline  characterUtic  of  tbe 
gnr  MihstADM  of  the  adult  cord.  The  gnj  eubetouoe  i»  also  eurrounded 
by  a  mautle  of  white  auhetance,  but  we  ohall  entirely  neglect  the  history 
of  tlu  davalopaieBt  of  the  Utter  in  the  meautime. 


Fro.  112. 


.%,■ 


I  US.  ttffr<iapmrt\t «/  A«  Anltriw  Ony  ffoma. 
The  oUMt  Qoticoable  feature  about  tbe  grey  atibittaaoe  at  tbe  third 
moalbiatbat  the  anterior  jpvf  horns  are  distinctly  dlBTereutiAteil  from 
tbs  poeterior  horaa,  not  niiiiply  in  tboir  gcuend  outline,  but  iu  their 
Intimate  structure.  Tha  groaiw  of  gan- 
ghcn  oeDs  an  now  begtoniog  to  bo 
dJrttonUy  reoogDisablo.  Of  these,  the 
aatar»-Ut4ra]  group  it  tbe  moot  advanced 
In  ita  (livelopoient  Lar^,  mostly  round, 
«fUi,  with  a  distinct  nudeus,  are  obeerred 
entiaddad  in  the  smbryonic  ttsauB ;  but 
tba  ealla  have  not  yet  aaaumcd  dlatiavt 
pTOtewuuL  Tbe  souUl  Intenisl  group  la 
alaa  wall  tepnaented  by  several  distinct 
lange  csHs.  but  the  cells  ace  more  elun- 
gafcod,  and  not  <iajt«  so  lar^  or  so  diatinet 
a*  in  tha  antero-latenl  group.  A  few  ccUa 
tuay  ba  observed  In  tlm  anterior  group. 
Tbe  pnUero-Uteral  group  is  npreeented 
bgr  four  or  Sve  targt  maud  eeUs,  but  th« 
laatral  group  b  not  yet  reprcseiited.  Th^i 
Mesa  la  which  tha  median  and  central 
gnaops  are  aubsaqoanUy  developed,  and 
tba  ana  wbiob  N|>anil«a  the  antero-Utcral 
anil  poaUro-kiml  groupa,  are  composed  entirely  of  cmbryoniic  ti«ae, 
wllh  amaU  nmod  oeUa.  The  veaicular  oolumu  of  Clarke  can  also  be 
imiMgillalilil  ai  (hia  period,  by  a  alight  incresM  in  the  size  of  tbo  cells  ia 
•SBparuwD  with  tboM  of  the  aornnuuUng  tjanie,  but  the  group  do**  not 
affmt  iu  tbe  portien  of  the  cord  from  which  this  »Mtioo  wa«  tixkeu. 


Flo.  lia.   SmUm  /rem  Uu  middU 
^  Vu   Crrtital  Sitlarotmnt  ef 

c/Kml^yMUH/A-C,  (Antral 
cuiaL  TheoUiM-lttUnmiUcsto 
ihi  ssei«  m  the  ootTtiptadlac 
kUenin  Kg.  111. 


S4 


ANXTOMICAL  XSXt  PHY8IOI-0GICAL  INTRODUCTIOX. 


A  still  further  ftdnaoe  in  dorelo^tcnent  in  noognliAbla  M  t&e  endof  ( 
fifUi  muiitbof  etnhtjtimaMhlFiy*.  113  and  lU).    The  cella  cf  Ibe  «al 
lateral  group  h&r«  not  only  incrcAMid  itill  further  in  atxe,  but  tbftir  j 
ocdB8s*renim  wdl  ilereloped  (Fiif.  IH,  O.aodMoh  ii»jbe«een  toU«l 
diittinot  oftvity.    TtioM  ot  the  anterior  t.nA  IcteniAl  groups  ua  olu  i 
<lovelnp«),  and  the  m mo  taay  butsaiil  with  retipeot  to  the  oolln  uf  tbe< 
of  tba  po»t«roJat«rat  group ;  and  bvmi  thorn  of  tho  oaatnl  group 
Curl;  woU  doToIoped,  kltboagh  ool;  two  or  tbna  of  tbom  hnva  m» 
detrttlnitw.)  iirocoiwes.   Tbo  iuvm  in  nbichtbe  median  group  lacabMqu 
dovolopod,  and  tbo  morgioa  of  tho  postcro-Utoral  and  ootitral  grnip* 
consist  of  ointiryonii:  tisdiio.    Tbs  larger  colls  of  thsM  &reu  ore  i«[ 
tu  J-'ig.  11-t,  S.    Tlip  soction  rcpc«a«atod  iu  Fig.  113  wu  taken  from 
tniddlo  of  tbo  cervical  enlargement,  and  tho  vesicular  oolumn  of  Clull 
not  loitroaeuled  ;  but  the  cella  of  tbia  coluum  ar«  fairly  woU  dovolopclj 
tha  fifth  moDtb  in  the  lover  end  of  tha  cervical  enUrgemont  aadini 
donal  regiou  oud  tn>yti  cud  of  the  lumbar  eulargemeut.   The  wotifl 
aented  In  Fi^.  1 14  was  taken  from  Lh«  middle  of  the  lumbar  ei 
and  no  traco  of  tbe  {>OHtero-l»l«raI  group  could  be  diaooveted  ;  but  la  I 
upper  portion  of  thu  lumbar  eulurtfeoieut  Lt  occui>iu  a  Kimibu-  poHittoaj 

Fio.  lU.  Yk 


/: 


K.. 


^ 


Pna.  lis  and  114  (YonngV  Sfttian*  n/  ^\nsl  CiM  ,./  n  fiit  MunUu  Btrntm' 
£Mf|Wi  fnnti  the  luddle  of  the  ccrviol  and  lumbv  cnlarKcmenu  leapee- 
lively.  — i,  intoriMii  a,  anlfrior;  e/,  aatcro-laterki  ;  p/,  pc«(cn>-Ulml, 
r,  central,  r.  meiUaD,  and  BTOnpe  of  gitgUim  mIIi  :  I.  ^aglieB  cell  of  Um 
«aiin  of  ibaaMonhlatoral group i  3.  ganglioo  cell  of  OMdiaaciDOB 


JUtjLTOMlCAL  AKD  PHYSIOLOGICAL  ISTRODUCTION.         25 


tk«t  which  it  oocQpi«s  in  tiut  carrical  ealai^gvmtot,  u  repreaeDUd  in 
nff.  113.  Tbs  nakuUr  coliima  of  Clarira  doon  oot  app«tf  in  the  lumlMr 
•alargeDkeot. 

Tbs  gviglton  ctilia  of  the  various  grau{is  lure  become  titll)  furtbtr  de-n- 
lepKl  U  the  tkinth  mMtth  [^gi.  U&  and  llf}> ;  vUI«  by  the  tlovolotimeiit 


ria.  11&. 


}''»).  lie. 


/ 


)^l.  nSuiil  ]!G  (Toubk).  SWttM*  «/ Ax'ndl  CarJafti  Kim  V-nUu  ITamaH 
Imlirjut,  (null  till  ibiildle  of  tbe  luoiMr  uid  crri)i<aJ  eulur'UwuU  rM|>e«- 
u'teljr.— A,  aoiufor,  uiiL  P,  inatcrior  hanw.  Tks  «nikU  Icittn  indicate  the 
MOB  as  in  E^.  lUuidlK.  Tfait  noniMl  sm  of  lb«  uctitu  (roEa  wbidi 
ite  dnwiac  wm  nkle  ieafaowD  itbov«  wub  fifsr*. 

^eniiUi  oella  in  the  oetitral  and  |Kwtoro-ItUn]  groups  U>4  rnrioub 
PWfa  bsfe  bocuno  no  approxtmatotl  w  not  to  be  so  diatiuctif  reoo||- 
■""•Uf  from  «ich  othor  *a  Ih*/  were  at  tho  fifth  Daonth  of  ftinbrjonio 
'iEs'  Tbe  MctioD  Rproseated  iu  Fig.  1 1  &  was  talran  from  the  midillu  of  the 
'^■Btw  tnlargemeat,  anil  the  postero-Iatenl  group  Is  not  ao  irell  repre- 
*t<rtAl  BB  It  is  iu  the  u^iper  iMrt  of  tbe  tuiubar  region.  The  meiliitii  area 
we  ontalea  dinUiict  ganglion  oolU  inttowl  of  consisting  entlrolj  of  eru- 
'T^ouc  tiau&  Thcao  ccIIh  ore,  hovorver,  not  much  larger  tbau  tboao  of 
lt»  at4ro4ataral  group  at  the  thifi  niooth ;  vrhil«  they  are  by  no  nieODB 
"xnD  Jereloped  m  tboae  of  tbe  laUer  at  the  fifth  tnotith.  Tlie  cells  of 
^  tfldillui  graup  Are  antAll,  anguUr  tniuuM  trith  a  distinct  iiucIouh,  but 
•^j  k  n'Utively  iimall  number  of  theaa  bave  deTcIo[)ed  procemea.  It  in 
m  imeemry  to  any  much  at  proMUt  with  rospoet  to  tbe  adult  oord.  Tbo 
Ant  DuiJcenblo  fcatuni  iu  which  tlio  cervical  aiid  lumbar  eolargenuoti  of 
I  uitilt  &inl  diflcr  from  the  correspoodiDg  porta  of  the  cord  of  a  iitiM 


26 


ANATOMICAL  AND  PHYSIOLOOICAL  INTRODUCTIOU. 


taontlM  ombryo  U  in  tho  fiivt  tliAt  the  ^nglion  oeUa  of  the  u«<liMi  gn 
havo  dcTcIopod  proccaaos  like  tboaa  of  the  other  grou|<e.    The  cells  at  C 
mediiui  group,  howiover,  especially  ia  the  carricAl  vnUr^mont,  ana 
oolj  much  AQiallDr  thao  those  of  the  other  groupa,  but  titoy  are  mm 
tbls&w  Btut  more  tmneparent.    Thau  twUs  are  m  inutpantA  that  Cbi 
HMj  be  verj-  readily  orerloaked  altogether  in  aoctioDS  clewed  by  oil  i 
elOTes,  and  moant«d  in  Canada  balsam  ;  while  the  oella  of  the  aatan 
lateral  gronp  not  only  intercept  the  light,  but  retguira  considsrable  chaD| 
of  focus,  in  order  to  bring  their  anterior  and  posterior  Kurfiooa  cUail 
into  riev. 

The  relationnhlp  which  tho  dereloplng  celU  bear  to  the  dJBtributinB  A 
the  bloud-vwM«U  ia  oigeodiugly  iut«rt!al;nh-.  Tho  uarlier^reloped  c«ll 
appear  to  be  thniHl  further  and  furLliur  awny  fnim  tho  Ttmeb  an  iofiiaf 
meut  advaooea.  The  postcro-latoml  grou|i,  for  inatanoo,  first  itbows  itsd 
by  ibs  daralopment  of  four  or  Svs  iargu  cull»,  which  appear  about  tbt 
oenlre  of  the  apot  ia  which  the  complutod  group  ia  aubacquoatly  situated) 
and,  IA  $ang1iou  cell  after  ganglion  oeU  becomes  developed  around  i 
centre,  ttie  arcA  becomc^in  increawd  in  siiie  by  tb«  ^oivth  of  addit 
omhryoiiio  tiuuo  around  the  circumference  of  the  group  in  the 
which  ia  in  relation  with  the  artoriolos  {/\;r.  111).  Tho  gnuglion  cellai 
the  centre  of  the  group  nro  tiro  fimt  t'>  bo  (lev«Ii)p(*d,  and  th« 
inoreases  in  aize  by  tho  gradual  dgvolopmout  of  new  coUa  around 
central  ones.  The  marginal  cells  of  the  group  are  oooaequeally  th«  I 
to  be  developed.  Similar  rvmnrlcs  apply  to  tha  ganglioo  oelli)  of 
oeatral  group,  as  well  as  to  the  aut^ro-Uteral,  anterior,  and  int 
groups,  except  that  the  last  throe  grou|>4,  iuatead  of  being  somiiiod 
all  sides  by  grey  auhstance,  are  on  one  of  their  aidra  in  ootttaok^ 
white  subatanee. 


%3b^  Ths  JMeator*/ ITtTM  NucUi  of  the  Spitvil  Cord. 
(1)  J/Mian  ^iwi.— The  comparatively  lata  period  in  thedevelopan 
the  cord  at  wbioh  the  ganglion  colN  of  the  median  area  of  the  anterior  ho' 
assume  procures  hIiows  that  this  anrn  rotut  Im  nvganled  as  on  acoaaaoi; 
structure  (J  33).  Tho  rolativoly  largo  ei£o  of  this  area  in  the  cen-ical,  w 
oomiKUvl  with  the  lumbar  enlargement,  ehaws  that  it  is  a  much  mora  iiB- 
portant  structure  iu  tbo  former  than  the  latter  region.  Ia  tho  fifth  mocitli 
of  embryouifl  life  the  median  area  is  not  larger  in  tho  ourvtuol  tli&n  in  the 
lumbar  rcfcioa,  as  shown  in  Fiyt.  1 13  anil  1 14,  whero  itwUl  be  oiwu  that  Uuare 
isaoaroeLy  anydilTerenoe  in  tho  general  outline  of  the  anterior  horns  lathe 
sootioua  from  the  middle  of  the  cervical  awl  lumbar  eixlorgomeate  respeo- 
tivoly.  In  tho  embryo  of  tho  ninth  month,  however,  tbu  mediau  arm  ia 
the  Gorvioal  ia  decidedly  hirgor  than  in  tho  lumbar  eaUrgoment  (Pi^t.  US 
and  llii),  and  oonsequeiitly  tho  aiiteriur  grity  horn  iu  the  former  regioo 
is  extended  laterally  to  make  room  for  thtn  nrua.  Tbo  rtlative  increase  in 
tho  size  of  the  median  area  in  the  conrical  enlargement  of  the  human 
adult  coid,  aa  compared  viththat  of  tho  lumbar  enlargement,  ia  still  nw» 


iSXTOUKAt  Ain>  PBTSIOLOCICAL  ISTHODrCTTOtf. 

tDufcttd  tliui  in  llio  conl  of  »  oino  tnootha  ombrjn,  as  Tt»y  be  aeen  iii 
#Vpw.  1  IT  and  119,  wbera  the  towliaii  area  occQpi«a  a  large  b|wc«,  and  tha 
lakral  out^rovih  of  tbe  auUrivr  grey  bom  oT  the  oerrinl  region  in  very 

On  obaerviag  tba  larje  raUtirft  nee  of  blw  median  area  in  tho  cervical 
anlargemeot  of  tbe  adult  biinuuD  ooni,  a*  comiumi)  wtth  that  of  Ibe  lumbar 
takr^aiiHiDt,  and  orao  ■■  oompariKl  with  iiuA  of  tbe  ccrrical  calargament 
«t  tbe  oont  of  tbe  embrjo,  it  occurred  to  me  that  this  area  miglit  not 


Pio.  117. 


Fio.  118. 


P=i 


X. 


hot.  1]7  ua  118  (ViioDii'.  Sutimui^  Iftc  AiUlt  AWwiI  Cord  fnm  (At  mt^Uof 
lUlr>itb*riui'l  Ctrrieal  £nlttrfftnmU  rffiiRtiiWy.  — Tlia  lettonindlMo  tlie 
«UM  M  ibem  in  /"i^.  113  Mid  111. 


)  aaj  ntatira  importance  to  tha  oerrical  onlargemeDt  of  the  aptoal 

>«4  Ld  auitnala.  In  order  to  test  this  godcIumod  I  applied  to  Hr.  Larmulb, 

^ibe  Oveos  Coltego,  «boae  beautiful  aections  of  tJw  ^^al  cord  are  well 

btovn  'm  MoDolmitar,  and  aaked  him  if  be  would  be  Idad  anopugh  to  let 

^  tkira  aectioo*  of  Ibe  lumbar  aud  cervical  oulargameDte,  a>  «^  as 

haa,  Un  ouddle  of  tbe  dona]  region  aiid  tbe  upiwr  portion  of  the  oer> 

'ital  r»gjvu  of  tbo  apinal  cord  of  tlio  ox.     ^Ir.  Lannutb,  in  kiudlf  coq> 

HDliuS  to  let  izM  have  what  I  wanted,  Toltiiit«ered  tlie  irtateinent  tbat 

tl  n»  qoito  unseMauiy  to  baro  a  aeclion  of  both  tbo  cervical  aod  lumbar 

Rpoua,  as  tbe  Lwu  wera  ao  aliks  oa  to  bo  iadiiittngiilsbable,  and  both  wero 

like  tbe  luiobor  enlargooMiit  of  tbe  hnrnao  cord.     Thia  waa,  to  a  lar][e 

nleat,  tba  vrij-  fact  I  was  io  acareb  of.     I  have  bad  an  opportunity 

■inee  that  tini*  of  oxacuiaiiiK  theaa  sectioua  more  ounutoljr    A  Mction 

hnn  tbe  cervical  enlai^meDt  of  a  calf  is  repnaentad  in  Fiy.  119,  and  it 


3D 


ANATOMICAL  AND  PnYSlOLOOICAt  ISTBODUCTIOK, 


|iared  with  the  compact  ftod  SbriUntcd  UiUiro  of  tlionciiiogli*sarrDu»diii 
Umi  ganglion  oells  of  thfl  eulier-devfloppd  grou|)i<.  Tbo  truisiMUvacf 
iocTMaMl  bj  tbo  Ctct  ttuU  tbo  i«rger  vosmIs  of  tho  autonor  horos  pa 
along  the  tnnaparont  anw,  wbila  ooly  tba  ■nwUlcr  TMWtU  pan  into  ti 
oubataace  «f  tbo  oarUn^onlopod  groupo. 

§  3ftl ,  Jkrd^pmmi  of  (Ae  Potlvrior  Qrty  UiriM 

The  dflvi^opmcnt  of  tho  poaterior  borua  appeara  to  procvod  on  •  d 
ferent  principlu  from  that  of  tba  aaterior  horns.  The  vesMl  which 
maiiily  JiatrihuUd  to  the  posterior  boni  i)aaseB  into  It  through  the  ceol 
oTtbe  post«Tiarroot8of  the  nerves,  and  tho  developtDent  of  new  subatani 
procvods  laoiul;  ia  the  ceiitie  of  the  born,  oo  that  the  ulder-foniieil  tian 
is  |itubed  out  laterallj'.  Tho  central  |>oTtioiL  of  the  born  oanaista  of 
ifl  GfcUod  tbo  aabataatta  geUtinon,  oad  ia  made  uji  in  lus*>  part  of 
roglla  and  flbriU,  in  which  inecltiim-itii«d  ^atigttoii  celU  ara  embodi 
Tho  lateral  [>ortioiia  of  tb«  horn  contaiu  woll  futinod  and  thicker 
fibnoi.  The  moat  iutemal  of  these  fibres  pau  throiigh  the  jxiatenor 
aonn  in  order  to  gatu  sooeta  to  tbo  jKHitcnor  grejr  bonu,  aikl  tt«M 
colled  tbo  in7t4r  radicular  /atactd^u  (Charcot).  The  outer  radii 
fHoiculoa  pouM  aloug  the  ftut«r  margin  of  tbo  pojft4rior  hoiu,  aad  bet 
It  and  the  pyramidal  tract  of  tbo  sanje  Mide.  1 1  ia  therefore  proi 
tbft  inner  oud  outer  radicnUr  faacicub  contain  the  Mirlicr-fortnod 
fibm,  &nd  that  cootequcntl/  they  pnsidie  over  tho  earlier-fonuMl 
moat  f uodoBtentAl  funcUona. 

§  SOS.  Dtfttopment  0/  ikt  CaUni  Qrty  Cofteinn. 

The  central  grey  ooluson  spiteara  to  grow  mainlj^  n>uiid  the 
artery  aa  a.  ccntm.    The  |tortioii  which  immediately  earrvuoda  the  oeal 
canal  consistt  almont  entirely  of  neuroglia ;  but  the  anterior  and  I 
portion*  contain,  in  addition,  nerro-fibrila  and  scattered  gaoglic 
the  latter  being  much  emallcr  and  not  ao  diatinctly  caudate  aa  < 
the  anterior  hnrna.    This  portion  of  the  grey  substaooe  oantaina  1 
tivcly  largo  number  of  Duitcr'a  oella,  and  Uie  nouroglia  ia  much 
s[iougy  tliftn  in  tbo  anterior  and  po^t^rior  horoa.    Tbe  posterior  and  ii 
part  of  the  central  column  coDtains  a  group  nf  Urge  caudate 
veeicnlor  column  of  Clarke.    This  group  liaa  close  to  the  internal ' 
of  the  poaterior  bom,  near  tbe  posteiior  commliuiare.  Itcotisiatsof  net) 
nerre-flbrw  and  ganglion  cells,  the  Utter  of  which  are  bipolar,  or  1 
not  oo  dbitiuctJy  caudate  as  thoaa  of  tbe  anterior  horn.    The  oe 
wiitch  the  cellfl  are  embedded  ia  more  deiiau  and  compact  then  that  1 
rcia&iiiiiiK  |H>rliuu  of  tlie  central  coIueuti,  being  in  thia  respect  eimilor  I 
the  iieuruglia  aurrouuding  tbe  oelbi  of  the  gniupe  of  tbo  anterior  home. 

With  the  eiQcption  of  the  veucular  column  of  Clarke,  the  central 
oohima  a^iiXAra  to  be  tbo  embryonic  puition  of  the  grey  aubstonoe,  Uw 
potion  •djoining  the  central  canal  being  tho  loet  formed,  and  oomiaUai 
vt  sooioeljr  aojFthiog  but  Deuroglia.     An  a  u«w  lojar  of  tinua  fseam* 


ANATOMICAL  AKD  PUTSIOLOGICAL   IKTRODUCTION.  29 

lAtvnl  gnrnp  iD  tb*  himbw  and  oerrical  enkigciaaDU  an  a«ulf  if 
Dot  quite  u  Urge  m  tbo«  of  the  eoutre  of  the  group,  Klthaugb  tbe 
Uttar  begm  to  dmlop  aX  m  mucb  Mrlier  period  than  Uu)  foriuor ;  white 
Uw  MUa  of  the  nuctei  of  origin  of  the  third  antl  fourth  iiema  are  mull, 
slthfKijh  UtFjr  hare  began  to  develop  at  a  oomporatirel^  inu-ly  period. 
The  aixe  of  the  cell  naj'  be  accepted  «a  a  mtigh  toat  of  ifai  ago  during  the 
period  of  dereloftaMBt,  attd  no  hmger,  just  aa  the  Hicu  of  a  growiug 
bunuii  bctiig  umf  be  accepted  a*  ft  roujh  ttut  of  ago  until  the  adult 
cunditiori  ii  attaiutd,  nheu  it  otiaftea  to  hi  a  tent  aujr  longer.  The 
■UK  of  the  gauglioa  ccUn  of  the  aut«nor  horns  of  the  oord  of  the 
adult  apjirani  to  depend  niaiul/  If  uct  eutirel/  upon  the  aise  of  the 
nmack  over  vboee  fanotion  it  preeidea  ;  heuGc  the  coUa  of  the  nuclei  of 
the  third  and  rourth  Dom*  are  uuoll,  whilv  the  gnuiter  number  of  the 
mQb  of  Uu  ccrrical  eulargttnOQt  are  large,  wid  tboae  of  the  lumbar 
eobujaiiMDt  an  atill  lai^vr.  It  frequentljr  bappena  that  the  later- 
dmiotpti  «elU  of  tlw  cord  are  email  in  the  adult  conditiou,  but  tbie  is 
bManw  the  most  Kpecial  muscular  adjustmenls  an  efiect^d  hy  the  con- 
tractione  of  smjll  tauaclca. 

$  SCO.  Xhr^poKTU  cf  rA<  Ktvnglia. 

So  lar  we  have  epokoo  odI;  of  the  deTelopment  of  the  gmgUoD 
o«lh>,  but  va  muct  now  brietl/  refer  to  that  of  the  neuroglia.  In  Uw 
Mrl;  WMb  cf  fatal  Lfo  the  neuroglia  conaiatfi  of  amall  round  uucleated 
wll^  or  rather  of  s  nucleus  surroonded  \>j  a  Ujer  of  soft  proCoplaun,  and 
vtth  acarceljr  «  trace  of  bui»  aubetaooe.  As  development  advouwa, 
Ibtt  pntoplaaa  oootracta  roond  tha  nuclei,  and  the  latter  beoome 
acabadded  in  a  &lpllated,  some  s*^  granular  bosie  subotance,  Thit 
ueungUa  becouMa  deuaer  and  mors  compact  iu  proportion  as  it  Aci)ulres 
mnm  and  taiun  of  the  basu  8abetauc«  sud  loeee  its  oeUular  character. 
This  change  dues  not  occur  in  ererj  part  of  the  grey  subntauce  at  the 
■■ue  time.  Speaking  broadljr,  the  neuroglia  a'AUflua  a  fibrilUted  texture 
fa)  the  ymrj  portions  of  which  the  gai^liuii  oells  are  earlimt  developed : 
vhila  tt  maintains  ita  embrjrenic  condition  tu  tliu  margiua  of  the 
gniapa  of  ganglion  cells  of  the  anterior  hums  and  aUiig  the  line  of  the 
Uood'TMMla.  And  when  a  aectiou  of  the  adult  oovd  is  held  up  to  the 
b^t  the  grmipa  of  targa  ganglion  ooUe  maj  be  seen  aa  dark  ^»ta  inter- 
cipting  tha  hgbt,  and  stronglj  oontraating  with  the  tnuHparvac;  of  the 
mdiaa  am  aikJ  of  the  margina  of  the  antcro-Utcral  aud  poeteyo-taleral 
§nMl|M  along  the  lines  of  the  veeseb.  The  trauaparent  portion  also  em- 
hra-«a  the  anterior  and  [tosteriur  grey  coromleaurea  aud  the  central  oolomn 
«f  the  gn;  anbtAanoe  aa  bu-  back  as  the  sabstantia  gelotinoaA,  with  the 
Kaotfition  vt  the  area  oocupied  hjr  the  reaicular  coluoui  of  CWke.  The 
tnDflpaiwnej  of  the  area  just  dsecrihml  la  no  doubt  due  in  sooie  naasura 
lo  tha  bft  that  the  aaall  ganglion  cells  thomsclTes  are  man  tnuwparciit 
than  the  Urfe  ganglion  eells,  bat  it  is  aba  iu  great  mfaaure  due  to  the 
leOM  and  spoagr  character  of  the  nourujlia  in  the  former  areas  aa  oom* 


30  ANATOMICAL  AKD  PET3I01OU1CAL  ISTEODUCTIOS. 

pared  iritlitbaooajpactud  fibriIIat«dt«ilureDf  tboii«uTugli4fluiTOi 
the  pnglioa  oelU  of  tlu  Mrlitr-d«ml«pnl  group*.  Tht  Imuran 
increased  "by  the  bet  Uut  tbe  larger  veeeete  of  the  ulerior  hisn 
■kog  the  t-raii^tir«nt  ftrcM,  while  only  the  sbulUct  veaeel*  pftu  u 
mibetanca  of  tbe  earlier-developed  groupa. 


§  3G1.   Dcvdopnunt  iif  (Ac  Poturiar  Or*g  Bona 

The  devetopciGiit  of  the  |XNtt«rior  boms  appears  ta  proceed  on 
ferent  priiiciplo  tram  that  of  tbe  autericr  hortie.  The  vueel  «{ 
miuiil;  diatributad  to  the  postenor  horu  passes  into  it  through  the 
of  thi)  posterior  roots  of  the  uervee,  auil  the  develoiiueut  oftiewinib 
proooedM  maiol  v  iu  tlie  centre  of  the  horu,  ua  that  tbe  older-fhnued 
10  pualied  out  lat«rally.  The  oealml  portiou  of  tho  horn  ooueiste  of 
n  called  the  nulMtiiiitift  giitlatiuoMi,  aixl  iH  made  up  iu  lu^e  parto 
roglia  and  fibrilo,  iu  which  mcdium-aizcd  ganglioQ  oella  nre  enlM 
The  Lateral  portions  of  the  born  ooiit«u  woU-funaed  and  thicker' 
fihrea.  Tb«  m««t  tnteraal  of  tbeae  fibrea  pau  through  tbe  poeterioi 
aones  io  Older  to  gain  acceiw  to  the  [iwiUinor  grvy  horus,  and  thai 
called  the  inner  radietUar  /attieuiiu  (Charc»t).  The  outer  r*d 
fwdculuB  psasos  along  the  outer  msri^n  of  tho  poatorior  horu,  and  be 
it  and  tbe  pTramidal  tract  of  the  eame  ndit.  It  ia  tberafore  probabli 
the  loner  aud  outer  radicular  fasciculi  oontain  tbe  earlier-formed  $i 
fibres,  and  that  conuquentiy  the;  preside  over  the  Mrlier-forom 
most  fiindameutal  fauclious.  ^m 

§  3G!,  Dnel'ypment  of  tht  CmIivI  Orttj  CUumn. 

The  oeiitral  gnr;  column  appoaru  to  grow  maiolj;  round  Ibo  0( 
artery  as  a  coutro.    The  portion  whioh  imtDcdiat«]jr  aummnds  the  c( 
canal  consists  almost  ontinjl;  of  noumglia ;  but  the  anterior  and  li 
portions  cotitain,  iu  addition,  nervo-flbriU  aud  scattered  ganglion 
the  Utter  being  much  sinallor  and  not  so  distinctly  caudate  oa  tho 
the  anterior  horns.    This  portion  of  the  gray  siiUatiiuce  coiitaiuaa 
tively  largo  number  of  Deitcr's  cells,  and  tbe  neuroglia  ia  tnuoli 
etwiigy  than  iu  tlie  aut«rior  and  posterior  horns.    The  [tofiterior  nod  I 
part  of  tbe  central  columo  contains  a  group  of  lurgc  cautlute  ocUs- 
vwiculor  column  of  Clarke.    This  group  liett  olwo  to  tbe  iutorual  b> 
of  the  posterior  horn,  ne&r  theposterloroommiaatin.  It  consists  of  nour 
nenre-fibrea  and  ganglion  ocUa,  tho  latter  of  which  aro  bipolar,  or  at 
not  so  ditdiootly  caudate  as  thoae  of  tho  antorior  horu.    'I'ho  neurogli 
wluch  tbe  eella  an  embedded  in  more  dense  and  compact  tlau  that  ol 
lemunlngportiou  of  the  central  column,  being  in  this  respect  simili 
the  neuroglia  suTroundiog  tho  ooUa  of  tbe  grou^  of  the  anterior  liomi 

With  the  oioeption  of  the  vesicular  column  of  Clarke,  the  cei 
column  app«ars  to  bo  the  embrfooic  portion  of  the  grey  mibataaoa, 
portion  adjoining  the  c«otrul  canal  being  t)ic  last  fanned,  and  oon^ 
o(  Botroel;  aajtbiog  but  neuroglia.     As  a  new  lajrer  of 


ANATOMICAL  AND  PQTSIOLOOICAL   UfTfiODUCTlOX. 


31 


maad  Uie  cmaaX  Ui»  oeotial  opeiitiig  b«coini»  amaller  and  anuDer,  and 

ha  rarli«r-fanued  kyera  aro  dJe|>l>onl  Away  from  tbe  centro.     lb* 

atcr>f«rninl  porta  of  ihe  aotcnor  aad  posterior  horua  gnw  at  Uio  expcitM 

M  tlw  omtnl  eolunui.     But  tlie   portioa  subtnoted  from  Ui«  cuutnl 

Uilamn  \tj  Mch  iDRtetneDt  mpertddod  to  tbe  ulterior  and  pwtcrior  boms 

U  npUmd  li;  tlw  growth  «f  •  oem  layer  of  ttMue  Brouiul  Chio  MOtnd  canal 

Tbe  nlla  of  the  osntnl  ooIiudu  do  not  dorelop  until  m  lata  pencd  of 

nnhfjeiiio  life,  and  tbef  mag  tberofoiv  ba  nganM  as  nlla  supenulded.  In 

(ht  flooiw  of  cToluttou,  to  those  of  ths  anterior  and  jxiaterior  boras,  and 

tC  the  veaiculw  ooluun  of  CUilw,  and  reodered  oeccnaary  by  uowljr- 

wqalred  conpUeatiooa  of  morcmeat.    Tbe  etoup  of  odls  itbich  I  haye 

iweribed  as  tbe  modiao  group  of  the  anterior  bctn  may,  Indcwl,  hti  ragardod 

m  an  anterior  onlgTowib  of  tbo  oentiml  oolamD,  its  relatively  largo  uu  bi 

tbe  cerrieol  regk»  being  rendered  neoomary  by  the  complicated  niov«< 

Mate  of  tho  baod.    I  n  addition  to  tbe  ganglion  ccUs  and  fibres  belonging 

la  lb*  ecBtral  column  itAOlT,  it  tmutoits  a  kige  number  of  intercou- 

BsMBttuig  fibrw. 


LimffUudijud  DidribiUion  of  Uia  Oitmps  vfOanfflion 

tbofemarlcs  which  have  hitherto  been  made  rcfur  particularly 

IkedcrelopmeDt  of  tbu  luiabor  and  cerricaJ  enlnrgemcDta  of 

the  oord  ;  but  a  few  words  mast  now  be  aaid  with  req>ect  to  the 

Lion  ot  tlie  various  groups  of  gaugUoD  celU  id  tlie  other 

r->>'^<uti  of  the  cord.     The  grej  subetanoe  of  the  dorsal  region 

impraseDted  in  Fi^;.  121,  where  it  will  b«  seen  that  the  moitt 

utcrior  portioo  of  the  aDterior  boro  ia  occupied  l>j  three  small 

pwfii  of  Lu:ge  ganglioD  cella.     These  groups  caatiot  be  bo  dis- 

linalydiatjuguiahed  io  ever;  aectioQ  as  tiiey  were  Id  tbe  one  from 

lliicb  thtB  dtmwing  waa  t&keo;  but  iodicatioos  of  such  a  divisioo 

uy  be  found  in  most  ticclions.     These  groups  appear  to  corrc- 

(pood  lu  the  iutemal,  auteto- lateral,  and  oantral  groups  in  the 

orrieal  and  lumbar  i«gio&s;  vrhilc  tbe  median  group  of  small 

<dllt,  which  is  80  conspicuous  in  the  cervical,  is  wholly  unrcpix.- 

Bcoted  in  tbe  dorsal  region.     A  very  remarlcahlo  feature  of  the 

gnj  rabttaoce  of  tlic  dorsal  region  is  a  comparatively  wide 

area  which  lies  between  the  autero-Iateral  aud  postero-Uttcrol 

ipi,  and  which    I  hare  nlready  named  the  medio-latenU 

{fig.  121,  nd) ;  it  ia  filled  with  small  ganglion  colls,  vrbieb 

only  developed  processes  towards  tbe  nimb  month  of 

Ufe. 


34 


ASAJOmCAL  AND  PHl^IOLOQtCAL  INTttODUCTIOl 


detachment  of  tbe  antorior  boras  from  the  centra)  graji 
A  careful  examination,  however,  shows  that  one  or  tf 
minor  bnt  cxceodingly  importAnt  oltoratioaa  have  takei 
The  triangulHr  nucleus  and,  at  a  littlo  higher  level,  the 
nucleus  (Fig,  122,  (w,  en)  give  off  arcuate  Jtbres,  wb 

Fio.  1S2. 


^#. 


t>a[ 


-X// 


« 


VC 


m> 


•^at 


FlO.  122  tVoune]-    Scrtion  o/  lilt  Loutr  End  of  llit  MrdutU  Clihnfnia 

itilh  the  erouini;  oj  iM  fhru  oj  ike  laiend  t«imnt . 
A,  AntMiM  gief  honu,  ibowing  tbkt  th*  ptj  matter  hu  be<<<MD« 

tht  n-biu  inbttiutue  of  ibe  uiteriLir  nuii'innp,  uid  vith  nmuU  ( 

fKof.InterDA]  KTonp  luid  Aportkngf  tho  kntcro-ktcrtt]  Kroii|i. 

ale.  Anterior  nudlrwi  ol  iho  Utorkl  onhiinn,  b«ag  %  portion  cli*l««li«d 
Mit«to-IU«nl  ffrour*. 

pic,  I'oMcrinr  Dooleiu  m  the  Uter%l  oclumn,  being  *  portion  deladifd 
po«t*ro-l»t<nkI  group. 
V,  SaboUntiB  nlatineui  (U>i>1«i:i>il  Ubvtilly. 

ui^Awandiiie  tool  at  the  uideiuiuiui. 

/,  ^Mffl«nliu  rvtnn«Iu«. 

te,  VMienlftreolnmnotCluke! 
P.  PymnMft]  tnd 

K.  (^Mtlng  of  tb*  tibnt. 
or,  Int«nu]  portlra  «f  th«  utMriOr  r««t-coD0, 
or,  HxlaraBipoTtiaaof  UMuUrionoot-sonv. 

Ill,  Hn>AgIo«Ml  n«rvn. 

Xt,  S^D*]  •CMMOJJ  iivrr*. 
G,  Ttac  oolomn  of  0«1I— Uw  ilenclcr  ludcalrm. 

en,  ^e  olKTste  aaolctw, 
pr,  ni*jMMl«rior  root-tont— lU  cUomU  ttuolculuii. 


XNJLTOSCiaU.  AIO)  PnrSIDLOOICAL  INTRODUCTION. 


35 


jped  fonrards  and  upwards  in  a  semiciFcutar  maaner  to 
jh  the  olivary  body  of  the  Batue  side.  Tbese  fihros  pau 
jQgh  the  posterior  horna  aod  thrust  tLem  still  further  in  a 
inl  directioQ,  and,  indeed,  almost  eutircly  separate  the 
iter  portion  of  each  horn  with  its  substantia  gelatinosa  from 
grey  substance  which  suirounda  the  central  canal.  The 
late  fibres  interlaco  with  the  fibres  of  tho  lateral  columns 
the  latter  bend  forwards  to  cross,  and  also  d«tacb  a  portion 
tbe  aat«ro-lat«ral  and  postero-lateral  groups  of  cells,  bo  that 
wtion  of  these  groups  now  extends  into  tho  whit«  substaoco 
;be  anterior  root-zones  {Fig.  123,  o^  pic). 
!he  continuation  of  the  anterior  root-zones  {Fij/.  132,  ar 
OtQ  '^^  '^^  ^^  through  tho  medultn  oblongata  is  broken 
ato  a  reticulated  fonnatton — ihc  fonmitio  r€iiculari»-~-&nt 


Fkl  123. 


'rvx-.._'5i',i?.-- 


.  ••■/ 


\{Vr<m  BnU'*  AMUaaife).    F-rrwimlia  Rilinlari*  p/Uit  itt^»lU  iMtragMa . 


ANATOUICAL  ASO   POTSIOLOOICAL   UJTRODDCTIOK.  3? 

bj  the  arcoate  fibres  or  tlie  triiuigtilar  and  clavate  nuclei,  antl 
then  by  tbc  axcuate  fibres  of  the  ioferior  p«duuclc3  of  tbo  cere- 
beUam,  and  tbe  wbole  of  tbU  tisjtue  is  tfaicklj  studded  with 
caudftte  guiglion  cells,  as  represented  in  Fig.  123.  Whether 
all  these  cells  are  tbe  representatives  of  those  detached  by  the 
arcuate  fibres  from  tbe  antero-lateral  and  poatero- lateral  groups 
of  the  cord  ii  not  known.  Tbe  colls  detached  from  theHe 
groups,  boweror,  a^ref;ate  into  two  more  or  less  dlsUoct  groups 
hi  tb*  lateral  part  of  the  foTmatio  retictUarit  of  the  medntla. 
These  gnwps  ma;  from  tlieir  position  be  called  tbe  ontenor  and 
posterior  nuclei  of  tbe  lateral  column  of  the  medulla  (Figs.  122, 
134,  and  125,  ale,  pic);  while  the  ternu  antero-Utcial  and 
postero- lateral  may  still  be  retained  to  designate  what  I 
bebevo  to  be  tbo  upward  contiQuatioDJD  of  tbo  portions  of  tbe 
ant«ro-lateral  and  postero-lateral  (Fi^.  109,  al.pl)  groups  of 
tbc  cold  whicb  have  retained  their  comiecUon  with  the  grey 
matter  that  may  bo  coosiderod  as  npresenting  tbc  anterior 

§  365.  C&niinvuition  of  Vie  A^erior  Grey  Hotm  0/  the 
Sjnrwf J  Cord  throwfh  ike  MtduUa  Oblongaia,  Pons,  and  Crura 
Certbri. — This  Blight  digression  into  Ibe  examination  of  tbe 
nwrmngeraoDt  of  the  white  snbgtanoo,  which  takes  place  in 
pawing  from  tbe  spinal  cord  to  tbe  medulla  oblongata,  appeared 
MO0WU7  to  order  fully  to  understand  the  redistribution  of 
tbe  groaps  of  gaoglion  cells  oecurring  in  the  medulla.  At 
tbo  lower  end  of  the  modnlla  portions  of  tbe  antero-kteral 
ud  postero-lateral  groups  may  be  seen  to  extend  laterally 
into  the  substance  of  the  anterior  root-zooe,  or  into  the  lateral 
column  of  tbe  medulla  oblougata  as  it  may  now  be  called. 

tm,  TUiaguUr  wulna. 
Ae,  TIm  tttMOt  a«i4idlv  tfMt  IjIm  «ii  tbe  mrfua  tt  tka  p«t«for  kM-hmov  aiuI 

lb*  wovikiliog  root  of  tbo  tiixtaBiniu. 
•1;  jtwiiiUm  iwol  o(  lk«  tdgttuiaai. 

m,  SotatMUft  pIttiiiMk. 
U  nMUilarlawfcvUBal  fudeoloa. 
Wt  Tb*  pwtba  o(  *^  ftrmaHo  retiatiarit.  wUdi  iipiuuiU  th*  intvivil  tlirUon 

tl  tike  Mi*«rior  nmtiine  at  tbe  «pi&Kl  oont 
^(  Tb»  poftkv  ol  Ut*  fmnmt'o  rttuultiru.  wlucli  npriOTaU  tli*  aUnat  •tiviuon 

«f  Uw  uiluiiv  nMb-»aiM  tA  lbs  fplskl  conl 

ft,  ytidaw  e(  Um  pynaii. 
fo.  FftraUrwT  botlr. 


3S 


ANATOMICAL  AND  PIlYSrOLOOICAL  MTBODUCTIOK. 


From  the  anterior  nucleus  of  the  lateral  column  (FigAZZ,  i 
fibroa  may  be  obaorved  prooeeding  inwarda  aod  passing  beti 
the  antero-lateral  and  postero-lateral  groups  Some  of 
fibres  ccoas  orer  and  appear  to  be  coanected  with  the  bj 
accessory  nervo  of  tbo  opposite  side.  Others  wind  rouud 
postero-lateral  group  to  get  to  the  &iMQEd  acMssoiy  neiro 
the  same  aide.  From  the  posterior  uuclc-ua  of  the  lateral  coll 
{Fijj.  1S2,  pic),  fibres  proceed  inwarda  to  reach  the  grey 
stance,  and  wind  backwards  along  the  boundary  line  between  the 
white  and  grey  subBtance  to  reach  the  spinal  acccBSory  nerve  of 
the  eame  aide.  The  nuclei  of  the  lateral  column,  therefon, 
appear  to  give  origin  to  some  at  leant  of  the  fibres  of  the 
spinal  accessory  nerve ;  and  wo  have  only  to  suppose  that  the 
eame  arrajigement  is  carried  out  aa  we  ascend  tlie  medulla  uA 
pons  in  order  to  understajid  the  origin  of  the  motor  fibres  of 
the  pneumogastric  and  glosso-pharyngeal  nerves,  those  of  a 
large  part  of  the;  facial  nerve,  and  of  the  motor  root  of  the  fiftk 
Tlie  arrangement  of  the  fibres  from  the  nuclei  of  the  lateral 
column  which  pass  out  along  with  the  glosso> pharyngeal  nerre  la 
represented  in  Fiij.  124>.  The  fibren  from  the  anterior  Ducleos 
(FigA2t,alc)  proceed  backwards  and  inwards,  and  pass  between 
what  will  be  afterwards  described  as  the  antero-Iateral  and 
poetero-kteral  groups.  I  bavc  not  boon  able  to  assure  myself 
that  any  of  these  fibres  cross  over  to  the  oppodte  side,  altbouj^ 
this  is  probable ;  but  some  of  them  may  be  distinctly  observed 
to  wind  round  the  postero-lateral  nucleus  to  proceed  in  the 
direction  of  the  glosso- pharyngeal  nerve.  The  fibres  from  tfai 
posterior  nucleus  (J^i^.  124,  j)ic)  proceed  backwards  and  inwards, 
and  on  reaching  tbe  grey  substance  bend  abruptly  outwavdi 
along  the  edge  of  the  whito  subiitance  to  reach  the  nerve.  A 
similar  arrangement  may  he  observed,  at  a  lower  level,  with 
respect  to  the  pneumogastric  and  spinal  accessory  nerves.  At 
a  higher  elevation  the  fibres  from  tbe  nuclei  of  the  lateral 
column  proceed  backwards  and  iuwanU,  tbe  majority  of  tbera 
(genu  nervi  facialis)  wind  rouud  th«  nucleus  of  the  sixth  nerve, 
and  pi-oceed  outwards  to  join  the  facial  nerva  The  fibres  from 
the  posterior  nucleus  of  the  lateral  column  {Fig.  126,  pic) 
appear  to  me  to  pojus  backwards  and  to  the  oiitHidc  of  the  nucleus 
of  tho  aixtb  neive  to  join  the  lacial.    The  anterior  uuole]; 


tbo  Ut«rtil  column  appears  to  terminatd  on  a  level  with  the 
origin  of  tbe  facial  nerve.  Fibres,  however,  seem  to  pass  upwards 
sod  backwards  from  this  nucleus  to  join  the  motor  root  of  the 
fifth  nerve.  In  F\.ff.  127  the  anterior  nucleus  of  the  lateral 
oolunm  of  the  medulla  is  not  represented,  but  tho  Sbres  trans- 
fnwljr  cut  at  (r)  shows  that  these  have  joined  the  others  from 

Fio.  ISS. 


.  115  (U«liS«>t  fpHii  Flecbim.    Stetian  a/  f\(  Xr«i«rin  OUmfula  m  a  Intl 
mlA  At  tuptrfieuil  oripin  0/  (k(  Aeomtte  iTcrw. 
tvm.  Ibkot  of  tlia  aecnsita  atirve. 

Tin,  r<M«riar  Bwdiu  adowtic  DsdauK 
rai',  PsMoiar bicnl aioaiiiitie aacUtu. 
H,  Nadmi  at  Uw  hniBgLMwl  mtt*. 
tji.  iMVttal  diiU«a  o(  uw  iofoto  paduiid*  of  th«  oanlitUinii. 
•p.  CxtaEiul  dtrUcB  of  tba  iaftrior  pwhincla  of  Ui*  cerebvUiuo- 

a,  Amfwiu  fitiFNk    Til*  wmtiniiig  bttera  tndicrtt  Uu  imm  m  Ute  coTrmwadiajf 


w 


ANATOMICAL  AUD  PHTSIOLOOICAL  IKTEODUCnOlT. 


11  tjifiercot  level,  aoil  I  bcHcve  thai  Ibeao  fibres  Iiavc  asce 
from  the  aaterior  nucleus  of  the  lateral  column.  Tfa*  n 
□Dclcus  of  the  fifth  (Fig.  127,  7)  appcnrs  to  be  the  oodUqui 
upwanis  t^  the  posterior  uucleaa  of  tbe  lateral  coiumo. 
DQcleua  DOW  lies  cloae  to  tbo  scnaoiy  fibres  of  the  nerve,  an 
fibres,  instead  of  winding  backwards  at  Brst,  as  tbey  do 
lower  level,  appear  to  pass  outwards  at  once  b>'  tbo  &ido  of 
sensory  fibres. 

Tbe  groups  of  cells  of  tbe  anterior  boras  maj  be  It 
upwards  more  or  less  disUactly  to  the  nHclciis  of  origi 
the  bypoglossal  nerve.  Tlio  hypoglossal  nerre  begins  o 
level  with  the  upper  limit  of  the  crossing  of  tbe  fibres  of! 
pyramidal  tract.    Tbe  crossing  of  the  fibres  bad  detached 


*  .fj 


Fia  ]Sfl. 


y 


i' 

FlO.  198  (Ue^&id  fram  Kth).  3Vdl*«raw  Stflh*  0/  the  Pom  on  m  lent 
AMutntanirheUil  lto«tt.  fromanintnotmutnJirtm.—Th'ngUl  half  : 
Mala  k  wction  mado  ft  lilcle  lowvr  than  tb»  Itft  P.  l'yrmni\Ah,\  it 
ttetmotj  portion  of  the  pYntDidal  tract ;  TV  and  TV,  tta.>inTrn«  libre*  1 
mun;  »\mappri<irtiittiytiody;  aSfiituipie,  ftMnriarBndixMtmcjrnuddt, 
lUcral  oolinnn  rMi)^!]*^)^.  rvprcaeuliuK  Uio  Dudoai  of  ilt<-  fkcial  iimr  i  i 
root  bl  tbe  ruial ncrvD ;  n',  noolnwof  thadxtliiurvt!  uvi.  f-i^l  vf  Urfj 
ntrvc ;  at,  MaaxluiB  root  of  th«  trigaidmia.  B,  Tkt  tiit«raa1  divhinn  f 
paduiuiliiof  thncvirmllnm  tntt  pnumfnim  tkocBTflwIluin;  £.,  jxmtmtarl 
tttilinal  fMCtcoIui ;  ar  anil  ar',  tbr  upward  onBtioiiatiw  of  the  intcniM 
fXiCRialdl'riiiontof  tbtanttnorTooCionsof  thf-spiBaleord;  (.faadeDliiaj 


^    Tbew 

however,  distioctly  armngcd  into  Bcveml  ^jroups  vbicb 

80  cloaely  mtb  the  arraugcmeot  of  tlie  groups  tn  tbe 

horns  of  the  cord  that  I  hare  no  hesitation  in  regard- 

ttboae  of  tbe  former  as  coaliauattonB  of  tbe  latter.     An 

Fio.  187. 


F, 


7>-- 


T' 


i-l 


42 


JUJATOJUCAL  ASD   PHTSIOLOOICAL   ISTRODUCTION. 


iutenaaJ,  aot«ro-lateral,  and  po9tero-lat«ral  (Fig.  109,  t,  al, 
group  may  be  distlaguisbcd,  and  these  appear  t4  coirtispond 
the  groups  of  tfae  some  narno  in  tbo  cord  ;  wbilo  a  largo  nnml 
of  cells  may  be  obaenred  at  tlie  rooUs  of  tUe  hypoglossal  nc 
{Fig.  109,  ft),  which  may  bo  called  the  anterior  gronp, 
which  correapooda  to  the  ajiterior  group  in  the  oord.     All 
huR  been  previously  Kaid  with  regard  to  the  development 
the  groups  of  cells  in  tbs  anterior  horns  of  the  cord  applii 
equally  to  those  of  the  hypoglossal  nucleus.     The  oeotral  Ofll 
of  the  latter  groupa  develop   Brst,    while  the  marginal  oel 
develop  Isint  and  close  to  the  blood-vessels  which  rmmify  betwc 
the  groups  as  they  do  iu  the  cord. 


e< 


a:<- 


_ir 


.— Tj- 


I'm.  129  fMixllfied  from  \ltpitTl.).  Trantrvrit  Section  n/  tJw  Pont  on  a  Itact  leitk 
wpcr  (M<l  <^  Ui*  Poartlt  VtJitriilr,  Jrom  a  nint  nuMiUj  Auutan  rai&rjM. — P,  p 
■Bulal  tnwl;  p,  uoMury  poKSoa  oi  th«  nymnideJ  tract ;  Tr,  Ti',  bmaa* 
flbTM  dt  ch«  pouw  I  Bf  aaperior  bndiiuni  <i  tlw  |kiu  ;  L.  pcalcTiar  ko|tMiL__ 
ilwiQulu:  aruiu«Kiipw>rdo»fil(Biiktioao[UMiBUnuJM»lext«nnfpoftioM 
M«p#pUr«lf  of  ths  kBlMior  rw>t-M3i«  nf  ihii  DiiiBal  cord;  f,  mUdl*  mmaorf 
Kn^tinxaiX  cuclciu ;  dt,  detoemliait  rout  of  the  irigemlniu ;  iv,  nudsiu  at  tlw 
fgnnl)  ik«T«  ;  ee,  Ktnadaot  of  Sjiriw. 


AKATOiaCAI.  AKD  PHT3I0L0GICAL  DTTaODCCTlOS. 


43 


It  is  not  easy  to  trace  tlie  continuatioD  of  the  groups  of  cells 
of  the  anterior  horns  of  the  cord  beyond  the  utickus  of  the  hjrpo- 
glosaat  Dcrre,  inasmuch  as  the  groups  become  separated  loogitu- 
dinallj  by  the  transverse  fibres  of  the  pons.    It  is,  however,  pro- 
bable that  the  QQcleus  of  the  sixth  Dervo  (Fig.MG,  vi*)  repneents 
the  poatero-lateral  group,  and  the  bending  of  the  fibres  of  tbe 
facial  nerve  round  the  nucleus  corrosponds  to  the  similar  bond- 
iog  of  the  fibres  which  issoe  from  the  anterior  nucleus  of  the 
Hberal  column  in  the  lower  part  of  the  medulla  round  the 

Fio.  129. 


f^.  IS  OlodiSvd  &0B  KnnH).  Traiurtnt  SoAm  oJ  tJu  Ct?u  C<rAri  on  a  Iml 
nd  (ir  anlcrur  pair  fj  Corjiom  Qmnttistmbin,  from  a  nine  mcnU*  nH&ryu. — 
&  enwU;  F,  pymiiitUl  lnoL:ii,  •ooenorr  [>ortiui)  of  tbe  iiyrkiuiiUl  Inul: 
XJr,  kXDi  odccv;  fi-V,  red  ducIcui  or  tho  t?);iDi?Dliini ;  /.,  [innterinr  lonKitndinM 
iMacolM:  wutdor'.  npwkrdcoulinnsU^n  »f  tha  iiilvm^  uid cxUrnaliicirliciM 
nmMtivHf  ol  tbe  anlertor  root'ioce  of  tbe  (jilDal  oord :  ill,  Ibird  ncrre ; 
tB\  imcUaa  of  tbe  tliird  Dcrre ;  it,  tourili  bcxvc;  it',  ouolctu  of  tbe  fourtb 
BB«« ;  IT*,  oroMUM  et  tbo  fibi**  of  tL«  (owtil  licrm  to  opi>ciait«  ddw ;  di. 
aaaoiiliBg  not  of  tb*  trisasiaw ;  w,  aqntdnct  «i  SyMm ;  z,  orMriiw  of  the 
fca  o<  ilM  npnlin  pcdnncln  ol  Ibe  cmMhnii ;  w^  fHCionlui  of  nodoUMcd 
ttns  rrawijinn  to  tlie  katerior  pair  «f  oorpon  qtaadntfonuiw, 


41 


ANATOMICAL  ASD  PHTaiOLOGlCAL  IimiODUCTIOH. 


postero-latcral  group  to  join  the  spioal  accessory  oerre. 
postero- lateral  group  cannot  be  traced  bejocd  tbe  nucleus 
tbc  sixtli  nerve,  and  probably  ceases  tberc.    The  internal, 
terior,  anil  antero-Iateral  groups  are  (Usiocn.icil  iipwards,  aa 
result  probably  of  tbe  longitudinal  extent^ioD  of  the  central 
tube,  wbtcL  Ih  rcnderod  oeoeeAarj  id  onlor  to  provide  accommfl 
dation  for  tlie  large  maaa  of  the  trAcsvorse  fibres  of  tbe  poi 
These  groups  reappear  in  front  of  tbe  aqueduct  of  Sylvius, 
form  tbe  nuclei  of  the  third  and  fourth  nerves  (Fi^.  129,  ill',  IV^. 
The  fourth  oervo  is  in  ray  opinion  merely  a  portion  detached 
from   tbe   third    by   tbe    decuiu^iug   fibres   of    the  superior 
peduncles  of  the  cerebellum,  and  tbus  compelled  to  seek  ita 
destination  by  an  independent  route.     Tbe  fourth  nerve,  there- 
fore, appears  to  belong  to  the  syfitem  of  anterior  molor  nervag 
reprexented  by  the  hypogloKsal,  sixth,  and  third  nerres, 
not  to  the  "mixed  laterid  sygtem"  represented  by  the  spu 
accessory,  vaguH,  glosso-pbaryogeal,  and  fiflii  nerve«t.     Altbou| 
ihe  fiicial  is  a  purely  motor  nerve,  it  appears  to  belong  at 
leaat  in  part    to  that  lateral  system.     Tbat  llie    nudem  of 
the  sixth  on  tbe  one  band  and  that  of  the  third  and  four^^ 
on  the  otber  really  belong  to  the  uinie  nucleus,  and   ai^| 
only  separated   from    one  another  by  some  structure  being 
intercalated  in  tbe  course  of  evolution,  is  rendered  probable 
the  fact  that  the  nucleus  of  the  sixth  is  connected  with  a  portic 
of  tUe  nucleus  of  the  third  of  the  opposite  side  by  a  distim 
bundle  of  Hbres  (Duval).     The  fact  that  those  nerves  are 
closely  related  in  their  functions  affords  further  corroborative 
evid^ce  in  favour  of  this  opinion. 


§  366.  ContintMtuin  of  the  Posterior  Orvy  Hoitia  of  th* 
Spvnal  Cord  tkrowjk  the  Medulla  Ohlongata,  Pons,  and  Ontv^^ 
Cerebri.— We  have  already  seen  that  the  substantia  golatinos^* 
of  tbe  posterior  horns  mui  not  only  tbnist  out  laterally,  but  also 
almost  detached  from  the  rest  of  the  grey  substance  by  tha 
arcuate  fibres,  and  we  must  now  observe  that  it  maintains  thi 
lateral  and  superBcial  poKitiou  as  high  as  the  level  of  the  poi 
of  emergence  of  the  fifth  nerve  (Plgt.  IS*  to  127,  at).     It 
may.  indeed,  be  said  that  this  structure  is  contiuurd  upward*! 
to  tbe  level  of  tbe  opening  of  tlie  a^^ueduct  of  Sylvius  into  lb 


AXATOUTCAt  AND  PHYSIOLOGICAI.  ISTRODDCTrON.  45 


ventricle,  since  the  deKendiDf;  root  of  the  fiflJi  nerve 
appetn  to  be  n  Bomowhftt  similar  structure  to  the  ascendicg 
root  and  gelatinous  substaoce  (Figa.  1S7  to  139,  d().  Tbe 
white  Kubstance  of  the  nsoending  root  appears  to  be  the  analogue 
of  the  posterior  root-w>nc3  of  the  cord — a  mere  continuation 
upwanls  of  these  zooes,  after  what  belongs  to  tlie  spinal  portion 
of  the  central  grey  tube  bas  terminated  in  the  davate  nucleua 

§  SC7.  Cdnlinuation  oftht  Central  Column andtiis  VeaievUar 
Column  of  Clarke  ikrov/jh  tk«  Medulla  Obtongala. 

fin  tho  lower  end  of  the  medulla  the  central  column  bccomcB 

ted  from  the  anterior  horn  by  the  decuauatJng  pyramidal 

Ibrea,  and  almost  separated  from  tbe  posterior  grey  horns  by 

tbe  lateral  displacement  of  the  latter.    A  buudle  of  transverse 

Sbres  still  connect  Iho  central  column  and  tbe  poaterior  Lotdb, 

and  these  separate  so  ae  to  leave  an  interspace  in  which  longi- 

ta^ol  fibre*  may  be  observed  to  ascend  towards  the  medulla. 

These  form  a  round  bundle  {Fig».  1 2i  and  1 H,  /),  which  reaches 

u fuutbo  upper  end  of  the  glosso-pbaTjngeai  micleus,  and  has 

been  called  the  "  ascending  root  of  the  lateral  mixed  system  " 

ly  Heynert,  and  the  "  respiratory  fascicle"  by  Krauaa     In  the 

■lonil  region  of  the  spinal  cord  the  middle  portion  of  the  grey 

(riHancQ  is  represented  by  two  columns  on  each  side  of  the 

tnltal  canal — the  vesicular  column  of  Clarke,  and  the  central 

tdmn — but  the  column  of  Clarke  is  unrepresented  in  the  tum- 

bu  aad  cervical  regions  of  the  con].  It  appears  to  me,  however, 

tlHrt  the  vesicular  column  of  Clarke  again  becomes  repreaeuted 

ID  the  bwer  end  of  the  medulla.    A  group  of  ceils  may  bo 

(^Ktved  near  the  posterior  and  intcmtil  margin  of  the  central 

nloBn  in  tbe  lower  end  of  the  medulla  {Fiff.  122,  v<-),  corrc- 

ip'^i:^  to  the  position  occupied  by  tbe  vesicular  column  of 

Chike  in  the  dorsal  r^on ;  and  the  cells  of  both  groups  raani- 

'ttta  tendency  to  be  bipolar  instead  of  multipolar,  like  those  of 

^  Ulterior  boms.    Assuming,  therefore,  tliat  the  group  of  colls 

■»  tlie  middle  portion  uf  the  grey  matter  in  tbe  lower  end  of  the 

Bedalla  ia  tbe  upward  coolinuatiou  of  the  vesicular  column  of 

CUike,  and  that  tbe  remaining  portiou  ropresents  tho  central 

<*tamo  in  tho  cord,  we  shall  bare  no  difficulty  in  tracing  the 

il>>|outioD  of  these  portions  of  grey  aubstance  in  tbe  medulla. 


46 


ANATOMICAL  AND  PHTStOLOOICAL  INTRODUCTIOl 


Immcdiatelj  above  the  cromlag  of  the  pyramidal  fibres,' 
the  aoterior  horna  are  pressed  backwards  towards  the  oe 
■-auial,  ihe  central  coIuuid  lies  poaterior  to  the  groups  of 
ToproooQtiDg  the  anterior  horns,  and  cIobo  to  tbo  central  c 
white  the  representatire  of  the  vesicular  ooluran  of  Clarlu 
«xtWDal  to  the  central  column,  and  postcnor  to  the  gr 
reprweoting  the  anterior  grey  horaa  {Fi^.   130,  XI}. 
nucleus  which  represeots  the  veftiailar  rolumn  of  CEarko 
tains    pigmented   bipolar  colls,   and  constitutes  the  post) 
nucleus  of  the  spinal  accessory  nerve  {Fig.  130,  %t). 
whoa  tho  central  canal  has  opened  into  the  floor  of  the  foi 

Fio.  130i 


./. 


ItXl; 


)fl 


iS^ 


^  (^ 


\iaa 


Fio.  130  (Yonngl.    Xittion  cf  9it  UtduTta  OUunffola,  •  Utile  Mew  U«  , 

CVumiii  StrifOvriat.  (Auvinp  Uit  ffrcntpt  of  CtUi  oj  tAe pTtf  iiUiAinef. 
Rxt,  Fit»w  ol  ungiiLof  tb«  ikvvnth  or  spinal  acooiMrr  nerre.  ^^_ 

XI,  Poattrlor  oadcui  of  Uw  clonoth  scriv.  ^H 

XI*.  AcoManry  nnclvus  of  lb*  i>l«*Milh.iirrTs.  ^^M 

Rxn,  «ll>r»«  ot  oritiiu  uf  Ihp  lovUtb  or  by^DitloM*!  iietv«, 

a,  i.  Hi,  j/l,  Antrrinr,  InicniAl,  uitcro-lfticral,  adiI  poitora-UtRral  ^roapi 
eilli  rt«Mo lively. 

ah,  AcwoMory  lijqN«l(MMl  ntiolciuu 

if,  lutoiv&l  acceMory  facial  nuclei> 

«/  Extuskl  MMMonr  (kcial  nuoUiui. 
C,  CrainJeuud. 
/.  Ifadnitw  r«nndu>. 


AKATOMICAI.  AND  PHTSIOtXMICAL   limtODUCrrON.  47 


'TCotiicIe.  tbe  representative  of  the  vesicular  column  of  Clarke 

Its  Uimst  bockwarda,  and  laterally  so  aa  to  form  tbe  principal 

>  part  of  the  anclei  of  origin  of  the  spinal  accessory,  vajfiu,  and 

:  glosso-pbaryngc&l  nerres,  while  tbe  central  column  winds  round 

tbe  gronps  repreaeotiog  tbe  anterior  bomii  {Fig.  124,  H),  so  aa 

to  lie  internal,  pot>t«rior,  and  external  to  tbem.    Tbe  posterior 

portion  of  tbe  central  column  is  elevated  into  a  ridge  (Junictdvs 

tcrts)  close  to  tbe  median  fissaro  in  tbe  inferior  port  of  tbe  floor 

of  tbe  foortb  ventricle  {Fig.  124,  if).    Tbe  central  column  is 

I  eontinued  upwards,  m  a  thin  film  of  grey  sulMtanoe,  ou  tbe 

fioor  of  tbo  fourth  ventricle,  and  lying  behind  tho  fibres  of 

origin  of  the  fkdal  (Fig.  12G,  0  &ad  the  fifth  (Fig,  127,  r); 

vbile  in  tbe  upper  end  of  tbe  poDi  and  crura  it  is  represented 

by  tbe  grey  matter  wbich  immediately  surrounds  tbe  aqueduct 

al  Sylvius  (Fiffs.  128  and  129,  cc). 

The  characteristics  of  tbe  central  column  are,  as  we  have 

ilready  te«n,  that  ita  texture  is  iipongy,  rcnilering  it  transparent 

on  nctioD,  and  that  ita  cells  are  ooropttrativety  late  in  their 

denlapiDent.    We  saw  reason,  indeed,  to  regard  the  central 

oalnn  as  being  tbe  embryonic  part  of  the  central  grey  lube, 

ud  that  tbe  portions  of  it  which  are  finst  developed  are  thrust 

outnrds  as  new  layers  grow  about  the  central  canal    If  this 

bt  tme,  we  may  expect  t«  find  that  any  additional  nuclei  wbtch 

OUT  form  in  tho  medulla  oblongata  in  tho  course  of  development 

«11  grow  in  tbe  representative  of  the  centra!  column.    This 

ttfectation.  i«  realised.    Whether  tho  spongy  portion  of  grey 

nUtuce,  which  lies  intenial,  posterior,  and  external  to  tho 

^Tfcglotsal  nucletti,  be  or  be  not  the  continuation  upwanlti 

•tf  the  ceatrol  column,  several  groups  of  cells  may  be  observed 

<3  it  which  do  not  become  developed  until  subsequently  to  the 

■nth  moDtb  of  embryonic  life,  and  which  do  not  ap[]ear  to  be 

■vpmeated  in  tbe  spinal  cord ;  they  may,  therefore,  bo  called 

tAi  aceestOTjf  nucUi  of  the  moduUa  oblongata.    These  nuclei 

tnitbe  carefully  distinguisbed  Irom  tbe  nuclei  of  origin  of  the 

vital  aoceasory  nerve. 

§  3C8.  Acccsdory  KudH  of  the  Meduila  Ohlonffata. 
(1)  Accuaory  KuoUi  of  the  Facial  Nerve. — ^Th«  fint  of  these 
tVhiiA  X  aball  mention  is  what  bos  been  described  by  Dr.  Lock- 


411 


A:4AT01UCJLL  and  PUTSlOLOaiCiL  KTRODCCTIOS, 


liorL  Clarke  us  tbe  iuferior  facial  nucleus..  TbU  uucleus  coi 
realty  of  Mvcral  small  nuclei.  Two  of  tbcsc,  wbicb  ma 
called  tbe  intorna]  accessory  facial  auetei  (Z^.  130,  if),  af 
OS  two  small  round  Duclei  cloae  to  tho  iaoer  side  of  tbe  I 
gloi&sul  nucleus  aad  the  central  canal ;  and  wbon  tbe  canal  t 
oa  to  the  tluor  of  tbo  fourth  Tdotricto,  they  are  situated  ii 
diatety  beneath  the  ependyma  of  the  vcDtricIo,  and  close  t 
middle  line  {Fig.  124,  if).  FibTCs  from  these  nuclei  ascei 
the  liinicujiis  teres  and  enter  the  fascicnluH  teres  {Fig.  13 
through  wbicb  they  join  tbe  other  fibres  of  tbo  facial  nerr 

Another  somgwhat  larger  group  of  smalt  celbt  is  sitt 
at  first  posterior  {Fig.  126,  tf)  and  then  exlerual  {Fig. 
ef)  to  iho  nucleus  of  tbe  hypoglossal.  The  fibres  vi 
issue  from  it  altio  join,  I  believe,  tbe  fasciculus  teres,  ani 
group  may,  therefore,  be  called  the  external  accessoiT'  I 
nucleus  {Fig.  109.  ef).  The  cells  of  these  nuclei  are  small, 
destitute  of  processes  in  a  nine  mouths  etnbrya 

(2)  Aaxaeory  Naclei  of  Uie  Eieventk  AVrrc — Two  grou|, 
small  cells,  which  develop  at  a  comparatively  late  period, 
be  observed  lying  behind  tbe  poaterior  nucleus  of  tbe  elevi 
nerve  {Fig.  130,  Xf).  Moyncrt  thinks  that  the  ccUs  of  t 
groups  are  connected  with  commissural  fibres  which  run  bei 
the  central  canal,  before  it  opens  into  tbe  fourth  ventricle. 

C3J  Accessory  NttclsM  of  tfie  £lypogl99$al  Iftrve. — The  \ 
most  important  nucleus  of  this  category  is  one  which  I  | 
constantly  observed  in  the  hypoglossal  nucleus  of  one  side  L 
{Fig.  130,  afi).  As  I  have  not  marked  my  sections,  I  as 
present  iinahlo  to  say  whether  it  is  found  on  the  right  ai; 
side.  This  nucleus  is  of  a  round  form,  and  appears  as  ) 
were  surrounded  by  a  kyer  of  white  Gbres,  arranged  l4 
tndinally,  which  separates  it  from  tbe  surrounding  tissuoj 
contains  a  large  number  of  very  small  caudate  cells,  t 
being  not  one-fifth  the  diameter  of  the  cells  of  the  b 
glossal  nucleus.  Tbe  nucluus  lu  some  sections  lies  beti 
the  internal  ami  external  convolute  of  the  nucleus  of 
hypoglossal;,  while  at  other  limes  it  is  embedded  in  the 
stance  ut  the  internal  convolute,  being  then  situated  neai 
margin  of  tbe  group  (Fig.  130).  This  nucleus  is  almost  ent 
limited  to  one  side,  altbeugb  faint  traces  of  tt  may  occaflioi 


SAXATOMICXL  AND  PHTSIOLOOICAL  INTHODUCTIOIT.  49 

<b«ervod  in  the  opposite  side;  it  is  ecarcclj  recognisable  on 
er  side  of  the  mcdulta  at  the  Dtotb  tuooth  of  embiyonic 
life,  Tbe  moat  reasonable  supposition  with  regard  to  it  is  that 
it  regnlal«8  the  movemflDta  of  nrticiiUtion,  and  that  it  is  c<m- 
oected  with  the  third  left  frontal  conrolutioc  of  the  brain. 

§  360.  SjiecUd  Nudei  of  iKt  ifedvdla  ObhngaUt  and  Pons. 

(1)  Tiu  acoustic  nttclei  can  scarcely  be  said  to  be  repre- 
Mated  by  any  portion  of  the  gray  substance  of  the  cord.  Thesi0 
■nctei  are  four  in  number:— 

(a)    The   poaterlor   median   nucleus    0/  the   acoustlcus 

fJKg.  125,  VIII)  comes  in  contact  with   the  nucleus  of  the 

n^Di,  but  is  more  supeHictally  situated  than  that  of  the 

litter,    and    somewhat    to    the    ontcr    eido    of    the    glosso* 

pliatyngeal  nucleus.     H  occupies  the  whole  space  between 

liie  aU  ctuerea  and  inferior  peduncle  of  the  cerebellum  up 

\a  tL4  anterior  border  of  the  stris)  mcdullarea.    The  posterior 

toot  of  the  acoustic  nerve  takes  its  origin  chiefly  from  this 

aiKltus,  and  posBes  oat  partly  in  siipcHicial  fasciculi   (strife 

wovstice)  and  partly  through  the  body  of  the  medulla. 

(*)  The  poflerior  laitrtU  acoueiie  nucleus  {FUj.  125,  vm*) 
ii  a  grey  nodulo  lying  in  tlie  peduncle  of  tbe  oerebellumf 
belveen  the  deep  and  superficial  fibres  of  origin  of  the  acoustic 
lerre. 

(c)  The  anterior  median  acouetic  nudeiis  belongs  to  the 
a&t«rior  roots  of  the  acoustic  nenre.  and  is  situated  anterior 
Uiihe  stfiie  medullares.  Il  occupies  the  external  angle  of  the 
foitnli  Tontricle,  about  the  middle  of  the  cerebellar  peduncla 

(d)  Tfte  anterior  lateral  acoustic  nudeua  appears  like  a 
{■roloagBtion  of  the  posterior  lateral  ucoustic  nucleus,  and  in 
vtdged  in  between  the  middle  peduncle  and  tbe  tlocculus. 
It  gtvw  origin  to  the  portio  intermedia  Wrisbcrgii.  Some 
tutonuats  believe  that  tbo  fibres  which  pa«s  in  the  chorda 
Ifopani,  and  which  confer  taste  on  tbe  anterior  two-thirds  of 
toe  tongu^  are  derived  from  the  nerve  of  Wrisberg  (Bigelow). 
Iliialso  probable  tliat  one  of  tbe  other  nuclei — perhaps  tbe 
pstteriur  lateral  acoustic  naclcus — give^  origin  to  the  fibres 
•applied  to  the  labynntl,  and  is  not  connected  with  the  purely 
uvuuic  fibre*. 


AHATOMtOAI.   AtTD   PBTSIOLOQICAL  IKTRODUCTIOH. 

(2)  Tht  corpoixt  quadrigemina  and  geniculate  bodies  are  the 
Budet  of  origin  of  the  second  or  optic  oerve ;  but  we  are  uuable 
to  saj,  in  the  present  sttate  of  oiir  knowledge,  what  HlructorM 
GOQetitute  tbe  ouclei  of  origin  of  tbe  first  or  olfactor^r  nerve. 

§  370.  Superadded  Grey  Matter  oftfa  MedtUla  Obi<mgata 

and  PiyM.  M 

(1)  The  davaie  KucUwt — The  columns  of  Goll  contain  in 
the  lower  part  of  tbe  medulla  a  nucleus  of  grey  matter,  which  i« 
from  its  form  called  the  clavate  nucicua  (>Vi/s.  122aad  I2+,  en). 
It  is  a  longitudinal  pillar  of  grey  substance,  and  produces  the 
enlargement  io  the  fusciculu)*  groctliif,  knuwn  aa  the  clava. 

(2)  2*^  triav^vdnr  niidcwf  {Figs.  122  and  124,  in)  ia 
grey  nucleus  enclosed  la  tbe  cuaeate  fasciculus,  tbe  latter 
which  18  the  coQiiDaatifru  upwards  of  tbe  posterior  root-zoii( 
of  the  cord.  It  ia  a  longish  grey  body  on,  the  iiiner  border  of 
the  cuneiform  column,  and  enlarging  as  it  ascends.  Tbe  claTal* 
and  triangular  nuclei  extend  to  the  poatorior  end  of  the  postero- 
lateral acouHtic  nucleuH. 

(3)  tbe  olivcmj  body  {Fig.  12*,  o)  is  situated  io  tbe  lateral 
columns  of  the  luedultu,  close  to  the  anterior  pyramid.  In  form 
it  iii  like  a  bean  or  au  almond,  with  the  hilus  directed  itiwarda. 
It  contains  a  number  of  nmall  ganglion  celL»,  and  is  in  Hubxtance 
very  similar  to  the  corpus  dentatuiii  of  the  cerebellum.  ^H 

{4)  The  jxiroUvarff  hvdy  {Fig.  124,  po)  is  a  band  of  gw^^l 
matter  which  bounds  tbe  internal  half  of  the  posterior  border 
of  the  oHvarj'  body.  ^H 

(5J  The  nuclciu  of  Ute  pyruTnid  (Fig.  124,  np)  (interna^ 
parolivary  body)  lies  opposite  tli<e  pyramid,  in  front  aod  to 
tbe  inside  of  the  olivary  body. 

(6)  The  amperior  olivary  body  {Fig.  128,  so)  is  a  longiab, 
grey  column,  situated  in  tbe  pons  in  front  of  the  facial  uuclcua 

(7j  The  red  mbcleas  of  the  Uymantuin  (Fij/.  1S9,  Rff)  of 
Stilling,  or  superior  olive  of  Luys,  is  situated  in  the  cms  cerebri, 
between  tbe  crus  and  tegmentum,  and  ia  similar  ii^  etructur*_ 
to  the  olivary  body. 

(8)  The  middl*  WMory  nucleus  of  the  Irigeminw  {Figa.  V, 
and  128,  v')  is  also  a  superadded  structure.    This  nuclexis  is 
ntuated  in  the  eubstance  of  the  afferent  fibres  of  tbe  trigcmiooi, 


iO'ATOMICLI.  AND  PHYSIOLOGICAL  INTKODUCTIOJI. 


51 


Dot  far  from  llieir  cntntiee  into  the  poDs.  In  structure  it 
»  iwmewlint  similar  to  tbal  of  tiie  gaogli&  of  tlie  posterior 
roots,  and  it  may  represcQt  tbe  gnoglioo  of  the  detioeading 
tuots,  while  tbe  OttKseriau  g&Dgliou  represents  that  of  the 
ueeodiag  roots  of  the  nerve. 

§  371.  Ihveloimient  of  the  WhiUs  Substance  of  the  Cord. 

Tbm  wbil«  nilwtaooe  i«  fomod  on  Uto  mrfao*  oF  thy  dwpcr  gny 

Soon  titer  the  tubo  irbivh  fornu  the  rudimcQt  of  tbe  conl. 

hn  doaed,  it  ia  seeo  ta  be  aoioewbftt  oval  on  aectioo,  with  a  mntral  canaL 

At  lUa  |Mriod  tbe  cord  consists  alniooi  entirolj  of  grey  tustter ;  ami]  bj- 

Um  aifeusDoe  nf  lateral  aliU  each  latwal  hair  buoomas  imperEectlj 

Allied  into  t«m  iwrts,  the  «nt«rior  and  poetemr.     In  tbe  human  etabrjo 

ft  IDU0  of  white  HilMtaaoe  a(>peftre  towaMe  tho  end  or  the  lint  tnoiitli  on 

Ibnlcriorof  Mohof  thcH  parts  ;  and  LbeM  may  resiwctircl;  bo  called 

lbtwiUriorand|>oat«norroot'£ODes(^^.  131,  a,/)}.    Tbe  anterior  portioint 

Fto.  131. 


/Im. 


p^ 


^"^ 


ar 


ta.  in  [Fiwn  KUftltfT).  rmunrn'  Stiiwn  vf  th*  Crrpiem  Pat%  ef  t\t  Smmal 
Critf^  ffMSHM  Kmbtyo  r>f  ni  Krfki.—t.  0«nlr»l  can»l ;  r.  r'.  Its  c|4tnelUI 
ImhI  a.  Gnymhili*i>^  ;  ir,  Antvriur  »roU  i  pr,  f  uatvriur  fwM  i  a,  Aulvrlur 
fW  ifliMi ;  p,  IfiMttrior  loot-ioaea. 

(f  Hftt  are  Bltenrtirds  tbe  lateral  columua  of  tbe  cord  d«v«Iap  ti  parts  of 
tt>*at«riar  roo4-si>n«it,  \nii  Uio  potUitior  ponioiitt  do  uot  begin  to  develop 
UC  almit  two  wmks  lat«r.  The  |>orti<ui*  last  dvvelgpwl  appear  to  belong 
^  Utf  pntarinr  root-suoes,  and  Juio  them  in  tbe  medulla  to  fonn  the 
(■iltim  bodiM ;  aod  FlecbMg  thiuks  tltat  the;  paw  directly  to  tbe  oortei 
of  tia  oovbriluin,  bence  the;  ma;  be  called  the  direct  c«rebellar  Rbres  of 
^hteral  cotumiia. 

At  tbe  aod  of  tha  eighth  iroek,  then,  the  grej  nubataiicc  of  the  cord  in 
Ut  hvmao  •nfacya  a  covered  Bnt«norlv,  p^ieteriorlj',  aiid  tfttarallj  b;  a 


AlCATOMICAL  ASD  PHT8I0L00ICAL  IMTBODUCTlOlf.        5S 

nt  oi  Uw  ooU  id  «qtuUy  tnie  with  respect  to  tha  diontetor  of  the 
fibcw.  Tbtt  diomoter  of  thoM  SbrM  tuny  ba  a«c«iitod  m  & 
rwigh  Utt  of  Um  ag*  of  tbo  fibrM  during  th«  period  of  d«Ttt)op(neat,  Init 
iu>  longer.  It  is  verj  probable  that  the  ataal\  maduiUted  fibres  of  the 
[^Tuoidal  1n«t  MimMt  togeiber  the  sdihU  udla  of  tbo  autorior  borua  uiil 
nl«tinly  snutU  oelU  in  the  cortex  of  the  bniu  ;  while  ou  tbo  oontrary  the 
t&idc  &bree  oocD«ct  th«  large  giU)gli<Ma  oelle  of  the  anterior  home  and  large 
oUa  of  1b«  cortex.  The  lar^st  oella  of  the  ^nal  cord,  for  instancs,  are 
lDandii)th«luml»rrogi4D,aiidtb«Urgeatiath<i  cortoxof  tb*brftin  in  the 
fuaoentnl  bbule — the  oeotre  of  the  movements  of  tbo  leg— and  it  ia  pro- 
iMblt  that  thaae  eeO*  an  oonneeted  with  each  otb»  by  thick  fibree.    w* 

Fm,  135. 

ar 


or: 


Jr^ 


w 


A 


r»«.«j 


sc 


fit- 


p/ 


fr 


It  "  C 

'^M.  Ppper  t»i  of  Xiuttar AifwvnKtf-— file  UlUn  ioJiuU  tha  ome  m  the 
e»tnipndla(  <»•■  in  iV  ^^*- 

'"illrcady  aeea  that,  as  a  rulv,  tbo  oOcoaaoty  are  amaller  than  tbo  fundu- 
^Btal  gan^oQ  ceUs  of  the  anterior  buroa,  aud  it  nay  therefore  bo  in- 
^l*i  that  tha  Koeeeorf  fibrM  of  the  pyramidal  tract  are  aa  a  rule  Amaller 
ba  tha  fattdsBMCtaJ  ooea.  The  smaller  Sbrea  are  found  in  greater 
wabew  in  the  tat«ntid  and  potlerior  part  of  tha  la.toml  column,  the 
pwtioQ  of  the  white  column  ithiob  adjoins  the  grey  sabstance.  At  this 
^*  At  ufH*  of  Manectiro  Useue  are  iMTget,  the  oeurogUa  is  more 


^ 


56        AXATOHICAL  AKD  rilYSIOLOGICXL  INTRODCCTIO!?. 


8(>ong7,  and  tha  lnzei)ft&-akai>ed  eiMcea  alreadj  deacrilAd  (/Vjt-  133)  m* 
more  difttinotly  mark«<!  than  in  the  more  external  latere  of  thft  irtute 
oubEituicff.  Tho  frrviatio  nticidarit  of  the  spiDal  oord  spiwarv  tixlMd 
to  o««  it«  wtructuml  pwuliSLritiM  miLinlj  to  th«  Gtet  ttut  it  conaute 
ill  gnai  part  of  longitudioal  fibres  of  Btaall  diametor  Mpatated  bta 
bandleB  by  comparativetjr  large  §epta  of  loosa  Qeun>(;lu.  Thia  povtioo 
of  the  oord  aUo  trausniilfl  fibras  which  iuue  from  the  grey  mbatimco  to 
MOMid  in  tho  pjru&itUJ  Irsct,  and  from  tho  v«rictilar  ooltimn  of  Clarite  to 
pan  oat  to  the  diract  oerobtHar  tract.  But  thn  Ion  gitndioal  fibrao  of  amall 
dianMt«r,  which  aro  to  abundant  in  this  portion  of  ths  oord,waaUl  appaar 
to  belong  to  the  acoeaaorj  portioQ  ot  the  pj-ramidal  tract.    lodoed,  tlta 


.Fio.  139. 


ar    T 


F)0. 13ll  LmetrenJ  *f  Dortat  Rttjion.—'T .  colnmn  oT  Tfitck ;  <ic  dlr««t  ombcUar 
tnwt.  'Xbe  otbvr  lotten  iudicsU  Uie  Mtme  at  tb«  oorrMiwiMtng  ooee  in  F>q,  1S|. 

apcngy  charoctAr  at  the  n«urog)ia  and  th?  roBoulantf  of  thii  voa  nadtr 
it  peculifLTly  adapted  for  the  growth  uf  uow  tiliiM.  The  Bbna  of  !&• 
oolunuiaof  GftUan  aiao  aapanitecl  by  tho  dutlribution  of  the  blood.Tnawb 
and aepte of  coDQOctire tuBue  intolazoDgcBbniwd  epocos.  Tbo  fibrea  at 
the  margina  of  theae  ^Moes  are  not  medullatad  at  nine  monUu  of  ombiTonie 
BSi^  and  they  are  ae  a  rule  loaa  in  iliamctor  tn  tho  adult  cord  thaa  the 
Ulna  which  ocenpy  the  centrea  of  the  apaoea.  These  amall  fibrea  must 
tberafon  b«  regarded  as  belonging  to  the  acceasin7  ajatem.  The  Sbne  of 
UupoatariorrDot-soDea  are  nuaUer  than  tboaeoftbe  anterior  and  latiiml 


JUUTCHDCAi.  A2i'D  PHYSIOLOGIC  A  I,   IlfTRODUCTION.         57 

ealtuiui%«ithtlMeiMptioaof  aoiaeofthea«cca)ioT7  6)>resof  tfa«  pyramidal 
(net  Tbe  reuon  of  tJiii  opiwiun  U>  he  that  (bo  fibres  of  the  pa>t«riar 
not-MQM  MniiMt  tba  c»Ua  u(  th«  [unibirtikr  hortui  with  e«ch  other,  and 
tbe  UUflT  being  thentBelvw  kqiaU  tbic  iaUtrcoQuauoicatinf  fifarea  we  olw 


§871  XonTiluffinai  Distribution  of  the  White  Substance. 
These,  tbeo,  are  tbe  component  parts  of  ttie  Bpinal  cord. 
coDudered  with  refereocc  to  its  tranavereo  section ;  tbe  longi- 
^inal  distribution  of  t\fne  parU  must  dow  be  described. 

Fio.  137. 


ar 


ary 


r  'v 


■A 


-ac 


Off 


pe 


<fr1 


fit 


dc 


c 

Fto.  m.  MbtdXt «/  Donat  AgtOH. 

'Tbagroy  matter  extends  the  wholo  length  of  the  cord,  aod  its 
Httataintains  a  cooatant  relation  to  tbe  number  and  vArioty 
of  eh*  tnovemeDia  to  be  co-ordinated ;  honcc  it  is  larger  iu  tbe 
IboW  and  cervical  regions,  where  the  moTcnaeuts  of  tbe 
umU  are  co-ordioated.  The  anterior  and  posterior  root^zones 
■W  axteod  tbe  whole  lougtb  of  the  cord,  and,  speaking 
lijr,  their  nze  maiDlaiiis  a  pretty  constant  relation  to  the 


58 


AltATOMICAL  AXD  PaT8IOLO0ICA.L  INTRODb'CTIOK. 


size  of  the  gKy  matter,  although  there  is  probably  a  slig 
increase  of  size  from  below   upwardii.     The  mo<tt  noticcali 
feature  with  regard  to  the  remaiDing  buodlos  of  fibres  is, 
they  increase  Bteadily  in  si7e  from  below  upwarda.    The  fibr 
of  GoU  (Fiy*.  13i  to  140,  O)  eitend  the  whole  length  of  thfl 
cord,  but  thejF  gradiinlly  diminiiih  in  size  from  tlie  medulla,  a 
that  mere  traces  of  them  arc  to  be  found  in  the  lumbar  region? 
ThepjramidiUGbiesof  the  lateral  columns  (/V^d.  ISli  to  IVi.pl) 
tho  extend  the  whole  length  of  thu  cord,  but  steadily  diminish 


Bfv 


w 


ft 


1 


da'~Jl 


.-  i 


pr    /r 


Qcc 


■/te 


FlO.  138.   Vpp*r  mil  e/  Donal  Jtrgitm . 


ID  size  &om  abovo  downwards,  ao  that  they  are  redaoed  to 
oomparatively  small  bundles  in  the  lumbar  region.  The  direct 
cerebellar  fibres  of  the  lateral  columns  {Fi{/a.  136  to  140,  de) 
appear  in  the  cervical  region  as  thin  lamelliB  of  fibres,  one  on 
each  side,  external  to  the  pyramidal  fibres.  They  dtmiaish 
ID  size  from  above  downwards,  and  disappear  somewhat  below 
tb«  middle  of  the  dorsal  region,  so  that  ia  the  lower  dorsal  and 


AXATOUCAL   AXD   PHYSIOLOCICAL   IXTBODUCTIOS.         59 

lambar  regions  th«  pTramidal  Bbres  come  to  tlie  surface  of  fbe 
cord.  Tlie  fibres  of  Tiirck  C**'^*;  136  to  140,  T)  also  diminish 
JQ  size  from  above  dowDwards,  aad  dieappew  about  tho  middle 
of  the  donal  region. 

The  relative  size  aod  position  of  the  different  eegmeuls  of 
the  white  substance  majr  be  seen  in  Fif}s.  134  to  140,  which 


Fk.  139. 


ar 


a 


nc 


'   ce 


.•JC 


pt- 


■  --.  .-A 


JC 


p'         A'*'    p'r         '^ 

Tm.  MB.  MidJlt  of  Ctrvwal  BuUtrytmnt. 

npraHDl  MctioDS  of  the  spinal  con)  of  a  nine  montha  human 
cmbt^o  At  different  elevatiomL  The  fibres  of  the  pyramidal 
tracu  iyl)  i>f  the  lateral  columns,  and  of  the  columns  of  Qol) 
(0)  and  of  T&rcic  (T),  have  assumed  a  medulla  at  the  ninth 
monili,  awl  ore  not.  therefore,  so  diKtioctly  marked  off  from 
iba  remaining  portions  of  the  white  subetance  as  they  are 


60 


AN4T0UICAL   AND  PnYSIOLOOICAL   IMTWDCCTIOK. 


repreaented  in  the  1igiir«B,  the  latter  being  in  this  respect  mc 
like  the  appearances  presented  by  the  oord  between  the  fifth 
and  fiixtli  moDths  of  erabryonic  life,  at  R  time  when  tlie  fibres  of 
the  acterior  and  posterior  root-zones  and  the  direct  cerebdlw 
tract  are  oJoue  meduUated. 


ar' 


■''■'.! 


/»•-. 


cc- 


^-.' 


^pC 


p^\ 


3C 


fa- 


de 


/»r' 


pr 


Ifi^i 


FlO.  110.  StTlifu  ana  ttvdwilhtht  StcoaJ Ctririca!  fi'ti-rt,- in.  Btiirul  uxcmoiT 
Dervo.     Th»  ottiw  Ictten  Indicate  tli«  nunc  u  llio  concipoU'duig  oucaia  ^ 

§  373.  Continuation  "upward  of  the  varioua  S^/ments  of  tht 

White  SubstanM  of  f/w  Cord  through  the  MeduUa, 

Pom,  and  Cms  C'erehn. 

(1)  Coluvms  of  GoU  and  Posterior  Root-sonea. — A  trans- 

veme  section    of  the  lower  half  of  the  medulla  Rhows  that 

the  columaa  of  Goil  are  continued  upwards  into  the  mednl 


ANATOiaCAL  ASD  PUTSIOLOOlCAt  INTRODUCTION-. 


61 


ID  the  form  of  two  bundles  of  fibres,  one  oa  each  sule  of  the 
posterior  mediao  fissure    Each  bundle  contains  a  nucleus  of 
grey  matter,  which  from  ita  form  is  called  the  cUvat»  nucleus, 
and    the    bundle    itself  is  called  tlie  pyramidal    coIuidd,  or 
fudculuH  gtacUia  (Fig.  122,0,  en).     External  to  this  fascicutuB 
is  placed  a  wedgc-sbapcd  bundle,  called  ttie  fasciculus  cuueatus, 
liolding  in  its  interior  a  grey  nucleus,  calleii  from  its  form  the 
triangular  nucleus  (Fig.  122,pr,tn).     The  greater  portion  of 
tike  fibree  of  the  poeterior  root-zone  of  the  cord  terminatea  id 
tlte  cuncAte  fasciculus  and  its  eucloscd  grey  nucleus.     The 
tU&der  aad  cuncate  fasciculi  of  the  medulla  are  mucU  larger  io 
•te  than  the  column  of  Qall  and  po«terior  root-zone  of  the 
mi,  owing  to  the  iQt«rposition  of  tbo  grey  nuclei;  beace  the 
!    pottmor  bora  of  greymstter  isdisplaced  outwardHand  forwards 
in  the  medulla,  so  tbat  the  continuation  of  the  gelatinous  sub- 
Sun  forms  a  masa  of  grey  matter  oti  the  Intoral  aspect  of  tbe 
udnlla,  known  as  the  grey  tuburcle  uf  Kukudu  (Fitj.  122,  ag). 
lUsmass  of  grey  matter  ia  continued  upwards  in  tbe  medulla 
ud  poos  to  the  level  of  the  point  of  emergence  of  the  fifth 
MRe,  and  gives  origin  to   the  ascending  root  of  the  latter. 
In  dole  relatioDsbip  with  the  external  surface  of  tbis  grey 
nam  ia  a  bundle,  the  fibres  of  which  are  medullated  in   a 
BlDe  montbs  embrya     Tbis  bimdlu  is  the  bomologue  in  the 
BtdvlU  of  the  posterior  root-zone  of  tbe  conJ,  and  La  frequently 
^ni  diseased  in  locomotor  ataxy  {Figs.  122  to  127,  al). 

One  of  the  most  remarkable  rcarrangcmCDta  of  fibres  in  the 
■wialla  arises  from  the  fact  tbat  tbe  cuneate  fasciculus,  through 
tbe  iatenuediation  of  ita  nucleus,  resolves  iteelf  into  arcuate 
'^  which  pass  forwards  and  upwards  to  be  connected  with 
tilt  Dodeua  of  tbe  olivary  body  on  tbe  same  mJo  ;  and  it  ia 
^  probable  that  the  slender  fasciculus  through  its  nucleus  has 
■  itmilar  termination. 

A  tiaosrerse  section  of  tbe  upper  part  of  tbe  medulla  shova 
tliu  the  fibrta  have  undergone  a  still  further  rearrangement, 
udtbat  they  are  greatly  reiufoi-ced  ia  number  ;  but  the  course 
<if  tbe  additional  fibres  will !»  more  readily  traced  if  we  follow 
tbna  fmm  the  cerebellum  to  tbe  medulla,  instead  of  from  below 
upwudH. 
[i)  Conjuctiona  of  the  Peduw^  of  the  CenbtUum  with 


62 


ASATOMICAL  AND  PHTSIOLOQICAL  ISTBODUCTIOK". 


thr.  Uc/ltdla  Ohlonf/nta,  Pons,  and  Cruni  Cerebri. — The  it 
fenor  peduncle  of  the  ccrcbQlIiim,  Bccording  to  Slilliitg,  br 
up,  on  ctitering  the  medulla,  into  an  iaternal  {Fig.  125,  ep) 
aa  external  (^tr/.  1S5,  ip)  dirisioa,  the  latter  of  ivbich  be  call* 
the  "«6tifona  body."  The  fibres  of  the  internal  dirimott 
spring  from  the  roof-miclei  of  Stilling,  and  on  reachiag  the 
medulld  resolve  themeelvcs  into  nrcuato  fibres,  which  pasi 
downwards  nnd  inwards,  iiiterlactag  with  the  aaceudiog  fibres 
of  the  nittcrior  root-zone  behind  the  olivary  body  of  the  mme 
Bide  ;  and  Kome  anatomists  believe  that  they  cross  the  mediia^ 
raph^  to  reach  the  olivary  body  of  the  opposite  side.  Ttnl 
fibres  of  the  restiform  body  are  derived  from  the  cortex  of  the 
cerebellum,  and  from  a  layer  of  fibres  surrounding  the  dentate 
niicleits ;  and  thia  division,  on  descending  to  the  medulla,  sub* 
divides  into  two  bundles,  which  are  separated  from  one  another 
by  the  direct  cerebellar  fibres  of  the  lateral  columns  of  the 
cord  in  their  ascent  towards  the  cerehellam  (Fig.  125,  dc).  In 
a  nine  months  human  embryo  the  fibren  of  the  roetiform  body 
arc  non- medulla  ted  (Fiy.  125,  ep) ;  while  tho-se  ascending  from 
the  lateral  columns  are  medullated  (Fig.  ISS,  dc),  »a  that  tlie  two 
sets  can  be  readily  dlatingutsheJ  from  oac  another.  The  fibre^H 
of  the  restiform  body,  like  those  of  the  internal  division  of  the 
peduncle,  resolve  themselves  iQto  arcuate  fibres ;  the  external 
bundle  forming  the  zonular  layer  which  paeaes  in  front  of  the 
olivary  body,  and  the  fibres  of  which  reach  the  median  raph^  by 
passing  both  in  front  and  behind  the  anterior  pyramid.  Tbos 
which  pass  in  front  of  the  anterior  pyramid  are  called  arclfo 
fibi-es  (Fig.  1 23,  a);  they  wind  backwards  to  reach  the  media 
raphtf  (Fig.  141),  where,  after  ducussating  with  the  correspond^ 
ing  fibres  of  the  opposite  side,  they  bend  outwards  to  reach 
the  olivaiy  body  of  the  opposite  side  where  they  terminate, 
gruat  part  of  the  arcuate  6brc8  of  the  internal  bundle 
to  pass  through  the  olivary  body  of  the  same  side  without  beii 
oonnectt^l  with  its  grey  substance  ;  and  afcer  gaining  the  raph^ 
they  also  cross  over  to  paas  into  the  interior  of  the  olivary  body 
ol  the  opposite  side,  in  the  grey  eubstance  of  which  all  the 
arcuate  fibres  of  the  reatifonn  body  terminate;.  The  olivary 
body,  therefore,  is  the  medium  of  communication  between  the 
cuneate  fasciculus  and  probably  also  the  sleuder  fuacicaloa  of 


AKATOMICAL  ASD  PHTSIOtOOICAL  WTKODUCnOK.         63 

the  same  sido  on  Ibe  one  lianiJ,  and  tbe  r^stifortn  body  and 
probably  tbe  internal  divisioo  of  the  cerebellar  peduncle  of  tbe 
oppoaite  nde  on  tbe  otber  band. 

The  Bbres  of  the  mixUlU  peduiu^  of  the  cerebellum  arc 
derived  from  tbe  cortex ;  they  poas  in  front  of  and  through  the 
mbitence  of  tbe  pons  {Figa.  1S6  to  1S8,  Tr  and  Tr'),  where 
tbey  separate  the  ascending  fibres  of  tbe  anterior  pyramids 
into  buodtcs  (Fif/e.  ISIj  to  ISti,  P,  -p),  and  interlace  in  tbe 
aiddle  line  with  the  fibres  of  the  middle  pcduoclc  of  the 
oppoeite  side.  On  reaching  the  opposite  sidetheyare  suppoeed 
to  l«rfain&te  in  the  cells  of  interposed  grey  nmtter,  by  means 
of  which  they  are  connected  with  fibres  deeceodiog  from  the 
craato.  Tbe  close  relationship  of  the  middle  peduncles  with 
the  lateral  lobes  of  tbe  cerebellum  is  well  illustrated  by  tbe 
(act  that  in  those  nnimnU  in  which  the  latter  are  deficient  or 
absent  tbe  tranaTenie  fibres  of  the  pons  are  few  or  entirely 
wanting. 

T\Q  141. 


fiy 


.1(1  rTraB  BnVi  "AnAknlr"V    XH<vr«n  d/ a  UnamUl  mMm  i^  Oc 
pnMM  I  Tba,  libra  aKalomm. 


64         ANATOMICAL  AND  PHTSIOLOajCAL  JMTaODUCTlOK. 

The  fibres  of  the  aupeTitnr  peduncles  are  derived  frooj 
dentate  uudei ;  Lbey  decussate  with  oue  another  id 
t^meDtum,  the  fibres  of  ooe  side  possiag  over  to  be  conol 
with  the  red  nucleus  of  tbe  opposite  side  (Fig.  129.  ;r).  ■ 
fibres  of  the  saperior  pedutKles  are  medullated  id  a| 
mouths  embyro  ;  they  may  be  seen  sutruunJing,  and  evtf 
the  substaoce  of  the  red  auduus  (fiy.  129,  RX).  aod  a| 
siderable  proporUoa  of  them  pass  upwards  unlatemi] 
into  the  tc^ental  portion  of  the  interoal  capsule,  and 
end  in  tbo  infi-rior  or  external  surface  of  the  thalamus, 
I  am  inclined  to  believe,  pass  uninterruptedly  along  ila  ext 
border  upwards  to  be  connected  with  the  central  conrolv 
of  the  cortex  of  the  cerebrum. 

Some  anatomista  think  tliat  part  of  the  fibres  of  the  anl 
root-zoneB  poM  through  the  crugta  to  juiu  the  lenticular  ni 
but  a  very  important  fact  had  been  ascertained  by  Fled 
which  renders  this  doubtful.  Flechslg  found  that  in  ai 
months  human  embryo  tlie  pyramidal  fihreii  in  thecrtuta  ud 
only  ones  which  have  actjuired  a  medullary  sheath  ;  and  my 
sections  confirm  thta  (Fig.  1S9,  P).  But  the  fibres  of  the  aat 
root-xoneti  in  the  cord  are  medultatcd  at  a  very  early  peria 
development,  and  long  before  the  pyramidal  fibres  have  aoqt 
A  medullary  sheath  ;  hence  it  may  bo  infcfrcd  that  none  of 
fibres  of  the  anterior  root-zones  pass  up  into  the  crust 
motor  tmcl  of  the  crura,  although  it  ia  veiy  probable  that 
fibres  become  developed,  which  connect  the  corpora  striata 
the  cord,  and  that  these  paaa  through  the  crusta  and  be< 
miiced  with  the  fibres  of  the  anterior  root-zones.  The  t 
connection  which  is  maintained  between  the  anterior  root-8 
and  that  portion  of  the  central  grey  tube  which  is  iu  immet 
relation  witli  the  effdrent  nerves,  seems  to  indicate  that 
former  consist  of  fibres  which  coordinate  the  vaiious  segtu 
of  the  cord  tongttudiDally ;  and  there  are  other  groundi 
believing  them  to  consiHt  of  a  series  of  looped  fibres  w 
originate  and  terauuate  in  the  auterior  part  of  the  ceotial 
tube. 

(3)  The  (iired  ccrehellar  fibres  are  represented  by  a 
lamella  of  longitudinal  fibres  lying  on  the  surface  of  the  cud 
fuciculus  end  of  the  grey  tubercle  of  Bolatido  (Figs.  124. 


AKATDMICAL  ASD   PilTSlO LOGICAL  IN  TBODDCTIOX.  65 


o).  The;  pass  iipirards  to  ihe  cortex,  and  thus  form  ao 
iateimpted  conDection  between  its  grey  aiatt«r  and  ihe  cord, 
ere  tbe  fibres  are  suppoeed  to  pass  iuwards  between  the 
ndlcs  of  the  pyramidal  fibres  of  tbc  latera.1  columns,  to 
miiuUe  in  ihe  cells  of  the  group  knoim  as  Clarke'^  column. 
«ir  fanclion.  however,  is  not  jet  asccrtaiuwl. 
[4)  The  PifraviidiU  Tract. — The  pyramidal  fibres  of  ihe 
eraJ  columns  at  the  upper  end  of  the  cervical  legion  of  tbe 
3d  pus  forwards  and  inwards  towards  the  aotcrior  motUan 
tare.  These  fibre4  decussate  with  one  aoother  in  the 
tdiiUa,  so  that  those  of  the  right  side  pM%  to  the  left,  and 
DM  of  the  left  to  the  right.  The  decussation  frequently  begins 
I  tbe  apper  portion  of  the  cord;  while  the  hoinaioguee  of 
MpjrraiQidal  fibred,  which  arise  from  the  nervc-uucloi  of  the 
5poglowal  and  facial  uerves,  cross  separately  in  the  pons 
bon  tbe  daeuasation  of  tbe  pyramids.  The  pyramidal  fibren 
f  tilt  lateral  columns  during  aud  ittibsequent  to  their  decus- 
Uioa  oome  forw&nU  into  the  anterior  median  fissure,  and 
«ih  aside  the  coiumns  of  Turck  {Fig.  1 10.  Tj.  so  that  the  latter 
onna  prismatic  bundle  of  fibres  external  to  the  former,  and 
hmmJ  without  decu^tsating  with  one  anotiier.  Tbeac  two  seta 
f  fibres  constitute  the  anterior  pymmids  of  the  medulla  (Fi^. 
IS  to  125,  P);  Cbey  can  be  traced  through  the  pon&(Figa.  12G 
BlSS,  P).  wbcro  they  receive  a  large  aocessioa  to  their  size, 
Uft  the  poduQcles  of  the  cerebnico.  .According  to  the  rceoarcbes 
fFlechsig,  which  my  own  sections  confirm,  tbe  pyramidtU 
ibm,  after  being  separated  into  distinct  bundles  in  the 
MS,  come  togellier  no  au  to  form  one  compact  bundle  in 
■ch  peduncle  {Fig.  129,  P).  This  bundle  occupies  about  tbe 
KiJidle  third  of  tbe  cruit  of  the  cerebral  peduncle,  and, 
nUiaiy  to  what  hn.s  hitherto  been  believed,  it  pasaea  into 
W  postarior  segment  of  the  internal  capsule,  lying  between 
k  Imtieular  nucleus  and  optic  tliaUmus  opposite  the  middle 
Indof  tbe  latter.  The  pyramidal  bundle  is  separated  from 
ketiuUle  nucleus  by  a  layer  of  fibres,  which  ascend  from  the 
Stenul  surface  of  the  optic  thalamus  to  n.-ach  the  corona 
■fisU,  while  it  rests  on  the  three  successiTc  segmeuts  of  the 
wUcolar  Qucleus,  and  reaches  tbe  corona  radiata  opposite  tbe 

^iMTter  of  tbe  caudate  nacleus  (rockontug  from  buforo 


AlTATOHICiX  ASD  PHYSIOLOGICAL  INTRODUCTION-  67 

'    Tho  cariiiDiil  facts  whicU  conccro  un  at  present  are,  thai 

fibres  issue  from  the  ceatral  convolutions  of  the  oetcbrum 

irhich  pass  through  the  laternal  capsules  without  communicating 

»ritb  the  htatd  ganglia;  that  the  same  6brcs  pass  through  the 

terebrol  peduncles  to  enter  the  pons,  where  tbey  at  once  begin 

10  diroioish  id  Dumber.    The  fibres  of  this  kicd,  which  pass 

throDgb  the  pons,  collect  together  to  form  tho  nntcrior  pyramids 

of  the  medulla,  which  also  diminish  iu  size  from  above  down- 

mnls.sbowiDg  that  some  of  these  fibres  are  lost  ia  the  medulla 

itielf     The   internal  and   by  far  the   larger  portion    of  the 

Pyramids  decussate  with  one  another,  and  these  portions  pass 

tsdcwards  so  as  to  form  in  the  cord  the  bundles  of  pyramidal 

fibres  in  the  hteral  columns — bundles  which  extend  the  whole 

kogib  of  the  cord,  but  gradually  diminish  from  above  down- 

nida     The  external  and  leaser  portion  of  the  pyramids  pass 

fcectly  downwards  to  form  the  columns  of  Tiirek — columns 

tttidi  dwindle  gradually  until  they  disappear,  usually  about  the 

oiddld  of  the  doreal  region.    It  is  not  yet  prov'<xl  anatomically 

bo*  ibeso  fibres  end  in  the  cord ;   but  other  considoratioDs 

nodGf  it  probable  that  tbey  end  in  the  grey  matter  of  the 

interior  boms  aad  its  continuation  through  the  medulla,  pons, 

nil  around  the  aqueduct  of  Sylvius.     The  pyramidal  fibres,  in 

aoe word,  form  an  uninterrupted  connection  between  the  central 

CKiTolatious  of  the  brain  uud  the  central  grey  tube  of  the 

fflfi 


tf,  tit.  Pint,  (eooad,  ud  tblrd  porUona  of  lli<i  len^cuUr  avcleuB  uVii'. 

JVC,  L'*i»d*t«  ■sol«iw.      n,  Oplie  tlutUiaaa. 
,  t'.  it.  A,  KiinU  IroiB  which  nbna  iwnt  cAiimeting  tha  oorUi  of  tbd  brain 
>oJ  Uwl  s»Of  Hun.  Mill  ktau  Uu;  cnr  >u)«utito«a(  tfao  putm  (I'l/l.    OiJ, 
PibvtB  evancrtiiig  tbn  OMcbcllom  nnd  uplio  tbalaoiiM ;   mi<1  Caip,  Utw* 
Maii««ttB([  the  CM*«b«Iluiii  tail  Ibo  frry  mtetUiiM!  ul  the  |Niiia 
iJBd  ft,  AuunoT  UidjpialMiot  pur  of  corpon  tiiuxiriifvniins  ruimstiirelr. 
r.  Miii  '',  lowtr  tatnt  cMuHcilug  iba  uli>*iy  bviy  Mid  tlic  coqji^r* 
~  lgMnh». 

Alia  nfticnluu  of  tb«  m»1iiilB  dilonimlo.  (unned  b^  fltirt*  troro  tb« 
..  .-jUisUHiMt  tf^i-  tbt  iutcrukl  (livbinn  ot  the  iufniur  poJunoli*  of  iba 
MmMlur*  lu-fji,  frxra  Uio  aiitnAl  oonl  (/f,  nr,  aud  ai'l,  ami  probabty  ftlkt 
tnm  tbe  cikiaW'  uuclsiw  (.Vc. 
OliTsrx  ("'•Ir  \   tni.  Kibros  at  Ui«  rBstifunn  ImkIIf*  ooDnrcling  the  olivMrr 
bodiM  mai  czHbetluin ;  otbcr  fibrta  oooncct  it  witb  tb<  IrlaiiyiLlitr  (.V^) 
•Dd  davala  UVC)  niiulct. 
_ ,  JJnim— linn  of  tfaoj'yrunids. 
f,  Fibrv  «t  lb«  jwalvoiir  tnr-t«  which  mm  a|iw»tla  kuil  downwMdi  into  Iko 
ffrvr  mtniancv,  uid  jivnu*  ool}'  *  ihorl  ooone. 
*.  tf'.  a  .  «".  a"'.  Anterior  mow. 
f,pr,fi^,  pr\  C,  llbrw  <ii  tbc  poaknur  rooU. 


68 


ANATOMICAL  AND  PHrSIOLOOlCAL  INTEODUCTION. 


The  Aeceasorif  Portion  of  the  Ptframid<d  Tract- — We  bw 
seen  that  tlie  accessory  fibres  of  tho  pyramidal  tract  oocup^f 
tlie  morgina  of  tho  lozenge-iibapml  gpaceti  into  wbich  tbe  latertl 
column  and  column  of  Turclc  are  dividetl  (^ti/.  133),  and  that  they 
are  very  abundant  in  the  portioa  of  the  lateral  coIuuiq  whicli 
adjolna  the  grey  substance,  auil  especiulty  iu  the  formatto 
retiaUaria.  But  on  ascending  to  the  anterior  pyramid  of  the 
medulla  the  aooessory  fibres  become  much  more  abundant,  and 

Fig.  143. 


% 


,.'$- 


•    -."—-; 


T 


^1 


1^^^ 


:/■>'■] 


rrt 


?.<-"A 


^i'JA. 


fcr!;v.:r: 


;r7*A0 


5^ 


Wf 


'pf. 


Bio.  143  (Alter  Ftn^msy     Dta;mtn  tij  Tftmawu  SedUm  t^  Mc  J^(W  Curi  to 
iipfitf  \alf^  tAc  DoTtal  lUffwn. 
C.  Antcricir  comiaiMun:. 
<<?,  Fibm  wbicb  t>Ms  frvm  tlt«  ««h1cuIm  wluuui  of  CIhIm  t«)  t«  tb* 

ecrebellu  trsct. 
P,  Pcntrrior  hota. 

Fioa.  112  uiil  143  (After  Flocli^l.-Lctlora  cumtnan  lo  i'ip*.  Ul  >q<1  142. 

/>(,  PprMaidiJ  tn«t  at  th*  l&t«r«l  oolumu. 

T,  ColuiDDtot  Tank. 

dc,  IMrect  occulnlUr  tract. 

ar.  Ibtonud  porlioD  of  the  MitMior  root-mna. 

ar.  Sx-Umu  pDniiia  til  tlui  •DMnor  root -inn*. 

pr,  Po«t«rior  rni>t-(OD«. 

^,  lUticaUr  (omuUnD  of  the  (pituJ  eofd. 
a.  Anterior  grcj  horna  o(  lb«  opiDd  cord. 


ANATOXICAL  ASD  rnTStOI/KlICAL  JNTEODUCTIOK.         71 

coQtrol;  but  the  ]ater*acquirecl  movemootfl  of  man  are  moro 
thoroughly  uudcr  voluolarj  guiJancc  tlifto  the  earl ier-awiui red 
or  frnidamental  actiooa  loasmuch  as  the  obsorration  of  the 
Jevetupincot  of  the  con!  has  enableJ  us  to  draw  a  hroa>l  H'ts- 
UnctioQ  betwaea  the  fundamental  and  accessory  portions  oftho 
structun;  of  the  itpiDal  cord,  it  will  bu  well  to  endearour  first  to 
connect  the  later-acquired  or  axxessory  fnnctions  with  the  later- 
aojuired  or  aoceasoiy  structure.  The  earlicr-acq^uircJ  or  ftinda- 
ta«tiUil  fuDctioD8  wilt  thea  be  left  as  a  rosiduum  to  be  con- 
oectad  with  the  fuDdamental  struclare  of  the  cord. 


(I)  Tht  A<ceitifnj  Functi^m  oJth«  Spinal  Cord  and  MedaUa  OMongata. 
Hm  moTuneotB  of  tbe  baud  aflbrd  th«  beat  exiUD[)le  of  the  occenoTj 
taactioba  of  tli«  ajiii^il  cord.  Theae  movetQ«uta  we  peouluir  to  tuun, 
aoil  hj  tu  the  greator  number  of  theai  tin  acquired  after  birtb.  it 
iDaj,  ih«Mforo,  be  «2p««t«d  tbal  tbe  dwelopiucul  of  tb«  «tni<:ture,  wbicb 
T^f/nmnU  tbow  movecneat*  in  ttie  itjiiiial  cord,  oituil  also  takv  pUo»  aftar 
birtL 

The  moTMneota  wbkh  are  inf>9l  cbaritctaristic  of  tbe  upper  ei- 
Iretaiij  in  nus  uv  tho«ft  of  pro[u.tioi)  And  niipinAtioa  of  tb«  foretvaa 
•od  tbseaaiplicated  moTOincQta  of  the  band  and  Augers,  and  it  ia  DXO»ed< 
is^ij  pvobalila  that  the  atnictunl  rvprMOntatives  of  aome  if  not  all  of 
theM  moremenU  are  to  ba  found  in  tlia  oiMliiu]  groa|)  of  cells.  Tbeaa 
eilk  ajipear  at  a  lato  period  of  the  detrelopmeot  of  tbe  cord,  fa«Doe  they 
liarm  a  apacialitj  of  tttntct^ire  vbich  ooirapooda  to  some  ii|)ecialit3r  of 
fonetiMi ;  agaio  Ibo;  tnaiiitain  a  auall  aiu  «rett  in  Uio  adult  oonl,  and 
CBOMqaeuU;  majr  ha  ex[)ect«d  to  pre>l(le  orer  Llio  nctiou  of  •iQall  uiuxclott, 
both  of  tbcM  ooDditioDa  boiog  rcaliaod  in  the  bond. 

Tbe  aoialler  nedkui  are*  in  the  lumbar  iiulafgeRient  of  the  ennl 
preddoB  probably  orer  the  taovementa  of  the  lower  litaba,  vbicb  di»- 
itfyrirft  Uie  adolt  man  fimu  tba  lomr  anitaaU  and  aUo  from  tbe  bnraau 
tolui.  Thaae  noTeoMnta  ant  oialnly  execoted  b/  tbe  eiteiiaora  of  tbe 
tag  en  tbe  (high  and  probably  alao  by  the  adducton,  and  by  tbe  flesota  of 
iWfiMtau  tbe  leg.  Indeed,  the  alijiht  elovntieu  of  the  ball  of  the  toe,  so 
a*  la  allow  the  paeaire  1^  to  atnng  forir&nU  by  ita  own  weight  iu  walldug, 
i«  the  laat  moTooMiit  Boqiiired  by  tbo  child ;  aud  we  abaQ  autMaqoently 
lum  that  it  ia  the  Srat  movameat  to  be  aSectod  in  diaeaae.  If,  then,  tbe 
laeJian  aiaaof  anaalloellalM  tbaafauotaral  comUlivoof  the  later-Aoquired 
and  nora  apaolal  novmianta  of  tbe  limba,  it  most  bo  abaeat  lii  tboae  por. 
tioae  vf  tbe  cord  wbjch  do  not  eupply  ncrroa  to  limbs,  and  we  biire  already 
aesi  that  thia  ana  is  abwnt  in  tbe  dnrvtl  and  upiior  oarvical  ngioiw  of 
thaaord. 

It  mtut  lie  rememberatl  that  tba  muaclea  of  the  band  are  connected 
>silk  Um  earltor-fiHiiwd  or  fuadMiHDtal  oeUa  of  the  aaUnM'  horua,  aud 


72 


ASATOMICAL  AND  PUrSIOLOOICAL  INTRODUCTIOM. 


tbAt  tha  BDin]!  calls  of  tha  mediaa  m«*  do  not  of  thenu«lv««  mi&o 
iht  roguktioD  of  thflir  moreiaeDts.  Tha  incK4avl  derelopmei 
tb«  mediui  ana  la  tha  oarrical  enlargvement  repreaents  tnaraljr  » 
)>UckttoD  oa  Iho  prerioua  structiira  of  the  cord  oorraapoudiDg  to 
compliration  of  muacuUr  odjuittnienbi  vhich  dittjngai«ti«n  the  hu 
lusu  from  the  interior  extramit/  of  ouimftb. 

Tha  h;[)ogIoMud  aacoMorj  Duclviia,  aad  tha  i&bamal  and  *xb 
mooonoTf  fiicial  nuclei,  appear  to  be  tha  bomologfuaa  in  tfaa  mai 
ebloagalA  of  tho  mediau  area  iu  the  oervical  aud  lumbar  eaUrgemen 
the  spinal  cord.  Tba  hypoglaaaol  acceasory  uucleiui  a«ems  to  be 
Additional  structura,!  oompUcatioa  roudered  ueoeaearj  b^  the  ooi 
CAted  tnoTCmenta  executed  in  the  |iro(Iiicti»ii  of  articulatory  apeech ;  ^ 
the  ftuial  aooaaaotj  nuclei  are  tho  atructanl  counterporta  in  the  taet 
of  the  movemsnte  of  facia)  expreaaion. 

Tha  u«xt  aeoeaaor^  fuu«tioa  which  I  ahall  meatioa  ia  tlte  mtM 
adjuatmeutii  neceaurjr  for  maiittaimng  the  erect  poatuie  Iu  niao.    T 
•djiutawnta  are  al40  acquired  a  cooajderablo  time  after  birth,  b«n< 
naar  be  biferred  that  tliair  atmutural  counterpart  in  the  cord  ia  not 
developed  at  birth.    TIm  tnadio-Uteral  area  com^p'^iida  in  my  ojititio^ 
these  adjaatmenUi  in  thedonaJ  rej;ioti  of  tho  cord.     The  cellx  i>f  thiai 
are  not  wall  d*v«1t>|>ed  at  birth,  and  tha  area  in  antirolj  al>»ent  is 
lower  animaU.    These  cella  are  alio  of  amall  aJie,  ovim  in  the  adult  9 
and  if,  aa  we  bare  airead/  atated,  the  aim  of  the  ganglion  oell  ia  reUtei 
tile  oixe  of  the  muscle  with  which  tb  ia  oonuected,  the  erectons  apitov 
the  maaolea  of  the  trunk  which  beat  oorroapond  to  this  dessription.    | 
uadiii-latural  area  appeara  olaa  in  the  iipiwr  cerrical  region,  and  Ul 
be  pnMumed  that  the  amal]  miuclea  wliioli  ext(>iid  the  vertebml  oolund 
the  uack,  and  draw  baclc  aud  rotate  tba  head,  are  aupplied  Froia  t| 
cells.    We  have  already  acen  that  aoine  of  the  fibres  of  the  elei 
nerve  (spbol  aooeaaorj)  arv  tkrirad  from  the  po»tcro-Ut«ral  group  ia| 
cord,  and  it  in  very  probable  that  the  acoaasory  nuelewi  of  thia  ' 
tba  raedoUa  ia  the  hotoolcgue  of  the  uedio-latml  ana  in  tho  npparl 
vical  and  doiul  ngioos  «f  the  oord.    The  aooeaaory  mioleo*  off 
vloventb  oarre  la  the  additional  organlBotieu  roDdeied  DeeeMuy  b^ 
complicated  movenieuts  of  tho  human  larynx. 

The  margiiMl  culls  of  the  posteroOataral,  antero-lateral,  and  cei 
groupa  appear  late  in  tha  development  of  the  cord,  and  these  thenf 
muat  be  regarded  as  belonging  to  tho  acoeoBory  ayatem,  even  alt 
the  ganglion  eells  are  of  comparativaly  large  mia     Tha  bet  that 
celU   aro   of  large   aize   ebow^    that   they   muat   be   engaged   in 
roguUtion  of  the  movementa  of  laige  muacloa.     It  ta  probable 
tbeae  marginal  ooU«  in  the   lumbar   region  regulate  the  oontnoti 
of  the   large  muaolea  of  the  lover  extremity   which   are   eti 
tnoiut^iniug  the  tnai  poeture.    The  great  relatire  aise  of  tb 
maiimus  in  man,  as  comparod  with  tliq  tower  animala,  -would 
render  aeoawary  i,  eomepoodiiig  incrwae  in  tho  namber  of  gau 


XXXTOaiCAL  ASD  PHTSIOLOOICAL  INTBODCCTIOS. 


73 


vt  tbe  vpionl  nacldus  which  ragnUtw  its  moveraouU  in  tb«  formor,  oa  com- 
puvd  wiUi  that  in  tbe  latter.  And  tnasmuch  aa  tha  gluteus  maximus  is  not 
nod)  calM  into  actaon  until  •  eoDsiderable  tinoa  all«r  birtb,  thoM  aupor 
added  cells  tmut  beloox  ^  ^*  accotsary  'tiytA«m.  These  additional 
MBa  maj  probably  be  npremated  by  tlie  isftrgina!  <Ht11ii  of  tho  postoco- 
ktonl  groap  io  the  loinbar  region.  The  iJttTanto  upward  rotattoo  of  tbe 
pelTts  which  tako*  plaoo  in  walking,  and  which  w  mainly  efloctod  by 
cootnctiou  of  tho  gluteos  modiusand  minimus,  is  Ukowise  a  very  special 
uoveneut  ;  and  it  also  may  bo  ragaUitvd  by  the  Ut«r-darelop«d  oella  of 
(Aoor  othdrorthesagroDiwof  ganglioD  oeUa  in  tbe  anterior  horna. 

Wo  bare  aeea  that  the  poatero-lateralgroap  in  the  upper  cerrioal  region 
(maoffthesiKnal  portiot)  of  tlia  xpitial  aooenory  nflr7e.ftnd  thiit  thi«  jiorlion 
fccma  the  external  branch  of  tho  nervo,  which  i*  diitributod  to  tho  atorao- 
elBdonustctdmnscleand  tbenpperportionof  thetrapeEiiu.  But  is  man 
the  steroo-cltido  mastoid  ia  ia  eloae  relabioQ  with  the  clavicular  portion  of 
tbe  pectoralia  m^jor,  beiug  only  eeparated  from  it  by  tl^o  clavicle,  and  in 
thoee  aoimahin  which  tho  ctaviclo  in  iloGciont  it  nina  with  tho  anterior 
peat  of  the  tnpenas  muscle  into  tJio  deltoid,  forming  a  roaabaido-humcral 
BMucIe.  All  of  these  museles  ore  closely  aaaoeiat^d  in  their  actions,  and 
a  is,  tberefora,  probable  that  all  are  innfirrated  from  ilio  poatero- 
ktand  fcoap,  while  the  latiaaimua  dorai,  rbombotdei,  and  several  other 
QMaDtea  nay  perhapa  be  added  to  this  lint.  It  in  very  probabla  indeed 
thai  tbe  muaclea  which  maybe  oompendiously  summed  up  with  reference 
to  their  fimctiona  m  the  aooosoory  musctcs  of  toapiratioa  are  innorrated 
from  thk  group  In  tho  eerrioal  and  dorsal  regions.  Thsne  uuwlds  an 
briefly  kbe  steruo-maetoida  and  Boaleni,  the  pocboraUs  major  and  minor, 
tbe  HRati  poctici  et  miporiores,  the  eabclavius,  and  the  olavaton  of  the 
liMil  «*nt  fintti  oolumu. 

The  poatefo-lateral  and  medio-lateral  groups  of  ganglion  oella  oonaiat 
nf  a  tmtim  of  BOpeeimpoaed  gaogUonio  oeutres,  oonatituting  a  coluraa  of 
erfla  wlikh  extaoda  IVoa  tbo  lumbar  n*j^OQ,  through  tho  doraal  and  oer- 
tioel  ngloiw  of  tbe  oord  bo  tho  medulla  and  pons.  Spcakiug  broadly, 
this  column  regolates  the  nuscular  oontnotiona  necaaMry  for  the  m^n- 
taaaoe  of  tbe  eivct  poatur»,  tho  contraction  of  the  oxtraoeoua  musclee  of 
wpratiaD,  in  part  at  leut  that  of  the  muscles  sappliod  by  the  sjiinal 
VMMory,  ta^poM,  glosso-ptiaryageal,  eovootb,  and  by  tho  motor  hronch 
'  Ike  fifth  Derrea  The  portion  of  the  facial  nerve  impplied  by  tbe 
tioQ  of  the  postero-lateral  group  in  the  m&duUa  probably  pre- 
'<41m  over  the  function  of  the  bclal  mnsclea  in  their  reUtion  with 
■■Ueation  and  leepiratioo.  The  eeriea  of  eupMnmposed  gaoglionio 
of  whkb  tho  poetero-laterol  group  coniiiHt.<t  cauitot  act  indo- 
T*i4tetly  of  each  other;  and  in  order  to  aecuro  harmony  of  aetioo, 
loT  these  centra  must  become  aut)oriliimte  to  other  centra!),  either  of 
^H*  aiBe  oolunD  or  of  aome  other  part  of  iho  nervous  system.  All  of 
■ue  doobtleas  oo^rJioat«d  in  tbo  cortcs  of  the  br&iii,  tnit  it  is  not 
^■baUB  that  the  inferior  centres  of  the  column  are  also  subordinated  . 


74        AKATOmCAL  AND  PHYSIO  LOGICAL  ISTBODUCTIOS. 


to  9n«  of  ttie  superior  centra!*  iu  tbe  raodullB  oblongabn.  If  xaoh  abfiuU 
b*  lb*  COM,  tbflrn  in  no  oooMion  for  ajwiiraiiig  the  esi<;t«a«»  of  a  disliiMt 
rMpirator;  oootr*  in  tlu  m«dulla  «blon^ta  apart  from  tlie  upward  ooa- 
tiitiiation  of  the  postera-lattfral  coluinn  of  cells.  It  is  much  mora  i»o> 
bablo  that  the  roipiratory  contra  in  merely  an  eDlarKeniaiut  iu  the  laedulh 
of  thl^  pa<it«ro-UteriI  coIuoid  of  c^Us.  It  is  alao  quite  lilcelj  that  thlg  en- 
laigameat  ia  oIoseLy  ooua«at«J  with:  the  other  groups  of  oelb  wbicli  have 
baea  coiitJDuecl  upwards  frotu  tho  cord  into  the  medulla. 

(S)  Fitmtitntntal  Voluntarfj  FitiKtCom, — With  rospeot  to  the  functiom 
of  the  autero-[at«ral  g;roiip,  I  nnut  content  myfielf  bj  aaylaf  vevy  Little. 
The  cells  of  this  j^iip  altrayo  nutiotain  the  lenxl  m  tho  conne  of  develop- 
meiit  It  i^  not  only  that  they  Ungin  to  dcvelnpHiii^  amume  processas 
at  iiu  earlier  p«riui'l  than  tho  colla  of  tho  other  groups,  hut  the  greatsr 
finrtioQ  if  not  all  oT  thoiu  Appoar  altuist  simaltanuounly,  and  maintain 
an  e^ual  rat*  of  growth  during  dcrelopcMat  Tho  autoro-latoral  dilTirra  ia 
this  raipect  from  the  pa<t«ro-lateral  and  central  groups,  which  iDcrvaae 
in  tin  by  tho  gnvd'jal  addition  of  uoir  gaogliob  cells  at  their  margiua.  It 
may  ba  eipeoted,  thsrafore,  that  thix  group  will  r«gu]Bt«  the  fundamental 
aetions,  or  tho  octioua  whidi  are  carried  ou  in  a  reSax  inaouor,  niid  which 
are  ■□  great  measure  independont  of  the  cephalic  ganglia.  In  this  con- 
n<wtion  the  int«rvu»tal  muscles,  the  diaphragno,  abd^oaiaal  miwel««,  and 
the  muscloa  constituting  tbe  Qoor  of  tbe  pelvia  will  imn]odiat«]y  suggest 
thdmnclm.  In  tbo  lower  extremity  tbe  murt  general  movement)  mty 
be  expected  to  be  regulated  by  th«  aiitern-liitcnil  irroup.  ThvAc  moT«- 
tnenta  are  dexion  of  tho  thigh  on  the  body,  of  tlirr  leg  on  the  thigh,  aad 
eleratioD  of  tba  heel  It  may  be  aaid  that  elevation  of  the  be«l  i*  a 
moToneot  atmoet  peculiar  to  man,  but  thia  is  rendered  necesaary  during 
locomotion,  owing  to  the  dopremioo  of  the  heel  which  baa  lieea  edeoted 
Id  the  coarse  of  ewlutiou,  by  the  progreaaire  increaso  in  tba  etnngtli  of 
tbe  flaxora  of  the  foot  on  the  leg. 

On  watching  the  first  movemsata  of  the  bucnaQ  infant  it  will  be  wan 
that  the  ]>awer  to  elera1«  the  heel  ia  aoquSred  early,  while  the  eleratioa  of 
Iha  too  *o  aa  to  allow  tho  foot  bo  awing  farwarda  by  its  own  weight  U  the 
last  moTomeut  acquired ;  henoo  it  ia  the  laoA  ai)ecial  movement,  and  it  will 
bo  ropr«8ont«(l  iu  the  cord  by  tho  anperaddition  of  new  ganglion  oelbi  to 
tboM  already  esiating.  \Vhat  the  mDTomenbt  are  which  are  regulated  by 
maaTiA  of  the  ant«^>Iatera1  group  in  the  on'vical  region  t  can  only  malte 
a  roitgh  ooc^ectura  They  aro  no  doubt  tbe  simplest  moTonuata,  aad 
tboao  vbiob  man  pasaesssainocmmon  with  tlio  hiwuraniinala.  Tfae  moat 
pnbablo  of  thew  mavemeuta  are  doiion  at  the  wruit,  aiiople  llctioii  aiid 
ettaaxion  at  tbe  elbow,  and  tho  backwarvis  and  forwanU  moi-ementa  at 
the  aboulJer,  and  Hextou  of  the  neck  and  hoad.  Somo  of  tbe  muadaa 
engaged  in  these  sotiona  we  have  already  fi>uud  raamn  to  believe  were 
inoerTated  by  the  pOBtcro-lateml  group  ;  hut  thia  doea  DOt  exclude  the 
poaaibility  of  their  being  innervated  also  b;  the  antero-Iateral  ffrou[x 
That*  ia  so  mu«b  uncetiaiaty,  howevtr,  witb  regard  to  the  fuactioo  of  tha 


^KATOUICIL  AKD  PHySlOLOOICAL  WTHODUCTIOS.         75 

AdtMiv-Utoral  group  iu  tho  ccrrloal  ngioQ  Uiat  it  would  b«  htuiitrdoua 
to  nmln  uij  asMrtion  witli  regud  l«  it.  Tbera  ia  oliio  quito  m  mucfa 
oiMwrtAiiity  witli  reipect  to  th*  fiuiotiooa  of  tbs  oeatnl,  ttit«mal,  «nd 
■ultrior  croui>a. 

§  375.  Rtfiex  Action. — The  production  of  reflex  action  is  ooe 
of  tho  earliest  and  most  fuDdsmcDtal  fniictioDS  of  the  spinal 
cord.  As  we  bave  already  seen,  ovorj?  reflex  act  requires  for  it» 
performaoce  an  afferent  ,and  on  efferent  fibre,  ami  a  centre- 
Tfae  eitrlier-formeil  ganglion  cells  of  tbe  anterior  grey  bums  con- 
st3tat«  the  oonlreg  of  rtflex  action ;  and  it  is  probable  that  the 
reflex  aflerent  Bbren  pasa  to  them  directly,  without  the  inter- 
TentioD  of  the  grey  snhstance  of  the  posterior  boras.  Inasmuch 
u  tbe  reflex  afferent  fibres  are  formed  at  an  early  period  in  the 
derelopment  of  the  cord,  thoy  muiit  be  thrust  out  laterally 
ilurio];  the  development  of  the  posterior  grey  horn,  no  that 
ibey  Trill  occupy  an  external  poKitiun  in  the  fan  formed  by 
Ibe  spreading  out  of  the  Hbres  of  tbe  posterior  root«.  We 
have  already  seen  that  there  are  grounds  for  believing  that  tbe 
ftfierent  fibres  of  the  tendinous  rotlcxes  pass  in  the  inner  radi- 
oobr  fMcicalu!^  and  it  is  not  improbable  that  the  alTeront 
fibru  of  tbe  cutaneous  rcflex&q  paaa  in  the  outer  radicular 
Eaaeiculus.  The  efferent  reflex  fibrefl  pass  oat  in  the  anterior 
FDoU,  and  tbe  same  tibres  probably  oonTey  botli  reflex  and 
rolantary  impulsesL 

§  876.  Trophic  Function  of  the  Cord. — It  is  well  known  that 
the  gauglioa  cells  of  the  anterior  horns  of  the  cord  exercise  a 
trcrphic  indueacc  on  the  muscles ;  but  whetherthcre  arc  trophic 
oellB  endowed  with  special  functions,  or  whether  all  tbo  cells 
■n  flodowod  with  both  motor  and  trophic  functions,  I  am  unable 
tn  eay.  With  some  degree  of  qualification,  I  fool  inclined  to 
adopt  the  latter  view. 

It  ii  well  known  that  within  certain  limits,  increased  func- 
titma)  activity  of  a  muscle  is  followed  by  an  increase  in  iU 
iiuUL,and,conveniely,  that  a  diminution  of  its  activity  is  followed 
Vr  JinuQutJon  of  its  bulk.  When,  therefore,  the  meclianism  in 
tbe  cord,  which  regulates  tbe  movements  of  the  muscle,  is  in  a 
■Me  of  activity,  this  iit  followed  by  an  increase  in  the  function  of 
Ibt  DMUcle,  and  consequently  by  an  increase  in  its  bulk.    11^  iu 


76         ASATOHICAI.  ASD  PUYSIOLOQICAL  IKTRODUCTIO». 

addition  to  an  increase  id  its  bulk,  the  mtiBcle  be  called  upoa 
to  make  a  new  adjustment  in  response  to  altered  circumstaQcea. 
the  Di^w  adjustment  can  only  become  ponnanent  in  the  race 
when  it  is  organised  in  tlie  cord  bj  the  growth  of  new  cells  and 
fibres  iu  addition  to  the  original  mcctianisin  by  which  its  more- 
ments  wero  giiided.  But  if  the  new  celirt  and  fibrea  beoome 
iocapacitftted  from  any  cause,  the  muscle  will  soon  lose  Uie 
structural  modification  wliich  corresponded  to  its  recently- 
acquired  functional  adjustment,  but  no  other  change  will  take 
place  in  it.  As  Ion;;  us  the  original  mecbanifim  is  maintained 
in  the  cord,  so  long  will  the  nutrition  of  the  great  bulk  of  the 
muscle  go  on  as  before.  But  the  case  is  very  different  wImq 
tlie  fiiDction  of  the  original  mec;hani»m  ts  destroyed ;  then  the 
nutrition  of  the  m.uaclo  is  injured  at  its  very  foundation,  and 
profound  tropbic  changes  occur.  It  is  very  probable,  therefore, 
thai  the  iniluonce  exerted  by  the  Inter-dcvoloped  ganglion  colU 
of  the  anterior  homs  on  the  nutrition  of  the  muscles  is  amall,^ 
while  that  of  the  earlier-developed  celts  is  very  great.  ^H 

§  377.  Aviomatic  Action — The  spinal  cord  contuns  a  oon- 
aiderable  number  of  what  are  regarded  as  automatic  oentne. 
but  it  is  probible  that  many  of  these  act  in  a  reflex  manner. 
The  lumbar  portion  of  the  cord  contains  centres  for  the 
regulation  of  the  acti  connected  with  micturilion,  defecation, 
erection  and  ejaculation,  and  parturition.  Tlie  oculo-pupillaiy 
centres  in  the  upper  dorsal  and  cervical  regions  of  the  cord  bai 
already  been  described. 

Vnao-motor  ccutrua  exist  in  the  cord  by  means  of  which  tl 
tcniis  «f  the  muscular  coat  of  the  vessels  ia  maintained, 
has  been  thought  th^t  the  spinal  cord  also  cxerciites  a  tonic 
action  ororthe  skeletal  muscles,  but  this  opinion  is  doubtfoL 
The  tone  of  the  sphincters  of  the  bladder  and  rectum,  howeTW, 
IK  undoubtedly  maintained  by  the  lumbar  part  of  tfae  cord, 
and  is  probably  re&ex.  in  character.  The  peristaltic  moremeDts 
of  the  tdsopbaguB,  stomach,  and  inteatiaea  are  regulated  liv  the 
ceutral  grey  tube.  Little  is  known  beyonil  conjecture  of  tlio 
localisation  of  the  centres  of  visceral  innervation  tn  the  cord. 
That  they  are  not  situated  in  the  anterior  grey  horus  is  ren- 
dered certain  by  the  fact  that  the  visceral  movements,  aa<i 


AKATOHICAL  AND  PHYSIOLOGICAL  INTRODUCTION.  77 

automatic  actions  of  defecstton,  miotiirition,  erection,  and 
pftrtDrition  reoiaia  unaflected  in  disease  limited  to  the  anterior 
grfjf  horns. 

Several  ronnderatioas  may  be  adduced  tending  to  show  that 

die  redcular  column  of  Clarke  contains  tli»  tpiaal  cuuLres  ol* 

riaoeral  ioDerv-acioa.    The  cells  of  this  column  arc  bipolar,  like 

those  of  tlie  Hjrni pathetic,  and  not  multipotiLr,  like  thotio  of  the 

anterior  horns  which  regulate  the  complicated  actions  of  the 

skeletal  musdoa    TbU  column  is  uUsent  in  the  lumbar  and 

nrrical  enlargements,  the  portions  of  the  cord  irhich  supply 

MVTM  to  the  limbs,  and  in  the  upper  half  of  tlio  cervical 

KgioD  wbicb  supplies  nerves  to  tbo  muscles  of  the  neck.    It 

a,  00  tbe  other  band,  present  in  the  upper  lumbar  and  the 

iaaal  regtoos  of  the  cord — the  portions  from  which  the  trunk 

u  innervated,  and  Ig  again  represented  in  the  medulla  oblongata 

IS  ibe  principal  nucleus  of  oiigin  of  the  vagus — tho  mom  im- 

portsat  visceral  aerve  of  the  body.    It  maybe  aasumed  that  oil 

^  actions  regubUed  through  the  vesicular  column  of  Clarke 

miobonlinated  to  the  high«st  expanded  portion  of  it  which 

noslitales  the  nucleus  of  the  vagus;  hence  there  is  no  reason 

UuKnne  that  the  medulla  oblongata  contains  a  circumscribed 

nKhmolor  centre  distinctly  separated  IJroni  the  nucleus  of  the 

ti(Ba 

§S78.  Pwnctions  of  tiu  PMterwr  Grey  Uoma  and  Ponterior 

RooOk 

Afferent  irapulsoa  are  conducted  to  tbo  spinal  cord  by  tbo 
pxtenoi  roots.  Aa  already  remarkod,  it  is  probable  that  tbo 
■Ittent  impuUes,  which  have  undergone  the  highest  urgani- 
wionin  the  cord,  are  conducted  by  tho  Abrcs  which  occupy  the 
pmphery  of  tbo  fan,  formed  by  the  spreading  out  of  the  fibres 
■^  tbe  poKterior  roots  as  they  enter  the  substance  of  the  cord, 
u  ibe  ant«rior  horuB  the  most  specialised  actioDs  are  repre> 
KBtsd,  partly  by  the  development  of  new  processes  to  the 
■liitii^  ganglion  cells,  and  partly  by  the  growth  of  additional 
i;  but  in  tbo  posterior  horns  the  llbres,  which  conduct  the 
,  Btit  specialiiied  impulses,  have  become  adapted  to  their 
fmctioai  by  the  gradual  development  in  connection  with  them 
<f  ipedal  peripheral  terminal  organs  on  the  one  hand,  and 


78 


ASATOraCAL  ASD  PHTSIOLOOICAl  ISTBODUCTIOK. 


central  tenuiual  orgnna  od  the  other.  The  stimulation 
certaiu  fibres  in  an  early  stage  of  development  may  give 
only  to  diffused  and  irregular  contractions,  while  at  a  higher 
fltage  of  development  complicated  and  apparently  purposire 
retlcx  movements  are  produced  hya  similar  stiniuUtion;  again, 
a  atimulation  which  at  on  early  tttago  of  development  gives 
rise  only  to  a  diffused  Jiensation  of  pain,  may  at  a  higher  sta^ 
of  development  evoke  intellectual  sensations  of  tonch  and  tern- 
peratare.  It  may,  therefore,  be  expected  that  the  6bres  which 
conduct  re6ex  impulses,  and  those  that  conduct  the  impulses 
which  on  reaching  the  cortex  of  the  brain  give  rise  to  the 
intellectual  sensntions,  will  occupy  the  periphery  of  the  fan  of 
the  posterior  rooLi;  while  those  which  conduct  the  impulses 
which  on  reaching  the  cortex  give  origin  to  the  common  or 
emotional  Eensations  will  occupy  its  centra  We  have  already 
seen  reason  for  believing  that  thoaSbrent  fibres  of  the  tendinouii 
rctiexes  paii»  thruugh  the  internal  radicular  fascleulua  to  reach 
the  posterior  horn,  and  it  is  probable  that  the  aSerent  fibres  of 
tho  senna  of  touch  and  locality  also  paaa  through  the  same  fasci- 
culua.  We  have  also  supposed  that  the  cutaneous  reflex  fibres 
pawi  through  the  external  radicular  fasciculus,  and  it  is  probable 
that  the  afferent  Bbres  of  the  senne  of  temperature  likewise  pass 
through  thin  bundle.  The  aSerent  fibres  of  the  common  sensa- 
tion of  pain  pass  through  the  centre  of  the  posterior  roots 
durectly  into  the  grey  matter  of  tho  poatcrior  horns. 

Section  of  the  white  posterior  column  destroys  the  scnaatioa 
of  touch  permanently  in  the  regions  situated  below  the 
section,  but  leaves  the  sensation  of  pain  unaffected ;  and,  coD- 
veniely,  section  of  the  entire  grey  substance,  leaving  the  poeteiior 
columns  intact,  dvatroys  the  sense  uf  pain  and  leaves  that  of 
touch  (SchifO.  fl 

A  retardntionof  the  conduction  of  sensation  occurs  when  tb^^ 
posterior  grey  horns  are  cut,  and  the  more  the  grey  Hub.'itiuice  is 
diminUhct)  the  more  miirked  is  the  retardation.  The  condnctioD 
of  sensDT}'  impressiouH  decussati;!;  in  the  cord  soon  after  the  root 
fibres  enter  it,  but  consiJerahte  difference  of  opioion  exi.sts  as  to 
the  mode  and  extent  of  this  decussation  with  regard  to  the  con- 
ducting pnthn  of  the  different  kinds  of  sensation.  The  further 
coarse  of  the  Cerent  fibres  through  the  cord  is  not  well  knot 


tu 

w 


jUSATOXICjU.  and   PITTSIOLOCICAL   tSTKOOL'CnOH.  79 

It  is  nippoMil  Ibftt  ttio  Moaoiy  patbs  of  the  lower  extremilies 
fe  &l  first  ID  tlie  lateral  columas,  and  do  not  enter  the  postorior 
eolumju  till  they  reach  a  higher  level.  The  posterior  columu 
the  lumbar  regioa  is  said  to  cootuiu  uiitj  the  nerves  of  touch 
the  pvlvic  regtOD,  sexual  oi;gaoii,  penoieuiu,  ootl  anal  r^ioa 
b). 

§  379.  Fti^Klions  of  tfu  Central  Gret/  Column, — The  central 
grejoolumaiBnotsapposed  to  be  eadQ»e<l  with  any  active  func- 
lioiis,  fot.  patfaologiolly  regarded,  it  is,  as  will  hercaftor 
^fpear,  one  of  the  mo«l  important  portions  of  tbo  grey  «ub- 
•taoce  of  the  tptnal  cord.  The  continuation  of  this  column  in 
e  medulla  oblongata  contains,  as  we  have  seen,  the  accessory 
iclei ;  anil  the  median  areas  of  the  anterior  horn  in  the  cervical 
aod  lumbar  enlargementa,  as  well  as  the  medio-lateral  areas 
in  ifae  doml  and  npper  cervical  r^ons,  may  he  regarded 
re^iectiTdy  as  anterior  and  lateral  outgrowths  of  the  central 
oolumo,  instead  of  being  regarded  as  portions  of  the  anterior 
bonoL  Theee  areas,  iadeed,  conatituie  the  border-land  botwcen 
the  ceotnl  ooIujqq  and  anterior  bom.  and  they  are  involved 
it)  the  dJseoMfl  of  both  structuies. 

g  380.  FuHctiona  of  the  Special  Xuclvi  of  the  Meduila 
OUotiffiU'it  Pon*,  and  Cntrvt.— The  functions  of  the  special 
ntKlci  do  not  retiuirfl  cxtendud  coasidvratiuD  at  present.  All 
of  ibem  serve  to  transmit  impulses  received  through  the  nerves 
ef  ipocUl  sense,  not  only  to  Ibe  cort«x  of  the  broio,  but  probably 
bIbo  to  the  cortex  of  the  cerebellum,  while  likewise  ministering 
lo  complex  r«tlcx  Actions.  The  corpora  qiuulrigemina,  for  instance, 
■le  anatomically  connected,  not  only  with  the  cerebrum,  but 
■IsD  witb  the  superior  peduncles  of  the  cerebellum  ;  while  they 
b«fe  been  proved,  both  anatomical!;  and  experimentally,  to 
form  an  important  reflex  centre  between  the  retina  and  the 
iBicm&l  and  external  muscles  of  the  eye  It  is,  indeed,  likely 
tbat  siJll  more  extensive  and  complex  reflex  actions  are  regu- 
klad  by  the  corpora  riuadrigemina,  since  they  are  known  to  be 
anatomically  canoected  with  the  upward  continuation  of  the 
anterior  root'Xonea  of  the  spinal  cord.  Two  of  the  four  nuclei 
si  ODgia  of  the  auditory  nerve  are  intimately  cuunt-cted  with 


so 


iJiATOMICAL  AND  PHTSIOLOOtCAL   INTRODDCTION. 


the  inferior  &Qd  middle  peduncles  of  the  cerebellum,  and  it : 
probable  that  one  of  thom  at  leael  conducu  labjrtDUiiDO  ii 
pressioDs  to  the  cerebellum. 


The  corpora  (luadrigdcaina  ure  homologous  viththe  ojitic  lobM  tail 
and  tba  Irjner  vertebrata— organs  which  ut>  dtivoUiiitMl  ia  coDDSctHo  iril& 
tbt  seoM  »f  sight.  Thew  ganglia  apptur  to  Im  tlio  ceutTM  for  the  wBat 
co^rdiDatioii  i>r  t\l  the  iiiuiiculiu-  lutinun  coucernod  in  tho  moTcmoata  of 
tbe  oyoballH  aod  of  the  reflex  contraction  of  tho  puj>il«  caiuod  bj  Ugbt 
falliug  oa  tho  rcliuw.  It  in  through  tbctto  bodies,  and  not  din»:tlf,  thai 
tb«  optic  trocta  como  into  rolation  with  the  coreboiluni ;  bonc«  it  maj  b» 
expected  that  tboy  will  bo  luaociatod  vith  tho  latter  in  ita  foDCtioas.  U*« 
have  already  eeoa  that  the  corpora  qtuulrisemiiia  are  oonoeoted  with  the 
anterior  root-nouea,  or  the  sjateui  oi  fibre.i  which  co-ordinate  the  actions 
of  tho  cord  li>DgitudiaaUy  oa  the  aide  of  the  outgoing  currents;  henee  the 
inforior  aeKiucitita  of  tbe  body  are  to  a  ooDsiderablo  extent  brougbt  under 
the  regulative  influsQce  of  these  ganglia.  The  corpora  quadrlgeralna  are, 
liowevBT,  siaiiila  ca-ordinatlag  ceiitrot,  arid  their  ragulative  ooUou  oa  the 
iiifurior  segmeuls  of  the  budjr  u  of  a  purely  raSox  character.  The 
following  maj  lie  tokeu  as  niJ  illustnitinn  of  the  Tnaiiner  in  whidi  I 
liehbvtf  tlieiu  to  act:— While  a  fish  ia  dwiuuiiiig  through  the  water 
a  siiddcu  iuiprvtMgiou  in  uiude  vu  tbe  right  eye  by  tlie  sluviuvr  vf  e 
large  approiLvhiiig  objout,  uiid  itointul lately  the  muscles  of  tlie  tail  oa 
the  left  bids  contract,  aad  tbe  hood  is  turned  awnjr  from  the  object. 
f^uch  a  movemunt  would  teud  to  secura  tbe  safety  of  the  fiab  from 
captttre  bj'  a  (uor«  powerful  aatagooiitt.  It,  on  tbe  other  hand)  Uu 
imprefiaiou  ix  modu  by  a  relatively  etnall  abject,  tbe  musotea  of  tbe  tail 
uu  tho  auuo  aido  might  contract,  so  as  to  tura  tba  bead  towards 
the  object — a  movement  which  wonlii  tend  to  necure  prey,  lu  Umpb 
muvviueute  the  laaiu  regulative  ceutrus  are  the  optic  lobee,  aud  tbervu 
no  occaaioa  to  believe  that  the  actions  are  ia  aoy  way  of  a  diffureut 
ohanct«r  front  the  ordiuary  reilex  muveiaeuts  of  tbe  spiusl  cord.  It  foay, 
however,  be  remu-ked,  iu  i»juiiiig,  that  siuce  a  large  approaching  object 
would  produce  a  greator  iinpreseion  thaa  k  saull  ohjeat,  a  mdiiaentary 
eye  would  be  uiure  useful  tu  ittt  poaaessor  for  avoidiug  capture  than  iu 
Hucuring  ]<rey ;  and,  ooiuequeatly,  the  primary  and  fundaueatolcotuiectioii 
between  the  eye  aud  the  inferior  segDioule  of  the  body  would  be  a  croaaed 
outt.  The  tawl  ready  communication,  tUerefore,  would  be  betireea  tbe 
right  eye  aud  tbe  muscles  of  tbe  left  side  of  the  body.  And  this  helpa 
MplaiD  tbe  orossing  of  the  ojittc  nerval,  iiiot  ouly  iu  tbe  lower  animal*  ' 
rudimentary  oyeti,  but  in  the  higher  orj^aitiama  ;  a!  ucu,  during  the  d«« 
mvut  of  the  Utter  ^m  the  foriiur,  tbe  primary  and  fuudamsntsd  eroestd 
however  much  it  may  bo  tawlificd,  is  still  retained.  It  is,  indeed,  very 
probable  that  tho  crossed  connection  which  may  bo  mippoeed  to  exist  in 
the  lower  vertebratA  between  the  rudimentary  eyes  and  the  mmctot  of  the 


AWATOMICAL  AND  PIITSIOLOQICAL  INTBODDCTION.         81 

bodj-wu  tlw  main  fictor  in  deUnDioing  duiiog  Ui«  coiinw  of  development 
lli«  eroMed  CAooMtlou  which  ennts  between  th«  cerebral  beousphcrra  aud 
tbe  apioAl  oocd  in  the  bigbcr  rcrtcbnta. 

g  381.  Functions  o/tke  Superadted  Grt}f  Substance  of  the 

UUdttliaOMonffaia.  Pons,  (md  Crttra.— We  hovi;  alrwidy  seen 

that  there  arc  do  grounds  for  bclieviug  that  the  ccnties  of 

re8|Hration,  d^Iutition,  masticatjon,  and  the  regulation  of  the 

heart's  acUoD,  the  vaao-motor  diabetic  and   so-called   coo- 

ralnrc  centre  of  Kothnagel,  are  roproscnted  by  grt-y  mutter 

in  the  uedolla,  apart  from,  that  which  is  the  upward  cod- 

liswtioD  of  the  grej  substanoe  of  the  spical  cord,  and  conse- 

qaeatlj  the  mosses  of  grc;  matter  wiiich  arc  HUpemddei)  in  the 

airlalla,  pons,  and  crura,  must  proBitle  over  other  important 

(oDcUona    Little,  however,  Ls  known  with  respect  to  theae.   The 

Dm  reasonable  supposition  I  can  form  is  that  all  of  them  arc 

MBoacted  with  the  cen;bello-spinal  system,  and  are.  tlierefore, 

^apgai  in  r^ulating  the  tonic  muscular  contxactions  rendered 

nwiiy  to  maiDtaia  the  various  attitudes  of  the  body. 

§382.  Fanitiotis  of  the  White  Substance. — According  to  the 
fsuduHOtol  law  of  development  already  mentioned,  wo  may 
B^«ct  that  the  part«  of  the  cord  which  begin  to  deveLop  at  au 
tuij  period  are  engaged  in  the  most  general  actions ;  while 
ihtsi  which  develop  at  a  late  period  are  engaged  in  the  most 
ipcaal  actiona  Ths  most  general  actions  of  the  cord  ore  those 
■^  it  performs  as  a  group  of  simple  co-ordinating  centres; 
Slid  the  most  special  are  those  which  it  performs  iu  subordina- 
tin  ta  the  compound  and  doubly  compound  co-ordinating 
ccirtrBL  We  may,  therefore,  expect  to  find  that  the  anterior 
Slid  posterior  root-zones,  which  appear  at  a  comparatively  early 
psood  in  the  development  of  the  cord,  belong  to  the  spinal 
^Mun  of  simple  co-ordinating  centres,  while  the  direct  cere- 
(xlUr  fibres,  the  column  of  Goll,  and  the  pymuiidal  tract,  which 
■FfesT  at  a  comparatively  tatv  period  of  devciopmeot,  bring  the 
*tttfte  cOHMdinating  centres  of  the  cord  under  the  control  and 
pritiiMO  of  the  compound  and  doubly  compound  co-ordinating 
■tttfibalie  ceatrea  So  far  as  can  be  ascertained,  this  expectation 
Buliied. 
0 


82 


ANATOMICAL  AND  PHrSIOLOQICAL  mTEODCCTIOH. 


§  383.  Funclions  of  the  A-ntciior  and  Posterior 
Thesu  consist,  as  already  sUti-cl,  of  looped  fib^e^  wbich  oonnecl 
ganglion  ccUs  at  diiTcreiit  elevations  in  the  cord.  The  anterior 
root-zone  raaintaioa  a  close  relatiouahip  witb  the  anterior  grey 
horns,  and  its  fibres  probably  assist  in  co-ordinating  efferent 
impulses  from  above  doivnwards,  IJut  although  the  anterior 
loot-zone  belongs  primarily  to  the  spinal  system,  it  is  not  im- 
probable thnt  it  may  Lnve  become  at  a  subsequent  stage  of 
developmeut  connected  indirectly,  if  not  directly,  with  same 
of  the  cephalic  centres.  The  cloiie  relationship  of  the  olivoiy 
body  with  the  anterior  root-zone  in  the  medulla  would  seem 
to  imply  that  the  latter  may  be  the  medium  of  conveying 
efferent  impulses  from  the  cerebellum.  The  anterior  rooL-zone 
ia  also  probably  connected  with  the  corpus  striatum,  aod  may 
therefore  be  the  channel  through  which  the  efTerent  impulses 
from  the  latter  are  conveyed  downwards  to  the  cord.  It  is  alao 
connected  with  the  corpora  t^uadrigemina,  and  may  serve  to 
convey  reflex  impulses  originating  in  the  retina  down  the  cord. 
Tlio  posterior  root*znne,  on  the  other  hand,  ntaintaina  an  equally 
close  relatioQship  with  the  posterior  grey  liorus,  and  its  fibres 
probably  aasiat  in  co-ordinating  afferent  impnlHes  from  below 
upwards.  We  have  seen  that,  with  the  esccptiou  of  the  part 
which  belongs  to  the  sensory  roota  of  the  fifth  nerro  and  tbe 
fasciculus  rotundas,  the  posterior  root-zoue  terminates  in  tbe 
triangxilor  nucleus,  and  that  the  latter  is  connected  by  arcuate 
fibrea  with  the  olivary  body,  which  in  its  turn  is  coaoected 
with  the  opposite  half  of  the  cerebellum.  This  indirect  con- 
nection with  tbo  corcb(>llum  would  appear  to  indicate  that 
some  at  least  of  the  fibres  of  the  anterior  root-zone  belong  tOa 
the  corebello-spinal  .system. 


§  3»*.  Functions  o/f/w  Dirtct  Cerebeilar  Tnacl.— This  tr 
belongs  to  the  cerebello- spinal  system,  its  fibres  connecting  the 
vesicular  column  of  Clarke  and  the  cortex  of  tbe  cerebellum 
(Fleeh,sig).  Little  is  known  with  regard  to  the  functions  of 
these  fibres,  except  that  they  appear  to  convey  afferent  im- 
pulses. This  is  presumed  to  be  the  case,  because  when  the 
fibres  of  tbe  tract  are  injured  in  any  part  of  their  course,  tbe 
portions  above  the  seat  of  injury  undergo  rapid  degeneration. 


g  383.  FtiTtetions  o/  the  Column  0/  GolL — Tliis  cotunm  must 
be  regarded  as  a  special  structare  from  the  coinparatiTely  late 
period  at  which  it  is  developed  Its  6bres  also  timlergo  rapid 
degancmtion  above  the  seat  of  injur/;  hence  it  may  be  iDferroil 
that  theycoDTcir  affl^roat  impulses,  but  nothiog  further  is  knowo 
with  regartl  to  their  functioDS. 

§  386.  Funetiftmofthe  Pyramidal  rrncfc— This  tract  ia  now 
w«ll  ksowR  to  l>e  the  means  of  comniuiiicatioQ  bctwcoa  the 
molof  aroa  of  Iho  brain  and  the  anterior  grey  horns  of  the  cord. 

The  fibres  which  pass  into  the  lateral  column  connect  the 
Mitonor  grey  horn  of  one  side  with  the  cortex  of  the  oppoiite 
side ;  while  those  which  constitute  the  column  of  TUrck  connect 
the  aateriur  horns  and  coitex  on  the  same  side.  Wliuu  the 
6brBs  of  the  tract  are  injured  in  any  port  of  their  coune  the 
portioni  below  the  seat  of  injury  undergo  rapid  degeneration, 
and  Ifaia  bet  alone  is  sufficieut  to  indicate  that  these  fibres 
coorey  etTercnt  impulsea.  This  tract  is,  indeed,  ttic  channel  by 
meaoa  of  which  Toluntary  impulses  are  mnTcyed  from  the  cortex 
of  the  brain  to  the  spinal  cord.  The  crossed  and  direct  counec- 
tiuQ  which  thia  tract  forms  between  the  cortex  of  the  brain  and 
the  grey  anterior  horns,  is  rendered  aeceesary  by  the  fact  that 
cTciy  moremcnt  of  one  side  of  the  body  alters  the  centra  of 
gtavity,  and  necessitates  a  new  adjustment  of  the  opposite  side. 
1  obuinod  this  idea  in  a  conversation  with  Dr.  Hughtingn 
Jaekion,  and  be  illustrated  his  mcaniog  by  showing  that  when 
a  IBMI  itonds  on  Ibe  bnll  of  the  right  foot,  and  stretcbee  bis 
rigbt  arm  apwards  and  forwards  to  reach  an  object,  the  body 
being  also  inclined  forwards,  the  left  leg  is  iDstinctivoly  thnut 
backwards,  and  the  left  arm  downwards  and  backwards,  in  order 
IB  kwp  the  centre  of  gravity  na  far  buck  as  possible  and  so  to 
prerent  Ibe  line  of  gravity  from  passing  in  front  of  the  ball  of 
tberigbt  foot  The  muacularcoutractionsof  the  right  side  of  the 
body  may  be  supposed  to  be  regukted  in  this  action  from  the  left 
cortex  of  the  brain  through  the  fibres  of  the  pyramidal  tract  of 
the  Utetal  column  of  the  right  side,  while  the  roovemcnta  of 
the  left  arm  and  teg  are  alio  regulated  from  the  lefl  cortex,  but 
tbe  impulses  are  conveyed  to  the  same  side  of  the  cord  and  of 
bod/  by  liie  fibres  of  tbe  column  of  Turck. 


MORBID    AKATOMY    AND    CLASSIFICATION    OP 
DISEASES   OF   THE  SPINAL   COBl)   A>'D    MEDO 
OBLONGATA.  M 


(Lj-MORBID  ANATOMY  OF  THK  SPINAL  CORD  AS. 
UKDULLA  OBLONGATA.  ■■ 

In  the  precediug  cbaplvr  wc  have  tmceil  the  operattOR 
Iaw  of  evohttioi)  in  the  dcTelopment  of  the  spinal  coi 
medulla  oblongata ;    we  must  now  trace  the  operation 
Iaw  of  diraoLutioa  in  the  breaking  down  of  the  struct 
these  organs  by  discAse. 


D^ 


§387.  Jli^logical  Changes.— The  histological  cl 
which  occur  lu  the  various  elements  of  the  structure  of  tt 
must  first  bo  briefly  described. 

1.  Morhid  Changu  of  the  OaitglioA  CtlU. 

(o)  Rf/pertrofhii^—la  »cute  iiiflaramation  of  tho  oord  the  giogf 
bMomo  awollen,  thsfr  oonteotA  cloudy  uid  gnuniUr,  the  prooHl 
takmg  piut  ia  tlie  vliangea  {Fig.  144,  S).  Tbene  oelU  often  W 
lurgo  UDOimt  of  }rellow  pigment,  ■  condition  whicli  hast  botta  da 
bjr  Dr.  Allbutt  as  "  yellow  .Jogeiicration  "  {Fiif,  \U,  3). 

(A)  SkrjnJu'nif.-  In  tbe  acute  diaeasaa  of  the  grey  aubstooes 
oord,  the  gknglioa  c«llai  cape«iAUj  tlie  atauJl  colli  of  the  medlu 
b«coiiio  «hrivflll«d,  their  fluid  contant^  npjteiLr  to  h»rt  escaped,  t 
cell  wall  to  ban  abrunk  around  tb«  uacluiu  and  a  amalL  qoat 
yellow  frignuiit  {Fig,  144,  4).  At  a  subwquent  period  tbe  oeQa  lea 
procewee  and  booome'  «oaTtrt«d  into  small  angular  inaMea,  ia 
even  a  nudetu  caimot  be  detected. 

(c)  Muftiplieation  of  th^  AWtnu  and  ^fueUotuj, — Tbe  nuctn 
nuoleotuB  may  at  timea  be  ab«arvixl  either  to  ha^'e  dirlded  into  i 
to  axbibtt  au  hour-glua  coatraction  isdicattng  tbat  tbo  proceee  oTti 
baa  ooauneticed. 

(ij)  VaauolaiuM. — Two  or  three  large  spberical  air  spaoe% 


MORBID  ASATOICT  OF  THE  SPINAL  COM). 


85 


wacmtie*,  nay  wimetiiace  bo  obsorwd  io  gaogliou  oolla  wliicti  baro  uoder- 
gOD«  a  gnoular  i]eg«n«nitioit  (fi^.  114,  7). 

(<)  CofMd  DtgatavHon. — ^Th«  lifp«rtniptii«d  oelU  of  tba  early  BUg» 
of  iufl«iiitiuti«a  B»7  sabMqovBtl/  oodergo  «OiUoid  de^nerktiou.  Tb«ir 
pn>c«aM0  beoocn*  tnosponat,  glistening,  brittle,  and  a  Urge  nuinber  of 
tb*m  U9  hnkta  off  m  that  the  ««1U  aasooM  a  i«uud«d  form.  Tbe  mU 
waQ  baa  a  glanjr  ^peuanee,  and  aasumea  biiUiaot  tiuta  vh#ii  »tAiiiatl  hj 
*wwu»  aoflio*  Ayt».  Tba  coUoid  appeuranves  nuij  probablj-  >>«  tbe  reault 
of  pcavmorlcm  clucgea,  aod  oooaequeutlf  oonaidenible  cautiou  must  be 
fi«rciB«<l  io  acoeptiog  tb«m  aa  cvi4«nW4  of  duoaae. 

(/>  Pi^attntary  Dtgtneri^wn. — Tb»  b«0t  «xftmpl«B  of  pi^votar/  d*- 
gnicaUiMi  ara  aeen  in  the  Dhiouic  daeaaM  of  tbs  conl    Tbo  ooU  ml) 


COVH  AS> 


opoBdM 


FlO.  144. 


'ognt 


■m 


#> 


'      .',.• ' 


J 


tih« 


« 


^HlfToanrt  am^km  Cttt*  »i  tU  At^a^  Or^  Benu  of  Ut*  SfvttH  Curd. 
L  H^ifcT  c*u.Ut<i  wU;  V,  Urp««r<tphi*d  c*ll  j  8,  Y.llow  dMwwrMldB  (Ui* 
Njdv  cnLiiu  r-kuniit  be  n;pr«aeQt*d  kece) :  4,  ^jtiiircIlMl  call :  5,  Clitunic 
tti|lV<*m«pt'c*llefn>maoM«of piMila-liypenrqpbicpvuyiic:  6,  Tik 
MMiy  Mnifliji  ?•  Vacaoklioii,  [nn  k  «ww  ol  cama*  cborM  <Uaw«r*r; 
*<  CbuBk)  atRflir,  (fom  a  BMa  d  pnviMiiv*  mDwilar  atiotlij— "jvUow 


m 


MOBBtD  ASATOUT   OF  TBI 


beoomes  contncted  iirouDil  &  most  cf  dark  gnaMhtr  pigment,  tbe  Due 
aud  Duoloolua  ora  indiatitict  or  obliterated,  the  proooasoB  ore  ai 
and  mouj'  of  them  hvre  diaApjieared  (yig.  141,  6). 

(ff)  Atrtiphy, —  lu  cbrouic  tliHeaaes  tbo  c«U  wall  bocamas  dfloM  ud 
(XiDtractod,  the  pKHMuea  brokcu  cS,  and  tbo  ifmnaiit  of  the  oaU  aoafBitod 
itiia  a  nmivU  ftaguhr  maiM,  wittiu\iL  r«cogiiUabl«  nucleus  or  Daolealn^  Mid^ 
flnalljF  nil  tnicuEi  of  tlin  eoll  taa.y  bo  loat  {Fig,  144,  6  and  8). 

{h)  CaUar«oMt  dtgtxttnUwn  of  tlie  gaiifitton  oeUa  of  tlie  cord 
obaerred  (Fdnter). 

%.  Morbid  C^Tiytt  oftltc  /i^ervt  Ftbrtt, 

Tbo  modiiUotcd  nerve  fibres  of  tbo  spiao]  oord  undergo 
more  or  Iom  similar  to  thoM  which  lure  ftlre&d/  b«en  doaeribed 
cast)  of  the  fibres  of  tbe  |wri|ili«ral  norreB,  and  couiaqueatly  theae  changM 
need  nnt  be  deacribBd  here  iu  detail. 

(u)  Hy/jertropfiy  uf  iht  Ajri»  Ci/UruUr. — [ii  myelitia  it  h  not  ran  to 
ottservs  ou  traaiversQ  aectlon  ttutt  tho  axis  oyliodeiB  of  iuaQy  of  tbe  flbs«« 
bsve  bcreoMd  to  two  or  throo  timen  their  uormal  dunanaivii.  lii  lorigitu* 
disal  BeotioDs  it  is  gc«a  tbut  tho  swalliug  doOH  not  extend  the  whole  langtb 
of  tlw  aua  oylioder ;  tfao  Uttor  pnieonts  a  vahoDno  appoarHMe,  ao  that 
■ta  diunetwr  is  much  diminishud  in  hizu  at  »nmu  [xiiiitii.  ^| 

(b)  Airophy  oftM  ncrnt  fibres,  aimilar  to  that  wliiob  ocoun  ia  ths  pcci^H 
l)lieial  tivTvse  wb«u  the  fibrea  are  Mvuml  trom  Lhoir  tropliic  c»utr«a,  mi; 
be  obbc'rved  in  tbu  mwlullatdd  fibres  of  tbo  apinal  oonL  Thia  atnpbj 
begioa  by  coai^ulation  of  tbe  myoliBe,  wbioh  becomos  graiiuUr  and  licokio 
up  iuto  globular  miuiHen  tliiit  are  finally  abaorbed.  The  azia  eyUiwlar  pa^ 
sUta  for  a  loug  time  ivfter  the  medullary  sbeatb  baa  diaappeand,  but  by- 
oud-by  it  alau  lUiuialabaa  iu  aieu,  lujd  ultiuaUily  diaapp«are- 

{e)  Caleareoiii  deyriunuinrt  of  tbu  Gbrea  of  tine  cord  has  beaa  «io^ 
tionaJly  obowvod  (Fontor,  Virchow), 

3.  Mcrhid  Changa  of  the  Xraroglia  and  Omnedwe  TVifno. 

(a)  Olii^t  oorpusdta  ooDHiit  of  Ihtko  globular  cella  filled  with  granalar^ 
o0Dt«ata.  Thetie  wslla  ia*y  bo  ubwarvod  iu  th«  apiuiii  cord  of  the  embryo, 
but  ani  iiover  mot  with  in  oonsidarablo  ntimtran  in  tbe  cord  of  the  adolti 
except  iu  casos  of  diaoaao.  They  an  auppowd  to  derivo  their  origin  firoa 
f&ttjr  deganeratiaD  of  the  cells  of  tbe  oannectiTo  ttaam  aud  iiminigUa,  tba 
white  corpucclea  of  the  blood,  aud  the  endothelial  ooUa  of  tho  timiIi  ud 
of  the  cspaulea  of  the  gaogUon  cells, 

(i)  Am^toiii  Curputcles  atvi  Colluld  lio(iiu.~~Amj\o\d  oorpuacles  (oot- 
pon  amylaoea)  an  small,  rouud,  concentrically  laminated  bodies.  ltfo«t  of 
them  are  turned  bluo,  or  bluiah  gny,  whoa  aotod  on  by  iodiue  alone,  and 
aaaume  a  beautiful  krig;hl  blue  tint  on  tbe  addition  of  sul[ihurio  acid. 
Colloid  bodies  an  irrcgaUr  moasea,  conaiating  apparently  of  chBoged 
inyoliiui;  they  aasume  beautiful  tiiitn  on  being  xtoined  with  loswood,  or 
•MM  of  tb«  asiliiu  dyw.    It  is  probable  that  tbeoo  bodies  na;  b«  tba 


SPINXL  COftO  jUCO  MEDTTLLA  OBLONGATA.  87 

nmiil  of  po«i-iiiort«ni  d«oompoaitJOD,  &ad  oditbtr  ihej  tior  Um  unj-lind 
ooqiuiicln  klTonl  tnutiroithj  arldeaoea  of  diiMraw. 

(s)  Dtinr'i  (4U  Kpptut  to  be  iDcrMMd  iu  uumbttr  iu  iuSuDQiator; 
dUuaNof  the  oori. 

(d)  BypefUop^*!  and  ffyptryJad*  of  A*  Conn^iire  Titn<.—Tbtt  septa 
«f  ooonectlTS  tu>ue  beooow  ■woUeo,  sod  the  niicloi  of  tb«  nouroglia 
hfgelf  ineruaed  tn  number.  It  t«  aim  prob^Ue  thnt  leuooc/toa,  «bi«h 
ham  mtcntod  from  the  veaaels  duriDg  inflaisiDator;  pracwMa,  may  aab- 
mpeotij  baoome  organtaed,  and  thus  iocroBae  the  noroul  volume  of  the 
fionaeetiTe  tboue  of  the  oord. 

(«}  Sti*r»tU  and  A^iPoettAA.— Wbeu  hyperplasia  of  tbe  eoaneetlv« 
tt—BU  hu  041M  takflo  ptaco,  tbe  nawlr-furtuad  tiiiaue  may  subqeiitiooUy 
Buiggu  ekatFJoia]  contnctioa,  and  thus  lead  to  tbe  dssttrujition  of  th« 
mnrna  etofBauta.  The  procan  which  leads  to  ooIanMia  oftao  bogius  in 
te nana etila and  fibres,  aud  maybe  oitlloiljmirrncAjrma£«ufacI«n»ia.  At 
AvtuoM  Um  morbid  chanjw  appear  to  begin  iu  tii«  couixmtiro  tianit 
•r  DMirogtia,  the  nerve  oella  and  fibrea  b«iug  secaodaril/  inraded ;  this 
hta  may  be  callod  inkntitiat  ttttntit. 

4,  MoHtid  Alicratioitg  of  tht  VtueU. 

{t)  tntraptuailar  CAan^M.— Th«  vioomIs  an  at  times  great!  j  distended 
•tib  btood,  but  tlua  is  not  a  tmstworthy  eiidenee  of  diaease,  ttuumuoh  aa 
tbtfirfeaaioti  niajr  have  oocurrod  from  tbe  mode  of  d^iog,  or  from  hy])u- 
*A(  eoogaatlDQ  after  daatfa.  Tbe  capillary  arteri«A  may  at  timeii  be 
JiMDiffd  with  amboU. 

[i;  Chaagw  ia  the  waOa  of  tho  epiiial  vokmU  ue  obaomd  in  ohroni« 
Bii[ki*i  diaeaai,  idaatioal  with  tboM  wtiiah  oovur  in  tbo  vaawb  oT  thu 
Uf  fHuraIfy  in  that  dt«Mse. 

6>)  PtrifHueular  CAvf^at-^-Tha  moat  important  periraecular  changaa 
itwiud  in  diaeiaeof  the  Bjunal  oord  an  cauwd  by  migntioaof  tbawhit« 
■f)«nlai  ol  tbe  blood  into  th«  parivtuKular  lymph-epaoee  and  aunouod- 
nttiMOM.  Ttu  nomber  of  lauoooytoa  Burruun'ling  areasal  may  some- 
tittM  b*  eo  (rent  as  to  oooatitute  what  bae  b«*n  called  a  mi^Mryo^vctM 
Clite  v.,  Fig.  3).  Kupture  of  a  vanel  may  occur,  giviog  rim  to 
fcwiiiiiLa^e  iotA  tbe  tiasoea.  K»d  Uood  rorpuaclae  are  nt  tiuve*  locaiiKMl 
B  •  tenvaaoular  apaoe,  but  it  ia  difficult  to  detcnmae  in  thoM  cases 
^lUMr  tbe  r«d  corpueclea  have  eKOped  by  rupture,  or  hare,  lilce  tbe  white 
Mfadet,  migrated  Ibrougb  tbe  wall  of  tbe  veawl 

I  >88i.  Let  us  now  pass  from  tUe  detiuls  of  the  morbul  cliangos 
*(  (he  oord  to  the  genenit  principles  wblcU  uaJurlie  them.  Iq 
Wxii&nce  with  the  lav  of  disgolutioD  (§  35)  we  may  expect 
tint  lbs  acoesaory  portions  of  tbe  cord  will  form  parta  of  least 
iMttsDoe  to  the  inronds  of  disease. 

U  the  gre/  subataace  tbe  leasb  rasistance  to  disease  will  be 


ftO 


HORRin   AMATOMT  OF  TBE 


otliera.  If  fiff.  145  bo  compared  with  Fig.  Ill,  it  will  be 
at  once  Ibat  the  disease  is  most  marked  in  ibo  vmsealar 
arCM  of  tLo  cord,  and  that  the  cells  which  havo  beeo 
last  developed  are,  ou  the  whole,  those  which  have  sulTered 
most  will  be  apparent  by  referriug  to  the  previous  descriptioo 
iind  illustrations  of  the  development  of  tte  oord.  It  is  inie 
that  the  earlier-developed  cells  of  the  iotema]  and  anuuioi 
groups  bave  disappeared ;  but  the  cells  of  the  antero-lateiBi, 
aad  those  of  the  central  portions  of  tbo  poatcro-lateral  and  of 
the  ceutraJ  group  are  well  preserved  ;  while  the  margiual  cclU 
of  the  two  latter  groups  and  all  the  cells  of  the  median  area 
are  completely  destroyed.  It  is  not  likely  that  this  law  will 
always  W  olisurvcd  in  a  (lisuaso  having  such  ao  acute  and 
sudden  onset  ba  infantile  paralysis  ;  but  au  cxamiaatioQ  of  tbe 
diagrams  given  by  Clarke.  Charcot,  and  Joflfroy,  shows  so  many 
indications  of  the  fultilmvnt  of  thia  law  that  its  occurrenM 
caanot  be  regarded  as  accidental.  The  eamc  law  is  observed, 
at  least  very  frequently,  m  cases  of  acute  aad  eubacuto  asceod- 
iog  central  myelitic,  as  well  as  in  tetanus  and  hydrophobia.  It 
was  while  examining  cases  of  this  kind  that  tny  attoutioa  was 
first  dircoted  to  this  subject.  In  alt  tbo  acute  diseases  affecdng 
the  groy  substance  of  the  Kpiual  cord  I  observed  that,  uoleas 
the  deBtructioD  was  no  great  as  to  involve  the  anterior  boras 
in  their  entire  extent,  tho  small  cells  and  those  in  the  line  of 
the  distribution  of  the  arterie-i  manifested  evidODCes  of  diSMM 
to  a  much  great«r  extent  than  the  large  cells  and  those  rei 
from  the  vessels. 

The  distribution  of  the  disease  in  the  cervical  enlargerai 
is  aituilau-  to  that  in  the  lumbar  region,  except  that  the  raedu 
area  being  much  larger  in  tbe  former  than  id  the  latter,  injury 
to  this  area  forms  a  more  conspicuous  feature  of  disease  In  tbe 
former  than  the  latter.  When  the  donjal  r^on  of  the  oord 
is  affected  by  acute  disease  of  the  grey  substance,  the  most 
marked  morbid  changes  arc  observed  iu  tbe  postero-lateral 
or  rather  the  medio-latoral  group;  and  tbe  satno  is  the  case  lo 
tbo  upper  cervical  region.  A  section  of  the  middle  of  the  cer- 
vical onlni^emont  is  represented  in  Fig.  146,  taken  from  a  ease 
of  subacute  ascending  spinal  paralysis.  The  disease  began  aft«r 
exposure  to  severe  cold  with  sudden  paralysis  of  th 


BPDUL  CORD  XND  MEDULLA   OBLONGATA. 


89 


ragUa,  it  may  be  expected  that  the  itpongy  and  loose  aeuroglia 
of  tie  Uter-dereloped  portiooa  of  the  grej  euhstance  will  resist 
its  ioruMls  lets  effectually  than  the  (Icuw  neuroglia  surrounding 
the  earlier-deTelop^d  fijoapa  of  ganglioD  cells.  The  ceatrol 
gnj  column  possesses  a  loose  and  spoDgy  DeurogUu,  luid  we 
have  ii««n  that  it  mnv  bo  regarded  as  tho  embryonic  area  of 
Ibe  spinal  cord,  so  that  it  may  ho  expected  to  offer  little 
renitjiDoe  to  the  iuvaaionof  disease.  We  shall  httreafter  see 
that  some  of  tbo  most  rapidly  fntal  diseases  of  the  cord  appear 
to  ascend  ia  the  ceninil  grey  coIudid.  It  has  heea  pointed  out 
that  ttie  later^fonoed  oclU  of  the  anterior  horns  grow  close  to 
the  arteries,  while  the  earlier-developed  celU  are  pushed,  in  the 
coune  of  development,  away  from  them.  When,  therefore, 
rapid  exudation  takes  place  from  the  vessels,  whether  it  consint 
of  •  Buid  and  granular  exudation 
or  of  migration  of  white  blood  ^i**-  N5. 

corpuscles,  the  cells  id  the  neigh- 
bourbood   of   these  vessels  will 

saffer  aooiiDr  ood  in  greater  dc-  .1^*——^  f 

gree  tlua  Ibose  more  remote. 

That  the  lines  of  least  resis-  ^ 

taace  to  disease  in  the  luiabar 
fcgioa  are  in  the  direction  uf  the 
reMeU  is  well  illostntcd  by  Fig. 
US.  which  is  taken  from  a  section 
of  tiie  middle  of  the  lumbar  eo- 
largement  in  a  case  of  inCuitile 
paralysis,  under  the  eare  of  Dr. 
Humphreys,  at  the  Peadlebury 
Buepital  for  Sick  Children.  This 
casa  is  described  in  the  "  Transac- 
tions of  the  Pathological  Suciotv  ^^ 
of  Loodou"  for  1871).  and  will  "'^^ 
be  aafasefiaeotly  meutiuncd.  My 
present  object  is  to  show  that 
Mrao  in  an  acute  disease  like 
lAfiutiie  paralysis  the  cells  near 
tlie  Toifrols  have  become  do- 
atfoyed    in    pcefereuce    to    the 


»^ 


^.•^ 


Fio.  115  [Youw).  StttiM  */Hn  Lum- 
tar  Rtpiottof  IX* Spinal  Omlfr»m 
«  cur  4^  ii^a  aWc  «pi  ■m' yoraf |mW. 
pit  poat«ra-lat«ral  |;niup;  ol. 
uil«Tn-Ulen]  snmp ;  e.  mntru 
irr.mp-  Tbi)  inlcnuilftiKl  kntarira 
|i«M)p«  ktT«  diMopavvd,  umI  tlw 
marslnsl  mUi  at  Iba  immUdc 
graapB  an  slto  dHtn^aiL 


9S 


MOBBID   AHATOMY  OF  THE 


to  be  quite  normal.  In  the  ceirical  enlargemeat  (Fig.  146) 
the  cells  of  the  medijiii  area  had  entirely  disappeared,  and  the 
marginal  celU  of  the  central  and  postero-lateral  groups  were 
notably  altered,  while  the  fuudamcQlal  cells  of  the  groups 
preseated  beautiful  long  procesecs,  and  appc&red  in  eveiy  , 
TKSpcct  aorraoL  ^H 

§  389.  Id  tko  wbitc  substance  the  last  developed  6bres  will 
^w,  other  things  being  equal,  otter  Ichs  resistance  to  the  inro«ds 
of  disease  than  the  earlier-developed  fibres.  In  proceeding  to 
verify  this  statement,  we  must  compare  the  later  with  the  earlier- 
formed  fibres  of  the  eamc  segment,  or,  in  other  words,  the  same 
functional  system  of  the  while  substance,  otherwise  the  whole 
result  will  be  vitiated.  Tbo  posterior  and  anterior  root-zone*, 
for  instaQCe,  are  developed  about  the  same  time,  yet  the 
former  Li  more  liable  to  become  diseo-sed  than  the  latter. 
The  posterior  is  probably  more  exposed  to  the  exciting  caoses 
of  disease,  such  as  periphi^ral  iujuriea  and  a«ceudtng  neuritis, 
than  the  anterior  rool-zoae,  and  the  small  fibres  of  the  former 
are  more  apt  to  bo  injured  iu  iufiammatory  allections  of  the 
cord  than  the  larger  fibreii  of  the  latter.  But  if  the  accessory 
be  compared  with  the  fundamental  fibres  of  the  p)Taniidal 
tract,  it  will  be  seen  that  the  former  are  much  more  exposed  to 
iajurtoua  influences  than  the  latter.  The  nmoll  diameter  of 
the  greater  number  of  the  acceaaory  fibres  permits  a  relatively 
larger  amount  of  nourUhment  to  giun  access  to  their  interior 
tbon  can  take  plaoc:  in  fibres  of  larger  diameter ;  hc-nco  both 
reparative  and  destructive  cbangos  ar&  more  rapidly  effected  in 
the  former  than  iu  the  tatter. 

The  accesHory  fibres  are,  as  we  have  seen,  more  olo»ely  relotod 
to  the  connective  tissue  septa  of  tbo  cord  than  the  fundamental 
fibres,  heoce  the  former  are  more  liable  to  be  injured  in  the 
course  of  the  diseases  which  begin  in  the  connective  tissue  ami 
neuroglia  than  the  latter.  An  appearance  which  is  presented  by 
the  spina.!  cord  in  various  diseases,  and  which  for  a  long  time 
puzzled  mc  \'ery  mttcli,  is  that  which  has  been  de.scribod  as  miliary 
aclerosts  (Rutherford,  Keaberen).  This  condition  appears  to 
oonsist  of  a  (twulliug  or  tbickcning  of  the  septa  in  which  the 
blood-voasels  run.    In  the  lozeoge-ebaped  spaces  {Fig.  133)  of 


SPINAL  C»RD   AND  HEOULLA  OBLOKOATA. 


flS 


Uid  pyramidal  tract  a  coDsiileralile  number  of  the  soiall 
fibres  which  tie  close  to  the  vessels  are  destroyed,  while  tbo 
kiger  central  fibres  remain  moro  or  leaa  healthy.  When  a 
tnocrerse  section  of  the  oord  ia  examined  under  those  circum- 
■tuuM  the  part  presents  a  iipott«d  appearaace,  but  tostcad  of 
tbe  miliaiy  spots  being  in  a  state  of  scleroeiii,  they  really  are 
tbe  most  bealtbj  portioiu  of  tbe  section.  The  proximity  of 
the  fibres  of  tbe  accessory  system  to  the  blood- vt^s»«l&  renders 
tbeiD  also  more  liable  than  tbe  fundumeutul  6brcs  to  be  iDJured 
by  iDflamtnatory  and  other  effusiona 

§  3110.  SccoTuiary  Vt{fcn«rati^8. 
'Tbe  medollated  fibres  of  the  spinal  cord  undergo  degeoe- 
nktiou  whenever  thetr  cootiouity  ia  interrupted.  The  sbort 
looped  fibres  of  tbe  anterior  and  pgeterior  root-zones,  however, 
only  d^^enerate  in  the  neighbourhood  of  the  lesion,  probably 
becuuo  they  soon  tctmiaatc  in  grey  matter.  But  the  fibres 
whicl)  pasB  from  one  end  of  the  cord  to  another  are  sometimes 
Ibaod  degenerated  throughout  their  whole  length.  As  a  rule, 
bowenr,  a  focal  leeioo  interrupts  the  coDtlauity  of  tbe  long 
fibres  in  some  port  of  their  course,  and  the  fibres  either  abovo 
or  below  the  scat  of  disease  undergo  degeneration.  Soms 
patbologista  think  that  an  irritative  change  spreads  from  the 
primary  lesion  as  a  centre  along  these  fibres,  but  the  moat 
reasonable  supposition  is  that  the  degenemtion  is  aoalogous  to 
what  oocuia  in  tbe  fibres  of  peripheral  nerves  after  tbey  have 
b««a  aefered  from  their  trophic  centres.  The  trophic  centres 
of  tbe  fibres  of  tbe  columns  of  Ooll  and  of  tbe  direct  cere- 
bellar tract  are  situated  at  tJieir  lufurior  extremities — the 
poatnior  bom  containing  tbe  trophic  centres  of  tlie  former, 
and  the  reucular  column  of  Clarke  possibly  that  of  tbe 
latter.  When,  therefore,  the  continuity  of  thc-sc  fibres  is  iutcr- 
mpted  at  any  point,  tbe  portions  above  the  scat  of  the  leHion 
niMlezgo  degeneration,  consequently  degeneration  of  these  fibres 
ia  called  tutcendituf  acUroaia.  But  tbo  trophic  centres  of  the 
fibres  of  the  pyramidal  tract  are  situated  at  tbeir  superior 
tztremiiies,  these  oenltM  being  probably  formed  by  tbe  large 
fssgtioD  cells  of  the  fourth  layer  of  the  cortex  of  the  brain. 
Wbec  tbe  continuity  of  these  fibres  is  interrupted  at  any 


91  UOSfim  ANATOHT  OF  THE 

point  of  tlieir  course,  the  portionit  bolow  the  aeat  of  the 
undergo  degeoeratioD,  ci>nstH{ueDtIy  this  form  is  called  detoend' 
iTig  scUrosis.    The  time  occupied  b/  the  degeneration  appeoA 
to  be  from  four  to  eight  weeks.      Schiefferdecker  found  id 
experiments  oa  duga  that  it  began  at  the  cad  of  fourteen  daji, 
was  well  marked  at  the  end  of  four  to  five  weeks,  but  changei 
in  the  counecLire  tissue  were  not  ohaerred  until  the  eighth 
week.     D^cnemtioa  of  the  fibres  of  the  spinal  cord  appetn, 
always  to  take  place  in  the  line  of  tbeir  conduction.    WbeU'^H 
transverse  section  of  the  spinal  cord  is  examined  by  the  oalcfl^^ 
eye  the  degenerated  portion  usually  presents  a  grey  or  greyish 
discoloxu-ation,  bnt  in  recent  cases  the  cord  presents  do  abnormal 
oppearancea  until  it  is  hardened  in  chromic  acid  or  bichromate 
uf   ammonia.      In   canes    of   long    standing  the  degenerated 
culumns  may  he  atrophied   to  such  au  extent  that  the  sym- 
metry of  ibe  cord  b^cumea  altered. 

MicroHcopic  ex.-LminatiGn  Kbows  that  in  the  earlier  stages  the 
nerve  6hres  are  exclusively  affected.  The  medullary  slieatbi 
undergo  fatty  degeneration  and  ultimately  diHappear,  while 
there  is  a  considerable  development  of  granule  cells;  the  axis- 
cylinders,  however,  persist  for  some  time  afterwaixls. 

In  the  later  ntages  of  degeneration  the  nerve  fibres  disappear 
entirely,  the  neuroglia  is  increased  in  i^uantity,  and  changes 
into  a  doDiie  finely  fibrillutcd  tissue,  which  contains  uumerous 
nuclei  and  epindlu  cells, 

1.  Hinory. — Sccfliuiary  ntrophy,  eitendlng  to  the  pons  snd  pyraiaids 
of  the  modulla,  van  observed  in  dineuse  of  tli«  bruin  b/  Cmralhtor  kod 
Bokitaofitcy,  but  tlii-y  did  not  follow  it  to  tho  Hi^inAl  cord.  TUrck  made  * 
thorotigb  esatniDaUaa  nf  th«  aecondsry  tlegouorntioDB  of  the  spinal  oofd 
in  18&I  sad  ISIV3,  and  their  bistolAgiesl  chiu'act«r«  ^kts  iiivmtigat«d  ia 
1803  by  Lejdea.  Various  Froiich  autbon,  as  Gharoot,  Oornil,  and  othen^ 
pubUabsd  casM  in  which  tbeno  degoii«nti<ms  wws  obssrred,  bat  tba  OMck 
eihaustlve  work  on  tlic  pathology  of  tho  afiectiou  was  publUhed  by 
Ooiichord  in  IStSS.  Hoou  ■rtvrwATtlH  Wvstphiil  showsd  tbat  aeoooduy 
d>?gctiKruti»nB  could  be  produced  eiperiinentaUy  Jn  dogs,  aod  tbU  «■■ 
afUrwdrde  coiilinued  by  VutptuD. 

S.  Oiitribiitvfn  ofth«  Dvgtntralitm. — Tho  obMrvaticns  of  Charoot  i'-^ 
Ptemt,  and  nubwqueatly  of  PluchAig,  t«nd  to  show  that  these  aec< 
dofrasntiont  of  th«  sywn.'l  cord  arv  d«t«rniiofld  b;  tb«  order  of  ttt  U«rc- 
lopawot.     The  devetopmeDt  of  tba  f^tnotboal  ^steuu  of  tha  wbits  sub- 


Uunae  of  the  eerd  aSbnts  &  good  illiutntion  of  th«  Iaw  of  evolution, 
«hO«  the  aeooulu;  dflgenentions  ftffnid  ui  tlcnoat  eqiuU/  good  itlustra- 
ttoo  of  the  Ikw  of  diasoluttoo.  TliA  distribution  of  tbAM  degAnenttioos, 
UMrabre,  IIU7  tw  mdiljr  mulecatood  bjr  referonco  U>  Figt.  134  to  14i>, 
wiikb  Ulwtnta  the  denlopmant  of  the  conl. 

(a)  Jjarw/iit^  lUffenenuion  takoa  pince  nbovo  the  aeat  of  the  lesion  In 
the  ooiouuu  of  GoU,  wxl  tenaiiutet  in  tt)«  up[)«r  end  of  the  medttUa 
J.I1J— j-*»  vhera  tha  fibnM  mid  in  the  ounette  nooleiu,  Tho  direct 
onbdtar  fibrw  bIm  undergo  auendiog;  dtgenenUon.  It  uia;r  begin  as  k 
tU& '— — «■  of  dogeaontod  tLMue  on  tbo  Bxteniol  aitrfuce  of  the  laUral 
ealODii  in  the  lomr  domJ  region,  the  vnm  of  tht!  il»i;i>tienitioii  gradually 
JaonMing  in  niia  upwnrda  BloDg  the  DOrd  ftod  the  extcru»l  surfeog  of  the 
■■Jifieiii  bodi«M.  In  kaioiu  i»r  the  cauda  eqiiinn,  ami  Mimetimae  tiler 
■nen  trmomatio  tojuriM  of  the  eciatio  D«rr«,  tlie  poetorior  rootBOooa,  ae 
«»UMtbeoolunuuo(Qol],iiudergOMc«ndiiijdegei)er>Linu  iti  the  lumbar 
and  peat«r  portion  of  tbe  dorul  re^otM,  but  tbo  degeneration  become* 
iiaKed  to  tbe  cohimiia  of  GoU  in  the  upper  donal  aud  oervitul  regioua. 


Fie.  1<7. 


Fm.  11& 


Fio.  HSl 


-^"- 


■'•W 


'Jr 


FlM.  1(7,  IVIt  aad  141.  Traiumtw  SfrtUiu  of  Utt  Spin^  CVpni./nnn  tht  tniJUe  V 
CM  arrtcolM/afWMNnf,  mUMt  of  Ike  ianaH  rtpUm,  aiul  miidU  »/  th4j>imlar 


icttlMidlteeti 


ahovtnc  aKeading  dqtuientioB  ot  the  coloma  of  QoU  W, 
Mla(t(M»t*). 


(fc)  AMm<h'i»r  i/«.7rntra(tDn  oooon  in  all  deatmctire  lesiona  of  tbe  hniu 
or  ^>bul  eonl  <rhu:li  injure  the  flbrea  of  the  fiyrainldal  tract  iu  their 
thrvngh  tlia  oorona  raduta,  istenial  oapaule,  crue  <:er«bri,  pona. 


FialSOi 


Fill.  UU- 


FW.1SS. 


Plan  UtO,lSUandl33{.UMrCbaroatt.   Tniiutvrtc SiMm4  ^  l>ie  Spinal  rvnLfnm 

(W  mMUt  tf  Ur  (•fTirfl/  tntarfratfitt,  nufJtt  of  OU  Hvrtal  r*tfi<nt,  dnd  midiU  tf 

(tu  Immbar  r«PMn  newdjrtfjr,  tbowiae  primarr  Uteral  Kleroaui  of  lb*  oocd,  or 
eManlarr  *o  ■  Iwioii  bl«h  up  in  lb*  oenl  or  OBMuUa  oblanKatik  —A,  A.  A,  !>«■ 
insalvtl  iTianidal  InKte 


96 


MORBID  ASATOMT  OF  THE 


Fig,  1M. 


madulla,  or  cord.  In  tbrdiauoacsof  bhooord,  tbedegoQentioaisgeiietsI^ 
biktoral  And  nymmotrical,  and  the  powtiou  ooou|ned  by  tb«  diKMcd  yof 
tioDs  of  tlio  cord  in  the  latora]  oolumna  ia  ropreaente^l  Ui  Fiyt.  160,161, 

and  Ui ;  tha  degenentton  of  the 
columiiR  of  Turtle  Ih,  bomver,  iwt 
abown.  Tbe  poirition  occa|^«i!l  by  tb* 
diMmsc'l  [lortion  tii  tbo  mcdull&  oly 
locigntA  in  rcjinnent^d  ju  tli«  ann«x(d 
woodout  {Fiff.  1C3,  A),  la  cenihnl 
leniniiti  the  dogonantive  Inct  in  gm*- 
rnll}'  limited  io  one  dde — thcifide  of  tin 
ctytil  o()po«it«  tlie  leaioa  In  ttio  liniD— 
aa  roirreseatcd  in  /V^f*.  IM  to  IM. 
Tlio  coIiiiunB  of  TUrck  oii  tho  aanw 
udc  OS  tbo  Icaion  of  tbe  bnuii  art  alM 
luiiHlly  HimultaDoouBl^  degaiiented, 
but  this  is  not  rcprwantttd  in  Hm 
figure. 


,1 


FiO.  153  (Altir  ChaKnl),  Trmttitrtc 

Itftian  r,f  tk(  mniKltit   fibiMjMtO, 
on  II  Inrl  u^'CA  tht  nti/ldlf  of  the 

diinrji  trails,— A,  A.  Sclwiwi*  of 
tilt  anterior  |>ymmidii. 


Fin.  354. 


FlO.  lU. 


rifl.  IK. 


'Cm 


Tvm.  U4,  llB.udl.'UItAIturl'hiirMLi.  Jrantimr SitliOHHif  Uit »pu»9l Oord,^ 

Ihttumliar  rtgyon  ritptttirtty,  ahnwing  dnofniliuK  idBroaU  of  tbe  pj 

tnot  in  tbs  iMenU  Mrlumn  MjountUf}'  to  %  cerebrftl  lMU<n.-'A,  A,  A,  D«- 

g'Qucratvd  prnuniilkl  tract. 

3.  DeytMration  oj  the  Spinal  Card  Swondarjf  to  Awipvtation,—^ 
ohiDgas  wbioli  occur  in  tli«  npinal  cord  after  «mputftUonb*v*bo«ti 
by  Bdraid,  CniTeilhler,  Tiirok,  Dickinsoa,  Luckbart  Clarkf^  Vulpian, : 
otbersi  and,  in  t,  reuent  uutobur  of  tb«  Jvunuxl  cf  Anatomy  and  Phym»- 
logy,  Dr.  Draacbfeld  baa  given  n  good  reanm^  of  tbe  pr«viaiu  obaemAioM 
of  others,  wl)il«  adding  nev  ot»ervatioua  of  bia  own.  Tha  general  renlt 
ap[)ears  to  be  that  the  parfpharlc  nerrea  and  tbe  white  anbataace  of  the 
cord  uo  UDASeoted,  tbe  poetcrior  roota  are  often  sltgbtlr  diminiabed  in 
size,  and  ohangos  in  tbe  ganglion  oelta  of  tlie  anterior  hams  areof  coostaot 
ooourrcnccu  Soin«  of  tbo  ganglion  collq  of  the  anterior  homa  bar*  com- 
pUteljr  di«i[j|K3arpd,  whilat  thuHe  that  remain  arv  atrophied  and  shorn  o^ 
tboir  proc«a«M.  Judging  from  the  various  draTinga,  the  ganglion  cMn 
the  margios  of  the  Tariouagronpa  disappear  first,  and  thoee  of  their  cent 
reoiaia  to  tbe  la«t.  The  cells  of  the  posterolateral  group  are  particularly 
liftblo  to  be  affected.  No  menliou  is  made  of  the  disappeanuoa  of  anj  of 
the  ganglion  cells  bom  tbe  anterior  born  on  the  side  apposite  to  that  ct 


SPIKjLL  oord  asd  hedulla  obloxgata. 


97 


Uw  wii]HiUtod  limb ;  bat  judging  from  ths  diagruna  wfcicli  tUuittntte  Dr. 
DnwihUd'a  fmpa,  1  ahould  think  tlut  lUo  number  of  oella  iti  tlw  tiit«nud 
|raii|i  of  Um  Of)puit«  aide  is  much  dimicUhwl  Th«  fibrw  of  tb«  extornat 
tHnculoa  of  tlie  tioatcrior  root  p«M  tbrongb  tlio  anterior  commUMuro  to 
jdtn  tbu  «AUi  of  tha  intonul  grwu|i,  and  In  futuro  cases  it  would  b«  worth 
■bUs  to  obouTs  wbctber  a  streak  of  dcgonciratioa  migbt  not  be  Actticted 
aldog  U)»  oonnw  of  Umm  film*  to  rsach  tiia  internal  grttu^)  of  thi!  appo«it« 
■Ub.  fl^tda  ton  out  ttte  sotatic  ncrre  of  one  aid«  iu  rabbiu,  aud  fouud 
ID  Um  knnbar  legiou  of  lbs  cord  ou  the  name  sidaKlBraalB  of  the  pwrtArior 
root  aod  |mstehor  gnj  nuUcr,  aloos  with  dsf^oeratiTa  alropby  nf  tha 
gaogUoo  csUb  of  tha  istermedio-Utaral  tract. 


§  891.  De/ormUU«  and  Malformations  of  the  Spinal  Cord. 

Tbe  deformities  aod  malformatioDS  of  the  spitial  cord  may 
be  fiubdivideil  into — (1)  the  congenital  deformities  wlitcb  are 
iDCompattblo  with  the  raaiotennuce  of  cxtro-utorioe  life  ;  (2) 
tbe  cuogenital  duri>rmitie3  which  are  ODiap«tible  with  life, 
mud  do  not  betrajr  tbenwelres  by  aoy  fiymptom  during  life  ;  (3) 
thaooageoital  deformities  wbtch  may  bo  recogaiscd  duriug  life ; 
(4)  lociuiieil  defonnities  reflulting  from  patholo^^icaJ  proceiaes 
^/riogomyelia,  Hjdromyelus  scquigitus)  (L«ydeo). 

The  followiDg  are  tbe  mora  frequent  oondJliona  observed 
(Loydoa; : — 

1.   OmgenUal /k/armitiet  of  StiU-horn  CAildivn. 
(m)  AmfJia,  or  ataeuoo  of  Uw  Byiuai  ogrd.     [t  ia  only  uwt  with  wbon 
th«  brain  b  aUu  altMut 

(fr)  Ahbmylia,  or  imperfect  dvralopniont  <St  the  apiDal  cord.     Tbe 
■  and  «r  tbe  oonl  is  koldng  or  impetfectly  developed,  the  brain  being 
abaaat  (anatujUMtia),  or  tbe  bead  defootiv*  (uocpkttiia).    The  m«- 
dollB  oUoDgata  la  abaent  or  emta  od)j>  in  a  rudimeutar;  form. 

(<)  Dia^€mat«mifetia  Is  a  cvuditivu  iu  which  the  tvro  latent  balvas  of 
tba  ami  «tth>r  du  imA  unite,  or  unite  only  tbrougheat  a  portion  of  their 
•atotiL     This  nMlfonnatioQ  oocurv  with  «n«noe|>halia. 

{4i  O^^bM^fMiVrduplicatlouof  the  •piiial  cord,  appeaniii  Lite  varinun 
I  nt  daabl«  a»Mi*t«n, 

i.  Omj^miLi/  Dt/armitiet  wki^  Ainntrf  b«  rtnofnUed  duriitf  tiff. 
(«}  JhmwA'n  in  tkt  IfTfjth  and  TAidbwu  of  tht  CW<^.— The  cord  u 
fboDd  at  tiaia  tbidc  atul  vuluiuiimus,  and  at  other  Umee  thin  and  email. 
It  d^eaitab  at  tinea  to  tbe  third  lumbar  rertebn,  and  ends  at  other  time* 
nppHtv  tbe  clereotb  or  twelfth  dorsal. 

(]  Aboaruial  anudliMte  of  the  eutire  spinal  cord  and  madulla  oblon- 
■tth  oomqiondiii^  smallueen  uf  the  nerve  fibras  and  oiis  oyliudera, 
H 


98 


UORBID  ANATOMT  OF  THE 


has  rsc«]itly  b6eii  described  by  F.  ScholtsOr  io  ooe  of  Fti«(lreich's  ca 
"  hereditary  tiaxy." 

(r.)  J«^TnnK<py  o/ tA«  (TTB^iubtfani^,  showing  UQBquol  «ridth  uid 
of  tlie  ant«rior  grey  borua  on  a  transvarse  Mction. 

(ifj  Aftnttrmalitits  o/  the  Pyramiilal  Tracts. — Fleohiiig  hM  raomU; 
show^  thfl.t  the  fit>ro9  of  tho  p^romiilal  trnoU  are  reiy  voriabto  ia  tbiir 
dubribiilioii.  Kacli  pynmid  may  Heiid  ita  tnann  of  librui  into  tho  apinil 
<!ord,  either  ontlraly  oroued  or  only  portly  crowied,  nr  dovn  tha  anterior 
oolumos  almottt  entirely  uiicroaaed.  Tbeae  tnola  an  abaent  ia  «aiia» 
phaloaa  moimtora  (Flochaig). 

Id  ouu  of  oaDgcnitol  absenoo  or  iiitra-utertne  arral  of  doTelopmcDt 
of  oertaia  eitremitioH  Atru[>iiy  of  iteKnito  |>ortioiiH  of  th«  a|ilijal  cord  m^ 
be  obaervad  produciog  asjnimotry,  which  v»  limited  to  tba  oorncat  m 
lumbar  eolargemaiit  aooording  to  the  oitmmJty  aflaotad. 

In  a  CAM  of  conKooital  taliiwa  equiuo-varua  of  both  Ivga,  1  fbuttd  I 
ooBiia  mcdiillana  remarkably  thin  atid  tapering.    Oo  tranave 
the  outorior  grey  tionia  n-ero  wdii  tu  Iw  ^vfomiad,  the  internal 
vhiob  ia  health  ntiis  iiamllrl  with  tho  niitvrior  fimure  buing  drawn  oat- 
wards  aud  backwards,  ao  as  to  be  almost  iua  Uuo  with  tba outorior  bocdK  rf 

Fia  157. 


y 


X 


'^. 


\ 


■<s 


r 


Pmi.  16?.  TrWitTCrtt  Jtttio*  of  tht  upfxr  fd  .■/  At  a>nus  MtAMilart*  ^  1A«  £^a J 
Cm4,fT9>n iicsM e/«nivitndaJ tatifu iqyiitararat^A.  P.  Anionor ud pourka 
borai  i«apMtlv«lr :  i,  int^nwl  aroup  BhuwinK  bn)Uir  mIIm;  •,  antmlar.  ■<, 
anten>4auml.  pt,  paa«n>-Ut«Tar.  muI  c.  ccDtnl  yn.i)|>«  of  odK  «aob  beam 
npTMMiied  oalS  bjr  ft  (vw  anBU  round  ulli  witliout  pIOomM. 


SPI.VAL  CORD  AND  MEDULLA  ODLONOATA.  99 

tKotenaroooiauMHre.  Tb«gaQgli<]iic«llsofUieiut«m(i]  group  were  well 
lovalopod,  ottbougb  U  «m  disjiliicotl  from  itn  iiannl  [initition  {f'tff.  IS7,  i). 
L  tew  cvUs  wen  oboorvcJ  iu  the  }Krataro-]ulcriil  otoa;  but  the  ccdiii 
>f  tbs  Ulterior,  mntnJ,  uul  anUn>-Ut«nil  groap«  were  eatimlj  nbaent 
u  BMoy  wctiotis,  while  in  cttutn  a  fvw  iai)M)Wi»:tJj^-<)«vcl[>)>eil  mJIs  were 
illMemd  in  IheM  areu (#lt^.  l&T.a.c.o/).  Tfae Bne  ObhllatMl  teitoro  of 
OhU^'s  dHwoiIc  and  the  small  (;li»t«uine  nacltft  of  tbo  iittorogli*  KpiimrKl 
^lure  been  Te|>]aoed  hy  \  loose  coooective  tisiue,  thiclcl/  Ktiuldwl  with 
it«  Uoaue  eorptuKkti.  Ur.  Bardie  Iodk  ^o  tOAiutoiued  tliat  con- 
Utljpea  is  due  to  an  arroat  of  derelopment,  and  that  the  f«et  ouctijijr 
I  alniiar  to  tboM  of  the  ernbr^o. 
IBbimuI  outgroirths  or  abaeooe  of  portiona  <tt  the  gny  nutter,  sucb  a» 
I  twwtiw  iitt«nnedio4at«rKli8,  ar«  occasietiallj  met  wttb.  Duptiea- 
loC  ane  of  the  grey  horns  fbr  a  longer  or  shorter  diatai»ce  hare  also 
lolMrrvd. 

iL  Cvi^nilal  A/vmu'fin  ttKick  may  be  recogiuttd  during  Lift. 

i4  fof^pMifaiJ  EniarifvmtiU  ^  lAt  CenJml  Canal,  a  coDcliLioti  which  baa 

>*ahouslj  called  A^HnrriaeAiM  inltnut,  k^nrntftlw,  or  hy<ij\imyrlu4 

ntlag.    Ill  tlte  ll|[hter  erules  of  the  Gongoiiitol  afibctiona  the  cviitral 

I  Ut  the  fccttia  is  coavertod  into  a  cavitjr  vntyiag  In  wiilt'a  from  that 

[la  urdimiy  kuitting  oeedle  to  that  of  a  ciow'et  quilL    The  cntiol  majr 

I  the  anUro  length  of  the  eord,  but  In  at  other  timtut  reKlricLed  to 

ipottioii^  guueralljr  the  oerviail  or  lutubar  mUis«iiieat,  while  the 

Dtsf  occaaionall;  be  moiiiliforui,  ur  the  aiitorior  and  [Kwtvriur 

majr  barv  grown  together  aciosa  the  middla  giving  rioo  to  the 

uoe  of  a  double  canaL    The  conl  diWK  not  ap^MMr  to  undergo  an; 

ohaugea  apait  Iroai  tho  dUphtouiBeat  of  ita  various  segunat* 

I  Of  Mm  great  dilatation  of  tbe  canal. 

UHm  hig^*r  yritdt  of  ooiigouital  hydrontyelii*  either  the  xpiDal  con) 

I  eutirvlj,  or  becomes  split  into  two  baWm  for  a  greater  or  temer 

,  while  titecai^ily  of  the  central  •.-Aim!  freely  commiinioaLes  with 

iwitf  of  ihesjiloal  arachuoid;  the  hjrdTorrauhia  Interna  la  then  iaer;ged 

ofcjJiuiachia  eitema,  as  not  unfrequeDt)}'  happens  in  spina  bihda. 

A)  Sfima  byUm  cansiats  of  an  abnonual  accumulation  of  Suid  within 

I  crrii;  of  the  ejAnal  araohnoid,  asBoctated  with  a  greater  or  leuer 

r  ef  the  vertebral  ooluaiti.    As  it  giraa  rise  to  serious  ajiaptoGoa 

:  Ide  It  will  be  suhMtqiMntljr  doaoribed  in  detail  along  with  tbs 

I  of  tlM  taoiubranea  of  tbe  epinal  owrdL 

1  dftf>ji>cJ  J^fvmiilit*  rttvi(ir»g  /rom  Pathohgieal  Proeunt, 
{■)  SYiiajamgtlia,  or  the  pathological  fonnatiou  of  CAvitiea,  may  bo 

1  m  vanuus  ways. 
1  OiJ  Uatiltea  an  fonaed  b;  the  softening  of  tbe  ceatnt  portions  of  new 
awh  a»  gH'imau,  (liomyxotnata,  and  cliosaixwrnata.     Tbe 
is  Mmetinetf  m  completelj:  disintegrated  that  onlj  a  capoole  of 
4>«^Te  tiMoe  or  mere  trsow  at  the  tutDOur  leinain.     This  softening 


100 


MOIUim  ANATOMT  OF  THE 


is  sometimes  iniUated  by  hmmorrhago  into  tint  iut«rlor  of  Uw 
Thin  aociilvnt  in  ]MirliciiI»rlx  a[>t  to  ocuur  iu  tho  tclcftngieclAtio  rftrieti«e 

(ii.)  Bnmkiu^  Jowii  and  sofleniug  of  apoplectic  foci. 

(ill)  CcatrAl  wftoatng  iu  orew  of  gnj  dusmmntioo  utd  ctkrMiW 
niyeltti!!. 

(ir.)  ObatructioD  of  lymph  chaiinvla  produced  hy  xh»  preuur«  «f  a 
ttuiivur  and  ottt«r  caivtM  (Wustplia.!),  Caviti«i  hare  been  focioed  in  Iba 
Kpiuil  oords  of  uIbuiXs  iubscqueut  to  rarioua  injuriei,  and  tb«H  ham 
beeii  auppoaud  la  liikve  boon  caused  by  olmtruatioD  of  Ijrupli  chann 
(Naunji)  and  Eiotihorat]. 

(&)  ffj/dromj/dva  acquisievd,  or  acquired  dilfitatioii  of  tlia  oeiitnl  Oii 
ma;  raault  ^m  the  following  cniiM4  : — 

(i.)  pBd-Dperidymol  tiijclitia,  which  conaista  of  a  prolifcnitioa  of  the 
eonnoctivo  tiwiue  Hiirmti tiding  the  centrikl  canal,  may  cauM  Moondafjr 
dilatatiou  by  tho  eliricildng  of  the  newlj •formed  tissue  (BatlopeMi)!. 

(ii.)  Cbmiitu  m  itiitigitt>i,  b;  pmduciug  adhesions  of  tbti  pia  outer  to 
tho  dura  mater  at  dafioito  poiiits,  ma^  aba  cauou  dJlatatiou  of  tha  i 
oaiiftl,  p^robably  by  (tbriuking  of  the  nawIy-form»d  tissue  (Simoo). 

(iii.)  OblheratioiL  of  tho  canal  at  one  [xiintmay  lead  to  dilatatioD< 
neighbouring  portions, 

The  cav'itbs  var^  ({reatly  in  size.  Tb«y  way  iudaed  bo  only  a  ft* 
milliuivtm  in  length,  or  oxtond  Iho  entiru  iuiigth  of  the  oord.  Tbcir 
nuoihor  aUo  varies  ;  iu  many  canei  oiin  only  is  futuid,  but  at  otb«r  timaa 
a  larxe  iiuiaber  of  Ibem  niay  Iw  ;>raaetit.  Tbi^y  are  elmoat  alnya 
situat«d  uetr  the  centra  of  the  cord,  and  their  relatinna  to  thecsntr*! 
oiuul]  cau  uuly  l)e  determined  by  carvful  cxaounation.  The  tmurene 
diitQiator  a(  thniie  cavitien  may  vary  frum  that  of  a  naodta  to  tha  tip 
of  a  man's  littlo  fingor.  On  tranaTerae  sootiou  thoir  form  is  rouucUi^ 
oval,  or  angular,  and  their  cont«tita  consist  of  light  and  clearor  turbid  i 
yvUowiah  Bnld. 

Tho  nallx  of  ths  caritiM  may  be  smooth  and  firm,  and  are 
lined  withalajer  of  uylitidriual  e^iilhelium,  or  they  may  be  rough,  1 
and  uneraii.  Th^  walla  vmy  nhw  be  dense,  aiid  rormed  orcirrfaoUo  timas 
or  of  tiautte  which  haa  uudorK&uu  grey  degeiioratiou,  w  of  tb«  various  ue<r 
fiiTtualions  which  have  already  been  described. 

The  eymptoma  caused  by  the  formation  of  oarities  in  th«  cord  depond 
ontiraly  upon  thuir  Hitiiution,  and  no  ileliuita  dnwase  which  can  be 
n«ogikiaod  during  lif4  can  b«  aacnb«d  to  the  premnoe  of  th«M  MtitiM. 


lILh-CUlSSIFICATlON  OF  THK  DISEASKS  OF  ri£B  SPINAL., 
COKD  AND  MEDULLA  ODLONUATA. 

§  392.  The  rule  which  hu  hitherto  been  followed  in  this  wurit 
i%  to  deHcrilie  finit  the  sim]ilest  and  most  elementary  dia^ssei, 
aud  to  reserve  cousideratiou  of  the  most  complicated  aflectiuni 


SPINAL  COBD   AND   UBDULLA  OBLONGATA.  101 

to  the  Imst.  Id  do  dineaxes  i.s  it  more  Hdriaable  to  follow  lliw 
nle  thaa  ia  tbose  afiecling  tlie  spinal  coni  and  medulla  ublon- 
K»U,  with  tiiotr  niembmnea  Tlie  aonexed  tabl^  id  which 
tb«M  dtMuet  are  classiHed.  carrier  with  it  In  thn  main  its  own 
tXplanatioD,  but  it  may  oot  be  out  of  place  to  make  a  few 
t^marks  with  r^;ard  to  tbe  principle  adopted  in  arrangiog  the 
ttractunl  difMses  of  tbe  ncrruuH  organs  them»elve8  as  dis- 
tioguUhcd  from  tboee  of  their  memhranes  and  Tessebi,  tbvir 
fuoctioDftl  affections,  iDJunes,  malfonnatioDfl,  and  neoplaeniB. 

It  bati  already  been  remarked  that  the  spinal  cord  may  be 
divided  into  longitudinni  se^^ents,  each  of  which  posdeases 
Afunctiuaal  uoity.  and  mny  bo  eeparately  diseased.  Diseosss 
of  fjee  nf  (he  fiiDCtioDal  segments  of  the  cord  are  called 
ajfttan-tiueOMs  or  fnacicvdated  diseases,  whilo  those  involving 
MTeral  of  these  BPgmentB  may  he  called  mix^  diitecum.  Id 
tbe  nvijple  syBtein^txeawa  ooe  functional  eegnioul  of  the  cord 
and  toedaiU  oblongata,  alone  is  afiected;  hut  it  Hometimca 
bappeoa  that  two  or  niuio  uf  tbem  bcootne  simultaneouHiy  or 
odDsecnlively  attacked,  and  these  affections  may  ho  called  com- 
pound synum-diseBaea. 

Tbe  B)-Btom-diaeaaes  may  he  divided  into  thoso  affucliag  the 
frey  matter  or  the  ixiiwmyelopalhies.  and  thoae  affecting  the 
wbite  matter  or  the  UucomyeiopathieiL  Tlie  poUomyelopathiea 
may  be  subdivided  into  tbe  dieeases  affecting  the  antfrior  grey 
hQn»,  tbe  central  grey  column,  and  the  posterior  grey  honid; 
bat  tbe  latter  is  never  a  true  system-disoue,  being  always  com- 
plicated by  letiona  of  other  structures,  such  as  the  posterior 
roota  and  potterior  columns,  Biseooe  of  the  central  column  is 
olao  probably  never  observed  as  an  isolated  affection,  the  proiiii- 
ncal  aymptAms  being  cnuKed  by  extensiou  of  tlie  lesion  into  the 
aoberior  boms;  but  we  shall  nevertheless  daasify  some  at  least  of 
tb*  dnaaaes  of  tbe  central  colutno  araoiigst  the  HyHt^m-diseaseB. 

Tbe  UtLornnj/dopatkieg  consist  theoretically  uf  disease*  of  tbe 
pontarior  root-iDoe  (locomotor  ataxy) ;  of  the  anterior  root-zone. 
illsfif  of  which  is  probably  oot  capable  of  being  separated 
ftom  disease  of  the  anterior  roots  and  anterior  grey  horns;  of 
tbe  column  of  Qoll  aud  the  direct  cerebellar  trucl.  to  both  of 
wbicb,  however,  no  definite  sytuploins  have  been  observed  to 
attadi,  and  of  tbe  p^nrniidal  tnct  (primary  lateral  Bclerosio), 


102 


HOItStD  AVATOMT  OF  THE 


Tlie  compound  gyfitem-difieaiie^  are  probably  numerous, 
only  ODo  of  them — amj/otropltic  UiUral  tsclei-oaU — is  reoognioed 
an  a  cltntinct  type  of  diaease.    The  aunexeil  diagram  (^Fig.  15S 
copied  from  Charcot,  represents  the  localisation  of  the  le«!oD 
traoaverse  section  of  the  cord  in  the  various  system-diseaaeft. 

In  the  mixed  disieaKCS  of  the  spinal  con]  and  medulla  oblon- 
gata Landry's  paralysis  h  fttsi  mentioued,  not  because  it  has 
l)een  proved  to  be  conoected  with  riDatoaiical  changes  in  th« 
cord,  but  because  it  is  closely  allied  clinically  nith  the  acut« 
forms  of  ccutml  myelitis.  The  classification  adopted  of  the 
dilTfrcnt  furms  of  acute  and  chronic  myelitis  does  not  requir 
any  explanation. 

Fm.  158. 


Xf 


'TT. 


f 


i./ 


/ 


^J 


A.  J>iMam»  of  tfie  Spinal  Cmti  and  Medulla  Oblongata. 

I.  SyAtem  diseases. 

(l.)  Poliomyelopsthiea. 

1.  E'cliomyclitia  ulterior  aoiita. 
■  (o)  Inr&utile  spinal  |)ar»l}'iLk. 

(()  Ativpliio  it|>iuul  paniysiii  oi  adulta. 


105 


CHAPTER    in. 


1.— SYSTEM    DISEASES   OP   TOE   SPINAL    COUD    AND 
MEDULLA   OBLONGATA. 

(I.)   POLIOMVELOPATHIBS. 


1.   Potiom^itli  Anterior  Acala  (Kofisniaul). 

Jmit  tiijlammalia*  of  ti*  tJrti,  AmtrtiM^  a«rn:—A(MU  Atroplkie ^10!  ParalytU. 

§  39S.  Dfjinition. — Acute  atxopbic  spinal  paral^'sis  Wgins 
»udJenljf  wiih  fever,  goaeral  coovuUioiw,  or  otber  cerebral 
■ymploms,  aad  paralysU  nliich  reaches  ilR  maximum  iuteDsitjr 
At  ODce.  Tlie  paral^'ais  is  variable  in  its  distributioo,  the 
affected  muscles  are  Haocid,  reflex  action  ih  iliminishcil  or 
aliolnboi],  some  of  the  muscles  implicated  undergo  rapid 
■tzopby,  anil  tbere  \s  entire  absence  of  scnsorjr  disturbances 
aim!  of  disorders  of  tbe  functiooa  of  the  bladder  and  rectum. 

I  3M.  ir<>iory.  — Tbia  dia«aM  wm  (iiwt  dcwtibMl  hy  I*  ndcnrood  in 
17M,  but  bo  dill  iwt  separate  it  diatinotly  froiu  other  forms  of  i>aralj«U  to 
«hit:b  chiUfctt  an  UaU«.  The  ftffectioD,  iod«e<i,  d»eB  not  appear  to  bavo 
attracted  tnucb  oatke  until  Heine,  in  1640,  directed  particular  attention 
to  it.  A  good  deaeriptioo  of  it  ma  givta  by  Barthez  and  RilUet,  in 
tMl  ;  bat  tt  vae  mnnli  more  thoraughlf  iuTeAttgatcd  alwut  tbe  aanu 
tim*  bf  DutiheaiM^  who  named  it  paralytU  atropMqtu  ffrauMtut  dt 
Tm^ifma.  In  1664,  two  mooograpba  apiMsared — the  thcu>  of  Diiobenm 
Uw  Toongv,  and  that  ef  Labonk — botb  of  whiob  an  \tTj  important  on 
•■Daaiit  of  iIm  wolth  of  clinical  Jact«  contained  iu  thcui.  Dr.  MUllta- 
kH  rtotntl;  eullfcted  and  anolj-sed  all  tbe  publislied  caMs  of  atrojilUc 
•inal  fsnlTsia  io  tho  adult  f^ni  tbe  time  of  Ducbenue  to  tbo  prceciit  dnj. 

%  393.  £Vtof<i^.— Tbe  moet  remarkable  feature  with  respoct 
IC  Um  etiology  of  this  paralysis  is  tbe  etron^  predi-fposition  to 
llMUSectioo  manifested  by  tbc  a^  of  childhood.  In  tbirty-two 
Ml  of  forty'four  cues  observed  by  Dr.  West,  the  disease  came 


lOS 


STSTEU  DISEASES  OF  TUB 


on  between  tha  age  of  six  montba  and  three  years;  while,  if  we 
analyse  tbc  caaes  cotlecLcil  by  Heine,  Ducbennc  tbe  younger, 
and  thoae  observetl  by  Barlow,  more  than  tbree-fourtb*  (164  out 
uf  20o)  of  till  the  casea  occurred  between  the  ago  of  six  months 
and  two  yeara.  But  Diicheone  reporta  a  ca«e  in  a  child  twetre 
days  old,  and  another  io  a  child  a  mouth  old,  while  csscotially 
the  same  di&eaao  occurs  in  the  adult. 

Sex  docs  not  appear  to  exercise  any  influeaoc  in  its  pco- 
duction,  nor  has  any  direct  or  indirect  hereditary  tendency  to  tlie 
nficctioD  been  traced.  Uoino,  indeed,  assert!  that  the  di£Que 
attacks  by  preference  the  healthiest  and  most  robust  childrea 

The  diHMLM  appears  to  be  most  common  dunng  the  BUramor 
months;  thus,  out  of  fifty-three  cases  in  which  the  dale  of 
attack  could  be  fixed  wilU  aociirncy  by  Dr.  Barlow,  twenty-BCToa 
occurred  in  tbe  months  of  July  and  August.  flH 

The  exciting  causes  of  the  affection  are  equally  obscure,  ano^ 
it  occurs  frequently  in  the  midst  of  roburt  health.  Of  all  tbe 
alleged  causes,  difficult  or  eren  normal  dentition  is  the  one  most 
frc({uenl!y  ajisigned  ;  and  it  is  probable  tliat  too  much  rather 
than  too  little  importance  has  been  attributed  to  this  process  in 
the  production  of  the  aftection.  Injurieii  of  variouK  kinds  are 
often  assigned  as  causes  of  the  disease;  while  nurses  are  fre- 
quently blamfid  unjustly  by  parents,  who,  unable  to  believe  that 
such  a  striking  phenomenon  as  paralysis  can  occur  suddenly 
withoutappreciahle  cause,  imiigine  that  the  child  has  been  lamed 
by  a  fall  through  the  careleKsncES  of  its  attcudaut^ 

Exposure  to  cold,  more  especially  when  the  body  is  OT«r- 
heated,  appears  to  have  inunediately  preceded  the  paralysis  io 
a  coneidcrable  number  of  cases ;  and  the  affection  often  occurs 
in  children  daring  the  progress  or  soon  after  an  attack  of  meaflleBj_ 
•carlatinti,  smallpox,  typhus,  and  other  acute  affections. 


§  396.  Sympfoma— Although  this  disease  is  essentially  the 
same  in  childreu  and  in  adults,  yet  the  symptoms  in  each  differ 
so  much  as  to  demand  separate  deacriplion.  Tbe  diaeasa  as  it 
occurs  in  children  will  be  first  described.  ^i 

{a)  Infantile  Spinai  Parati/sia.  ^^ 

It  will  conduce  to  cleamees  of  descriptiou  if,  like  Labonie,  <*< 


8n.VJU.   COBD   AND  U£DULLA   001»KOATA. 


107 


(livi<le  the  diaical  history  of  tbU  affection  into  fonr  periods : 
(I)  InvKUon  ;  (S)  Reinissiou ;  (3)  Regrescioa  of  paralytic  plieiio- 
meoa;  (4)  Alropbj  and  deformities.  It  must,  however,  be 
romeinbervd  ihat  tliese  peiiods  overlap,  iDHtead  of  being  dis- 
tincUy  Ki«ratod  from  each  other,  aud  that  tliix  subdivision 
ii  merely  adopted  for  tlie  soke  of  oonrenieQce. 

(I)  Period  of  InvfMion. — ^The  diaea«e  is  commonly  ushered 
ia  bjr  a  more  or  less  intense  ferer.  which  is  often  prf.-<(x-dfd  hj 
^^^^bl  mulai«e,  paio  in  the  bead,  invntul  initability,  frctfubeaa, 
^^^Ttftrlinge.  TUo  fover  ia  aa  a  rule  of  short  duration,  la«tii)g 
otdy  from  oue  to  two  days.  Ia  some  cases  it  passes  off  in  a  few 
bcwn.  while  ia  other  ca^s  it  may  ooDtJDuc  from  aix  to  fourteen 
day*,  or  even  toager.  As  the  fever  becmaes  establjfihed  the  cero- 
bral  eympUtrns  become  more  pranouoced,  confusion  of  ideaa  and 
slight  somnolency  are  oUerved,  the  child  may  become  udcoo- 
adaoj;  or  delirium  of  varying  dogrc'ea  of  intensity  muy  supervene. 

The  di^easu  Is  not  uutmiticntly  ushered  in  by  convukiona 
SomctiDies  the  paralysis  occurs  after  a  singlo  convulsion  of 
ibort  duration,  while  at  other  times  they  are  repeated  many 
liiBM  ac  variable  intervals  beforo  the  paralysis  is  definitely 
dadared  (Laborde).  The  coDvuUioDS,  aooording  to  Laborde, 
oftaa  asMimo  Oio  tonic  form,  the  spaAmK,  as  a  rule,  being  re- 
athcted  to  tlie  extremities,  aud  only  extending  on  rure  occasions 
Ld  the  fice;  and  he  belteVvsi  that  even  in  these  latter  cases  the 
attacks  are  uoaccompanied  by  any  other  cerebral  symptoms. 
But  in  one  of  the  cases  quoted  by  Laborde  in  support  of  this 
opinion  tbo  convulsion  was  accompanied  by  unconsciouaooeB, 
M  that  there  are  not  sutiicient  groundn  for  believing  that 
these  attacks  difTcr  in  any  way  from  ordinary  oclumptic  attacks 
M  comiDoa  in  children.  In  the  cases  ushered  in  by  convul* 
aioM  fever  is  often  not  mentioQed  as  having  been  present, 
but,  OS  Lflborde  suggests,  it  is  probable  that  the  coD\'utsicn3 
aaomtsnch  paramount  proportions  in  the  min'lsof  tbo  Atten- 
dants that  minor  symptums  are  not  obeervcd.  Iti  some  few  caaa 
all  genenl  sympt^nu  nro  nbaeDt,  the  child  in  put  to  bed 
^tpareolly  io  good  health  and  is  found  in  the  morning  ptualysed. 
Ib  mod  of  theae  oases  the  paralysis  is  limited  to  a  portion  of  a 
Rmb,  indicating  that  the  primary  lesion  is  circumscribed.  It 
K  bowever,  probable  that  in  many  of  these  cases  transitory 


10» 


SYSTRU    DISEASES  OK  THE 


fever  and  other  gtmeral  syoiptqms  may  have  been  prcscot,  ami 
overlooked  ovring  to  the  defective  observation  of  parcnta 

(2)  Period  of  liemissioyi.—The  initial  symptoms  subside  id  a 
few  daya  and  the  general  licaltii  improves,  but  wbon  ibe  child 
is  taken  out  of  bed  to  be  batbed,  or  fur  same  otber  purpoee,  it 
is  observed  for  tbe  first  time  that  one  or  oJl  the  limbs  bang 
down  relaxed  and  powcrlesii.  Tbe  parulysis  ia  oe  a  rule  developed 
with  great  rapidity,  probably  never  with  the  instaDtaaeoiUDDM 
of  that  caused  by  cerebral  lia-morrhage  ;  bat  it  creepe  on  som«* 
what  gradually  during  iseveral  hours,  half  a  day  or  a  Digllt 
before  attaining  itn  acme.  lu  some  few  cases  tbe  paralyfll 
may  tiprvacl  more  slowly,  and  not  rettcb  its  maximum  for  several 
days.  Id  other  cases  two  or  more  attacks  of  paralysis  succeed 
one  another;  at  the  first  one  limb  is  affected,  aud  this  is 
followed  by  improvement^  but  the  child  relapses  in  a  few  days 
into  a  feverish  state,  when  another  limb  is  found  paralysed 
(Altbaua).  Still  more  remarkable  cases  are  recurded  by 
Laborde,  in  whii^  the  paralysis  did  not  become  permanently 
eslablished  until  the  third  attack. 

But   uotwitbstandi[ig   slight    variatioos,    one   of    tbe   most 
characteristic  featureH  of  this  affection  is  that  tbe  paratyni 
reaches  itii  maximum  of  extent  anil  iotenslty  wtthiu  a  cnil^| 
paratively  brief  space  of  time  from  the  ooset.     The  paralyi^^ 
poasesaes  no  progressive  character  ;  it  recedes  but  docs  not  ad*     ^ 
vance  further.  ^H 

The  distribution  of  the  paralifnis  is  exceedingly  variable    1^^ 
is  fretiuontly    general,    involving    the    muscles  of    the   fuar 
extremities,  as  well  as  a  gtL'at  part  of  the  muscles  of  tbe  trunk, 
especially  thoKc  of  tbe  vortobrul  column,  nod  sometimes  those 
of  the  neck,     it  also  frequently  assumes  tho  paraplegic  fonn: 
but  tbe  upper  extremities  are  probably  never  exclUBivelyaffeCtdH 
Tbe  diaease  occasionally  presents  itself  in  the  form  of  a  heim^ 
plcgia  (Ducbciino  Gla,  Barlow),  and  in  these  cases  tbe  trido  of  th^i 
Deck,  of  the  face,  and  of  tbe  tongue  tnay  be  implicated  at  fii'^H 
but  do  not  remain  pennaoentlr  paralysoii  ^^ 

The  mnaihilUif  is  almost  entirely  unatfected  througboot  the 
whole  progress  of  tho  discaso.  At  tho  outaet  of  the  nfTection 
patients  may  pompUin  of  pains  imd  paTfL-stbesifc,  but  tben 
symptoms  ore  of  short  duratioD.    A  certain  degree  of  cut 


SPIXAL  OOBD    ASD  MEDtTLtA  OBLONOATA- 


109 


byperSHtbceuu  «  rather  lijperalgcsw.  bna  b«ea  described  as 
being  present  Jiuiug  tlie  febrile  atage,  but  ihe  teudoroess  U> 
loach  described  maj  bar©  b«en  due  to  affeotioDs  of  deeper 
Mrudures,  sucb  u  rheumatic  inHammation  of  joint& 

iip/4f  «rfio».  both  cucanootia  and  lerKliaous,  is  coinpletel/ 
abolished  iu  all  Iho  musclea  which  arc  scTvrely  attacked,  and  it 
ta  much  lowered  or  temporarily  oxlinguished  la  ihoao  niuecles 
that  are  onl;  slightly  affected. 

The /andwrui  o/lltc  bliutder  aiui  rectwrn  are  rarely  aftecled. 
Daring  the  first  days^  however,  there  may  be  reteutiou  of  urine, 
but  more  fre<|ueolly  there  is  iDcontinence,  and  the  stools  may  be 
puaad  iii7ol(iiitarily.  Id  young  children  a  slight  weakness  of 
ibc  bladder  with  occasional  incontinence  may  remain  for  (tome 
UoM.  but  aa  a  rule  all  diHtiirbances  of  the  bladder  and  rectum 
bare  disappcftred  in  from  three  to  eight  days  from  the  onset  uf 
tbe  discasa 

(3)  Period  of  Reffre»wii.—A(wt  a  certain  time,  which  varies 
from  a  few  days  to  a  few  weeks,  a  gradual  iroprovumcat  of  the 
paralyiis  takes  place.  This  improvemenl  may  afiect  a  greater 
or  emalter  number  of  the  muNcIe«  involved,  and  some  authors 
ihtok  that  all  Ibe  paralysed  muscles  may  comptett-ly  recover. 
TTjc  caaea  in  which  complete  recaYery  takes  ptutoe  have  been 
called  Umpifrnri/  eintutl  piirttlyais  (Kennedy).  Dr.  Edge,  of 
Maacbesler.  reports  an  int«n»itiog  cose  which  appears  to  have 
baloDged  to  tliJH  category.  It  wiks  the  caAu  uf  u  boy,  aged  ten 
ycftrs,  io  wburn  the  muscles  of  both  estremittea  as  well  us  those 
of  the  back  were  paralysed.  Some  of  the  paralysed  muscles 
were  altgbtly  atrophied,  the  faradic  contractility  was  diminished, 
tbere  were  oa  bed-sores,  and  no  disturbances  in  the  functions 
of  the  bladder  or  rectum  ;  but  there  was  tranHitory  impairment 
of  OQtaneous  Bensibiltty  io  the  lower  extremities.  Kecovery 
vms  complete  in  four  weeks  from  the  oommencement  of  the 
ailBck. 

As  a  rule,  however,  there  in  only  complete  restitution  of  some 
lb*  moKtes,  while  the  rest  remain  permanently  paralysed, 
mode  in  which  the  paralysis  recedes  is  peculiar,  to  six 
CMS!  of  geoeraliaed  paralytts,  which  Labonle  had  ttie  oppor- 
tunity of  obsenring  accurately  from  the  commencement  of  the 
attack,  the  paralyaii  to  the  upper  half  of  the  body  began  to 


no 


SYSTEM    DI8KASES  OP  THE 


improTO  between  the  thinl  to  tlie  fifteenth  d&y  from  tl^^ 
conamcQcemeDt ;  and  it  dtsappeored  rapidly  from  the  oei^H 
upper  L-x Uemities,  and  trunk,  and  l>ccame  restrictetl  to 
the  lower  extremities.  This  improveiaeat  L&borde  calls  Uie 
period  of  first  refftvssion,  inMmiich  as  it  is  followed  after  s 
variable  intcrTal  of  tirao  by  a  second  period  of  amendment 
which  he  calU  the  aecond  regrwsicm.  During  the  secomi 
regression  there  is  a,  gradual  improvement  of  the  panUysis  i& 
both  lower  extremities,  and  the  muscles  of  one  of  tht^m  maj  be 
completely  rcntored  to  full  power;  bnt  the  paralysis  become* 
permanenlly  established  in  one  or  more  groups  of  the  muscles 
of  the  other  lower  extremity,  the  anterior  and  external  gnnp 
of  muscles  being  tho!ie  most  frequently  left  paralysed.  Bui, 
although  the  improvement  usually  takos  place  from  above 
downwards,  it  sometiiues  oocuis  in  the  revente  order,  and  then 
the  paralysis  becomes  perraaaently  lucalised  in  a  Nuperior  ei- 
tremity ;  and  'm  rare  cases  it  becomes  Iocalifl«d  in  the  lausclea 
of  the  truDk  or  neck.  In  the  case  of  a  child  two  years  of  age, 
under  the  care  of  Dr.  Simon  at  the  Southtru  Hospital,  tba 
muscles  of  the  neck  alone  remained  paralysed,  and  all  of  th«H 
were  completely  paralvKed  and  atrophied. 

The  chiefs  facts  which  concern  us  in  this  affection  are  thai 
the  paralysis  roaches  its  maximum  of  extent  and  iutcnailyat 
once;  that  id  all  casos,  without  exception,  improvement  occun 
in  Home  of  the  paralysed  muscles ;  that  the  irnproromeut 
proceeds  most  actively  during  the  first  four  to  eiglit  weeks,  and 
substrquently  at  a  much  slower  rate;  and  that  thisimprovomeot 
may  continue  for  from  xix  to  nine  months,  and  under  appropriate 
treatment  may  go  on  for  one  or  two  years  from  the  commeoce- 
iQCnt  of  the  attack. 

(■4)  Period  of  Atroj^y  and  DefomiHiea. — AH  tnusdea,  in 
which  motor  power  is  not  soon  restored,  become  the  subjectfi  of 
a  rapidly  progreneive  ntroi^i^ ;  and  even  the  muscles  which 
are  but  slightly  affected  emaciate  to  some  extent^  but  sochi 
recover  on  the  restoration  of  voluntary  power. 

The  atrophy  usually  begins  in  the  fiivt  week  of  the  duesM, 
and  it  is  generally  well  marked  in  the  course  of  a  few  weeks  in 
the  muscles  which  are  severely  affected.  The  muscles  become 
more  and  more  Qnocid  and  attenuated,  and  after  a  tJma 


RPIKAL  OORO  AND  MEDULLA  OBLOh'QATA. 


Ill 


disAppoar  so  coniptetely  tliat  the  skin  seems  to  lie  imracdiately 

upon  the  bone.     But  tbo  extent  of  tJie  altupby  of  the  mueciilor 

mtbstODoe  is  notalways  exactly  iiteaaured  by  tbo  lo8«  of  bulk  of  tb« 

muscle,  ioasmucb  aa  the  amount  of  atropby  la  frecjuently  marked 

by  tbe  acctimulation  of  fat  in  ibe  couaoctive  tissue.     At  timeit, 

ii>d««<l,  tbe  volume  of  the  muscle  appears  to  be  increased,  owing 

to  tbu  fatty  accumulation,  giving  riae  to  tbe  condition  which 

Dncheone  has  called  pacudo-bypcrtrophy ;  but  in  these  casea 

•dranced  atrophy  can  be  readily  recognised  by  tbe  extreme 

bceidity  and  doughy  feeling  of   the  affected  muscles  when 

cOnpared  with  tbe  bcaltby. 

TlieoouditioQ  of  the  electrical  irritability  of  the  motor  nerves 
ltd  maeclcs  dcaervcs  special  attcution.  Duchcnne  -wot)  the  first 
b>  use  tbe  faradic  current  aa  a  test  of  the  degree  of  alterattoa 
ib  tho  causclce;  and  be  found  that  tbe  faradic  irritability  of 
IcUv  nerves  and  roUKcles  begins  to  sink  quickly  in  those 
thicli  are  severely  afi'ectod.  Ue  found,  indeed,  that  it  was 
Oktctially  dimlniKlied  at  the  end  of  three  to  five  days,  and 
nttrely  abolifihcd  hy  the  fieventb  day  or  during  the  course  of 
ll«  woond  week.  He  also  laid  down  a  rule  wb  icb  lias  Iweu  con- 
£naed  by  all  subsequent  ubserrers,  and  the  practical  importance 
tf  vtiicb  it  is  dtfHcult  to  exaggerate — viz.,  that  all  the  paralysed 
otucles  in  which  the  faradic  irriubility  is  only  more  or  le«H 
diniaiBhol,  but  not  completely  lo»t,  during  the  cotin^e  of  tbe 
MODfid  wcvk,  do  not  remain  permanently  [paralysed,  the  restora- 
tioQ  being  the  more  prompt  and  complete  the  less  their  faradic 
initkbility  has  been  diminished. 

The  galvanic  irritability  was  first  investigated  by  Solomon, 
*tio  tbewed  that  the  course  of  the  alteration  resembled  that 
of  Mrere  traumatic  paraly«iti.  There  is  rapid  lu&i  uf  galvanic 
iiiiiibitjty  in  the  nerves  during  the  Bnit  two  weeks  of  tbe 
putlyiis,  and  the  irrltuhility  of  tbe  muscles  manifeete  the 
fvliUlive  changes  which  characterise  the  reaction  of  degencra- 
ooa  Daring  tbe  first  weeks  of  the  paralyals  there  ia  an 
)*astae  of  the  gnlvatiic  irritability,  the  contraction  on  onodal 
>  (tiODg«r  than  ou  cathodal  closure,  and  the  contraction  is 
ituggish  and  protracted,  instead  of  being  instnutaneous  aa  iu 
kwlth.  In  the  course  of  two  or  three  inontha  the  galvanic 
ity  Biulu  again  much  below  the  normal  slaudard,  hut 


^^ymglaJit 


114 


SYSTEM  D19B&SB3  OF  TBB 


this  U  doubtful.  When  tlio  deformity  is  caused  by  »hor 
of  the  paraJyscd  muscles,  tbc  latter  are  found  io  the  ooocavitji 
the  distorted  extremity.  But  whatever  may  be  the  mechanism 
by  wbicli  tbo»e  dvfurmitiua  ore  produced,  it  would  seom  th&t, 
disregarding  a  certain  degree  of  ineciuality  and  diaBgurein«oi 
caused  by  the  arrest  uf  devetopaieut  of  the  long  bone*,  paralyw 
of  certain  muKclea  and  group»  of  utuBcles,  oloug  with  reliu»tioB 
of  the  ligamoota,  is  the  main  cause  of  tlio  various  distortions 
obserTed. 

Some  of  the  muscles  of  one  lower  extremity  suffer  mo 
frequently  thno  others  from  permanent  paralysis  ;  ami  of  th«« 
tbe  antero-oxtom&l  group  of  the  leg — tbe  long  extensor  of  tb« 
tow,  tibialis  auticuH,  upeviol  extensor  i>f  the  great  toe,  and  the 
long  and  short  peronei — are  thosB  tnost  commonly  affectwl 
Tbc  most  frequent  forms  of  paralytic  tnlipos  are,  therefore,  a* 
migbt  have  been  expected,  talipes  i^juinus  and  equiuo-vorus 
(Plate  II.,  5).  When  tbe  anteriur  gruiip  and  the  adduclorii  of  tlie 
foot  are  affected  at  the  danie  time  talipes  equino-varus  results; 
auJ  when  the  muscles  of  iLe  calf  are  alone  atfected  lAlipcscaloi- 
neus  is  produced,  but  this  form  is  exceedingly  rare  ;  and  siraplfl 
paralytic  talipes  rarus  is  of  still  rarer  occurrence.  Aootber 
€K)inraon  deformity  ia  tbe  "  pes  cavue" — "  talus  pied  creux"  of  the 
French — iu  wbicii  tbc  solo  ia  hollowed  and  tbe  instep  rendered 
proiQiuent.  Ducbenne  tbiaks  it  is  caused  by  a  more  or  lets 
complete  paralysis  of  tbe  muscles  of  the  calf,  along  with 
aimultaacous  coalractiou  of  the  flexors  of  the  foot,  either  tbe 
long  Hexor  of  tbe  toe«  or  the  long  perooeus.  Tbe  great  laiily 
of  tbe  ligameutB  of  the  foot  allows  the  bitter  to  become  bmt 
upon  itself  from  the  transverse  tarsal  joint,  where  the  foot  is 
unsupported  ;  but  when  it  is  placed  upon  tbe  ground  it  astumes 
tbe  form  of  "  flat  foot"  ~ 

Various  deformities  occur  in  tbe  inferior  extremity, ; 
to  tbe  extent  and  localisation  of  ibo  paralysis.  Tbe 
and  intemal  muscles  of  the  tbigh  are  most  usually  affected 
above  the  knee,  and  in  that  case  the  predominant  action  of  tbe 
flexors  of  the  leg  on  the  thigh  maintains  tbe  former  iu  &  per- 
maneut  condition  of  partial  flexion  (Genu  recurvatum),  the  1^ 
being  also  abducted.  Tbe  condition  is  always  associated  will) 
talipes  equiuo-varus.     All  tbe  muscles  of  both  legs  are  sot: 


SPlKJkL  CORD  AXD   HEDULU   OBLOXQATA. 


115 


liiDM  pAiutjsed  so  that  tbc  patient  is  compelled  to  walk  oa  bis 
kneet.  draggtDg  his  amall  tbiQ  legs  after  bim.  lafitill  more 
«ggnvat«4  emses  tho  mowles  or  botb  legs  and  tbigba  arc  per- 
Bkanaotly  paralysed  so  that  tbe  smnll  fiexiblo  Jimbe  dauglo 
about  like  the  Hmbs  of  a  dolt  (membrc  de  policbiaelle). 

PanUysis  of  the  muacles  of  the  truak  doee  not  give  rise  io 
tbtB  disease  to  a  true  active  curvature  of  the  vertebral  colunua, 
but  the  attitudes  impoeod  by  other  deformities  may  produce 
oompematoty  curratures.  Of  thecurvatUNedtrectty  altributable 
to  the  paralysis,  torJoais  ia  the  moat  frequent  and  most  im> 
portaoi  Lonloais  is  caused  by  partial  paralysis  of  the  sacro- 
i^&al  mnacles,  and  in  order  to  prevent  the  permaneat  beudio^ 
forwanla  of  the  body  by  the  predominant  action  of  the  flexors, 
kbe  patient  voluntarily  throws  the  trunk  back  wards,  thus  relieving 
cbe  weakened  exteoaora  aod  tbrovriog  additional  weight  oo  thu 
Svxota,  M>  that  the  balaoce  between  the  action  of  the  two  seta 
of  muscles  ts  re-established.  The  spinal  curvature  which  results 
fma  this  actioa  dilTcrs  from  other  forms  of  lordoeia,  inasmuch 
a*  Ihe  pelvis  ia  pushed  forwards  inatead  of  backwards,  and  the 
battodu  become  less  ioBtcad  of  more  promiaeut. 

The  deformities  of  the  upper  extreraiUea  are  much  [ess 
fraqiifinl  and  serious  than  those  in  the  lower  extremities.  The 
miimIm  of  the  sbouldor,  and  particularly  the  deltoid,  arc  the 
most  uaual  subjecta  of  paralysis  and  atrophy  in  the  upper 
astnmity.  In  these  cnsoe  the  shoulder  is  flattened,  and  the 
ptomiDence  of  the  deltoid  is  replaced  by  a  more  or  less  deep 
depraanon  according  to  the  degree  of  atrophy;  the  humerus 
becomes  aeparat«d  from  the  glenoid  cavity,  so  that  diiilocatiuu 
raaj  ooonr  spontaneously,  or  ia  readily  produced;  the  arm  hangs 
ponrerUis  b;  the  side;  and,  to  use  the  apt  comparison  of 
Heine,  Jangles  about  like  the  loose  end  of  a  0atl.  lu  excep- 
timial  cases  the  forearm  and  hand  may  andergo  distortion;  but 
tiiMe  daformitiea  are  not  of  sufficient  importance  or  freijuency 
Io  require  descriptioa  All  the  organic  functions  are  well  per- 
formed, and  the  patient  may  live  to  extreme  old  age,  as  iu  the 
caea  of  a  patient  observed  by  Charcot,  who  died  at  the  age  of 
•eratty.  carrying  with  him  indelible  traces  of  the  disease  from 
•hieh  be  bad  suffered  eiity-fivo  years  before. 

Tbe   muBclea  are  poratysetl  ia  infantile  spinal  paralyeia^u- 


116  SYSTEM   niSe^ES  OF  TBE 

groups,  in  accordance  with  tlioir  aiusociatioD  in  action.  Particular 
atteDtioD  hoa  raceatly  been  directed  to  tbis  point  by  £.  Remak. 
In  wbat  ho  calls  "  the  upper-arm  type '■  of  atrophic  paralyeiB. 
tbo  eupinator  longus  is  involved  along  with  tb«  d<^ltoid,  coraoo- 
bracbialie,  and  bicops  muscles.  In  what  Remak  calls  "  the 
forearm  type"  of  infantile  paralysis,  as  well  as  in  lead  paralysui, 
the  extensor  muscles  of  the  bond  are  paralysed,  white  tii^^ 
supinator  loagus  is  spared.  ^H 

Analogoiis  facts  have  been  observed  in  the  various  atrophic  ' 
paralyses  of  the  tower  extremities.  Caaes  of  iofaatile  panu 
lysis  are  recorded  by  K.  Kemak  in  wliicli  the  tibialis  aaticus 
and  alt  the  muucles  supplied  by  the  crura!  nerve,  with  the  1 
exception  of  the  Rarto^iu^  were  paralysed,  and  be  iberefore  ' 
conjectures  that  the  spinal  nuclei  of  the  funner  and  those  | 
of  the  latter,  with  tbo  exception  of  that  of  the  branch  to 
the  sartoriiis,  lie  near  each  other  in  tbo  spinal  cord,  and  are 
liable  to  be  diseaMed  at  the  same  time.  Duchenne  bos  proved 
that  the  sartorius  ia  aasociated  in  its  functions,  not  so  tnudl 
with  the  quadriceps  and  adductors,  ua  witb  tbo  tlcxori.  Tbt 
sartorius  flexes  the  leg  on  the  tbigb,  and  the  tbigb  on  the  pelvil. 
Bernhardt  box  compared  tbo  sartorius  to  the  supinator  loogui, 
and  it  appears  also  to  correepond  with  the  latter  in  having  ita 
spinal  nucleus  near  that  of  the  flexors,  and  not  of  the  exten- 
sors with  which  it  is  in  anatomical  rolatioo.  Cases,  however, 
have  not  yet  been  recorded  showing  that  tbe  Etartorius  is  para- 
lysed along  witb  the  Hexors  of  the  tef^,  the  extensors  beiag 
spared,  corresponding  to  what  occurs  witb  the  supinator  longoi 
in  the  ujiper-arm  type  of  atrophic  paralysifi.  The  tibialis  antieut 
is  also  frequently  spared  in  iDfantile  pnralysia  when  the  other 
anterior  muttcles  of  tbe  leg  are  implicated.  Kematc  states  that 
when  lead  paralysis  aflfects  the  lower  extromitios  the  peroneal 
group  are  affected,  but  the  tibLalia  amicus  is  spared,  and  tie 
conjectures  that  tbe  spinal  nucleus  of  the  tibialis  aoticus  is  oo 
a  higher  level  than  those  of  the  other  muscles  of  tbe  peroneal 
region. 

(b)  Acute  Spinal  I'amlyeit  of  AduUt. 

Acute  spinal  paralysis  of  adults  is  essentially  the  same 
diKcftBt!  as  infantile  spinal  paralysiis.  Tlic  differences  between  the 
two  affections  result  from  tbe  facta  ibat  tbe  l>rain  of  tbe  adult 


SPINAL  COKD  AND  MEDULLA  OnLONOiXA. 


117 


ofien  greater  resistaaoe  than  tbat  of  the  infant  (o  the  initial 
distorbaacea ;  that  the  organism  of  tlit:  former  in  not  so  di^poised 
to  fever;  that  the  growth  of  the  hones  is  already  completed  i 
and  that  the  ItgmmenU  and  joints  are  firm  ani)  Tt-siHting. 

Tb«  disease  hcgintt  iu  tfiu  adult  hy  pain  in  the  back  and  the 
extremities,  panestbeMs,  such  as  formication  or  numhueaa,  and 
fever,  which  at  times  U  very  iatensc.  There  may  bo  serore 
h4ada^«,  vomiting,  somnolency,  or  even  slight  delirium,  but 
ooovnlaiOQS  have  never  been  observed. 

The  paralysis  ia  developed  more  or  less  rapidly,  ^nerolly  in 
the  course  of  a  few  botin,  and,  as  in  tho  case  of  children,  it  is 
more  or  tcss  widely  spread,  complete,  and  associated  with  entire 
lUcndity  of  the  [nmlysed  muHcIex.  Reflex  action  in  either 
much  lowej-ed  or  abolished  in  the  paralysed  muscles,  but  may 
be  ret^ned  In  those  which  are  only  slightly  affected.  Tempo- 
nry  weakness  of  the  bladder  may  he  present  at  first. 

The  initial  general  symptoms  pass  off  in  a  few  days,  soon 

afterwards  the  paralytic  symptoms  begin  to  improve,  and  after 

■M&e  weeks  or  mouths  restitution  of  motor  power  may  he 

omptete.     Frey  has  called  this  variety  (emj>or«ry  paruly»i6, 

^corresponding  to  the   form  of   the  same  name  in   childretL 

^Hhnerally,  however,  tbere  ia  only  partial  restorutiou  of  motor 

fo»er.  some  of  the  muscles  remaining  permanently  paralyBed. 

Th«  latter  mitfcles  undergo  rapidly  progressive  atrophy,  as  in 

tlu  ewe  of  children,  and  afford  the  usual  ovidonces  of  the 

nactioQ  of  degc-nemttoa.    The  akin  becomes  lax  and  withered 

ud  the  extremities  cold  and  cyanotic. 

The  sensory  di&turbanoee  which  may  have  existed  at  the 
txgiaiiiiig  soon  subside,  and  the  sensibility  becomes  normal, 
llie  ttiuat  functions  are  tlirougboiit  unatfected,  there  ore  no 
hed-nree,  and  the  general  health  is  good. 

Puatytic  oontiactioDS  supervene  with  their  resulting  deformi- 
tiei,  but  tbe  Utter  never  attain  the  same  degree  as  in  children, 
becuse  the  joints  and  ligaments  are  firmer  in  the  adult,  and 
tb  long  bones  of  the  extremities  have  attained  their  full 
4«tlopmeuL 

S  3117.  Cottrae,  Duratum,  arid  TenniruUwns. — The  ordinary 
*BVne  of  tbe  disease  is  generally  the  same  as  tbat  already 


lis 


8TSTKM   DISEASES  OF  THE 


deecribed.  Caees  of  tbia  diec&fio  divide  themsolT«s  into  tn 
classes:  (1)  Those  in  which  complet«  recovery  takes  place,  and 
(S)  those  iD  which  tho  recovery  renuiius  iccotnpletc.  In  tb« 
first  variety  ooropleto  restoration  of  all  the  muscles  t&kes  place 
in  the  course  of  a  few  weeks  or  moaths.  In  the  second  Tariety 
Bomeof  themuscloBrcTnaiD  permancDtly  paralysed, and  atrophy, 
wjtli  secoudary  deformities,  rcMults.  Tho  paraly^  does  not 
greatly  interfere  with  the  general  well-^ing  of  the  patient,  and 
does  not  appear  to  have  any  ioflueDce  in  accelerating  deatli,  at 
l«&«t  directly,  altbuugh  the  reaulting  deformiUea  may  do  m 
indirectly.  PersuDs  who  have  had  an  attack  of  spinal  paralysis 
do  not  indeed  appear  to  be  moro  liable  in  later  life  to  other 
afTectioua  of  the  spinal  cord  than  healthy  persons  generally. 

§  39S.  Morbid  Anaknny. — The  main  pathological  chaE 
which  haru  been  found  in  infantile  paralysis  may  be 
divided  into  thoae  which  have  bcou  met  with  (1)  in  tho  muscle*. 
£Qd  (S)  iu  the  ncrvouB  system,  Cliang^s  have  been  foond  to 
the  tendons  and  bones,  skin  and  joints,  but  tbese  aie  o( 
subordinate  iuipoitauce. 

(1)  Morbid  Changte  in  the  Paralytod  MiuUm. — It  ia  quite 

Fio,  189. 

a  u  c 


Pio.  ISO  lYoDng).  AtuKviar  FUmt  from  a  ease  of  adrtmetd  It^fantUt  Pvalfwii, 
mtthdntm  6y  LacK't  bveiai-.  —  „,  MiucuIaf  tibna  pnMCLtiaK  a  man  or  !■■ 
hoalthy »pp»MMi ce ;  b.  mauulitr  fibm.  uoRinwlut  ittrnphlMl  uul  with  gtMnhr 
OOtitMitl :  t,  hhuobIm-  flhm  grcMly  >triMitilL-il,  but  pn!*enti[iB  taint  tno«  I  ' 
tnosvcrae  Rtriktioai,  m»1  bavuii;  Utur  aunacea  Uiiddy  iioddod  with  nudcL 


SFIXJU.  CORD   AKD   MEDULLA  OHLONOATA. 


119 


nooecceaarjr  to  describe  at  leogtb  tho  changes  which  occur 
ID  tbfl  poral^Md  muscles,  inHiSumch  oa  the;  hare  alTca<ly  been 
detcribcd  in  the  first  part  of  thU  woik  (^  108),  aiong^  with  the 
«bor  troptonoH roses.  By  the  kindness  of  Vr.  Leech,  I  am, 
however,  enabled  to  show  in  Fig.  159  the  coudittoa  of  the 
inuKolar  fibres  ia  advanced  atrophy  when  a  portion  of  the 
mnsele  ii  withdrawn  by  means  of  Leech's  trocfatLT.  In  almost 
every  tDBtaoce,  Dr.  Loecb  asBuree  me  that  some  of  the  fibros 
appear  more  or  less  beattby  (a),  while  otheni  hare  lost  their 
nannal  Btriation,  tbeir  contents  are  granulsr,  but  they  are  not 
nacb  diDiiuuthed  id  size  (b).  A  large  number  are,  however, 
rsdocad  to  slender  and  transparent  Bbres;  their  surfaces  are 
ooTered  by  nuclei;  the  transverse  atriatiou  is  still  distinctiy 
risible,  although  it  ia  very  faint  (c).  At  times  two,  or  even 
three,  naclei  may  be  seen  close  U^cther,  suggesting  that  they 
have  been  derived  by  proliferation  from  one  nucleus  originally. 
The  nuclei  may  also  be  obeerved  to  project  distinctly  from  the 
surEace  of  the  atrophio<l  fibre,  and  it  is  therefore  probable  that 
Ihey  have  been  derived  either  from  the  nuclei  of  the  sano* 
IsBUBft  or  of  tbe  endumyeiiura. 

(8)  Nervous  System. — The  leeiooa  which  hare  been  Found 
in  the  ipioal  cord  aro  uodoubtodly  tbo  most  intereflting  and 
impoftAnt  of  all  tboee  which  have  been  observed  in  atrophic 
pomlysii.  For  a  long  time  theoretical  arguments  were  adduced 
the  one  hand  to  show  that  this  disease  was  a  nervous  aifec- 
ettber  of  spinal  or  peripheral  origin ;  while  on  tho  other 
band  it  was  maintained  that  tlie  seat  of  the  lesion  was  pri- 
marily in  the  muscles,  and  bence  it  was  called  "essential 
paralysis."  Baine  declared  in  favour  of  the  spinal  theory  of 
the  disease  in  1860,  in  the  second  edition  of  his  work.  This 
view  was  also  adopted  by  Duchenne,  but  it  was  not  confirmed 
by  peotrraortem  examination  untd  LSCi,  when  Comil.  a  pupil  of 
^arcot,  first  recogiUBed  distinct  alterations  in  the  spinal  cord, 
and  drow  special  attention  to  the  atrophy  of  tbo  aotcnor  grey 
bonia  Prdvost  and  Vulpian,  however,  ia  1866,  were  the  first 
to  cuke  the  ponUve  obsorration  that  the  essential  aoatointcal 

sion  was  situated  in  the  grey  anterior  horn.     Tbis  observation 
subsoquttiUy  oonfinoed  by  the  obRerrations  of  Lockbart 
Gbaroot  and  Jofiroy,  Cind  of  many  others. 


120 


STSTEU    DISEASES  OF  THE 


When  tlie  anatiimical  bu^Is  of  clie  diaeuae  was  once  eiitablfi 
it  soon  appeared  that  the  atTectioo  naa  tiut  exduttiveljr  coDfiD«d 
to  cLildhood.  Morits  Me^'er  waa  the  first  to  poiut  out  tbat 
essentially  the  same  duease  was  met  with  iu  adults,  and  tfata 
opiuioD  was  afterwards  conftnned  by  Duchence.  Reports  of 
cases  have  recently  accumulated,  eatablUliiug  tlic  occurrence  of 
acute  atrophic  apinul  paralyBia  iu  udulla  (Hallopeau,  Qotnbiuilt, 
Bernhanlt,  Frey.  Charcot,  Soguin,  JSrb,  Weiaa,  F.  Schultzc, 
Sturgc,  and  others). 

It  ia  unnecessary  to  enter  into  a  minute  descripUoo  of  all 
publieilicd  reporU  of  post-mortem  examiuatioiu  lu  casM 
infantile  spinal  paralysis.  The  essential  anatomical  change 
eista  in  the  destruction  of  a  largo  number  of  the  gaoglton  odl 
of  the  anterior  horns,  and  ttiia  lesion  is  the  cause  of  th^  poralj^ 
and  subsequent  atrophy,  The  lesion  is  generally  more  or  leas 
diffused  through  the  anterior  grey  horns,  but  it  generally  reocbd 
its  groatest  iutonsity  at  tho  cervical  and  lumbar  cnlai^nieoU, 
aud  as  a  rule  leaves  no  pcrmanont  alteration  i^xcept  at  tliese 
pointa  It  inay  extend  at  certain  puinta  somewhat  backwards 
towards  tlie  posterior  liorna,  aud  also  forwards  and  outwnrdR  to 
the  antoro>1ateral  columns,  and  the  anterior  roots  of  the  oerves 
are  usually  atrophied,  but  the«e  are  Bccondary  cliaoge*  and  do 
not  appear  to  be  necessary  to  tlie  production  of  the  symptoms. 
The  observations  upon  which  this  conclusion  is  based  may  bs 
divided  into  those  which  have  been  observed  within  two  yean 
from  the  beginning  of  the  disease,  aad  those  which  liave 
observed  after  long  intervals  of  titae. 

Unfortunately  no  observations  have  yet  lieen  made' 
respect  to  the  diaeH5e  during  the  tirst  few  days  or  weeks,  owing  to 
the  fact  that  the  disease  of  itself  is  not  fatal  Dr.  Clifford  Allbutt 
reportB  the  case  of  an  infant  sevoD  months  old  who  waa  sud- 
denly paralyaed  in  alt  the  citremitlea.  Death  resulted  ia 
abort  timu  from  implication  of  the  respiratory  nen-es. 
poat-mortem  examination  two  bcDmorrbagic  clots  were 
covered  iu  the  cervical  region,  one  of  small  size  being  situate 
in  the  left  poaterior  bom,  the  other  being  turger  and  situated 
in  the  right  posterior  horn  and  lateral  cotumn.  Dr.  Allbutt 
thinks  that  if  ihc^o  lesions  had  been  found  in  the  lower  dorval 
rogioD  the  infant  would  probably  bavo  survived,  and  the  awe 


might  baro  been  ty^ttrded  as  odo  of  infantile  tpioal  poralynB. 
It  U,  however,  much  more  probable  that  tbia  was  a  caso  of 
ba^raatomjelio.  An  instructive  case  ia  reported  by  Dr. 
Chailewood  Turner  Id  the  Patbolo^cal  Transactions  for  1870. 
A  ehild  twe  and  a  half  years  of  age  foil  ou  ber  back,  but  plajed 
aboftt  as  usual  for  a  fortnight  afterwards,  and  then  became 
suddenly  ponUj'sed  in  her  Lower  extretnitie!!,  and  in  a  few  day* 
aftenrarJs  in  her  upper  extremities  likenisi;.  On  admiiigiioa  to 
tha  London  EEcwfutal,  a  fortnight  after  the  beginning  of  the 
attack,  all  the  extremities  were  cotnpletuly  paralysed,  reflex 
action  in  them  was  also  abolished,  there  wa^  absccice  of 
saltation  in  the  lower  extremities,  and  the  stools  were  paMed 
involuntarily.  The  child  had  an  attack  of  measles,  and  died 
about  six  weeks  after  the  commencement  of  the  paralynis.  On 
post-mortem  examination,  which  was  made  by  Mr.  R.  W.  Parker, 
cbangee  were  obscrvnl  in  the  anterior  horns  and  aotero-laleral 
oolumas  throughout  the  whole  length  of  the  cord,  these  being 
more  prooouuced  on  the  left  ttian  the  right  side.  A  patch  of 
redfUned  gelatinous-looking  matter,  about  the  size  of  a  swan 
shoi,  was  observed  in  the  left  anterior  grey  horn  about  the  centre 
of  the  lumbar  eulargemcnt.  The  margin  of  the  patch  was  of  a 
dariier  colour  than  the  ceDtre.  "as  from  the  decolorisation  of  an 
tunnenbagic  extravasation."  In  the  neiglibourhood  of  tliis 
bamorrbagic  focus  the  nervous  tissues  wore  completely  disin- 
lagnUed,  so  that  no  nerve  structure  oould  be  distinguished 
in  the  anterior  grey  horn,  the  outer  part  of  the  base  of  the 
posterior  coraiia.  Tlie  whole  grey  subatanco  was  abundantly 
infiltrated  with  leucocytes,  a  considerable  number  of  them  being 
alio  observed  in  the  white  substance ;  white  they  were  massed 
in  great  numbers  in  the  sheaths  of  the  larger  arterioles.  The 
renetilar  column  of  Clarke  did  not  appear  to  have  been  any- 
wbara  afected.  In  the  portions  of  the  cord  which  were  remote 
from  tbe  Beat  of  ha-murihage.  the  nervous  structure  was  Dot 
coispletaly  destroyed,  although  many  other  evidences  of  dise«M> 
w«ie  observeti  This  case  tends  to  confirm  Dr.  Allbutt's  theory 
of  tb«  origin  of  the  disease.  It  is,  indeed,  quite  probable  that  a 
•audi  huaorrbage  into  the  substance  of  the  anterior  horn  may 
sometJnea  be  the  startiug  point  of  the  affection. 

In  tb«  Fatibological  Transactions  for  187^  the  case  of  a  child 


1S2 


SrsTEH   UISeiSES  OF  THE 


tbree  autl  a  half  years  of  age,  who  hhA  aufforcd  from  ao  aXiatk 
nf  iofatitile  paralyois  at  tlie  age  of  seventeeu  months,  is  Tepociod 
by  Dr.  Henry  Huniphroya.  On  adiuisaion  to  the  Pootllebuty 
Hospital  tL«  child  presented  well-marked  talipeit  calcaaeus  of 
the  left  heel  Soon  after  admissioo  the  patient  derclopod  b 
scTcrc  Attack  of  scarlet  fever,  from  which  she  died.  The  chaagM 
obeerred  by  Dr.  Humphreys  in  the  spiiiaJ  cord  were  limit«i 
to  the  himbar  region,  and  connsted  maiuly  of  a  remarkable 
diminution  in  the  number  of  tho  ganglion  cells  belonging  u 
the  anterior  and  lateral  parta  of  the  left  anterior  grey  bom. 
The  onneied  diagram  (Fig.  IGO)  shows  ths  oonditioo  of  the 
anterior  comua  at  the  middle  of  the  lumbar  region.  Dr. 
Humphreys  examined  eighty-Heven  Hections  of  the  lumhar 
Tcgion  of  the  cord,  and  averaged  the  number  of  cells  they 
contained. 

The  otbor  moat  notable  cases  which  hare  been  repor1«d 
at  an  early  period  of  the  disease  are  those  of  Roger  and 
Damaachino,  Rotli,  Lcyden'a  second  case,  Parrot  and  Joffroy.  and 
a  cuBc  briuHy  reported  by  Hineckor,  which  waa  cxamiucd  by  Voo 
iieckliughaueeu.    Nu  marked  changes  were  discovered  iu  the 

Fio.  1«0. 


r 


s 


t 


<^ 


i\'f 


V 


X7 


Tis.  IW  (Aftfir  nDi))T>bT«r>).  Th«  lotUn  a,  tf,  e  uidic»t«  n«p«eltv«tr  Um  ocmtnl. 
iuit«r<r-1*t*r«l,  knil  |VHli>m.Iit*nd  frmup*  oE  gMi|:li&B  ccili.  Un  tbe  left  (id* 
Ltia  tiruuii  i  Itu  iJEuoRt  ■.■ntltFl;  diMpixMrcd,  OAUilDe  >  mBrk*iI  Ulinn  Id  ot  tlw 
circumference  nf  the  gnrmBttcr,  'i'fiL-gnnipiaanacan'fnitlywaUrqirgMBtiA 
on  the  kft  ddo,  bat  ihc  mIIj  f .>rDiio>tiig  xtum  an  not  *o  DumcMiu  m  oa  tk* 
rigbt.    Hm  IntoniAl  gim>s  tiM  diMpp«tf«d  fram  both  mdi*. 


SPINAL  CORU  AKD  UBDtJLLA  OBLONQATA. 


123 


with  tbe  oftked  eya.  Id  some  coses  tbo  substAncc  of  the 
oopd  Becmcd  tougbcr  at  Uio  level  of  the  cervical  or  lumbar 
eslArgemoDts,  and  the  antero-lateral  column  on  tbo  Bido  affected 
KppMnd  atrophied  and  distorted.  Oa  tmnsvone  section  the 
KUterior  gwy  bonu  were  observed  to  )ie  more  or  lets  diaooloured, 
whitish  or  rcddiah,  sometimes  aoft,  diffluent,  and  dimininbed 
io  VEdome.  Tbe  anterior  roots  at  tha  level  of  tbe  parts  maioly 
affected  wore  found  grejr,  traoiilucenl,  and  atrophied. 

On  microicoptcal  examination,  the  main  leaions  hitherto 
cAnenred  have  been  diffused  through  the  grey  substance  of  tbe 
axiterior  boms  with  areas  of  greater  inteosity  in  the  cervical  and 
lambar  enlargements,  espoctally  in  tbe  latter.  In  the  lumbar 
region,  sometimes  on  one  side  ouly.  hut  usually  on  both  eides,  an 
areAof  aofbening  has  been  found  in  thvauk-rior  grey  horn,  some- 
ttmce  extending  the  whole  leogth  of  the  lumbar  eDlargcmont, 
and  sometime*  ooenpying  only  a  portion  of  it  in  longitudinal 
exteoL  Tbe  area  of  soficning  was  sometimes  situated  towards 
the  centre,  sometimes  towards  tbe  aaterior  pott  of  tbo  horn, 
being  separated  from  the  lurroundiog  parts  by  a  more  or  less 
sharp  line  of  demarcation.  Similar  areas  were  often  also  found 
occasionally  in  tha  cervical  enlargement  of  tbe  cord,  and  occa- 
■ionaUy  in  tbe  dorsal  and  uppor  cervioal  portiona  The  substance 
tti  ibeie  areas  was  friable,  soft,  and  diMemioated  with  numerous 
granulation  cells.  The  blood-vessels  were  dilated,  there  was  a 
1m|«  increase  of  connective  tissue,  and  the  nuclei  were  also 
iDereas«d  in  number.  Many  of  the  large  multipohir  ganglion 
mHs  had  disappeared,  and  of  tboeo  which  still  remained  a  large 
proportion  were  observed  in  all  stages  of  degeneration  and 
atrophy.  The  nerve  Bbrei;  and  axis  cylinders  within  the  area 
of  softening  were  also  found  to  have  entirely  disappeared. 

Slighter  and  more  diffused  Ganges  occur  much  beyond  the 
limita  of  the  softened  areas.  These  chnngen  consist  of  niogle 
pannlarceUa  acattorvd  through  the  grey  substance,  multtplica- 
lioo  of  nuclei,  dilatation  of  blood-vessehi,  ujid  disappeaiance  or 
d«g«licratii»i  of  individual  ganglion  cells.  Sioiilar  choogMare 
aften  observed  throughout  a  greater  oi  luster  portion  of  tbe  gi«y 
MbstaLDce  of  tbe  dorsal  region.  Tbe  antero-lateral  columns  have 
oocasiooally  been  found  diminished  in  size,  and  the  seat  of  a 
slight  sdenwia    The  trabeculic  are  then  tbtckened,  and  indi- 


124 


flTSTEH  DISEASES  OP  THE 


Tiduo.!  nerve  tibrtis  are  atraphieil  (JoSroy  aod  Daraaschino], 
The  niiterioT  roots  aro  dimiaUhGd  in  nize,  and  .show  sigm  of 
degeocrative  ntropliy  when  examined  microscopically.  ^M 

OlM^rvatioiia  liavo  beeo  made  from  seventcea  to  rixtj-oirt^^ 
years  afWr  the  origin  of  the  disease,  by  Coroil,  Provost  aiul 
David,  Vulpiao,  LocTthart  Garke.  Charcot  and  JoflVoy,  Pelii 
fib  and  Fierret,  Leyden,  Gombault,  DcfjeriDe,  F.  Scbultze, 
othera. 

The  morbid  changes  wbicli  bare  been  observed  in  these  canes 
are  generally  tbusame  as  iu  those  which  have  been  examined 
within  two  years  of  the  onset  of  the  dlBeusa  The  anterior  horns 
are  shrunk,  and  the  antero- lateral  columns  appear  to  the  oakod 
oyc  grey,  trausluccut,  and  atrophied.  The  posterior  columns, 
posterior  groy  bornt,  aod  vesicular  column  of  Clarke  are  almc 
if  not  quit(«,  Dormal. 

On  microscopic  cxamioatioD  circumscribed  lesions  are  foni 
in  the  anterior  horns  at  the  lumbar  and  cervical  enlargement 
and  in  ndiiitioD  to  the  main  lesions  more  or  Imt*  dUfuaed  changes 
aro  met  with  in  the  grey  suhetance  aud  white  columns.     The 
anterior  horns  aro  atrophied  and  shrunk,  and  within  the  disaaeed 
foci  which  they  contain  there  is  a  more  or  lees  firm,  fibrillated 
connective  tissue,  rich  in  nuclei     The  blood-vesselH  are  eolai^ged, 
probably  also  increased  in  number,  and  their  walls  are  thickened. 
Granule  cells  are  generally  absent,  but  a  largo  uumber  of  corpora 
amylacea  as  well  as  pigment  granules  have  been  found, 
multipolar  ganglion  cells  and  nerve  6bres  are  more  or  less 
pietoly  ileatrnyed  in  the  diseased  foci,  and  some  of  tbe  ganglia 
cells  which  remain  are  found  in  all  stages  of  degenerative  atropl) 
pigracutarY  degeneration,  and  shrivelling.     Well  preserved 
glloQ  cell»  may  be  found  outside  tbc  diseased  foci. 

la  the  portions  of  the  grey  cnmua  which  aro  companiively 
hMlebyj  Bucb  as  the  dorsal  region,  the  ganglion  cellfl  are  lau 
aumerooa  than  normal,  the  counectivo  tissue  ia  iuc 
the  nuclei  are  abundant, 

A  greater  or  lesser  degree  of  sclerosis  of  the  aatC 
columns  may  be  diacovercd,  the  neuroglia  is  tbiokvnftS,  aaft 
generally  there  ia  somo  degree  of  atrophy  of  the  oerve  fibrea. 
The  sclerosis  may  vary  greatly  in  extent     It  is  sometimes 
ooufiued  to  the  immediato  vicinity  of  the  anterior  boms,  and 


SPtXAL  CORD   AKD  MBDUU.A  ODtiOKOATA. 


IS5 


other  times  it  is  diGTiised  over  ih«  entire  antero-latenil  cottiraus, 
the  pj7Biiud«l  tract  betag  specially  liable  tu  mffer. 


7m.  lei. 
—  > 


X 


w 


X' 


f 


.y 


Vte.  1$\  (ProB  Cbatvot*.  Tymttrtrit  Sttticv  ef  the  8pii*al  C^ri  tkl:m  liom  the  ow 
«i«^  rayion  nf  «  vobim),  tgcd  fifijr  yean,   vha  dird  in  tbe  Salp^cri^n,  of 

tanljikt  «(  u«  ti>lit  Mptrim  ckimaicy.    11ift«  mt  fibroid  ftti«|ib;  «filw 
richt  aMMtor  <»»■,  lad  urot>li}'  of  kli  tbe  whiM  oolnauu  of  (ba  oonMpoodiiig 

The  annexed  diagimm  (J*^.  161)  well  illustrates  the  morbid 
altMTatioas  wbicb  are  u«uall;  observed.  Tbe  anterior  roots  arc 
tbm,  gnj,  trsQsluceut,  and  tbe  greater  part  of  tbeir  nerre 
iibnss  are  atrophied,  tbe  coonoctiTa  tissue  is  ofloD  intiitrated 
with  fat  cells,  its  nuclei  are  abundant,  and  tbe  walls  of  the 
*c«eb  are  tfaickeued.  Almost  uU  pathologists  uow  regard 
the  primarj  Itwoa  as  an  inflammation  of  the  anterior  grey 
boras,  although  tbe  cases  reported  by  Dra.  CliH'ord  Allbutt  and 
C  Taraet  appear  to  ibow  that  a  slight  hemorrbage  into  the  grey 
sabstatMW  may  occasionally  be  tbe  starting  point  of  tbe  morbid 
pneesi.  Tbe  inlUtpmatoty  process  spreads  along  more  or  less 
diffiusly  «rer  tbe  greater  part  of  tbe  anterior  lioruR,  but  attains 
its  greatest  totensity  iu  tbe  lumbar  and  cervical  enlar^^ements, 
in  wbicb  localities  diittinct  areas  of  softening,  and  destruction 
of  tbe  multipobir  ganglion  cells  are  produced. 


1S6 


SrSTEH   DISEASES  OF  THE 


Wb«n  (he  inflaniinatioD  subaides,  a  gradn&l  imptxive 
takes  place  in  those  plocee  where  tbo  dMUuotioD  of  tbo  grvf 
Bubstauce  hsH  been  incamplete  ;  l>iit  wkorc  tlic  nt-rvc  etructan 
boj)  bceo  tLuTou^bly  difiiutegrateil  tbere  is  a  gradual  develop- 
ment  of  cicatricial  coaovctivc  tissue  in  its  plaoa  TLe  aoturo- 
lateral  columns  become  secondarily  alTectod,  and  wh«Q  th« 
lesion  takts  pUce  during  childhood  the;  beoomo  retarded  u 
their  development,  appear  narrow  and  atrophied,  and  cause  a 
considerable  change  in  the  fonu  of  the  spinal  cord. 

Whether  thJH  affection  is  to  be  regarded  as  aparenchj 
or  an.  iutorstitial  affeclioD  ia  not  }'«t  settled.  Charcot 
others  uuppurt  the  former  view;  while  Roger  and  Damascfaino, 
Roth  and  others,  are  in  favour  of  the  latter.  Dujardin- 
Beaumelz,  however,  suggests  that  both  tisarues  become  io- 
6amed  at  the  same  time,  and  that  the  myelitis  is  both 
parL'nchymatous  and  interstitial. 

Tlie  peripherai  nerves  undergo  degenerative  atrophy. 
Schultxe  foand  increase  of  the  interstitial  connective  (i 
with  atrophy  uf  the  nerve  fibres. 

Tlte  tendons,  atrophied  and  stretched,  appear  as  thin,  m 
bands. 

TJte  bonee  are  always  retarded  in  gronth  when  the  db 
occurs  in  childhood,  the  normal  protuberances  and  pmeesBet' 
being  ieaa  developt-d,  and  their  epiphyaes  stunted.  The 
medullary  portion  is  relatively  increased,  its  fatty  oontoits  are 
more  abundant,  aod  the  CKtcmal  hard  lamella  of  the  bone 
lliin  and  friable. 

The  hgaments  of  the  joinU  are  thin  and  loose,  while  the 
articular  extremities  of  the  bonca  oro  stunted,  ground  off. 
eroded,  and  their  cartilages  attenuated.  The  alterations  in 
the  joints,  ligaments,  and  articular  cartilages  greatly  aid  the 
njDBcular  paralysis  in  the  production  of  the  differonl  forms  of 
club-foot,  and  the  various  other  deformities  already  described. 

The  arteries  are  slightly  diminiebcd  in  calibre,  the  »kin  and 
inlemtd  orfja'ns  aio  cither  normal  or  only  show  changes  which 
have  no  neccHsnry  connection  with  the  spinal  disease.  The 
braiu  is  uoraiaL  In  one  case  Sander  found  the  two  aiocDdiDg 
conrolutions  and  the  paracentral  lobuk' — the  motor  area  of 
the  cortex   in  relatioo    with   tlie   paralysed   parts — relatireljr. 


SPINAL  CORD  AND  MEDULLA  OBLOHQJlTJl 


127 


dimioiBbtd  in  size,  but  as  tlio  spinal  disease  mu  BuociBted 
Vttb  idiocj,  the  conacctioD  botweeo  the  atrophy  of  tiie  cortex 
AQiI  the  spinftl  leuoo  may  have  beoa  merely  accidental  Far- 
ticuUr  ftttcQtioD  should  be  paid  to  the  c^aditioa  of  tbe  cortex 
ia  future  post-mortem  eaatninatioas  ia  cases  of  the  Uii»ease. 

g  399.  Zoeatiiiatifm  of  the  Lesion  in  the  ATUerior  Boms. 

A  TOj  IntGnating  C49s  iu  thia  n)&r«tic«  ia  descnbed  bjr  Pnfvoat  oud 
IMvid.*  It  WM  tliat  of  ft  mail,  aged  suty  years,  who  oulTertKl  fnini 
febrile  wxl  t^'pbnid  njxa\>Uiaia,  irbicb  Mused  bis  death,  Tim  uiau  bail 
eomplcttt  slrophjF  of  the  mufloleti  of  tha  tlioiiaremineuo^of  thertijbi  bmid, 
vliicli  Mwonlirjg  to  hu  oiru  Mcount  vuno  oq  iu  childlioud.  Tku  outerior 
toot  of  IIm  «ighth  corvinl  norvn  of  tfaa  right  sido  wm  iiutably  tliDiiiiiithed 
to  sm,  H  goufanil  mtb  thxt  of  tho  left  aide,  &ud  the  (ujtcrior  root  of  the 
wraotb  nem  vu  alao  aUghtly  diminuibed  in  voluma  ou  thu  right  side. 
OppMit«  the  atropbml  root  of  the  eiglith  itertra  thu  &ut«ritir  horn  ou  th« 
■UU0  ilde  waa  ubaerTed  to  be  aeiuiibl^-  dimiiiiAhtid  tai  compared  iclth  tliftt  of 
the  lafl.  The  diaeaecd  [*ortioa  bad  «  longitudJuiil  «xt«ut  of  «bout  two 
nnttmetna,  ukd  the  ceiitn  of  the  leaioii  wwi  <■»  u  kvel  with  the  atro^hiud 
mt.  It«  greatcot  traii9T«rae  ext«at  was  abo  «i>i>o!>itti  the  diseiuMd  root  of 
ibe  amm  ukI  It  gmluallj  dimiuiahad  tu  >lt«,  hot^  upwuds  aud  downwiuds. 
The  anUker  «>;•  that  ia  the  dueaasd  portiona  tb«  txtoriud  or  litt«nil  (postcro- 
tateiB])  gnmp  wnv  i«{)irBMnt«d  by  a  few  healthy  cells,  whila  tb«  autetrior 
{aDt«r»-Ul«M])i  and  the  nuddle  or  iotaruAl  (iiit«ru«l)  groap«  w«ro  normal. 
JoiI(iag  tnta  the  dnwiog.  bowerer,  the  median  aud  c«ntral  Brou|a 
van  aetlraly  dsetitute  of  wUa,  while  the  aDt«ro-bt*ral  g»up  was  only 
wyretiated  bjr  ooe  cell 

t  A  earn  hu  r»eantjy  boea  deecribed  by  Kal^ler  and  Pick  which  appears 
to  iletsnBbte  tfae  kKwlisation,  in  the  anlcrtor  boma,  of  tba  epiual  centitM 
fv  Ibe  Mttsclsa  nf  the  calf  of  the  leg.  The  case  waa  that  of  a  womjui, 
twenlj-fiiiir  jeera  of  age,  who  died  ttom  an  attack  of  typhoid  fever.  The 
MaplM  of  tbe  calf  of  the  right  leg  were  found  almoet  com^letuljr  atrophied. 
()a  eiaBBlMtioo  of  the  siiiual  curd  the  ri{bt  Anterior  giv/  hum  wits  found 
■tfopfalad  tbmigh  the  greater  portioa  of  the  loiubar  oiilargemuut,  hut  the 
mast  mariced  diiuigca  were  dnerred  on  a  ktel  with  the  fourth  nnd  fiftfa 
MormI  oarvea.  Tbe  tvola  of  thass  narvoa  mn  aim  atDjihiml,  thvrw  wse  a 
sfigbt  UkcrvaM  uf  tbe  mtcntitlil  cotmectirc  tiMuo,  which  vrtui  espcciall/ 
well  marked  io  aome  buudlea.  The  central  group  of  c«lU  whs  mainly 
•fleeted. 

I  Is  a  eaaa  of  fttnphlo  qilnal  pan]y«ts  of  adnlta,  ebaernd  by  Scbultze 
ia  a  tnao  aged  forty-two  yeamv  the  niusclea  in  tbe  regioua  of  dintri- 

*  Aiebi*.  da  Pbraiolagw,  Scrie  II.,  Tome  i.,  1S74,  p.  BSS. 

TArchit.ftiirirL-tiiainp,  Bd.  K..2Upri.  i>mo.  «.  3atf. 

tViRhowi  ArcliiT..  Bd  iKiii.,  mn,  ■.  W3. 


ISO 


STStac  mauasB  of  the 


aLtaclced,  and  the  disease  by  slow  and  suocesnve  ittepa  giad 
invadeH  tlie  luore  fuudameutaJ  celts.  Id  sucli  a  disease  m 
expect  that  the  clioical  symptums  orparalyms  and  atropbj 
pursue  a  totally  diiFertriit  course  from  that  which  obtaii 
iafautile  spinal  paralym. 


Fia.  ISS. 


•^ 


H^\ 


\ 


f 


■.'.» 


Fm.  112  (ProiD  Oharcut).  SKfJon  n/  tht  ^ual  Cord  in  tht  J/»mltar,_ 
a  mtt  af  iiifrtntUt  fmrn/jwui.  —  A,  L«ri  uitcrinir  oonia,  botlthf:  i 

mintiiui  HTnuf  •>(  KUiglieiii  colU.     B,  JUgkt  anlainr  tiomu ;   t,  B14 

c[  (iKiLulii'ii  (vlJs.    'i'lie  cellt  uw  (iMtrojBil,  uid  tlie  |[ioup  la  rapratmU 
patch  n(  iHil«nin«. 


Th«  fai^t  thnt  the  dioease  occurs  in  certain 
areas  explains  the  distributioo  and  extent  of  the 
the  immunity  of  certain  inuscleH  and  groups  of  muscles. 
acute  inflammatory  niitnre  of  the  pmcess  explains  the  su 
appearance  of  tlic  puralysta  as  well  as  the  fever  and  i 
violent  symptoms  which  occur  at  the  onset  of  the  dil 
The  reKolutlon  of  the  acute  tnfiamiiiatioti,  in  part  oi  io  « 
explains  the  rapid  disappearance  of  the  first  severe  symp 


SPIHAI.  COBU  AUD   MEDULLA  OBI.0NnjLTA.  133 

will,  according  to  the  Iaw  of  Duchunae,  ntmain  permanendj 
pwaljrsed  and  atrophied ;  and,  coaverselj,  vhea  it  is  Qot 
aboUehed  bv  Ibul  tiui6,  the  musclcn  will  regain  their  mobility. 
and  th«  rMtoration  will  be  tho  more  prompt  ikutl  complete  the 
kat  tbeir  faradio  irritability  is  diminished.  After  the  second 
w*dc  tho  galvanic  current  may  be  usefally  employed  to  tost 
the  probability  of  the  degree  of  recovery  vrbich  may  be  ex- 
pected in  tfao  paralysed  musclea.  So  long  ax  a  muecle,  or  even 
a  portion  of  the  muscle,  reaponds  in  the  alightest  degree  to 
mtber  carrent,  a  certain  degree  of  recovery  of  motor  power  may 
be  expected. 

The  muscles  that  do  not  recoror  a  certaiD  amount  of  motor 
power  during  ibe  6ntt  few  months  Retdom  recover  at  a  later 
period;  and  after  six  months  of  complete  paralysis  all  hope  of 
reeovery  may  be  abandoned,  althuugh  even  then  slight  and 
partial  improvomcnt  may  occur  under  appropriate  treatment. 

TUc  usefulness  of  the  paralysed  limbs  may.  however,  be 
groAtly  improved  by  muaaa  of  orthopcvdic  operations,  gymnoe- 
lio,  mad  eloctrical  treatment  The  pmgnosis  in  this  respect 
will  depend  apoo  the  degree  and  extent  of  the  paralysis  and 
atrophy,  the  amount  of  deformity  already  prc^-ut,  the  age  of 
the  patieoit  and  the  duratioo  of  the  diseau  at  the  beginning 
of  the  tfeattnont., 

g  403.  TrttUtnent. — The  treatment  may  1m  sabdiTided  into 
Ihax  which  is  appropriate  during  the  acute  iniUal  stage  and  that 
which  is  ti)  bo  adopted  during  the  sub.>iequent  stages  of  paralysis, 
atrophy,  and  deformity.  During  the  initial  stage,  wlieo  fever 
u  pment^  rest  in  bod  is  absolutely  necessary,  and  leeches  may 
be  applied  over  the  lumbar  and  cervical  enUugements.  Rubbing 
in  of  tnarcurial  ointment  and  counter-irritation  by  means  of 
tinBtiin  of  iodine  and  bUtttem  have  boeu  recommended,  but 
Umm)  DieaMiraa  ihould  certainly  not  be  adopted  until  tho 
tampenturo  has  fallen  to  the  normal  standanl.  Ergotine  faas 
beeo  employed  subcutsneoualy  in  doses  of  one-fourth  of  a  grain 
for  ■  cbilJ  from  one  to  two  years  of  age,  one-third  of  a  grain 
for  one  from  three  to  five  years,  half  a  grain  for  children  from 
firo  to  tea  ycArs  of  age.  and  a  grain  for  patients  upwards  of  ten 
yean  of  ag«,  repeated  uithcr  daily  or  twice  a  day,  according  to 


132 


SVSTEU  DISEASES  OF  TBE 


has  been  paralysed  by  presnure  of  the  blades  of  the  forcq 
tbe  brachial  plexus,  atiirstbesm  remains  with  tbe  poralysia, 

The  tpaamodic  spinal  jmrali/sis  of  children  may  be  re 
distiogulshed  frura  uotcrior  poliomyetilia  by  tbe  slorr 
gradual  developraeot  of  the  pan»i»,  which  rarely  goes  | 
complete  paralyaia,  by  the  muscukr  teosioD  and  coDtxai 
the  increaaed  irritability  of  the  tcndoos,  aod  by  the  abscn 
atrophy  and  tlic  reaction  of  defeneration. 

A  myotrophie  laUral  aderoeie  begins  In  the  upper  extrea 
which  become  more  or  less  paralysed  and  wasted,  whili 
antagonists  of  the  paralysed  muscles  become  rigid  aod 
trocted;  the  ann  is  held  tightly  to  the  body,  the  foreat 
flexed  and  pmuated,  and  tbe  bands  and  fingers  are  str 
fiexed.  The  initial  fever  is  abiient,  and  the  subsequent  pn 
of  the  disenso  totally  differs  from  that  of  anteriur  poliomye 

The  periplienil  pandfjsia  of  single  groups  of  muscles 
pressure  on  their  nerves  by  tight  bandaging  or  other  cause 
be  distJDguished  from  anterior  poliomyelitis  by  the  absence  i 
characteristic  initial  ttage,  the  strict  limitation  of  the  par 
to  the  area  of  distributioo  of  a  single  nerve  trunk,  tbe  occui 
of  an  injury  to  tbe  nerve,  the  preeence  of  disturbaacea  of  i 
bilily,  and  the  rapid  recovery  which  generally  takes  plac& 


§  102.  froffnoaia. — Anterior  puUomyelitis  does  not  ij 
ever  directly  to  threaten  life ;  and  consequently,  so  far  as 
concerned,  tbe  prognosis  is  very  favourabla  It  is,  boi 
possible  that  some  of  the  children  who  die  from  codtu 
may  be  suffering  from  the  initial  stage  of  this  affection,  altt 
this  opinion  has  not  yet  been  conSrmed  by  poa^^ 
exam  i  nation.  ^| 

So  far  as  complete  recovery  is  concerned  the  prognoaU  ] 
favourable.  In  recent  cases,  therefore,  the  only  prognosis  i 
warrauted  in  making  is,  that  recovery  will  take  place  to » 
considerable  extent,  but  that  a  certain  amount  of  pemu 
paralysis,  with  atrophy  and  deformity,  is  likely  to  b< 
behind.  The  electrical  reactious  of  the  paralysed  muaclw 
a  valuable  aid  in  prognosis.  If  the  fiaradic  oontractili 
certain  rouscks  and  nerrea  is  diminished  at  the  end  a 
days  and  ubulialicd  during  tbe  course  of  tbe  Beooad 


SPISAL   COBO  AND   MEDULLA   OBLOS'QXTA. 


135 


Hha  current  be  sent  througli  the  oonl  first  in  ono  direction  ami 
thsn  in  ajiotlier,  but  Althaus  preferi  the  action  of  the  positive 
pole  aloQO.  Tbe  treatmeat  must  be  coatjaued  for  a  lonff  iimo, 
kod  aftarwsnls  reptiatcd  al  intervals  for  ycani. 

At  the  later  period  of  the  disease,  vheo  atrophy  of  the 
paralysed  muwlQi  baa  set  in.  a  peripheral  application  of  the 
ooDStaat  carreDt  and  faradisation  of  the  paralysed  nerves  and 
mmdea  may  be  combined  nitli  the  applicatiou  of  the  current 
to  the  spine.  So  long  aa  the  nerves  and  muscles  have  not 
eotirely  lost  their  faradic  irritability,  local  application  of  the 
badic  correot  vrill  be  of  serrice.  The  coastant  current,  how- 
arcr,  U  on  the  whole  superior  to  the  induced,  eveo  for  peri- 
pheral applicatioD,  nnoo  in  the  majority  of  coses  it  is  the  only 
■gent  which  will  produce  any  mueculur  response.  Appropriate 
grouMUtic  exercises  of  the  muscles,  Khampooing  and  friction, 
with  or  without  stimulating  liniments,  may  he  omploy«d  as 
adjoncta  to  the  electrical  treatment  When  the  case  coinea 
under  treatment,  six  months  or  longer  after  the  invasion  of  the 
diaaio,  iodide  of  potaadum  is  uaelew,  and  great«r  benefit  may 
ba  expected  from  phosphorous  a4id  cod-liver  oil.  Arsenic  bu 
also  been  highly  recommended  at  this  stage  of  the  diseasa 
The  use  of  strychnia  has  been  advocated,  especially  in  tbe  form 
of  subcutaneous  injection,  hut  I  have  never  seen  any  good 
results  from  its  employment,  although  I  have  seen  the  remedy 
poabed  to  an  almost  dangerous  degree.  A  strenuous  endeavour 
ibottUi  be  made  to  prevent  the  oocurrenoc  of  contraclures  and 
deCotmitieSL  A  great  deal  may  be  donu  in  thi^  respect  by  means 
of  electrical  treatment,  gymnastics,  and  light  frictions.  In 
goMtUag  against  talipes  e<{uinus,  Volkmann  udvises,  during 
th«  earliest  stag^a  of  the  diseaiie.  that,  wheo  the  patient  is  lying 
dowD,  tbe  foot  be  futtaed  to  a  light  footboard  by  means  of 
a  Aumel  bandage,  and  its  extremity  drawn  up  somewhat 
tomrds  the  le^  Children  should  wear  stout  laced  boots,  with 
a  steel  shank  on  the  outer  or  toner  side,  or  with  the  sole  slightly 
thicker  on  one  side,  so  that  the  tendency  to  the  rlevelopment  of 
talipaa  vmrus  or  valgus  may  be  countemctetl.  The  fonnation  of 
taiipes  catoaoeos  may  he  counteracted  by  supplementing  the 
defective  action  of  the  posterior  muHcles  of  tbe  leg  with  a 
strong  iodianibber  band  or  ring,  which  passes  from  the 


186 


SrSTEM  DISEASES  OF  THE 


to  a  tTOUgh-lilce  fixture  that  Lh  applied  to  the  leg  jiut  1 
the  koec.  and  which  ia  held  firmly  in  its  place  bj  Ji  sid 
(antcned  to  tiic  nhoc.  In  the  severer  forma  tenotomj 
forcible  means  of  correction  must  be  adopted;  but  it  is  nc 
of  this  work  to  enter  into  the  details  of  orthopcedic  surgery 
the  reUer  muat,  therefore,  be  referred  to  special  works  fo 
further  diacussiou  of  the  subject. 


2.  PoliomydUis  Anterior  Chronica   (Chronic  Ai 
Spinal  ParcUjfiia). 

§  404^  DeJiniHon. — Cbrocic  atrophic  Bpioal  paralya 
tdnlts  presents  itself  as  a  motor  pamlysis  luaociated 
muscular  atruphy,  which  begins  in  the  lower  eztromitiea^ 
gradually  progrei^ee*  tipwanlsi  tmtil  the  muscleH  of  tbtf  1 
aod  upward  cztremities  are  involved.  The  affection 
termiDate  in  death  ^om  rcHpiratory  paralyua,  or  in  gn 
recovery,  the  motor  power  returning  in  the  rsvevse  ord 
that  in  which  it  was  lost 

^Mtiiry.— Dn«h«nno  6nt  dMcribod  tbis  affootJoa  in  II 
1BS2,  and  ho  garo  a  detailed  doecription  of  it  in  the  tbird  clitioD  i 
EUHrUaiiun  I^iealitft.  in  1872.  Ho  bolioved  on  thoonttical  graond) 
bhtt  dioeuo  coanistcd  in  chronio  dogDiiorfttioD  of  th«  ^^j  antorvar  I 
and  ooiuoquBntly  ho  dBsigoated  it  "  PaniyHia  geoerala  ii|iinal«  vA4 
■ubtu^t."  Sioglo  iDEUucea  of  the  <liiie4ne  hAte  aiuoo  bv«a  deoerill 
vartooj  authoTB,  such  uj  PotW,  Fnij,  Erl>,  Webber,  Comil  am}  J 
Kloec,  Uoltdouuuer,  Bernliardt,  Aufroclit,  and  otbcn. 

§  405.  Etiology.— T\iQ  causes  of  this  disease  aie  exceed! 
obacure.  All  the  coses  which  have  been  observed  occ< 
ID  adults  between  the  ages  of  thirty  and  fifty  years. 

Amongst  the  exciting  causes  the  most  fretiucDt  are  traail 
injuries,  such  as  a  fall  on  the  back  or  hip.  exposure  to  8( 
cold,  damp  dwelliu^^a,  and  alooholic  and  sexual  cxoi 
Chronic  lead  poisouing  leads  to  a  couUitiou  very  ait 
chronic  atrophic  spinal  paralysis. 


§  40G.  8ymptova». — The  Brst  symptoms  art:  usually  lass{ 
and  fatigue  in  walkiag,  with  p&ia  and  stiflfoess  io  the  I 


SPINJLL  CORD  ASD   MEDULLA   OBLONGATA. 


137 


lower  extremities,  whicli  Diaybeaccoinpanied  bj  alight  fever,  gas* 
trio  disinrbaDces.  and  headache.  The  patieot  may  uJm  complain 
of  TftiiouB paiawthftai^  After  a  time  tboro  is  diatinct  muscular 
vealniess,  somdtimes  only  io  ono,  at  other  times  iu  both  leg". 
Th«  miucular  weakoeas  gradually  increAaea,  the  movements  of 
tbo  ankle-joiot  beiog  usually  more  interfered  with  thnn  thoee 
of  th«  bi|>-joiiit.  After  &  time  tho  paresis  iacreases  to  complete 
pumljrgift  of  single  muscles  and  groups  of  mueclee^  or  of  the 
entiro  oxtromilj.  The  muBcles  are  Haccid  and  soft,  and  no 
renBtaooe  ia  offered  to  passive  movemeota  of  tho  p&rulysed 
eElrcmitiea.  The  rapidity  with  which  the  pamlytiis  takes  place 
varies  greatly.  Sometimes  it  occunt  io  a  few  days,  sometimes 
not  tiU  a/tcr  the  lapse  of  many  months,  or  even  yean. 

Soon  after  the  paralysis  is  establiKhcd  the  affected  muscles 
begin  tu  waste ;  the  calves  of  the  legs  become  converted  into 
looae,  flabby  sacks,  ibe  muscles  of  the  Uiigb  and  gluteal  region 
grow  thb  and  soft,  and  the  limbs  may  ultimately  be  reduced  to 
aoonditioQ  in  which  the  akin  appears  to  rest  immediately  upon 
tba  boDca.  Pibrillary  twitcbit^  of  the  muacIcK  usually  accom- 
paay  the  earlier  stages  of  atrophy.  R«9ex  action,  both  cuta- 
atoua  and  toodtauus,  is  completely  abulisbcd  io  the  pandysed 
mtuclM. 

The  stituibLlity  of  the  skin  usually  remaiiu  Dormal;  but 
occuionally  the  patient  may  complain  of  ft  slight  degree  of 
iosooubUity  and  oumbness. 

Tbe  paralysis  ^odoally  spreads  to  the  upper  cxtrcmitic*, 
titeir  movements  become  awkward  and  feeble,  and  complete 
pualysb  of  them  ultimately  supervenes.  All  the  muacles  of 
tfae  upper  extremities  ore  not  simultaneously  affected;  at  times 
tho  exteaaor  muscles  of  the  forearda  are  earlier  and  more 
■evflRlj  paralysed  than  tjie  rest;  at  other  times  tlie  flexors  and 
iatrixksic  muscles  of  the  hand  are  tbe  first  to  be  attacked  ;  and, 
as  a  rule,  tbe  Sogers  and  bantis  are  more  severely  paralysed 
than  the  foreann  and  shoulder.  Tbe  bands  assume  cbarscteristic 
poutioos.  aod  the  arms  He  ftaccid  and  immovable  as  they  are 
placed.  Rafudty  progressive  atrophy  ensues,  which  leads  to  the 
highest  degrees  of  emaciation,  eapecialty  in  the  hands  and  fore- 
amis.  Reflex  action  is  generally  abolished  in  the  paralysed 
niusclcB,  iKosation  is  DonnaJ.  but  the  patient  may  complain  of 


13S 


STSTEH  DISEASIH  OF  THE 


numbDess  ia  the  itngers,  and  of  parffistbesU  in  ttie  regioo  of 
distribution  of  the  ulnar  cerve. 

Tbo  inusctes  of  the  back  sixj  abdoniien  are  occasionally 
implicated;  the  patienti  enn  uo  loager  Bit  up;  expimtjon, 
coiijrhing.  8noe»ing,  and  defecation  are  rendered  difficult  The 
bladder,  rectum,  and  sexual  organs  remain  entirely  unaf- 
fected. There  are  no  bed-sores,  and  the  general  health  ii 
satisfactory. 

The  electrical  phenomena  in  tlie  paralysed  Dorves  aad 
muscles  cutq  the  saino  as  in  acuta  anterior  poliomycUtia,  oolj 
moiiiBed  slightly  in  coFre»pondenc«  with  the  slower  develop- 
ment of  ttie  malady, 

Duchcnno  showed  that  faradic  excitability  was  dimioisbed 
at  an  early  period  of  the  paralysis,  and  wa*  soon  entirely  lost. 
In  a  cone  obserred  by  Erb  the  nerves  did  not  respond  either  w 
t-he  faradic  or  ^Ivanlc  currents,  and  the  muscles  manifested 
the  typical  reaction  of  degeneration. 

Dunns'  recovery  tbe  electrical  excitability  returns  to  tbft 
norma!  »fandanl  only  very  aluwly  and  gradually.  The  further 
course  of  the  disease  Is  somewhat  variable.  In  the  majority  of 
coaes  the  puralytic  symptoms  remain  stationary  for  &  time; 
although  the  muscular  atrophy  may  continue  to  advance  to  mom 
extent  and  moderate  "  paralytic  contractions"  to  be  developed. 
After  9ome  weeks  or  months  gradual  improvement  seta  in,  which 
begins  in  the  arms  and  bands,  and  ns  it  gradually  advances  from 
muscle  to  muscle  the  galvanic  excitability  of  tbe  musctea  sinks 
more  and  more,  and  slowly  gives  place  to  tbe  normal  reaction, 
while  the  contracturos  also  gmduatiy  disappear. 

Recovery  \>i  so  slow  that  it  m  only  after  the  lapse  of  monthi 
that  the  patients  can  feed  tbonisclves  and  perform  other  actioofl 
with  their  bauds. 

Tbe  improvement  extends  after  a  time  to  the  lower  ei- 
tremities,  the  movemeata  of  the  hip-joint  first  becoming  more 
powerful  than  those  of  the  kncc-juints  and  last  of  all  those  of 
the  foot  and  toes,  until  ultimately  recovery  may  be  complete. 

More  frequently,  however,  the  recovery  is  iitcumplele.  Oar- 
tain  seta  of  muscles,  especially  tlioso  in  the  region  of  diotributioa 
of  the  peroneal  nerve,  remain  paralysed  and  wasted,  so  that  the 
patient  is  partially  disabled  for  life. 


SriXAL  COBD  A-VD  MEDL'LLA  OBLOSQATA.  IS9 

lo  a  certain  small  number  of  cases  the  disease  progre88«s  up- 
wanls  lo  the  medulla  oblongata,  when  artiCTiIalioa,  mastication, 
deglutition,  and  idtimAU'tj  respinition  are  interfered  with,  and 
lbs  patient  dies  from  asphyxia.  At  other  limes  death  super* 
nam  from  simple  exhau<itioo.  The  progressive  cases  tenninate 
ID  from  Doe  to  four  year&,  and  the  farourable  cases  gouemlly  la«t 
months  or  ycara, 

I  am  indebted  to  Mr.  K.  L.  Luckman,  one  of  the  Hoiiso 
Phrsictaos  to  the  Royal  Infirntary,  for  the  notes  of  the  following 
«u«: — 

Clisa  B ,  aged  16  yun,  eDt«i«d  the  Royal  InfiriDary  oq  August 

S3r^  IBM,  Hinder  the  care  of  I>r.  Ram. 

JliUory.'-&ha  hu  b««n  wcnltly  from  tnfuioy,  and  liaa  worked  in  tha 
mill  ua  a  hot  rtxmi  nucv  she  vnm  vhvta  jrvan  of  ago.  About  six  montha 
afO  ber  work  iuii«m1  hor  aii  iinwontoi)  amount  or  ftiti^tip,  and  xhe  eoon 
aftcmanlB  noticed  thnt  ihen  ma  disbnct  loaa  ofpoirar  iu  Iho  lati  leg  and 
am,  folknreri  «fl«r  a  brtof  iut«mU  of  time  by  weakneu  or  th«  Ivil  leg. 
Tba  wtwktMB  of  tbo  lowor  eitmuitiM  jradaally  iocnaMxl,  so  that  iu  two 
BWnths  troat  tbv  comoKiKeiaeat  of  the  attack  she  was  compelled  to  leave 
ttt  work.  She  atatea  that  vhe  has  been  unable  to  walk  tor  th«  la«t  three 
nairfha,  bat  it  waa  finnd  that,  with  udataooe,  she  oonld  males  a  few  atepa, 
Ibe  lanba  hoing,  as  tt  wcrv,  dragged  forward.  Sha  has  eutire  coatrol  orcr 
(be  ■phioctitn,  and  the  ouly  Mnaoty  diMturbancM  conipUiiied  »r  have 
been  ■*  eprinsiug"  {»uw  in  both  logs. 

J*n»nU  OfndiliQn.  —  Aa  she  lies  in  bed  she  hax  a  nuSttring,  uixjoua 
enaij— iiM.  and  the  uuacUs  of  thv  trunk  and  vxtromiUM  *re  Men  to  bo 
amdi  wMted  The  upinr  lips  ate  dry  and  cracked,  the  teeth  are  oorered 
wilb  mrif,  and  the  ttingoe  hsa  a  beef-eteak  ^)p«anuice. 

Left  arm  hea  by  the  side,  the  elbow  being  removed  two  inches  from  the 
bndy.  Th*  left  foreenn  ia  flexed  at  rifbt  anglen  to  the  upper  arm  ;  it  is 
■boo^y  [ironated,  ao  ihat  the  ubiar  side  of  tlie  band  Is  directed  upwards. 
TVa  bead  ia  slightly  extended  ntk  the  forearm,  the  Gret  phalan^  ere  semi- 
flaxed  fls  the  metecaqw)  bones,  the  second  phalanges  are  aeml'flexed  oa 
the  flnt,  and  the  thiM  on  the  second.  The  mu<>cl«s  of  the  bnll  af  the 
Uannb  are  decidedly  wasted,  sod  those  of  the  hypothenar  oroiDrnca  era 
also  atwphied.  The  patient  canuot  produce  opposition  of  the  thiitnl), 
and  addnotiOD  0  feeble.  The  metacarpal  bone  of  the  thumb  Itea  00  a 
leral  with  the  mataesriiia]  bona  of  the  index  Soger.  The  first  phaleaz  of 
tbe  Ihamb  is  citendetl,  and  atigbtly  abducted,  the  saeoud  phalanx  being 
atiglUly  flexed  on  the  first.  The  geoeral  podtJoa  of  the  right  arm  c^ne* 
epoada  to  tbat  of  the  left.  AK)tictiou  of  the  thumb  In,  however,  much 
■an  powerftiUy  perfonuMl  on  tho  right  n<lo  than  on  tbe  left  side,  the 
tagmaid  bolfa  bands  «nt  in  n  eemi-cloned  pnnitinn,  the  index  and  middle 
Issa  eloNd  thaa  the  ring  and  Uttlo  fingoie.     The  interoasei  are  atrophied, 


140 


SYSTEM   DISEASES  OF  TDE 


caiuing  deep  grooves  to  tippear  botttrouu  the  metncariMil  booca.  All  tba 
moveiueiitA  of  tb«  (ii3«reut  segments  of  the  right  ami  oui  b*  pcrfemwd, 
but  itii|>luAtion  nf  the  foroarm  b  very  foeblo.  Bud  caa  auly  be  eflocted  to 
&  positiaii  midwAy  between  pronatian  and  aupiruktion.  Tb«  kft  buid  Im 
powerleM,  in  tlio  pomtioD  alreiuly  ilnscrilMMl,  and  cau  be  tnoTwI  onlf  to  » 
•light  utODt. 

The  lower  vitremitics  an  almMt  completely  inaralytied,  and  arben 
tho  patgpnt  ie  fl«ksd  to  caovo  tham  aaiy  a  alight  movcmoot  oeetm,  which 
in  eBoobod  by  the  muBolu  of  tho  thigh..  Tho  aaterior  inuocloa  of  the  ait 
an  4]iiite  paralysed.  Both  fvet  occupy  the  pomtion  of  talipes  aqoiniui 
but  tho  deformity  can  ho  r«adily  modo  to  dloappoar  hy  produoiotl 
pauive  dorsal  flexion  of  the  foot.  The  difforeot  mgnieiits  of  the  laww 
•stremitiea  can  t>e  readily  moved  upon  one  another,  the  uusclaa  an 
flncoid,  and  there  is  a  complete  abteuu  of  the  quadric«pa  tando-reSex  nd 
of  ankle  clonus.  There  are  do  treiDOn  or  fibrillary  oiiiitracliona  of  the 
muscles  of  the  lower  oxtreniity,  but  a  few  fibrillary  oontractjotu  ue 
occaaioEially  uhacirved  io  tho  loft  hypothonar  omiDonoo.  Tho  patuat 
cannot  raise  henwtlf  iu  bed,  but  on  hoing  oslced  to  do  ko  tfae  mti  nmMlM 
of  the  abdoEnou  may  he  folt  to  ooubraot  nlightly,  but  bare  aot  aiittdort 
power  to  raiw  the  body.  With  the  exception  of  an  occaninnal  dribUttg 
of  uriiitr,  thofonctionsof  the  hi  udder  and  rectum  ore  normally  pcrfomed, 
and  tho  abdominal  muscles  contmct  dlightly  during  the  acta  of  dofeoation 
and  urination.  Wlicn  efao  if  rained  in  a  sitting  i>oatura  she  oaatMt  hold 
the  hody  orKut. 

At  tho  iMiiwt  of  tho  attack  eho  had  some  "ni^nnging"  paiiw  ta  tta 
lower  extrenntivM,  but  tfaviqa  nliiinrcaal  setisntiniiN  havit  now  diaa{)p«and. 
5be  can  di^inguioh  two  painta  touohing  the  surfoco  of  the  outer  aidet 
the  \vg  whon  two  inohfla  apart- 

Thfi  aenso  of  temperature  ia  very  aocurato  and  that  of  touch 
Every  fornj  of  deriaibility  is,  indeed,  perfBctly  nonua!  all  over  the  body. 

Thu  n-Hvx  of  tho  sole  of  tbu  faot.  th«  i;lkitoal,  abdominal,  epigMtiK, 
and  iK*j»ular  refleioa  are  abaeiit. 

Th«  furadic  uontniatility  of  tho  afi«oted  nervea  and  muKcloB  la  antinly 
aboLbbed. 

The  galranic  current,  applied  pvroutenoously,  obtains  no  napODse  from 
the  anl^or  muscles  of  tho  Icgx,  uvea  when  fifty  Leoludi^  «eUa  aie  uaed 

Od  the  ciirmnt  )>nit)g  ap]>lti!d  by  electric  aoupunoture,  the  imiaoll  of 
the  anterior  part  of  the  leg  contract  sligbtly  with  htieen  cells  od  cathodal 
oloaure,  but  do  not  oontntcfc  on  anoilal. 

When  the  gatrauic  current  is  now  applied  after  the  needles  hare  been 
removed,  tho  anterior  muodea  of  the  leg  ooatnct  dlatinotly  oa  cathodel 
clasuro  with  ftfty  cells. 

The  ettensors  of  the  right  foraann  eontnot  slightly  nn  oatliodal  doaon 
with  flfl;  Leclanchij  (.'ella,  but  gtra  no  naobiou  on  auodal  doeare. 

The  exteiMnr*  of  thn  Uh  f.^rearm  give  no  reapooae  mthsr  on  cathodal 
ranodal  donure  or  opening  when  fifty  oella  are  used. 


SPINAL  CORD  AND  URHUlhX  OnLONOATA.  141 

Tbo  trMtnient  coasiatMl  of  tho  stabile  application  of  the  cotuUnt 
eorrtbl  to  tbo  cpiiwfor  a  few  miiiutos  dulj,  tha  outroMt  b«ing  ako  puned 
•  loQger  pehoJ  Uuljr  tbrougli  t^  kiTucted  nervcn  and  muscloa.  No 
i\ii»  ftlterBtion  took  plaoe  in  b«e  oondiLiun  utiUl  th«  evtaiug  of  Sep- 
tUmr  16tb,  when  tko  hrMthtog  ww  obaenrod  to  bu  cmburvwed.  At 
lo'olock  m  tliu  luimiiDg  the  h&ndBaiid  Upt  were  livid;  tbcfl^es  were 
balf  elooed ;  bvc  beo  tai  bodjr  wen  batbod  iu  cold  peni>iralioii ;  thu  jo'ux 
«■«  mmk  i  tbo  di^hntgm  bad  coasod  to  ^y,  ro*|iiratioii  conaiotiDg  cfaisfl^ 
of  an  «l«vatioa  moveiDiHit,  and  could  txft  b«  jaada  to  (xsotract  hj  a  strong 
lanJtc  miraDt  paoNMl  thnagh  the  phroiiic  nvrroH.  She  atMuie^L  to  nlljr 
a  liltlo  for  •  abort  time,  but  ibv  diaphragm  remalMd  ponUyMd. 

At  nine  a.tii.,  8e{it8mb«r  17th,  (he  surfiBce  waa  b«tlud  in  {irofuso  p«r- 
apintiou  :  tbe  aldn  waa  oold  and  clauunj,  tbe  touporBtuTe  Wng  07 IS; 
tbe  li[>  and  bands  wars  livid ;  and  tbe  puis*  was  fooblo  aiid  'luick,  t>«4ttitig 
15i  ia  tba  miuat* ;  Hm  rea|»ratious  won  alow  and  icvffMtuftl,  but  «bo 
iwttMaad  cDoacioua  to  tbe  laat,  aud  died  at  elevou  a.u. 

Amiepitf. — tromediatl;  after  dealb  the  body  was  placed  face  dowuwaxda, 
Iks  wfiia»  was  corend  (ritb  ice  until  tho  poBt-uortam,  L'omlucted  by 
Dc  Alfted  Vootgr,  io  tbe  creiiin);.  No  Dh(ui};eii  worth  reoordiag  were 
^htmmd  bf  the  naked  eye  in  the  Imuu,  or  oven  in  the  spiua)  cord.  The 
TMOB  nvcr  tho  pooteriur  vurfuco  of  the  lumbar  regiun  of  the  cord  vrcre 
giually  diateadod.  Oti  makiug  traaaverm  wotiouH  uf  tbe  siiiual  oord  at 
iatovvala  of  a  quarter  of  an  inch  from  above  downwards,  it  wan  obaDrviid 
delnita  araaa  of  the  white  Babetaiic«  von>  of  a.  j^roy  tuA-yar  aud 
appearance.  The  grsy  subatance  of  tbo  central  oolumua  »iul 
borna  from  the  &rtb  er  aiztb  oervical  Dorvea  downwards  was 
lielow  tbe  white  «ubetanoe  in  eacb  eectiau,  and  apiiearod  of 
mA  «oaii*Uoc«^  and  waa  inteneeted  in  every  dimelion  by  dilated  and 

I1.1lipi1   llMlllllI 

JKcrMMpu  aMmiMifion  abowed  that  tbe  ganglion  oolla  cf  tbe  ant«nor 
'  bonm  bad  altooat  completely  dieappcercd  throughout  tbe  entire  length 
!lbeeplaal«ord(/^.163,  lta4).  Tbe  uetitnd  column  end  anterior  borne 
imn  intMMCted  with  dilated  blood-WMela,  the  walla  of  tbe  vemela  were 
thidnned,  tiM  nnelei  of  tbe  oourogtia  wore  greatly  increased  in  number, 
and  tbe  tiMoe  wae  iu&lmibed  with  leucocytee.  In  miqo  sectioua  tbe  oella 
the  TflBtculor  column  of  Clarke  appeered  smaller  and  rounder  than 
boi  on  the  whole  tbie  column  did  not  aeem  to  be  niucb  aflbcted 
^tli  duMoa  The  postenor  grey  home  appeared  normal  in  every  reajiect. 
Tbe  upward  ooatiaoaUoaof  tbe  centrat  grey  oolumn  IntbemednUaobJuu- 
fila  {i^if.  103,  S)  pweented  eimJtar  morbid  appearancee  to  thooe  obaerved 
in  tbe  grey  anhatance  of  the  aiNiial  cord,  and  the  cells  of  the  eoooaaary 
DiKJri,  oa  well  as  thoee  of  the  uuuleue  of  the  eleventh  uerve^  bad 
diaappearad  i  but  tbe  fundamental  oella  of  ibebypugloaaal  uuoleuo,  inatead 
c<  being  dealnyed,  were  hyptrtrD|>bied.  A  few  hj  jiertropLiicd  uvlle  wvre 
•las  iilMiiiiid  to  aooe  aectlooa  m  the  ocntrov  of  tbe  internal  and  antero- 
bteid  greai»  In  Iha  oord,  eapeclally  in  the  cervical  n^on,  while  o 


142 


SYSTEM    Dlt^EASCS  OF  TBE 


>: 


■^-;;i 


\r 


wer«  r«)ireMnt«d  \>j  «mall  angul&r  Tnifitrn 
vithinit  iinicvK.-w<;  but  xll  tbe  nrniiiiiirf 
ooIIm,  and,  iiidcMl,  thft  m^imty  of  tli*  fuad*- 
meuUl  colla  ill  tbe  oori,  had  disq>paand 
without  a  tnco  of  thorn  being  left. 

Oil  holdiug  d  aectian  Ooui  the  taiiiiUo 
of  the  dorsal  regiaa  up  to  tli«  light,  ■  paUk, 
wfaich  was  more  hisblyoolouTMllijrcaRDtM 
tbao  tba  Burrouuding  tiaaue,  could  be  dis- 
tinctly observeil  in  the  |)ost«rior  rvoi-ioni^ 
nhere  it  adjoius  tl>o  columu  of  GoU.  1( 
be){ati  Clear  tlio  jiontorior  cuuiiaiMiu'e,  wtd 
extended  baclcwanla  towards,  althoojh  It 
did  nut  reacb,  the  iioBtorior  aorfaoo  of  tba 
oord.  Tli«  d«tii>l/-Htsiiivd  portions  «ws 
■jrtBiiiotncsllj'  placed  ou  cacti  sido  of  tfas 
ooluTutis  of  Uoll,  aud  to  tbe  naked  efe  tbej 
prowMiUtd  all  tlio  «liatacton  of  patches  of 
BClenjua  {Fij.  1S3,  2J.  Similar  patdiM 
wan  obetirrod  In.  tbe  cerrical  i^oo,  but 
tbey  nere  [ours  diffused  than  tfaosa  in  tbs 
duRttl  rogiou,  tLeir  ar«at  ir«re  largar,  and 
tbsy  did  not  atain  »o  deeidy  iritb  cannin. 
lu  Buuiy  eootioiis  tko  pori|)hond  lajer  sf 
tbe  cord  was  de«[ily  Btaiued,  this  being 
otipeuially  tuiixkediu  tbe  aukriorriKti-souta 
atid  uoluiuua  of  Turck.  When  tbe  deepl/- 
utaiuvd  purtiouB  were  examtued  micro- 
B(Wpi<;ally,  tbii  coiiiieotive-timue  sujita  www 
foiuid  swlleo,  a  lew  of  tbe  nerve  flbras 
bad  diaappejmd,  but  tbe  tniijon^  of 
tbeas  wsrc  uoruial  The  moit  tvouricabW 
tuvrbid  altsraUoD,  bowerur,  otMerred  was 
tbu  t;>^u^>a«i'«M4  in  th«  fiaiiiber  vl  I>eiter'» 
cells. 

A  Uri;«  uuml>er  of  the  oerre  Gbreeef 
tbu  uuleriitrT  ri^uU  bad  uiidergoue  atr<D|ib^, 


Fia.  t(J3  (Younic)-     Tranttw  StcKnP 

Hpinal  and  MiJi'iU  OIAenp«aa  ol 
itedt,  /mm  a  cam  nf  ehnmic  atrapkte 
paraijitit,  altoieinf  i\e  iSiMttjmuama  itf  CM 
foa^ivn  <tlU.  —  l,  MM\o  of  IIm  hualw 
mlur^uient ;  2.  AliiliUe  of  ilia  iatmd  regwn; 
3.  Mi>]<lliM.f  (hru-i^rvioalwilaiyemDMt  i. Unc- 
tion uu  a  lt!V»l  witb  Uie  vrigia  ef  tb«  ■■cmiJ 
o«r*io4Ll  oerv* :  5,  Svctim  of  tli«  nmittiU 
nl>louu>U  >jii  ■  Invsl  wil-li  Itie  middle  I 


uuAui  ijii  ■  In 
tbs  uilvsij  body. 


SPUtkL  COBD  AND   UBDULLA   OSVOSOATA. 

and  aoBM  of  the  ImtMlles  mon  replaced  hy  cooti«ctiTe  tiwue.    A  coaai<)<.T< 
•Ua  nnmber  of  the  fibred,  bofteier,  »i>|i«arBd  Doniial. 

PorticMwi  af  ttw  u>t«r)or  inuselM  of  tli«  leg,  «ii<l  of  llivao  «f  the  hjpo- 
timuai  numcoce,  wore  robjeot«d  to  microacopical  eumtitDitiou  by  Dr. 
Lmah,  «ba  Inndl/  tnuuiited  thotw  muHclm  for  me,  aud  sut>Daitt«d  the  ful- 
losingnpofi: — 

"  Oil  truwrane  sectiou  tbe  mUAcaUr  RljnM  are  acoa  to  be  a&|Hiriit«d 
hf  an  undtM  usDuut  of  flbrviu  tiMuo,  whilo  the  ducIm  i>f  tlio 
^■domjiiurji  are  greatly  inoreMcd  in  number.  Tfae  Sbroa  tbeaHKlreii 
Tuj  io  dtuoettTf  une  of  thotn  beiug  eoi»idet>ably  Rinnller  than  others, 
■ad  tbo  nacln  bematb  tbe  osroolemmA  un  iDcrvoaod  in  niitnlwr. 
ZnauoatioB  of  loDgituditiftl  M<ctio»ii  ithi>w)i  thftt  t)io  mueole  corpuacles  are 
iacnMod  ia  Dwabcr,  and  tbnt  tbo  ntruotaro  of  the  muscular  gbre  in 
gntUj  alterad  in  otlivr  roapootA.  ilaay  of  tlie  iuiumsuIu'  fibrea  4>e 
r,  their  tiiuur«no  Btnntioa  u  indistinct  or  vrantiug,  and  tbe 
I  oaqMuclea  are  incmsed  in  nnaiber.  Tbe  most  remarkable  cbaogca 
kI,  botrareTi  ooaaiated  in  au  attention  of  the  uormal  rvlatiou  of  the 
ile  and  intentitia]  dine.  Tbe  oontraotUe  diaca  Heemml  to  bo 
led,  attd  ewellMl  out  Intarali}'.  In  ocuwequeuoe  of  thie  ohaage,  the 
Itial  dwca  apjiaaretl  an  trauftveiw,  mom  or  leas  trooa^jAKiit,  baodii 
Wl— «P  tilt  daricM*  ban  fonocd  by  tbe  coutractilo  diKs,  and  tbe  former 
fanog  alao  Barrawer  than  the  latter,  the  ouUiue  of  the  fibre  boa  a  nigone 
or  awntleiJ  a|tpearauoe. 

"Sevcfal  nuclei  an  oometimes  obaerved  tQ  tbe  transparent  bantls, 
vliil*  one  oi  aaon  maede  ccrpujeclaa  are  obvoorelj  weu  iu  th«  tlarkcr 
nuiL 

"  II  u  doubtfol  how  tu  tbo  obaogee  jiwt  dceoribed  ate  the  roault  of 
,  inasmucb  aa  Bimilor  ajipeanuiceM  may  sometimaa  be  aeea,  altbou^ 
'  to  tbe  MUiifl  extcut,  in  bocithy  uueclo  vithdrawn  during  life  by  the 
I  tncar  ;  and  tbe  autojHy  in  thin  caw)  bein^  c(>ui)ii(-.tvd  a  few  houra 
'  death,  the  muaclewoald  have  been  t>lao«sl  in  prAMrvativo  fluid  before 
poet'tDoitent  ligktity  had  taken  place:" 

A  cue  of  cbrooic  atrophic  spinal  paralyns  has  recentljr  been 
d««ciib«il  by  Aoftrcbb,  ia  whicb  a  post-mortem  ez&miDation 
bad  been  obbaiDed,  and  the  spinal  cord,  ncnreit,  and  muscles 
■objected  to  cateful  micruecopic  cuiminatioD.  Tbe  appearance? 
obaeired  oorrespoDd  on  tbe  wbole  pretty  closely  with  tho«e  just 
dcacribed.  Iu  Aufreclit's  case,  however,  the  ^nglion  cells  of 
tbe  anterior  lioms  were  by  oo  means  changed  to  anything  liku  the 
MCM  extent  they  were  ia  the  case  observed  by  me.  From  a 
careful  examination  of  Anrrceht's  description  of  the  morhid 
ftlti-raCionii  in  the  aoterior  borna,  it  is  crtdent  to  me  that  the 
fandamenUil  cella  were  hypertropbied,  and  that  some  of  tbe 


144 


ilYHTBU    DISEASCS  OP  TUK 


accessory  cells  were  shrivelled,  while  probably  a  oansideral 
uuinber  of  them,  lind  disappeared. 

g  407-  Dia^noaia. — ^The  ckronic  may  be  distingiiished  from 
tliu  ticatc  tWm  ol'  anterior  poUomyelltia  by  the  slow  aud  gradual 
tnEinnBr  in  which  ibo  runner  and  the  suddon  way  ia  vrluch  ttie 
latter  begins.  The  subacute  or  cbrooic  form  has  for  some  time 
a  progreaaire  course,  and  extends  more  or  leaa  graduaUy 
upwards,  and  tbe  diseasd  may  tcrmiuatc  fatally  or  advuioe 
ttlowly  towards  recovery.  Tbe  course  of  this  disease,  tlierefoTf, 
differs  greatly  from  that  of  tho  acut«  form. 

Progr^^''^  muwttiar  atrophy  may  bo  distingnishGd  from 
chrooic  alrophiv  spinal  paralysis  by  the  circumstance  that  in 
the  formor  the  pnralysis  aud  atrophy  proceed  side  by  side, 
while  in  iho  latter  the  paralysis  precedes  the  atrophy ;  again, 
in  the  former  tbe  atrophy  ia  partial,  and  in  the  latter  tbe 
muscle  wastes  as  a  whole.  In  pro^re&iiive  muHcular  atiopby 
tbe  middle  form  of  the  reaction  of  degeueratton  ia  met  with, 
and  reflex  action  is  retained  ;  wtille  in  chronic  atrophic  .tpinAl 
paralyaift  tbe  reaclion  of  degoueration  is  well  marked  and  KA<fX 
action  is  abolished ;  and,  lastly,  progressive  miucolar  aUopby 
runs  a  slow  and  always  imfavoiirable  course,  while  cbronk 
poliomyelitis  runs  a  cumpurutivcly  rapid  course  aud  frequently 
cuds  favourably.  It  ia  not  improbable  that  some  cases  wfaidi 
arc  usually  classed  as  partial  progressive  muscular  atrophy,  but 
which  arc  not  progresstve,  really  belong  to  tbe  category  of 
cbrouic  anterior  poliomyelitis. 

AmyciropkiG  lateral  sc^rom  resembles  chronic  poliomyelil 
in  the  paralysis  and  atrophy  of  the  mnacles  of  the  upper  ei 
tremitiee,  but  in  tbe  lower  extremities  there  is  paralysis  without 
atrophy  along  with  tenxion  of  the  muscles,  contractures,  and 
iucrease  of  the  tendon  reHcxes,  and  only  the  middle  form  of  the 
reaction  of  degunerntlou  is  met  with.  Tho  diaguosis  between 
paralysis  ascendena  acuta  and  chronic  poliomyelitis  will  ba 
subBequently  described. 

Cbronic  atrophic  spinal  paralysis  may  be  distinguished  from 
transverse  myelitis,  multiple  sclerosis,  tabes  dorsalls,  apactic 
spinal  paralysis,  and  all  other  forms  of  chronic  spinal  disease 
it'  due  attention  be  paid  to  tbe  state  of  tbe  sensibilitijr^ 


SPISJJ.  CDS!)  ANI>  HEDtTLLA   0BLO»(IATA. 

fanctioD!!  of  the  bUdder,  tbo  DQtritioti  of  the  ekin,  reflex  Mtioo, 
and  the  electrical  excitability  of  the  ranitcles. 

§  408.  Proffnofia.— The  prognosis  ia  compamtiTOly  favourable, 
Reoorety  takes  place  in  the  majority  uf  cases,  and  improvement, 
as  a  rule,  goea  much  further  than  in  the  acute  form.  At  the 
same  time  it  must  be  remembered  that  chronic  atrophic  spinal 
paralysis  is  not  like  infantile  paralyns  in  being  free  from  all 
danger  to  life.  The  more  partial  forms  of  the  dineuse  are  never 
dugeroot  to  life,  although  tboy  may  lew!  to  permanent  atrophy 
of  tbo  muMlefl  affootcd. 

§  400.  TrealvuTit. — The  same  prindplca  are  applicable  in  the 
treatment  of  this  diseago  as  for  subacute  and  chronic  myelitis 
generally.  Antiphlogistic  treatment  should  first  be  employed, 
aiwl  altervanls  the  use  of  the  galvanic  current  and  a  stimulating 
and  mp|>onin£  tnatment. 

3.  Progremive  ifiuoular  Atropiiy. 

Frogressive  muscular  atrophy  is,  as  ita  name  implies,  a  pio* 
fresaivft  wasting  ot  the  ruluntary  miucles,  which  pursues  a 
ebrooic  course,  and  attacks  eucceuively  iadiTidaal  muscles  nnd 
fronps  of  mUBCIes. 

{ 410.  //iitM?.— EUppocratM  nsdo  a  di8tincbi«n  Ixtweou  pual^ia 
wiUt  and  wtthoat  wuting  of  the  limbo^  and  obsemd  that  the  former  wan 
incunbla.  Cmw  of  movculAr  inutiof,  but  witb«at  puulfaut,  wore  |>ut>- 
Uahei  in  tlie  fint  half  of  this  onntury  by  Abercroml)i«,  Darwal,  Coolce, 
Ball,  Romberg,  Unvaa,  Dnbois^  and  Ducbennc,  but  the  &lT<Klit)u  tm  not 
rwogBiMduftilttiUiM^tdijHtM.  Ducbsoutf,  Amn.  kndCruveilhier.m  18&0, 
iadsptadwitly  of  «ach  otlinr,  gave  taoro  occuntc  dMoriplicus  of  tb* 
aihcdoa,  and  retM^imd  its  cliiina  to  be  rwguded  m  ».  dijrtJuct  t/po  of 
diHMs.  l>r.  WillifttD  Boberta  in  1656  oollectod  oU  the  iuformaion 
Miattiig  DO  tbe  subject  up  to  that  time  in  an  enay  entitltd  "  On  Wuting 
PsLqr  i"  and  ebc«  that  tine  tbo  patbolasj  of  Hm  diacaM  baa  been  to- 
varti|ated  by  Oull,  Lockhort  CUrke,  Lujm,  Charcot,  Harem,  Leydeit, 
Fricdmcb,  Ertv  and  tamuj  othcm. 

§411.  Etioioffy. — Hereditary  predisposition  u  a  powerful 
factor  in  the  jH'oduction  of  progressive  muscular  atrophy.  Dr. 
Koberts  collected   the   histories  of  ten  families  in  which  a 


146 


STSTEU    DISEASES  OF  TDE 


tendeac;  to  tbedisease  prevailed;  but  the  cases  described  by  Dr. 
Herjoa,  wbiob  ace  iocludcd  ia  this  li«t,  were  probably  Lmtaacet 
or  the  advanced  etage  of  pseuJo-h3rpcrtropbic  paralysis.  Aiter 
Dr.  Meryon's  caries  are  eliminate<i,  it  may  be  stated  that  out  of 
the  eight  families  referred  to  by  Dr.  RoberUi  twealy^three  indin- 
duaU  were  afTccted,  and  of  those  four  only  wore  females, 

In  a  case  deBcribed  by  Hempteamacher,  the  disease  could  be 
traced  amoagst  the  braaches  of  three  families,  who  had  re- 
p«atedly  inter  married,  and  who  had  sprung  from  oae  parentage 
a  hundred  and  fifty  years  aga  lu  this  instance  males  only  were 
attacked,  but  the  disease  was  frequently  transmitted  through 
the  female  Friedreich  found  that  the  disease  was  transmitted 
by  a,  woman  to  her  children,  though  they  were  the  products  of 
thrco  BCpurate  marriaj^ea.  Trousseau  mentions  a  family  in  which 
the  grcat-grojidfathcr,  grandfather,  father,  and  son  suffered  Utaa 
the  disease,  the  course  of  which  closely  coincided  in  all  tho 
generations.  Guleaburg  mentions  the  case  of  a  family  wber^ 
out  of  seven  children,  two  brothers  and  two  sistora  mn 
attacked,  while  the  remaining  three  brothers  escaped. 

The  mate  sex  shows  a  much  greater  tendency  to  the  disease 
than  the  female  sex.  Out  of  176  casca  collected  by  Friedreicb 
only  33  were  fcmaloH.  The  disproportion  between  the  sexes 
probably  depends  on  men  being  much  more  exposed  to  the 
exciting  causes  of  the  disease.  Dr.  Roberts  asserts  that  womea 
of  tho  working  ciasset;,  such  as  washerwomen,  domestic  aenraots, 
and  sempti tresses,  are  not  much  less  liable  to  the  disease  than 
men  employed  in  kindred  occupations,  while  on  the  other  hand 
females  belonging  to  the  middle  and  upper  classes  etijoy  a 
remarkable  immunity  from  the  disease.  It  is  difficult  to 
explain  the  cases  which  arise  in  childhood  and  in  which  the 
male  members  of  the  family  alone  are  attacked.  Mr.  Darwin, 
however,  has  shown  that  many  variations  which  first  appear  ts 
one  sex  are  transmitter!  to  that  sex  only.  If  this  fact  does  not 
afford  an  explanation,  it  at  least  merges  tho  special  into  a 
general  difficulty.  With  regard  to  the  influence  of  ago,  tlw 
disease  is  found  amongst  young  adults  and  middle-aged  io- 
dividuals;  and  where  there  is  a  marked  hereditary  teodeney 
to  the  aAection,  children  are  not  unfrequently  attacked.  Tl 
development  of  the  disease  in  advanced  Ufe  is  exceptionaL 


SPINAL   OOBO  AKD  XBDtJLLA   OBLONGATA. 


U7 


Progressive  mascal&r  alropby  ia  often  developed  during  cod- 
valOKencc  from  acute  diswiLses,  such  as  tjphoid  fever,  caeastes, 
•cote  rheomatian),  aad  cbolpra  with  protracted  typhoid  Riage ; 
and  Charcot  and  Joffroy  have  oboerved  it  to  occnr  iDimcdiatcly 
after  childbed.  Veneraal  exceu;  eipccially  oDaaism,  has  been 
•uppoaed  hy  many  autbon  to  be  a  ihiitful  Kouite  of  the  affcc- 
tioo,  although  the  evidence  upon  which  the  opinion  Ls  foiindod 
is  doubtful  Chronic  lead  poisoning  in  not  unfrequeatty 
atteodod  by  a  difTuaed  wastiug  of  the  muscles,  closely  resem- 
btlDg  progreaaive  iau«cuUr  atrophy ;  and  a  similar  wasting  alao 
ocean  in  coostitutional  fiyphilia 

Of  the  exciting  canaee  of  the  disease  uouauat  mascular 
ftxertioD  deserves  the  chief  place.  That  excessive  muscular 
aflorta  tewl  to  davdop  the  disease  is  showD  by  the  fact  that  the 
atrophy  attacks  by  preference  the  groups  of  muscles  which 
must  be  maiutaJQed  in  long-continued  contraction  with  persons 
fultowiDg  certain  avocatione,  aucb  as  bUckHmitbs,  tailors, 
muOM,  and  shoeroakers.  Betz  observed  atrophy  of  the 
masde*  of  tbe  right  side  in  smilha  aud  aaddlor^,  who  had  to 
do  bea'vy  work  with  their  right  haods,  and  Gull  observed  tho 
MUM  10  a  tailor  sAer  excessive  exertioo.  Id  tbe  cose  of  a 
ilooeiiuuoQ  which  came  under  my  notice  the  atrophy  began  io 
tbe  muscles  of  tbe  right  band.  In  persons  who  have  tu  per- 
fofiD  maoual  labour  tbe  disease  generally  begins  in  the  muscles 
of  the  shoulden,  arms,  and  hands;  and  the  right  aide  is 
gananDy  the  first  to  be  affected.  Iq  children  the  atrophy  not 
nnfrequeDLly  begins  in  the  lumbar  muKltM,  and  extends  to 
tboae  of  tbe  lower  extremities,  a  mode  of  invasion  which  is 
pmlMlfaly  due  to  the  preponderant  use  of  the«e  muscles  ia 
■taading  and  walking.  I  have  observed  a  mmilar  mode  of 
iDvasion  in  a  cuUier,  who  was  compelled  to  work  in  a  bent 
poature. 

Exposure  to  cold  aud  wet  appears  to  be  of  itself  sufGcicot  to 
prodnca  the  disease.  C.  U.  Rtcblcr  saw  a  total  atrophy  of  tbe 
bands  in  a  man  who  BufTered  from  &evere  sweating  of  the  h&uds 
and  whe  was  accustomed  to  bathe  them  in  ice-cold  water  and 
•DOW.  DuDwinil  obMr%-cd  atrophy  of  the  lower  extremities 
after  long -continued  standing  In  water  whilo  fishing ;  bat  io 
this  ease  it  is  doubtful  bow  much  of  tbe  effect  is  lo  bo 


148 


STTTEM  DISEASES  OF  THE 


attributed  to  exposure  to  coM  and  bow  mach  to  ezoaH  of 
miucular  exertioo.  Tbe  disease  is  doabttesa  more  likely  to 
be  developed  when  these  causes  ttxa  combioed.  Oases  arising 
from  exposure  to  onld  ore  ^ubjucl  to  neuralgic  or  rheaniatic 
paiuB  in  the  oflfectcd  parte,  bcace  tbeee  eaaes  are  fret|iieoUy 
aMomed  to  be  due  to  rbeumalistn.  lu  tbiit  class  of  caaos  the 
ioTasion  ia  oflea  siiddeti  aod  accompaoied  hj  cramps  and  inu>- 
cular  tvjtcliing  (Roberts),  (ind  tbe  ati-opby  ia  more  apt  to 
extend  to  tbe  musciee  of  the  truok  tban  in  cases  due  Ut 
overwork.  Aocording  to  Br,  Roberta,  of  twenty-fire  casM 
attributed  to  overwork  cigbtecn  were  partial  and  only  serot 
ge&eral ;  whereas  of  the  sixteen  caeca  charged  to  the  agsocy  of 
cold  six  were  locat  and  ten  general. 

Injuries  of  various  kinds  may  bo  tbe  exciting  causes  of  tbia 
iLfTocuon.  In  a  youth,  under  the  care  of  Dr.  Roberts,  who 
ultimately  died  fnim  implication  of  tbe  renpiratory  mascles,  the 
Br^t  symptom  of  atrophy  occurred  in  the  hall  of  the  right 
tburab  six  months  after  tbe  fall  of  a  bale  of  cotton  on  fais  ncdc. 
Ca^es  similar  in  ussuutial  particulars  are  recorded  by  Clarke 
and  other  authors.  Local  injury  to  some  of  tbe  muscles  of  the 
body  is  Rometimes  followed  by  progrcaxive  muscular  atrophy. 
Friedreich  relates  a  case  in  which  the  hand  bad  been  criisbed, 
aud  eubsequcutly  tbo  atrophy  extended  progressively  upvmids 
over  tbo  onttre  upper  extremity,  and  iiniUly  led  to  the  ood- 
plication  of  bulbar  paralyHis.  At  olber  times  the  inflammatory 
irhtatioD  appears  to  bo  propagated  from  ucigbbounng  parti, 
•Qcb  as  the  shoulder  and  hip  joints,  and  the  disease  appean  at 
times  to  have  been  caused  by  cicatrices  or  suppurating  wouada 
These  oases  are  grouped  by  Friedreich  under  the  nam*  of 
m^paikica  propagata. 


g  412,  Stfmptoms, — The  invasion  of  the  disease  is  slow  and 
insidious,  and  il  is  nsualty  in  existence  some  weelu  or  months 
before  itti  presence  is  discovered.  Tbe  patient  first  experience* 
some  difficulty  in  performing  otirtaiu  ntovemeats;  and  OD  attaa- 
tioD  being  directed  to  the  affected  liinbR,  some  of  the  musdet 
are  discovered  (o  be  more  or  less  wasted.  At  other  times. 
especially  when  the  disease  has  been  caused  by  exposure  to 
cold,  tbe  mode  of  invaiioD  is  attended  by  more  prominrat 


8PIMAL  OOBD  AND  HBDULLA  OBLOXOATA. 


H9 


■jrmptonu.     Faroxrama]  pains,  like  tbo«e  of  rbeamatiitni  or  of 
Mi)nJ}ri&,  are  felt  in  tUc  affected  limb  wreral  weeks  or  tnontbs 
bafora  tba  atropby  of  the  miisclex  is  noticed,  aDd  wbea  once ' 
the  alropby  begins  in  tbese  cases  it  proceeds  more  rapidly  and 
becomes  more  gsoenltaed  tlum  in  tbe  painless  rariety. 

Tbe  (Itsease  nsuallj  begins  ia  one  of  the  upper  extremitieid. 
moic  commonly  ia  the  right,  either  in  the  interoa8«i.  the 
mnaclM  of  tbe  tbenor  and  hypothcnar  eminences,  or  in  those 
of  tbe  shoulder.  Eulenbui^  Bays  that  whea  the  diseaae  b^ns 
ia  tbe  hand  tbe  interossei  (and  especially  the  Brat  tnterosMus) 
•n  geiMnJly  att&ckod  before  the  muscles  of  the  ball  of  tbe 
Ibumb;  wbile  the  contrary  opioioa  is  held  by  Roberts  and 
Friedraicb.  Tbe  opponeus  polIt«is  and  tbe  adductor  potltcts 
an  the  first  muacles  to  be  affected  in  the  ball  of  the  tliumb, 
while  tbe  extensors,  abductor,  and  flexor  of  the  thumb  are 
spared  for  a  long  limo,  or  may  escape. 

In  some  few  casus  Iho  diMaM  b^;ii)8  in  the  muBcleA  of  tbe 
•b(ial4er,  and  in  these  tbe  deltoid  ia  almost  always  i^xclusively 
•flbot«d  at  fint.  When  cho  atrophy  liegins  in  tlio  lumbar 
■aaaeles  and  lover  extremities  children  are  almost  always  the 
sabjects  of  tbe  disease,  and  it  then  frequently  simulates 
|lscado*bypertrophic  paralysis,  which  will  be  sabsequently 
described.  Uunng  the  progress  of  tbe  disease  certain  muscles 
or  groups  of  muscles  are  attacked  while  their  neighbours  are 
apaivd.  and  tbe  hvoltby  or  less  atrophied  muHcIcs  overcome 
tho  tesistanoo  of  those  more  diseased,  so  that  characteristic 
aoiilraalioins  and  deformitiea  ara  praduMd. 

Tbe  disappearance  of  the  tnteroesei  is  shown  by  the  deep 
fiirtows  which  appear  between  the  metacarpal  bones,  tbe 
thenar  and  hypothcnar  ominenocs  sro  flattened,  and  tbe  dis< 
•ppoanuiee  of  the  musclte  of  the  palm  briugs  into  view  the 
diverginfi  flexor  lendoDs  which  are  stretched  between  the  wrists 
aod  the  bulging  bases  of  the  Bngertt  (Roberts).  The  deformity 
pfodueed  hy  paralysis  of  the  interottei  gives  to  the  hand  tbe 
qipausaoa  of  tbe  talons  of  a  bird  of  prey  ;  hence  it  has  been 
called  the  cUw^haped  band  or  main  en  grije  (Agr.  77).  Tlus 
tlelbnatty.  botrwer,  is  not  peculiar  to  progn.tMive  mutcular 
attupfajr,  inaemuch  as  it  mar  be  cansed  by  injury  to  tbe  ulnar 
in  coosaqcteace  of  tbe  atrophy  of  the  opponeos 


ISO 


SYSTEM  DISICASES  OF  THE 


adductor  pollicis,  tbe  thumb  19  extended  and  abducted  (Pbto 
II..  1.  2,  3). 

WUen  the  forearm  is  affected,  the  auterior,   poelerior, 
extenor  osp&ct  of  tbe  limb  is  flattened  aooording  ns  tbe 
extensors,  or  supinators  are  affected. 

When  tbe  miiscies  of  tbe  shoulderH  are  afiected,  tbe  arma  vmf 
hang  by  tlie  side  or  rather  in  front  of  the  patient,  as  if  they  were 
merely  attached  to  bim  by  stringB  and  did  not  belong  to  bim; 
the  natural  rounded  configuration  of  tbe  tihouldcra  i»  replaced 
by  a  boUew  in  wKicli  tbe  palm  of  the  bund  may  be  lodged 
under  the  projecting  acromial  and  coracoid  processes  of  tbe 
scapula,  which  etaud  out  in  relief.  The  biceps  and  tbe  otbei 
mudcles  of  the  arm  may  aUo  wa^te,  no  that  tbe  limb  loMS  iU 
roundnesd  aod  becomes  flattened,  and  tbe  humerus  appears 
to  be  surrounded  merely  by  the  tdtin. 

When  the  abdominal  muscles  aio  affected,  the  lumbar  cun« 
IB  greatly  exaggerated  by  the  unopposed  acttoo  of  tbe  erecter 
spiniu,  the  abdomen  ia  loose  and  protruding,  but  tbo  thorax  is 
held  well  forwards,  so  that  a  plumh-Iin«  let  drop  from  the  raoct 
prominont  of  the  spinous  processes  of  the  vertebnc  will  pan 
well  withiu  Ifae  sacrum,  contrary  to  what  occurs  when  the 
lumbar  muscles  are  affected.  When  the  atrophy  is  anet^oall} 
distributed  on  both  aides  of  the  body,  scoliotic  or  kyphotic 
bending  of  tbe  vertebral  column  may  be  produced.  Wb«o 
the  erector  Hpin^  and  extensors  of  tbe  thigb  are  implicated. 
the  deformities  proiluced,  as  well  as  the  gait,  are  \'ery  lumiUr 
to  those  seen  in  paeudo-hypertrophic  paralysis,  and  it  11  dd- 
uecessary  to  dcicribe  them  here. 

When  the  lower  extremities  are  invaded,  deformities  occur 
corresponding  to  those  observed  in  tbo  upper  oxtremitiet; 
but  the  former  are  of  much  rarer  nccurrence  than  tbe  latter. 
The  various  forms  of  club-foot  may  appear,  especially  tbe  para- 
lytic pee  equino-varus. 

Tlie  accessory  respiratory  muscles,  as  the  pectoralis  major, 
serratua  mugous,  trapezius,  &c.,  aru  frequently  Implicated;  and 
although  the  wasting  and  loss  of  power  of  these  muscles  do  tM>( 
directly  endanger  life,  yet  tliey  may  do  so  indirectly,  iDannodi 
as  a  slight  intorcurrent  attack  of  bronchitis  may  lead  to 
asphyxia  since  tbe  loability  to  make  a  strong  expiratory  effort 


I'l.rvTi-  II 


/^ 


\  ■ 


.y& 


\^ 


SPIKAL  CORD  AND  HEDtXLA   OntOSQATA.  151 

preventa  tbe  tubes  from  bebg  effectually  cleared  of  mucus.  Id 
the  Uter  stages  of  tbe  afTectioo,  tb«  diaphragm  and  the  int«r- 
OMtal  miudes  become  affected,  expectoration  fails,  mucus  collectii 
in  tbe  tubes,  aad  the  patient  dies  asj^yxiatcd. 

Tbe  facial  lingual,  aod  laryogeal  muscles,  as  well  as  tbe 
noacles  of  deglutitioQ,  are  frequently  affected  towards  tbe  ter- 
minal period  of  the  disease;  but  the  symptomx  caused  by 
implicatiun  of  tbcee  muscles  will  be  described  as  labio-glorao- 
luyDgeal  paralyaia, 

A)f  tbe  following  ca*e,  which  is  c&rcfuUy  reported  by  Ur. 
CuUingwottb,*  affords  a  good  example  of  progreasire  muacutar 
atrophy,  where  the  uuaclee  of  tbe  back  and  some  of  the 
naacolu  group*  of  the  lower  extremities  are  affected,  I  shall 
quoce  it  at  length : — 

Ctuu-LoUe  A ,  aged  forty-one,  »i]mitl«d  into  SU  Marj's  Hosiiital, 

HADtilMwUr,  F«l)Tuafj  3,  IS78.  Slio  la  msmc^  uid  hM  hid  ihnt  lining 
cbildnai,  all  of  wbotn  died  in  infancy.  Thorre  »  uo  family  tiistory  of 
bcrroiu  diMtdor  or  «f  imjiainDsnt  of  powor  of  locomotion.  Her  fiilber, 
an  iateiDpcnt«  man,  died  of  oluub  diacaM  at  the  ago  of  thirlyidz ;  ber 
■oUmt  ifiBd  in  hor  fifUath  y«%r  of  heart  diaaana  Of  «ix  brothara  and 
daben,  tvo  died  in  infancy,  oaa  from  tho  ooDaoqaeoooa  of  hor  huaband's 
U-tnutDKut,  aud  three  arv  liring  ici  good  health. 

Bba  worked  in  a  factory  troai  tho  ago  of  nioebMo  until  ftro  jooni  ago, 
baring  had  oooBtaotly  two,  and  aometinMa  more,  looms  under  her  charge. 
Tbe  nalon  of  bar  vork  nftoeaaitatad  tbe  atoopUtg  poeture,  aud  for  aomo 
jraara  this  had  be^  a  paiuful  itrain  to  ber.  She  was  a  Itng  time  iu 
■Ini^leaiug  bvraeU  wbcu  tba  daj'e  labour  waa  over,  aiul  tbe  |trooeea  woa 
uot  only  difficult  tmt  painful.  Aboat  six  yeara  a^,  when  she  waa  prag* 
uool  of  h«r  laat  vUild,  she  wm  awMonly  «dz«d  wiUi  an  attack  of  unooQ' 
Kinuaueaa  wfatte  at  her  work ;  aha  Ml  down,  and  was  carried  uiioonacioua 
booM.  Sbe  bad  othvr  attacks  of  the  aam*  kind  both  boforv  and  aftor  hor 
qonfioameot,  aiid,  indeed,  had  one  Hhortly  before  her  admlMion.  Her 
bMhand  aaya  that  there  ia  abaf>lutely  tw>  warning,  that  nbo  frcquantl; 
hnrta  hvnelf  la  ralUng,  that  she  foama  at  thu  mouth  aod  rolls  her  eyw, 
but  that  tbera  is  bo  violent  etruggliug.  It  was  on  account  of  these  fita 
thai  her  oYerlooker  adTJaed  her,  for  her  own  safety,  to  ceoae  work  aereral 
years  ago.  She  cauuot  t«l)  exactly  wlivn  tho  peculiarity  in  walking  was 
ftnt  noticed,  but  is  certain  that  ahe  has  had  dilliculty  In  riaiug  from  a 
oliair  ever  sine*  her  last  oonfinenant.  This  dtSculty  has  f^adoally 
htcraassfl. 

Sfat  U  a  tbiu,  sallow^oaaiplexioned  wwnan,  of  average  tieight,  and  of 

•  Tk«  MfdwU  l^nsi  and  OaseUe.  vol,  U.,  1878,  p.  131. 


152 


8TSTEM  DISKASES  Of  IHB 


feeble  inttllMtual  powtr.     Hn-  lips  bftconw  mukcdly  livid  oa  the 
exertion  or  oiposuro ;  the  wbalo  body  ia  noootivo  ti>  coU.    Tber*  ia 
nothing;  aboormol  iq  tii»  iMiniiitioD  of  tbo  tboricio  or  ftbdntuiu^  viaetrt. 

Eitaniiiiaiion  uhiU  Standmff. — Tho  KmuI  is  enict,wid  tDavaUa  bjr  tlte 
ptluat  Id  all  directioos;  tbe  sboulders  are  somewhat  higher  than  umal  in 
ftvetnaa;  the  upper  part  of  tha  spiua  U  carrieit  backvanla  more  than 
iwoal.  A  plumb-liue  from  tbu  mwit  prumiDaot  of  the  apioea  of  th«  upper 
tlcni&l  vurtobnu  fulin  lui  itiich  Whind  anil  awaj  frum  Ihs  aacmm.  Tbe 
kiiecH  are  verj'  aligbtly  bent ;  the  feet  are  plac»d  firm]/  oa  the  ground, 
irith  the  hti«U  touchUig,  the  toea  iuru«d  oatwunl)  oud  extended  natofaUf. 
The  upper  eztremitiea  proaeut  no  appearance  of  muaailar  dedciouoj'i  aod 
the  deltoids  are  proimueiit  and  well  developed.  The  tower  estteoutiea 
pnaent  tiiia  ainomnly :  that  while  the  llii^ba  are  tbiaaer,  aoftar,  and  toon 
flaccid  thau  Qfttural,  tba  calveSf  90  tbo  wntiary,  act  of  a  site  quite  oat  of 
proportitm  with  tiiu  mtuoular  derelopineiib  of  the  net  of  the  bodjr.  TIm 
following  EDCuurcmentA  were  Uikeii ;— Circumferonoe  of  upper  am  below 
peotorale,  HJtii. ;  forcurm  nt  thicVeat  part,  8|ia. ;  middle  of  thigh.  HSio. ; 
thichott  part  of  calf,  14^in.  It  will  thui  bo  acou  that  the  circumfeno«e 
of  the  oalf  ia  anarlj  equal  to  that  of  the  middle  of  tbo  thigh.    Thia 


Fia.l». 


Flu.  tS& 


Tu.  1CI  *b<iw«  tbe  podttoD  ammed  hjr  tho  acapalie  vbm  thn  lam*  am  extended] 
furwardtt.  TLvra  is  a  drep  euletu  betw««n  iha  iwu  twtiM.  tbs  iKntwinr  bcwden 
of  wkiab  TiToJMt  twd  tnehM  frmn  tha  eoetal  wall.  The  pMUmr  bofdep  «(  the 
left  ecapuui  ia  iiarallol  with  tbe  mediaii  line.  bavuii{  Ii«cb  adjiurted  Inrlbe  Mlian 
of  iha  terratui  magiMUi  whoM  fibroa  (pawint;  ^livmwwda,  eutwKd*.  and  for- 
wanla  from  the  lawar  angle}  are  Mca  eentni'ting  hanrktb  a  fnld  erf  aldn.  TUa 
niavcQivul  of  adjuitiaent  hat  nnt  j*t  talcen  iilaceeo  the  right  M<l  whan  the 
Inwcr  *D^I«  of  ibe  scapula  la  Dcanr  the  vertebral  oalmnn,  a  little  nigbefj  Md 

actieot/Uinclt'lCiiil;  tho  iii>rTAtiui  mwnnii.  fimnt)  in  ■  oondltlea  cf  ralaxaimB.  li 
mecb  lea*  ntitiutabk-  vu  this  (riic)iij  BiJi*.   The  imMvttraefibna  d  the  wapeainik 

I>iwuna)(  f  mm  tho  outi^r    half  "t  tlig  apiao  of  the  icaiiolk  to  the  laat  orrvioeJ  awl 

tint  (l<inal  wrtnbrn.  are  well  min  :  with  thwe  fibiee  tbe  nppce  and  unaltaeled 
hkl(  t4  (he  miwrlc  abruptly  tf  nninatrj, 

PiG.lCJ  ihnwt  ibekupcirkQLyiDrtbulicick  wben  >  healthy  auUectb  pUetd  in  tkc 
nmo  attltadn.  Tno  acapuloi  aro  applisil  iici  dnwlj:  B^auial  toe  ci«lal  wall  ibat, 
•Itbovah  the  pereoD  Is  b;  no  meana  *toiit,  tbv  outhue  ol  tbe  IxMie  ia  ecaccidj 
tfaaeable.    The  lewtr  aagle  )•  In  tbe  axillary  Udo. 


SPIVAL  COED  AKD  MEDULLA  ORLOKOATA. 


153 


■beucnUoM  gav*  riM to  »  suapieioa  of  pasudo-hypratraphy,  and  kDunute 
pnrtioa  or  ntaacW  wm  wHbdravo  tma  the  v»lf  hy  tho  miiKlft-trocar,  ftad 
fcmdlj  OTamin«d  for  dm  under  tb»  nicrosoopa  bj  mj  frivod  Dr.  Diwwiifeld. 
Tbo  BMiMulu  tiMUA  mi  oot  fouod  to  ban  andergone  anj  chaiixe. 

Aatbe  iatlMitctaiidssteMe,wiUiber)»ak  U)thsobaerrer,iitt«titJonu 

ftt  otkM  fetlnet«d  to  Um  uuustuU  projoctiua  of  tb«  poateiior  borders  of  the 

atapalsB.    Tbej  sUod  b*clc  ui  i»oh  from  Uw  pcwterior  cheet-wall,  relaiDiiig 

UMb-pusUolittin  witb  tbo  modiu  Uiw,ftDd  Iraviag  a  foaea  between  them  four 

iocfaaa  iit  brMilth  aud  ui  iiich  in  depth,  bounded  oa  mcb  aide  by  a.  vail  of 

■Ida,  vhieh  pataea  perpendicularly  from  tho  acapolar  bordera  to  tlte  back  ot 

tfca  thorax    71)ac90iii]itionaftb«iDt«r-acapii]araiascIea  can  be  best  studied 

wfceo  the  arou  are  bald  horixoctolly  formrds  (My.  194,  aod  Plate  11., 

<  and  GJ.     The  apinal  bord«n  of  the  tcapulat  tban  project  backwards 

ta  a  diataaca  of  two  inchee  from  the  obwt-wall,  and  approach  within  an 

aub  and  a  half  of  eecb  otbor,  stiU  preserriog  their  jiaiallelisiii.     Etatman 

Q»  anterior  varfioe  of  the  Bcapube  and  the  chont-wall  tbor*  ia  a  doep  groove 

pQBleriorlj,  eattUy  admitting  the  tipa  of  the  fiugen  whea  they  are  best 

eier  Iha  poatarior  adga  oftha  aoapula.  The  trapwiiw,  perfectly  aereloped 

it  Ma  daYicolar  portion  and  ta  Uta  uppar  half  of  its  middla  third,  ter- 

naica  abruptly  by  a  atrong  buiuJIo  of  flbme  atrotchiDg  acrom  from  the 

ifmoaa  prooaanua  of  tbo  last  cervical  and  firat  doreol  rertebno  to  tho  outer 

W  of  tbe  nfAua  oS  the  scapula.    There  is  not  a  trace  of  the  rauaele  to  be 

MUow  this  point.    Betveco  tho  posterior  border  of  the  ecapulra  and 

ibe  ifetial  oolama  tban  are  oo  muacular  fibres  to  be  felt,  except  one  little 

Ait  band  paaoing  to  the  middle  of  th«  edge  of  the  eoapula.    Thie  la  all 

Ail  rmuns  of  the  rbomboida.  The  latisaimus  dorn  baa  abo  diaappeored, 

Ml  tkn  in  no  revixxiee  to  the  atroiigeot  bradia  cirrent  in  the  oour«e 

■tbr  of  tbU  musole  or  of  tho  lower  half  of  the  trapesius.  <»-of  the  rhoin- 

Wdi,  euept  i&  the  aliiMkr  baowulua  of  fibrca  jnat  uaaed.    On  the  other 

^Md,  the  levator  angoli  soapvbD  and  aerratua  mtgnua  can  be  felt  to  coii* 

(■tferctbLyt  "^^  ^7  reapotM)  readily  to  a  modante  current.  The  lower 

^natt  of  the  latter  muBole,  pasatog  d^ywnwairla  and  forwanU  froni  tbe 

^**  U^  of  the  scapula  to  the  lower  ribs,  etaade  out  promiuetitly  when 

wtnn  an  raiaed ;  and,  being  utkcorared  by  tbe  littisaitDus  dorsi.  can  be 

^■1*1  uudenMatb  tho  aldn,  which  la  rattfed  into  a  fold  by  the  oocitractioo 

</lbt  ffluade.  Tbe  dee])  ecapular  utuaclaa  (aupra^ploataa,  iufra-eptnatua, 

«b«a{>dBna,  teree  nuoor,  and  t«rH  major)  an  well  denloped  and  oaaily 

ihdaed.    The  pectoral  miuwles  are  also  unaffected. 

Tlie  [latiettt  cAunot  oleTatu  her  ann«  rertioally  ;  the  tiureat  ap]>roach 
k  tki*  which  ahe  caa  nuke  U  to  laise  her  eU>ow»  until  thoy  are  oci  a  lerel 
■iUi  the  ear^  at  a  dtetaooe  of  about  sjdo  ioobea  (mta  tho  head.  When 
this  poatioD  is  aaenmed,  instead  of  the  soapalo  beuig  cloacly  applied  to 
(ba  eheat-waU.  and  rotated  so  as  to  brinf;  the  lower  irni^le  <iutward4  awl 
&rwda  aa  (ar  &■  the  axillary  line,  the  (xieteriur  bbr:lcr«  of  tbe  acapaln: 
anlnxt^  into  actual  contact  with  each  other  at  their  upper  extrenu^, 
d^Uy  diTertbg  from  above  downwards,  ao  that  the  lower  an^ea  are  two 


156 


STSTEH   mSEASES  OF  THE 


Ia  Uu  out  of  ttus  woBiU)  tbo  foot  u»  bold  cIom  la  laatib  other,  ami.  i 
Ur.  Oiilliiigirortb  obsorres,  tbo  gait  is  oot  awUIiAff.  lu  waUcii^  the  baadl 

don  not  deviate  Ut«nlly  from  the  middlo  lio*  daring  tho  tnuidtmno*  ei 
tbeooutreof  gravitj  ftrota  tlia  acliro  bo  tlio  paimve  log,  bub  it  nnjrba 
obaeiTed  to  vtnuuB  bj  a  wetim  of  veitloal  ourrM.  In  hia  raiiurln  on  tl» 
caaa  Mr.  CullitifiwurUi  obaorrtn  thftt  tha  fmbieut  U  onablo,  when  Ijing 
horizontally  on  hor  sida  with  thu  legit  attended,  to  up«nt«  bar  Uuglw, 
thus  allowing  that  tho  gluteua  modiuA  and  miuimiw  tin,  at  leaai  to  aona 
extent,  afliMlod  by  jiaralyKia.  On  plactrif;  oiia'n  own  haiidti  over  the  pelrb 
of  the  patient,  ono  being  held  on  each  aido  immodiatoly  above  the  tr»- 
obanter  of  the  femur,  it  is  felt  that  the  gliitoiu  modiiu  nn  the  wtdo  of  the 
aotin  leg  does  not  contract  diirinit  Locoinotion.  The  coosoquooot  ie  Ihat* 
inKt«ad  of  the  pelvis  ou  the  side  of  the  pasaive  leg  beiog  aUghtly  alevatad 
M  in  health,  by  the  wiitraution  of  tha  (cluteua  naedioa  of  Iho  opponle 
«de,  ao  ea  to  allow  the  leg  to  awing  forwards,  it  Is  dixtioctly  felt  to  drop 
oil  that  tii(l«  1(1  a  lower  level.  The  pclvi«,  therefore,  ri>riiw  a  nion  ov  leas 
•outc  angle  with  the  active  leg  icuttaad  of.  aa  i»  health,  funoing  an  obtoae 
aogit  with  it  It  is,  howevor,  naiotaiood  in  a  nearly  honMnlal  poatttoo 
by  the  fact  that  tlie  active  leg  itmlf  alanta  dowDwanbi  and  inwaida  tma 
the  hip-joint.  The  liuo  of  gravity  passas  through  thu  ptWU  about  Ha 
middlu  ;  and  iu  ord«r  that  it  may  paw  through  the  arch  of  tlio  fioot  of 
the  active  leg,  th»  latt«r  nimtt  oc&upy  a  poaitioo  directly  balow  tho  aiddla 
of  the  pelvis,  and  coiuequently  the  hip  of  that  mdo  prcjocta  outvarda. 
Tho  paaaivu  log  U  prevented  froEO  awinging  fonrorda  with  the  nerDMl 
pendultim  motion,  iiutamucli  aa  tbo  hipgoint  on  that  aide  bocofnaa  lomtr 
when  the  leg  ia  fueed  off  tha  ground,  iaatMd  of  b«ing  eleratod  by  ooo- 
tnivtinu  of  the  gluteua  mediiu  nf  the  opposita  nda  a*  in  hnalth.  "His 
neoataary  elova*i<»n  of  the  pawivo  foot  i*  ohtainod  by  ationg  tlexioo  of 
the  thigh  upon  tha  body,  bo  that  the  legs,  m  doacribed  by  Mr.  CuEing* 
worth,  appaor  to  bo  in  advaoco  of  the  body.  Tbo  altemabi  pmjoction  ef 
the  hip  on  tho  aido  of  the  activo  log,  and  the  alternate  falhtig  down  of 
the  hip  on  th^i  Hid«  of  the  pA8«ivo  log  during  sucooinire  step*,  render  the 
gait  of  thia  lutiont  totally  anliko  that  which  ia  ao  chamctodotic  of  |«eodD- 
hypcrtrophic  paralyaia. 


The  loss  of  muscular  power  keeps  pace  with  the  alrophj, 
is,  oa  a  rule,  directly  in  proportioL  to  the  degree  of  the  latter,' 
aod  so  loDg  as  any  tauscular  Gbres  arc  left,  tliey  can  be  mado 
to  contract  by  voluntary  effort,  for  a  very  long  time,  iDdeed, 
tho  various  movomenu  are  capable  of  being  perfortaed,  altboogb 
with  muob  dimitiisbcd  power,  and  it  is  only  id  the  last 
8t«go  of  the  aSectioD  that  complete  immobility  of  tbo  limb  ia 
produced. 

At  times  the  loss  of  motor  power  appareotly  mncb  exoeedii 


)BJ1  AHU   HRODLL&  OBLOKOATA. 


167 


ll»'lM»Af  llllwialwmb>tsaoe;  but  in  these  cases  the  bulk  or 

tte  muaelaB  b  vtuntajoed  or  even  increased  hy  au  intfrslitiol 
fatty  byperplana,  wbilo  tbo  individual  ntuttculnr  fibres  ara 
atrophied,  90  tbiU  tho  duproporttoa  b«tween  the  loss  of  tnus- 
raiiu'  power  and  tbe  loss  of  muscalar  aubstance  is  only  appArcot 
and  DOt  r«AL  Tbia  condition  nill  be  more  fnlly  described  when 
thft  doMty-Allied  dtsMse  eallod  pseudo-hypertrophio  paralygia 
coBW*  onder  oontidemtioti. 

Tbe  rejiex  mownuntt  are  occaaionally  exaggerated,  but  this 
modification  it)  oot  coostaDt  (Jaocoud). 

The  tUcirical  rtaction  of  tbe  atropbied  muscles,  as  a  role, 
ootreaponds  closely  with  the  diminished  volume  of  the  muscles 
and  the  loss  of  voluntary  power.  The  normal  fanulic  oontrao- 
liltty  ia  maintainctl  until  the  muscle  has  undergone  a  liigli 
dagrae  of  atrophy,  aad  it  is  only  in  the  last  stage  of  muscular 
alrupby  that  tbo  excitability  in  diminished  or  abolished.  It 
»eed  loarcely  be  added  that,  altliougb  tbo  fanulic  excitability  is 
Bat  dimioished,  jret  the  energy  of  contraction  becomes  ireaker 
aod  woeker  ia  proportiou  as  the  coutractite  elemeDts  of  the 
■laaole  diaai^tear,  I'bo  faradic  excitability  of  the  nerre-trunks 
ia  ratftinod  tonger  than  that  of  the  muscle,  and  both  diisjipptiar 
aome  Uiae  before  complete  loss  of  voluntary  power  occurs. 
Galvuio  mtiMul&r  oontrutility  usually  remains  oormal  for  a 
Icng  tuna,  alchoagfa  tbe  ODcrgy  of  tbe  contraction  dimioisbea 
in  proportion  to  the  degree  of  atrophy,  to  that  stronger 
currSBts  are  required  to  produce  a  minimum  contracltoa 
(Eolcoburg).  The  galvanic  excitability  of  the  nerve-trunks 
kIm  rsmaina  uoinipiured  for  a  loog  time.  RoHontbal  has  directed 
oMentioo  to  tbe  &ct  that  the  nerve-trunks  behave  difTereutty 
at  diffsreDt  points  in  their  course,  >o  that  while  electric  atimu- 
iMiim  applied  to  a  portion  situated  near  the  centre  may  pro- 
duo*  normal  effects,  its  results  may  be  less  than  normal,  or 
•atirely  wanting  when  a  more  peripheral  tract  is  stimutated. 
SUghlqualiLKtive  changes  lo  the  muscular  reaction  may  attend 
the  ultimate  stage  of  atrophy. 

FilrriUary  eoniratAions  of  the  affected  mnectes  are  fre- 
quently observed  during  thu  entire  active  ati^>  of  the  diaeeae. 
These  coostst  of  vibratory  tremors  or  quivering  of  the  muscular 
fibffM    Tbey  occur  spontaneously,  but  may  be  provoked  by 


158 


SYSTEM   DISEASES  OT  THE 


gently  tapping  tbe  aurfiico,  by  exposing  to  tho  air  parts  which 
arc  usuaUjr  covered,  by  electrical  excitatioD,  and  by  active  or 
passive  movements  of  the  i^ected  musclea  These  fibrillary 
contractions  arc  sometimcB  the  earliest  symptoms  of  a  freah 
advance  of  the  disease  into  parts  previously  unaflecled,  and 
tliey  disappear  altogether  when  the  atrophy  bas  reached  aa 
extreme  degruo,  or  when  its  progress  is  arrested  (Roberts). 

OccaBionally  clonic  or  tonic  contractions  of  entire  mufclot,  or 
gtoupa  of  mufldeB.  may  oocur,  accompanied  by  intense  paiin, 
anoJogous  to  the  well-known  cramp  of  the  calf. 

The  sen»U>ility,  aa  a  rule,  iit  entirely  unaffected.  In  aome 
coses,  however,  the  atrophy  of  the  muscles  is  precAded  by 
paroxysms  of  pain  in  the  affected  piu-tg.  At  times  the  pains 
follow  the  course  and  distributioD  of  single  nerve  ininks,  as 
that  of  the  median  and  ulnar  Dervei;  but  at  other  times  the 
pains  appear  to  have  their  origin  in  tte  sensory  nerves  of 
the  musclex.  lu  the  latter  case  compression  of  the  affected 
mueclei),  as  well  as  active  and  pa.»ive  movements  of  them,  pro- 
vokes or  aggravates  the  pain,  and  in  sorae  cases  the  electro* 
muscular  ecoaibility  soems  to  be  increased.  In  the  later  stages 
of  the  affection  a  moderate  d^ree  of  aniesthesia  may  he  present, 
eapccially  iu  the  Haudci  and  tips  of  the  fingers,  in  the  form  of 
blunting  of  common  sensation.  The  faradoHmtaneouB  sensi- 
bility loay  also  be  diminished,  and  complete  analgcna  of 
circumscribed  areas  is  not  uncommon.  SensationH  of  cold  and 
numbness  in  the  finger  tips,  formication,  and  other  sensatioM 
are  frequently  observed. 

Vano-motor  diaturhancfH  of  various  degrQM  and  ozteot  may 
occur  in  the  affected  region*  In  the  beginning  the  t«mpeni(ure 
of  the  affected  extrcmitii^H  is  increased.  Baerwiukel  found  an 
elevation  of  1"  in  one  case,  and  Froromann  found  in  the  side 
first  attacked  a  riiie  of  OS"  or  OS"  C,  as  compared  with  the 
opposite  side.  In  more  advanced  stages  the  temperature  is 
not  raised,  and  at  a  stitl  later  period  a  distinct  lowering  occura. 
which,  acconling  to  Rosenthal,  may  amouDt  to  4°  C,  and 
according  to  Jaccoud  to  3  or  *°  C.  below  the  normaL 

The  alTected  porta  are  cold  and  pale,  and  this  is  especially 
likely  to  be  the  case  in  the  hands.  This  local  ischemia  is 
followed  by  relaxation  of  the  ressels,  and  oODsequeiit  wanntb 


SFIXAL   CORD  AND  UEDIJI.LA  OBLOKOATA. 


159 


tod  rednoBg  of  Uie  affected  part.  An  excesnre  swoatiag 
(hyperidrosis)  of  a  geaeratised  character  occurs  in  the  later 
Bta^  of  the  nfTectioQ,  liut  whether  this  is  due  to  vaso-motor 
dUturbance  is  uDknown  (KrommAnn,  Friedreicti). 

TVopkic  didiirbajuxs  occur  at  times  in  other  timueR  io  addi- 
tioQ  to  tbc  muscular  affectioii.  The  iikiD  is  uot  unfreqtiently 
implicated ;  and  in  these  cases  both  the  epidermis,  cutis,  and 
mbcutaoeotts  tissues  are  affected.  The  affectiuu  of  the  akio 
may  be  eottrely  waoting,  nod  scoiccl;  ever  reaches  a  high 
decree,  eveo  where  the  muscular  diAeasa  ia  far  advanced. 
Fatofal  swclliogs  of  the  joiiits  ha.ve  been  obaerred  in  the  early 
itagea  of  tbd  ditMOM  (R«mak).  Tfacae  swellings  (arbhntla 
BoddM}  gdQerally  occur  in  the  phalangeal  joints,  and  ar«  in  a]l 
imbftbility  closely  related  to  the  arthropatliies  of  tabes  donolis, 
except  that  the  latter  are  more  frequent  in  the  large  than  in 
tbe  nuill  joiota. 

OnUo-pupUUtry  sytaptAms  are  on  rare  occasions  observed  in 
this  diaeaia.  Tbey  consist  of  flattening  of  tbc  cornea  (Voisin), 
and  ooQttaclioD  and  sloggish  reaction  to  light  of  one  or  botb 
papib  (VouBD,  Baerwinkel,  Scbneerogt,  Rosentbal).  These 
lympioma  are  in  all  probability  due  to  paralysis  of  the 
^mpatbetic  6bre9  of  the  iris. 

In  the  early  stage  of  progressive  muscular  atrophy  the 
patient  may  compluiu  of  chills,  and  there  may  be  a  oontinuous, 
though  slight,  increase  of  teropemture,  which  laste  for  days  or 
moDtba  This  febrile  ctoidition  may  sometimes  be  asaociatcd 
with  arthritis  Dudosa>auii  may  probably  be  due  to  tbe  affection 
cf  tb«  joint*  (Beoak).  In  tbe  later  stages  of  the  dtsvase 
tranaitory  or  perroaaeut  elevations  of  temperature  may  occur. 
wbKh  are  perhaps  due  to  eucb  complications  as  diueasee  of 
Um  langt  or  a«ut«  bed-sore;  No  constant  chaagea  have  been 
found  In  the  unoe. 


{  413l  Courac  and  Duration. — Tbe  course  of  progrpsaive 
oraicnJsr  atrophy  is  essentially  chronic.  It  may  at  timeR  be 
pcnnanently  arrested  after  a  certain  group  of  muscles  is  lie- 
itnyed,  bat  it  may  progress  steadily  until  nearly  all  the  voluntary 
■Kudm  ATS  implicated  and  the  uofortuoate  patient  is  reduced 
to  aoob  UUar  belplBHOeu  that  he  cannot  raise  a  hand  to  feed 


1«0 


STSTBC  IK8U8ES  OF  THE 


himself  or  turn  bimsolf  ia  bed.  Tbe  ad7aoc«  of  tho  due* 
seldom  contiiiuoas  even  when  it  ii  progressive,  but  ia  ioterruptcd 
\ty  repeated  rcmiseioDs,  Tbcso  may  exteod  over  &  few  weeks, 
moDths,  or  years.  i>r.  Ro1>erta  tbiiikH  that  tbe  cmses  emnaed 
by  over  exercise  of  the  mtiocles  nearly  always  termioftted  io 
permaDent  arrest  of  tbe  aflection  after  tbe  destruction  of  one 
or  more  gruugis  of  mtiacles;  wbile  cases  which  were  cmowd 
by  exposure  to  cold,  or  id  which  4.  decided  bereditai; 
predispoeitioc  could  Iw  traced,  showed  a  greater  tendency  to 
a  progressive  course  and  a  fntal  tenninatioD.*  In  come  few 
casen  the  atrophied  muscleH  may  by  treatment  be  restored  to 
their  former  bulk,  but  the  atl'ected  muscles  usually  remain 
disabled  to  a  more  or  luss  extent  for  the  remainder  of  life. 

The  duration  of  the  dinense  ia  very  variable  and  uncertaia. 
In  twenty-eight  cases  analyaeJ  by  Dr.  Roberte  the  mcao  dura* 
tioQ  was  thirty-eight  mouths;  of  these  four  coaee  eoded  in 
recovery,  their  mean  duration  being  fourteen  moDtba ;  to 
thirteen  cases  the  disease  was  on-csted  with  a  ineao  duration 
of  twenty-seven  months,  and  the  remaining  eleven  coKt  diad 
with  a  mean  duration  of  the  diiMitttHi  of  upwards  of  five  years. 


§  414.  Morbid  Anatmny.—T:h9  essential  anatomical  cbaogn 
found  on  post-mortem  exatnination  of  those  who  have  died 
from  progressive  muBcular  atrophy  are  confined  to  tbe  mtiscles 
tbe  spinal  cord,  and  the  nerves. 

The  muBcUa  of  tbe  atfected  rej^ona  are  wasted  in  vtrioos 
degrees,  and  even  different  ports  of  the  same  muscle  may 
present  differences  in  the  degree  to  which  the  atrophy  baa 
extended.  A  small  portion  of  an  Bffeeted  muscle  may,  indeed, 
retain  its  normal  bulk  and  appearance,  wbile  the  rect  is 
reduced  to  a  fibrous  baud.  The  altered  musclea  are  ganergJly 
of  a  pale  red  or  rose  colour,  while  at  other  timea  they  may  bo 
buff  or  ochre,  and  streaks  of  adipose  tissue  may  be  seeo  to  ran 
in  tines  bcLwei-n  the  Sbrea. 

The  curly    iuveetigatora   (Ueryou,    Ducbcnne,   Gruvei 

Wachsmuth,  and  Valentiner)  regarded  the  muscular 

as  being  tbe  remilt  of  fatty  degeneration  of  tbe  fibres,  nith 

secondary  disappearance  of  tbe  aarcolemma  ;  but  the  laboon  of 

*  BqnoMi'  SjsUn  of  Mtdkinv.  Art  Wailing  ViUkj;  rol  il.,  p.  17£ 


SPtXAL  OOBD  ASD   MKDULLA  OBtONOATA. 


161 


recent  JDvestigAtcra  (Robin,  Friedberg,  Focntcr.  Schueppel. 
QAjtm,  and  KrieJreich)  h%ve  showD  that  tbe  fatty  nietii- 
norplioii*  of  tbo  primitive  6br«R  is  a.  secoodarr  resutt  of  a 
gwrioTM  iDflaromaior}'  change.  Tho  first  cbooges  bc^n  in  the 
ptranyriam  inu-rtniui.afia  bypi-rpJaoiic  gtx)wth  of  tb«  int^ratitia] 
comuKtive  tissue  io  its  finest  ramilidtionB  among  the  siagla 
priiaiUTQ  bundle*.  Swolliog  and  multiplication  of  tbe  musculiLT 
ooq»DBcl«s,  Along  with  proliA-mriuu  of  their  nuclei,  may  be 
ofaMtred.  and  at  times  pareDcliymatotui  gnuiiilar  cloudiness  of 
the  tnuuvemastripeil  5brillary  iiub«<tanc«i.  Fricdreicli  says  that 
ba  baa  observed  bypertrophied  muscular  fibrcii  nloag  with  a 
tHdiotoaioua  or  trichotonioua  division  of  their  fibres.  Wasting 
of  the  miiarular  mihfitatice  goes  im  aide  Ly  side  with  increasa  of 
the  intentitial  tiasue,  a  procesa  which  ultimately  leads  to  a 
fibnnu  degcncratioD  or  true  cirrfaosisof  tbe  muscle.  A  develop- 
ment of  fat  may  take  place  vithia  tbe  bypcrplontic  ooundctive 
tMsae^  leading  to  a  peeudo- hypertrophy  of  tbe  muscle. 

He  oonditioQ  of  the  spinal  cord  and  of  tlio  anterior  Hpinal 
Dcrre  roota  baa  beeo  examined,  aocording  to  Kulenburg,  id 
lorty-nine  cases,  and  out  of  tlicsc  positive  changes  have  been 
(duoJ  io  tbirty-four,  while  io  fifteen  tbe  results  were  negative.  If, 
howttTbr,  the  special  methods  and  special  skill  which  are  required 
tor  eoadacting  tho  cxamituttioD  of  tho  spinal  cord  be  taken  into 
ccaiid«r>tioQ,  too  much  weight  need  not  be  attached  to  the 
negative  tttntcmcnts.  In  the  bands  of  experts  in  tho  present 
day  cbangee  are  almost  always  found  lu  the  eord,  hence  the 
negative  results  of  the  <^der  observers  may  he  fairly  nttributed 
to  defective  methods.  Cruveilbier  wbls  the  first  to  draw  atten- 
tkw  to  tbe  condition  of  the  auterior  rooU  of  the  tierves  in 
this  disaasa  Id  the  body  of  the  »bowmaD,  L«  Compte.  who 
died  from  progressive  muscular  atrophy  of  five  years'  duretioa, 
he  found  llint  the  auteriur  roots,  especially  in  the  cervical  region, 
were  remarkably  Hmall  as  compared  with  the  posterior  roots; 
and  in  a  second  catw,  observed  by  liira,  a  similar  condition  was 
foQcd.  In  these  cases  the  brain,  cord,  and  posterior  roots  were 
stotad  to  be  normal  Atrophy  of  the  anterior  spinal  roota, 
cither  with  or  without  other  morbid  chaDges,  has  siuoe  thai 
iinM  beee  found  by  various  competent  obsorvcre,  amongst 
whom  may  be  mentioned  Clarke,  Vul[HaD,  Luys,  Rosenthal, 
t 


IBS 


eraTEH  uisbases  op  tiie 


Hayem,  Charcot,  Joffroj,  Friedreich,  and  xaaoj  others.  The 
antetior  nervs  routa  have  iti  some  cases  been  found  oonoal 
l>y  Claike,  FrommaTin,  Gtill,  Friedreich,  Tiirck,  Von  Redtling* 
liauseii,  Joffroy,  and  Frerichs.  It  may,  therefore,  be  coticluded 
thtt',  the  atrophy  of  the  auterior  root8  is  not  the  esseullal  morbid 
change.  Valcntincr,  to  1855,  found  a  c«atnU  softening  of  the 
grey  matter  in  the  neiglibourhood  of  the  lowest  cervical  and 
the  iippcrmost  dorsal  oerves;  and  Scbseuvogt  also  found  a 
softening  of  the  cord  from  the  fifth  cervical  to  the  second 
dorsal  nerves.  Frommann  observed  changes  in  the  anterior 
column  and  anterior  ccmmi«sure  extending  from  the  medulta 
oblongata  downwards. 

Luys,  however,  was  the  first  to  direct  atteatioD  to  the  morbid 
chaogOBin  the  grcyRiibitaacc.  A  man,  the  subject  uf  adrane«>d 
atrophy  of  the  miutctes  of  the  loft  baud  and  forearm,  along  wtili 
slight  atrophy  of  tlie  nmxcles  of  the  right  hu)d,  having  died 
of  pueumouia,  the  spinal  cord  at  the  autopsy  appeared  healthy 
to  the  naked  eye,  but  microscopical  examiuatiou  showed  increase 
of  the  capillary  veasuls  iu  the  giey  subHtaace  of  the  cervical 
enlargement.  The  walls  of  the  vessels  were  thickened  and  sur- 
rounded with  granular  exudation,  which  extended  into  the 
adjaceut  tissues.  Many  corpora  nmylacea  were  scattered 
through  tht:  grey  substance.  A  considcmhle  number  ot  the 
ganglion  cvlla  of  the  anterior  horns  had  disappeared  in  the 
part  aflfected,  and  were  replaced  by  granular  maHses,  and  of  the 
remaining  cells  some  were  in  a  condition  of  d^eneration,  of  a 
brownish  colour,  full  of  dark  granules,  and  destitute  of  pro- 
cesses. The  degeneration  affected  principally  the  lelt  anterior 
cornii,  corresponding  with  the  seat  of  the  muscular  atrophy. 
The  anterior  norvo  roots  on  the  left  side,  corresponding  to 
the  disease  in  the  auterior  horn,  were  atrophied.  Six  cases 
have  BiDoe  been  described  by  Lockhort  Clarke,  confirmiug,  in 
all  eseentinl  reRpcctR.  the  observations  of  Luys;  aud  similar 
observatioos  have  beeu  made  by  Dum^nil,  Schueppel,  Hayem, 
Charcot,  and  Joffroy. 

In  a  case  described  by  Charcot  the  ganglion  cella  of  the  left 
anterior  grey  horn  (Fiff.  167,  A)  could  still  be  distinguished, 
but  were  observed  to  be  iu  au  advanced  stage  of  atrophy,  [o 
the  right  anterior  grey  horn  (.Fijf.  167,  B),  however,  the  oelll 


llfl  only  be  distinguishutl  in  ooe  group — the  poslcro-Iateral 
(Fiff,  167,  b) — while  the  cells  of  the  reauuniog  groups  were 
gotupletcly  dcalro/e<L  It  baa  appeared  to  me,  however,  that 
tew  Little  atteatioo  bu  bithecto  beeu  paid  to  the  coDdition  of 


Fio.  187. 


no.  Utr  (Chutnt).  Trwuttnt  $K*ion  <^  tA«  Ctrtitat  Htf^n  Df  thi  Spituii  Cant, 
tnm  •  OMU  ^  jmiynawire  MMwaJar  aJnipAf.-  A,  lieh  UMtUr  Knr  Wb:  tba 
g*^Uo«  mU*  itwn  pvniiWil,  but  wc  mudi  »lt«f«d  in  kppMnno*.  B,  lUitbt 
■sUriM  irnj'  Ivm.  aloun  m<D|4eto  Urophy  o(  Uw  wIm,  ana  group  tmlf  lb) 

the  oeDtrml  colama.     In  Uie  aonexed  diagram,  from  Charcot 

I    {Fiff.  167),  the  central  coluinu,  especially  the  left  ooe,  is  seea  to 

L^Mg||nMt«<l   by  enlarged  vmseeU,  aad  tbat  of  itself  afiurdtt 

^^IHRlBkce  that  tbia  colama  vaa  not  firee  from  disease  in  the 

MOtioB  from  vhich  the  drawing  was  taicen.    It  seema  to  me, 

uidaed,  that  the  morbid  proceu  begins  on  each  side  of  the 

Motnl  canal,  probably  iu  the  tissues  immediatoly  adjoioiog 

I   Uu  oential  artury,  and  tbat  it  extends  outwards  and  forwards 

M  well  as  upwardd  and  downwardi*  from  this  point  as  a  centre 

Id  a  transverse  section  uf  tLu  middle  of  tlie  cervical  enlargement 

in  my  possession,  from  an  advanced  cai«o  of  progressivo  rauscuUr 

atrophy,    the   material   of   which   I    owe   to   the   kindneas  or 

Oc  Drasokfeld.  it  was  anmistakable  tbat   the  central  grey 


164 


SrSTEM  DISEASES  OP  THC 


column  was  more  scTerely  diBeaGDil  titan  any  otber  ptirtioa  cf 
tbe  section.  The  central  column  was  traversed  by  enlArgcd 
veesels,  and  almost  all  structura  was  oblitenUd,  whUe  the 
various  groups  of  ganglion  cells  in  iho  anterior  boras  were  di*- 
tiactly  recognisable.  The  cells  of  tbe  median  aroa  were,  indeed, 
comptct«ly  destroyed,  8o  tbat  not  a  trace  of  them  could  be  seen, 
and  A  large  number  of  the  ma^nal  cells  of  the  other  gronpst 
were  also  destroyed,  ho  that  the  groups  themselves  were  sepamted 
by  unusually  largo  spaces  which  were  de-stitute  of  cells  {Fig.  168), 
The  colls  of  tlie  centres  of  the  groups  were,  however,  distinctly 
recognisable,  although  all  of  them  were  observed  to  be  io  a 

Fiu.  168. 


W 


■^'4 


"fiS 


^_i-v 


Fid.  1G8  (Yonnet.  Tntnntnt  SMtitm  from  Ou  UidJU  n/  tkt  Otni^t  BnUrgfttOil 
o/  tlu  Spi»al  Cord,  from  an  aiUviutd  our  vj  pragptHiiw  wtrwfnr  ntntptr  — 
fC  OnHsl  otttu] [  I,  InUnal,  al,  AntcrvloiMnil,  uid  p(.  PoaMro-lMml 
gKtap*  ot  gA^Lan  Mil*.  * 

State  of  pigmentary  atrophy  (Fiff.  144, 8).  I  have  also  olMerv«d 
in  one  of  my  sectioaH  a  Klrt;ak  of  degeneration  to  paas  along  Ibe 
posterior  branch  of  the  central  artery  (Fiff.  Ill,  1")  into  tbe 
substaoce  of  the  posterior  grey  horns,  and  this  may  cxpbun  wh; 
auaJgeeia  of  patches  of  the  skin  is  frequently  aaaoctated  with 


SPIXIL  OOBD  ASV  MttDULLA  OBLOKQATA. 


165 


pngraiive  muMutir  atrophy,  la  the  accompaQying  woodcut 
iFi^.  IBS),  borrowed  from  Leydea's  great  work  on  the  dixcaeca 
of  ihe  spiiuU  oord,  it  may  also  bo  distinctly  reoog^ui^cd  that  the 
(bMaaed  portions  o<;cupy  mainly  the  central  columns  of  the 
oord,  and  that  lli^re  are  liitcral  cxtco^on^  of  the  difiease  towards 
the  anterior  grey  homii  and  between  the  groups  of  ganglion  cells. 


Fm.  160. 


/ 


rill.  IM  iYraa  I.«rd«Bl.  IVmmivw  SMiM  0/  lAj  SpiiuU  Cord  from  ULi  UiiHt  oj 
A*  Cv*ioU  B»tmftmmt,  tkiming  Omt  Ou  tmtnU  orfiimji  nni^  a  larfpoftim  v 
M(  Mricnor  grtf  Mnw  art  iliMAMrf. 

A  caM  at  progre«sive  muscular  par&ljais  haa  been  recently 
ittMcribed  by  Erb  and  Scbultze,  in  which  tbc  erector  apinfe 
thratigboat  their  entire  extent,  the  trapezius  on  both  sides,  the 
miucles  coonedcd  with  the  shoulder  blades,  those  of  the  upper 
ami,  U>«  pectorals,  tho  gluteal  muiwlcfl,  and  the  flexors  of  the 
lags  00  the  thighs  were  atrophied.  The  caao,  indeed,  appeon 
lo  have  bfieo,  tafuu  the  distribution  of  the  paralyBis  is  cod- 

oenwd,vetyiikethatofCliarlottoA .already described.  Th« 

IHtMDt  diad  &om  an  attack  of  syncope,  but  without  any  trace 
at  bulbar  lymptoms,  and  a  microttcopical  examination  of  the 
•ptnal  cfinl  showed  that  the  most  pronounced  changes  were 
liraod  io  tli«  "  central  region  of  the  grey  Bubstance."  It  ia  also 
owutiooed  that  in  the  lower  half  of  the  lumbar  and  cervical 
enlargements  the  gau^'liuu  cells  bad  disappeared  fi^im  the 
oiadiao  Coeotral;  group.     The  oelU  of  Uie  other  groups  were 


IW 


STSTEM    DISEASES  O?  TEB 


degenerated.  The  whole  microscopical  report  of  the  caae, 
inde«d,  beats  out  the  idea  that  the  disease  began  in  the  oentral 
column,  and  extended  forwards  ioto  the  anterior  honu. 

The  uature  of  the  disease  in  the  cases  jiist  described  appears  { 
have  been  a  chronic  iDflammation  of  tlie  grey  matter,  but  in 
another  series  of  cases  the  affection  of  the  grey  matter  is  caused 
in  a  different  waj. 

In  the  annexed  woodcut  (Fig.  170),  borrowed  from  Lejrdai's 
work,  a  section  of  the  cervioal  enlargement  of  the  spinal  cord, 
from  a  case  of  syringomyelia,  is  represented.  Tt  will  be  recog- 
nised that  the  destruction  of  the  ganglion  cells  of  the  anterior 
boms  takea  pidoe  io  this  case  much  in  the  same  way  aa  in  caeea 
of  ohroDic  inflammation  already  described,  but  in  which  distinct 
cavities  are  not  obserred.  It  is  indeed  doubtful  whether  any 
essential  difference  exists  between  the  two  classes  of  caaei, 

Fio.  170. 


9k      ^m. 


Pio  irO(FramX4V<lak]>    Tnmirtm8<K(ion  vftU  Spimal  Cinit  fnm  tkeMU^X 
Ott  OtnUa  aaargmmitt  fnm avmoj  SyNwy^^w.  rt^iriiy  a enrito Mil _ 
tk  potttrtor  eenmimiTt,  siut  iatriiavm  qf  u  larg*  portiau  n}  U<  jMNfMo*  "^ 
af  Ui€  anttrwr  ynji  horn*. 


inasinuch  as  the  cAvitios  probably  n^ult  either  from  inflamma- 
tion of  the  tissue  of  the  central  grey  column  and  of  the  odjoao- 
ing  wbitQ  substance,  or  of  the  walls  of  the  central  canal. 

In  a  case  obtterved  by  Sir  William  Oull,  a  couaiderable  dilata- 
tion of  the  spinal  canal  was  found  in  the  cervical  region,  betwaen 
the  fifth  cervical  vertebra  and  tbe  origin  of  the  third  nnd  fourth 
dorsal  nerves.  Tbe  cavity  was  full  of  serous  tluiil,  and,  with  tbe 
exception  of  a  thin  layer  which  surrounded  it,  and  could  be 
stripped  off  like  a  membrane,  the  grey  substance  had  dis- 
appeared, while  the  white  substance  and  the  anterior 


oecka  the  morbid  chaoges  in  the  oord.  or  wbclber  ti)«  former  aie 
noumtary  to  aoil  csiucd  by  tlie  Latter.  Pro^esiuTe  muscuJar  atro> 
{A7.acoordiog  to  Friedreich,  liegins  as  a  primary  clirooic  myositia 
The  ittlra-muscaUr  Dcrvus  are  aMX>Ddari]y  implicaUxl,  and  a 
<^n»iic  oeuritia  asceods  along  Uio  courae  of  the  nerve  trUDkt 
to  their  roots.  The  neuiittft  may  then  extend  in  the  cord  ituulf, 
prodtKang  a  chronic  myelitis,  which  may  spread  in  Tarious 
directiotUL  This  chan^  may  extend  to  the  anterior  cornua, 
bat  the  Quthlion  of  the  peripbcral  nerre  fibres  and  of  the 
gaaglioa  c«IU  of  the  grey  anterior  cornua  of  the  cord  isaUo 
afliaflfeed  by  the  diatiirbcd  motor  functions,  caiiscd  by  the  disewe 
in  the  miiKlea.  Variong  objectiong  may  be  urged  a^iDst  this 
thconr,  net  the  least  important  of  these  being  the  fact  that  the 
pcriphc-ral  Dorvex  and  anterior  ucrvo  roots  have  been  found 
qaite  nurinal  in  a  coosiderable  number  of  cases. 

FritNlrvioh  would  mipptenient  the  theory  of  oearitia  asceDdeoe 
by  the  Hubordiuate  theory  that  simple  suspension  of  muscular 
action  woald  of  itMlf  cause  atrophy  of  the  ganglion  cells.  But 
tlw  diangM  obtervod  in  tho  anterior  horns  of  the  cord  in  the 
cam  of  ampatated  limbs  do  not  equal  in  severity  those  found 
ia  progrewivo  muscular  atrophy.  Tliia  theory  also  utterly  fails 
tn  aooount  for  those  cases  in  which  tbe  destruction  of  the  grey 
raalLer  of  the  anterior  boms  is  produced  by  slow  compression 
from  gradual  (liatcndon  of  the  central  canal  by  fluid.  Various 
Other  objactious  might  be  urged  )^aim«t  the  myopathic  theory, 
btit  ooougb  haa  been  siud  to  show  that  it  at  least  prcscnla 
wide  gap!  which  must  be  filled  op  before  it  can  be  considered 
ertablisbed. 

TiM  neoropatbio  theory  has  at  least  the  merit  of  being 
•tiDple,  and  of  presenting  fewer  difiicultieft  According  to  it, 
the  atnpby  is  duo  to  the  progrceeive  changes,  primarily  of  an 
ifritatira  charmolcr,  of  tbe  ganglion  cells  of  the  anterior  boms. 
ProgrcHtv*  bulbar  paralysis,  which  is  so  frequently  associated 
with  pfogr— tfo  muscular  atrophy,  is  an  analogous  affectioo 
caiMed  by  morbid  ohongra  in  the  groups  of  motor  cells  lying  in 
the  floor  of  tbe  fourth  ventricle,  the  reason  that  tlie  two  diseases 
are  aa  frequently  associated  being  merely  that  the  morbid 
pncess  riteuds  from  the  anterior  bonis  by  continuity  to  tbe 
motor  centres  in  the  floor  of  the  fouTtfa  ventricle.     Tbe  dis* 


170 


SYSTEM   DISEASES  OP  THE 


tJQctioD  betwdOQ  Ihc  two  diseases  is,  indeed,  depcndtJDt  tipon  tbe 
locality  of  tbe  lesion  in  «adj  case.  In  both  these  dieeases  the 
nature  of  the  l«?sion  wliicb  destroys  the  gnoglion  oeUs  h  of  little 
importaDce.  Mucb  the  same  results  (except  probably  in  respect 
to  the  rapidity  witb  wbtch  the  atrophy  is  developed)  follow 
ordinary  grey  degeneration,  chronic  induration,  myelitta,  red 
softening,  Clarke's  granular  degeneration,  or  isolated  pigmeDlary 
degeneration  of  tlie  cell  elements^ 

On  the  supposition  that  the  disease  begins  in  the  central  grey 
column  and  exteEidft  out  wanh  and  forwards  into  the  anterior  grey 
liornH,  it  may  be  readily  explained  why  the  gronps  of  muHclea 
engaged  in  special  actions  are  usually  the  Brst  to  be  affected. 
Wo  buTQ  alruady  seon  that  the  central  column  is  the  ciiihryonic 
ujoa  of  the  grey  auUtance,  and  that  the  median  area  of  the 
&utenor  boms  in  the  lumbar  and  cervical  enlargcmentfi,  and  the 
nivdio-latcml  areas  in  the  doreal  and  upper  ccrvtail  regions  of 
the  cord,  msy  be  regarded  as  ontgrowthfi  of  the  central  ooluoia 
The  median  and  medio<latcral  areas  will  consequently  be  the 
first  portions  of  the  anterior  horns  to  bo  afTcctod,  and  the  por- 
tions which  contain  the  fundamental  cells  will  be  the  last  to 
become  digcase^l.  When,  therefore,  the  lumbar  and  dorwil 
regions  of  the  cord  are  afTected,  the  muscles  which  maintain  the 
erect  postaro  in  man  will  he  those  most  liable  to  be  affcetod, 
as  will  bo  more  fully  pointed  out  with  regard  to  pseudo-byper- 
tropbic  panilysin.  Again,  when  the  cervical  enlargement  is  the 
first  to  Vje  atfcctod,  the  morbid  process  will  extend  more  readily 
forwards  to  the  median  area  than  in  any  other  direction,  and 
the  small  mtiKcleit  of  the  band  will  be  finst  ntfected.  It  will 
hereafter  be  pointed  out  that  whon  the  medulla  oblongata  U 
first  affected  the  disease  begins  in  the  upwaid  continuation 
of  the  central  column,  and  thai  the  accessory  nnclei  will  be 
liable  to  become  first  diseased ;  and  hence  it  is  that  the  oom- 
plicutcd  movements  of  articulation  are  genuratly  tho  first  lo  be 
aBectcd. 

On  the  supposition  that  the  morbid  process  begins  in  the 
central  column,  it  may  also  be  readily  explained  why  muaclca 
innervated  from  different  levels  of  tbe  cord  may  be  affecte*!. 
white  muscles  innervated  from  the  interrening  portion  ore 
spared,  without  our  being  obliged  to  assume  that  the  morbid 


SrtKAL  COKD   AND   irEDUtXA   OHLONOATA.  1?) 

pctKWH  ID  the  cord  bas  stsrMd  from  two  or  more  centres  of 
origio.  Tho  tnori}id  process  may,  for  iDBtance,  extend  forwards 
into  the  medtao  area  io  the  cervical  ODiargemcut,  while  it  nmj 
pttH  upwvds  through  the  upper  cervical  regioit  and  keep 
timtted  to  tho  imm&diate  neighbourhood  of  tho  central  canal, 
where  it  would  produce  no  symptoms,  and  then  on  Feaching 
the  medulta  oblongata  extend  to  the  acoeswry  naolei,  and  thus 
pmdoce  the  symptoms  of  bulbar  pnralyflis. 


§  416.  HbOffnoaia. — ^The  partial  fonn  of  the  dU^^asc  is  liable  to 
be  confuuDded  with  muscatar  atrophy  caused  by  direct  mechanical 
iojury  to  the  muscle,  or  with  the  various  diseaaea  of  tbe  peri- 
pberal  nerveo.  If  the  diaeaae  remain  conBned  to  the  muscles 
Dneioally  affected,  or  to  the  region  of  a  siogte  nenro  trunk, 
IR-ogTBasiTe  raoBcnlar  atrophy  can  be  excluded ;  and  muscular 
atrophy  resulting  from  dii^case  of  a  mixed  nurrc  is  usually 
accompanied  by  loss  of  sensation. 

The  disease  may  also  b«  confounded  with  lead  palrf ;  but  io 
the  latter  tb»  invaeion  is  comparatively  suddun,  the  paralysis 
being  at  its  height  in  a  week  or  a  fortnight  at  roost;  while  the 
electric  cootmctility  is  diminished  or  lost  at  nn  early  period. 
In  the  former  the  paralysis  precedes  the  atrophy ;  while  in 
the  latter  the  toss  of  muscular  power  is  almost  always  directly 
in  proportion  to  tlie  wasting  of  the  muscular  mojues,  and  the 
electric  contractility  ts  maintained  so  long  as  any  muscle  is 
pteaerved.  The  general  symptoms  which  characterise  lead 
poisoning  will  also  assist  the  diagnosis. 

Ordinary  general  paralysis  of  central  origin  may  be  distin- 
guished frum  progrcasiro  muscular  atrophy  by  tlie  fact  that  in 
tbe  former  tbe  paralysis  occurs  as  an  early  symptom,  and  it  is 
rare  that  .the  muscular  emaciation  bears  any  proportion  to  the 
loaswf  power.  Frogresiive  muscular  atrophy  attacks  tbe  muscles 
in  separate  groups,  dissecting  out  either  individual  muscles  or 
gnupe  of  muscles  from  amongst  othera  which  remain  healthy, 
and  docs  not  attack  at  the  same  time  eztcoBivc  regions  or  the 
eotire  bc)dy. 

Tbe  diagnosis  botwoon  progressive  muscular  atrophy  and 
infantile  paralysis  has  been  mentioned  already. 


172 


HVHTEH   DISEASES  OF  THE 


§  417.  Prognosw. — Progressive  maacutar  atrophy  is  alwKjn 
very  intracUible,  and  when  the  muscles  of  tbe  trunk  are  invaded 
it  always  progresses  slowly  towards  a  fatal  tcnaiuation.  Id  the 
purti&l  formK,  wlicu  th«  dUease  is  limited  to  one  or  two  ei- 
tremities,  there  is  no  danger  to  life,  but  the  limbs  ars,  aa  & 
rule,  permanenlly  damaged.  Id  many  cases  the  advaooe  of  the 
disease  may  be  chocked,  and,  m  long  as  voluntary  motioD  and 
tbe  electrical  reoctioos  are  not  completely  lost,  some  hope 
may  be  eDtertained  that  partial  redtoratioa  of  tbe  affected 
musclce  may  take  place.  Tbe  moat  unfavourable  caaee  are 
those  vhtch  begin  in  a  multiple  form  and  Bprcibi  rapidly.  Tbe 
caaee  in  which  the  disease  b^ius  iu  the  thorax  or  shoulder  are 
unfavourable,  bt>canse  the  affection  ia  very  liable  to  implicaU 
the  respirntoiy  muscles.  When  bulbar  symptoma  supervene 
the  progQoaiH  is  specially  tinfuvourable,  and  when  tbe  muaclei 
of  respiration  are  invaded  a  fatal  termination  may  be  expected 
within  a  short  time.  \Vben  the  diaeaae  can  be  tracad  back  to  a 
hereditary  prediRpOKition  it  manifests  a  greater  tendency  to 
become  generalised,  and  consequently  the  prognosia  is  more 
unfavourable.  The  prognosis,  on  the  other  hand,  is 
favourable  vhen  the  afiection  is  caused  by  overwork  and  w 
it  is  cou6ued  to  the  bands  and  forearms. 


lOUID 

mor^^ 
irh^l 


§  4I&  Trtatment. — An  attempt  must  first  hematic  to  remove 
the  cause.  When  the  disease,  for  imtance,  is  caused  by  a  ayphilitic 
taint  tbo  usual  antisyphilitjc  treatment  most  be  adopted.  Wheo 
ovcrvrork  of  the  affected  muscles  appears  to  have  bMU  tbt 
exciting  cause  of  tbe  disease,  tboy  must  be  allowed  to  rest 
Whon  a  decided  hereditary  predispositioa  to  the  uffeotion  is 
maoifeeted  in  a  family,  prophylactic  measures  may  be  employed, 
such  as  a  regulated  course  of  gymnaetioa  The  members  of 
such  bmilies  should  also  be  shielded  from  deleteriotu  iofla- 
eooea,  especially  those  which  arc  known  to  excite  the  diaeuei 

Tbe  direct  treatment  of  the  established  disease  embraoee  tbe 
employment  of  hygienic  maasuree,  such  as  baths,  methodical 
exercise,  change  of  air  and  good  diet,  and  the  employmeot  of 
galvanism  and  friction  to  the  affected  muscles.  No  medicine 
has  hitherto  beeu  found  of  any  use  in  the  treatment  of  this 
disease    Tonics,  aa  iron  and  quinine,  may  be  useful  adjun^ 


SPtNAI.  CORD  ASD  MBD0rJ,A  OBIOSGATA. 


178 


the  treAtmeot,  ftod  the  oitratc  of  sUver,  arseoic,  phosphonis, 
and  iodiilo  of  potasadam  have  been  employed,  but  with  doubtful 
aiooeiB. 

Thermal  and  sulphur  baths  have  been  reootomooded,  and  the 
vraten  of  Aix-larChapelle  have  been  mitch  praised,  but  appa- 
Tontly  on  inrafficient  eridence.  Tho  cold  water  cure,  conducted 
in  a  good  bjdrop&thic  e«tabli«hment,  may  occasiouaJly  be  found 
ocefaL 

GalTanUm  is  undoubtedly  the  moat  efficient  remedy  for  the 
disease.  The  local  use  of  the  faradic  current  was  applied  by 
Docheone,  who  obtaioed  farourablu  rusults  from  it,  but  the 
galvanic  ia  proluibly  more  ofHcient  than  the  faradic  current. 
The  local  use  of  both  cuirente alternately  baa  given  good  Fesalls. 
When  the  muscular  excitability  is  very  low,  strong  curreuta  are 
Kqaired,  and  their  effucta  should  be  intensified  by  ioter- 
rnptioDs  and  rcvoKals,  but  as  the  excitability  returns,  weaker 
currents  should  be  employed.  I  have  observed  favourable 
results  from  the  use  of  electric  acupuncture.  Suitable  gym- 
nastics, ti>  call  forth  the  activity  of  the  atTecteil  muscles,  passivo 
motion,  shampooing,  and  frictioo,  are  all  usoful  io  the  treats 
ment  of  the  disease.  \V^cn  the  muscular  atrophy  is  associated 
mtb  neuralgia  the  subcutaneous  iujection  of  morphia  may  be 
employed.  Dr.  Roberts  recommends  an  injectioo  to  be  given 
in  the  muroii^.  and  be  states  that  it  often  enables  the  patient 
to  pursue  bia  employment  with  comfort  during  the  day. 


♦.  Primary  Lahio-GlwatO'Laryntffd  Paralj/ait. 

{Ckrmie  JVas*rwwiiw  Bulbar  Pap<Uyn».~\V»e\utaniL.) 

§  419.  Df/inition. — Labio-gtoitso-laryiigeal  paralysis  consista 
of  a  progressive  paralysis  and  atrophy  uf  the  muscles  of  the 
tongue,  lips,  soft  palate,  pharynx,  and  larynx. 

j  430.  ffi»t«ry. — A  hriaT  nfott  of  o  oase  «f  Uua  affoctioa  was  wtit  to 
Sir  Chariw  BeU  lu  1H2&  b;  I>r.  F.  W.  Rot^nsou,  and  TrouMtau  wrubtsa 
■M«nt«  aocooot  of  the  aTmptoms  of  tbc  afTecliou  iu  1S41,  but  did  Dot 
poblMh  hia  obsomtjons.  Tbo  iniliviilugilily  or  th«  diitesw  wu,  however, 
not  diilitioUr  nooiriuaed  until  1801.  vbo:i  Duolisnuo  described  tho  affiMtMa 
with  hia  luRial  exbsnstiTcoMs  and  tborouglitieea. 


174 


SYSTEM   DISEASES  OP  THE 


§  42].  Etiuloy}f.~~\\i  does  not  appear  that  hereditjr  exercises 
any  influeDce  in  the  prodncliouof  labio-gloetto-laryageal  paraljru& 
Ic  occurs  moiil  frequently  betweeo  the  fortieth  and  seventietli 
ycara  of  a^,  mid  only  exceplioQiJly  before  the  fortieth  year. 
Tlio  disease  attacks  mva  mure  frequently  tboo  vrouiQu,  the 
proporlioQ  being  two  of  the  former  to  one  of  the  latter  (Doirae). 
All  ranks  of  society  from  the  highest  to  the  lowest,  and  oveiy 
profession,  appear  to  te  liable  to  the  oJfectiotL 

Of  the  excitiog  cause»,  the  mont  frequently  mentioned  are 
exposure  to  cold,  traumatic  inllueaces,  as  a  blow  on  the  back  of 
the  Deck,  violent  nnd  continuous  mental  excitement,  exoe«uve 
meutal  activity,  siraiuiu^  of  the  muscles  affected,  as  in  siogiim 
and  Hpuaking,  and  bad  and  iuHufBcient  food.  Syphilis  U  not 
an  unfrequent  cause  of  the  disea-se ;  but  the  authors  who  regard 
this  affection  as  being  almost  always  of  syphilitic  origin  are 
uodoubiedly  iu  error. 


§  422.  Symptotm. — Slight  premonitory  symptoms  uaually 
precede  the  full  duveluptueut  uf  the  flisoaAo,  but  they  are  ofteo 
entirely  wanting  uuil  are  uut  in  any  way  characterJsuc  of  the 
affection.  These  consiut  of  pain  in  the  bead  and  bock  of  (be 
neck,  aliijht  dizztueas.  and  great  diminution  or  complete  loas 
of  the  ivUux  imtuhility  of  tho  hiryox,  Gusophagus,  and  pharynx. 
The  reBex  iosenGtbtUty  of  the  mucous  membrane  of  the  fauces, 
epiglottis,  and  pUaryax  is  sometimes  so  great  as  to  lead  to  ■ 
certain  amount  of  dysphagia,  and  the  pasiage  of  food  into  tba 
larynx  for  a  considerable  time  before  any  octuxd  p&r»lysia  u 
observed  (KriababcrJ, 

The  disease  may  begiu  suddenly  with  difficulty  in  the 
mt»ats  of  the  tongue  and  Ups,  and  of  deglutition  ;  hut  in  tfa4 
«u«s  it  18  probiiblo  that  a  alight  hssmorrbage  baa  occurred  in 
the  medulla,  and  cuniief]uenUy  tbey  cannot  be  regarded  as  tnii! 
iuittaucus  of  the  primary  disease. 

The  symptoms  of  tbe  true  progreuive  disease  creep  oo 
gra^lually  and  stealthily.  A  slight  affection  of  speech  is  usually 
the  tirsl  symptom  to  attract  attention.  Utterance  is  less  disdact, 
the  prouuuciation  of  certain  letters  presents  special  difficulty, 
and  tlie  tongue  and  lips  are  soon  fatigued,  so  that  prolonged 
reading  aloud  or  speakiug  is  impossible. 


SPtNAL  OOKD  AUD  HEDUlXi.  OBLOHOATl.  l7fi 

This  ia  followed  by  a  gradual  weaknoas  in  tho  lipfl  and  palalo. 
Tbe  expressioa  of  tbo  ^tee  is  altered,  the  voice  becomes  nasal, 
sad  faligiie  of  the  mtiacles  of  mantioation  and  dcglucitioD  ia 
readily  induced,  so  that  the  patient  i»  soon  compelled  to  eat 
onlj  pulpy  food,  and  ia  uouble  to  uvrallow  much  at  ooe  meal, 

Tlie  paralytic  symptoms  ma,y  at  times  begin  in  the  lips  and 
kte  iiHtead  of  tho  tongue,  and  then  the  order  oT  ftuccossioii 

tbe  symploms  wdl  differ  to  some  extent  from  that  Just 
described. 

Tbe  initial  period  of  debility  and  &tiguc  of  tbe  affected 
maacloa  may  extend  or«;r  a  period  of  yeant  before  the  stage  of 
(Ibtiact  parulysia  is  reached.  When  once  distinct  paralysis  is 
establisheil.  tbe  disease  a&iumu»  a  more  progrcasii^e  character, 
•ad  ftdranciM  steadily  and  surely  to  a  fatal  tcrrainatioa. 

VVheu  the  afftfction  begios  in  tbe  tongue,  the  patient  expe- 
ri*O0M  an  cvor-iocreasing  difficulty  in  pronouncing  the  dental 
•nd  galturat  aouods  which  are  respcctiwty  produced  by 
approumatioD  of  the  tongue  to  the  teoth  or  bard  palate,  and 
of  the  root  of  the  organ  to  tbe  sof^  paUt«L  Since  the  rowel  i 
raqqirea  tbo  greatest  raising  of  tho  tongue  for  its  production, 
ita  pronnncialioo  is  the  first  to  suffer;  and  then  tbe  pronuncta- 
itoo  of  tho  consonants  r,  s,  I,  k,  g,  t,  nnd  lastly  d  and  d.  becomes 
difficult,  imperfect,  and  linaliy  impossible. 

After  a  time  tlie  patient  is  unable  to  effect  the  coarser  and 
least  complicated  lingual  movements.  He  may  at  fir^t  be  able 
lo  protrude  tbe  tonguo,  but  not  to  raise  tbe  tip  towards  the 
hard  pahtte  or  towards  the  nose  after  protrusion;  while  ina- 
btli^  to  move  tlie  tip  laterally  indicacei  a  still  greater  degree 
of  parslysia.  Aa  tbe  paralysis  iacroaacs  the  tongue  cAnuut  be 
lengtbeoeil  into  a  pobt,  or  made  hollow  in  ibe  ccutre;  and, 
Soallj,  ptvtnisoa  ts  impossible,  and  the  organ  lies  behind  the 
tower  row  of  teeth  completely  helpless  and  mutiooless,  or  main- 
taiood  iu  coost&nt  vibration  with  flbriltary  twilcliiogs. 

The  tongue  may  ouviutaiu  its  normal  aspect,  or  become  large 
•od  fiabby;  but  much  more  frequuotly  it  is  sodden,  grooved 
lopgitudt&ally.  wrinkled,  und  shrunken,  while  simultaneotia 
Mfopfay  of  the  papilla  gives  to  the  surface  a  glased  ap- 
peanace. 

At  an  Mfly  aUge  of  the  affection  deglutition  is  rendered 


1T< 


ffrSTEM  DISEASES  OP  THE 


•itfficult,  umply  by  the  increaeing  weakness  of  the  toogue: 
QcMt  difficulty  is  experiencetl  in  oollectiog  the  food  in  the 
nKmtb  so  as  to  form  it  into  a,  boliiR.  and  in  prenemg  it  back 
■gmtnat  the  soft  folate  and  iuto  the  pharynx  ;  aud  the  patient 
adopts  various  duricct)  in  order  to  ttupplcment  tbo  deficicncin 
of  the  first  stago  of  deglulition.  He  takdfi  care,  as  Trotiaoeail 
rumarles,  to  cbew  troll  what  be  eats,  and  to  facilitate  its  gliding 
down  by  drinking  and  throwing  bis  bend  backwards,  while  at 
otber  tim«s  be  assiHtK  the  imperfect  moTemenU  of  the  tongue 
with  bis  fingera,  using  thorn  to  extract  the  food  wbicb  bos 
lodged  between  the  teeth  and  cheeks,  and  to  push  the  bolns  to 
the  back  of  Llio  toague  till  it  is  caught  by  ibo  retlex  iiiov»- 
mentg  of  deglutition. 

The  muscles  which  pass  from  the  inferior  maxilla  to  the 
hyoid  bone,  and  whidi  elevate  the  l&tyox  as  well  as  tbe  baaeof 
the  tongue  during  dpgluUtion,  are  implicated  in  the  paralysis 
along  with  the  intrinsic  mu»cles  of  the  tongue;  hence  it  tnay 
be  observed  that  the  larynx  docs  not  rise  so  readily  as  in  heoltli 
during  tbe  second  stage  of  deglutition.  The  root  of  the  tongue 
cannot,  therefore,  be  brought  during  d<^lutition  over  the  de- 
pressed epiglottis,  the  glottis  is  not  completely  closed,  porticlet 
of  food  and  fluids  easily  find  their  way  iot^i  tbe  traohsea,  aod 
cause  distressing  paroxysme  of  cuugh  and  dyspucco. 

The  saliva  cannot  be  swallowed  and  accumulates  in  tbe 
mouth,  and  owing  to  the  advancing  paralysis  of  tbe  orbiculari) 
oris  Bows  from  it  in  an  almost  continuous  stream.  Of  tbe 
raiuclos  innervated  by  tbe  facial  nerve  the  orbicularis  oris  is  tba 
first  to  suffer.  With  the  increasing  weakness  of  this  mnvele 
the  patient  b&comcs  unable  to  whislle,  blow,  compress  bis  lip(^ 
or  kiss.  The  patient  experiooces  difliculty  in  pronounciog  tbe 
vowels  0  and  u ;  and  with  the  advance  of  tbe  paralysis  tbe  latnal 
consonants  p,  f,  b,  and  m,  become  increasingly  diStcull  lo 
articulate. 

Farulyais  of  titA  palate  readers  the  formation  of  the  exploare 
labial  causonants  still  more  difficult;  since  tbe  current  of  air 
necessary  to  force  the  lips  suddenly  asunder  escapee  tbrongh 
the  nose,  and  the  consonants  p  and  b  are  conscqucntty  turned 
into  JM  and  ve.  Duchenue  bas  shown  that  if  the  patient's  nose 
be  closed  these  letters  are  much  better  pronounced.     Paralyxis 


SriSlL  OOBD   AND  MEDUtXA   OBUlIfOATA.  177 

of  the  palate  also  gives  a  nasal  resonance  to  tti4  voico,  aad 
permiu  food  and  fluids  to  escape  readily  through  the  ao§c 
danog  efforts  at  deglatitioo.  WIioq  the  tnusdea  of  the  toDguo, 
apt,  aad  palate  are  sitntiltAneuuHly  paralysed,  speech  booomM 
more  and  more  iodUtinct,  aad  tbc  patioot  cjui  oaly  give  utWr- 
anoe  to  ioartieulate  aud  gninting  iMUutls.  The  vowel  a,  bow- 
vwet,  can  still  be  pronouQcud,  iaatimiicU  as  it  is  a  purely 
Uiyogeal  sound,  and  quite  indepeodent  of  the  articulatory 
moTem«atft  of  the   tooguu  and   lips. 

But  although  the  orbiculam  oris  suffers  more  profoundly 
than  the  other  facial  muscles,  the  quadmtua  and  levator  mcoti 
■re  mure  or  lu«s  implicated  lo  the  paralysis.  The  muscles  of 
the  palpebral  and  nasal  regioua  are  uever  alTect«d,  aad  even  the 
•levAtors  of  the  superior  Up,  as  veil  as  the  levator  mcati  and 
tucciaalors,  are  only  on  riu'c  occasions  involved  in  tlio  paralysis. 
The  pttndya«d  muscles  are  almost  always  distinctly  atrophied, 
■o  that  the  Ups  look  thin,  sharp  edged,  and  furrowed,  and  fribrit- 
lary  eoalractioos  are  not  UDfr(.>quently  observed  io  them.  The 
|iataeat  now  presents  a  very  strikiDg  and  characteristic  appear- 
MKW.  The  lower  lip  haogs  loose  and  pendulous,  tlio  mouth 
oatmot  be  cloaed,  it  is  somewhat  increased  io  breadth,  and  the 
saao-tabial  folds  become  markod,  and  give  to  the  patient  a 
Uchrymoae  expfcsnon.  During  stales  of  omoUomU  excitement 
tha  lower  port  of  the  face  remains  comparatively  motionless, 
mad  contrasts  strongly  with  the  vivacious  movemeDta  of  the 
upper  half  of  the  face,  and  wiib  the  brightDMs  and  activity 
of  the  eye*. 

Tbe  saliva  oow  flows  from  Uie  mouth  in  a  continuous  stream. 
and  causes  much  annoyance  to  the  patient,  iuasmucb  as  it  soaks 
through  the  pillow  at  uighl  antl  requires  to  be  constantly  wiped 
from  tbe  lips  witb  a  handkerchief  during  the  day.  The  saliva 
appears  lo  be  secreted  as  a  rule  in  normal  quantity,  but  in 
•Otoe  cases  the  amount  of  accretion  is  very  largely  increased. 
Scbalx  estimated  in  one  case  thai  the  secretion  was  six  or  eight 
tiiDM  the  Dormol  amount,  and  Kayser  found  that  he  could 
iaereaM  tb«  Bow  by  rcBcx  irritation,  and  arrest  it  temporarily 
by  foeaos  of  atropine; 
Jfosficaf ion,  as  already  mentioned,  is  impaired  at  an  early 
of  tbe  affeclion  from  tbe  difficulty  of  moviag  the  tongue, 


178 


arSTEM  DISEASES  OF  THE 


aod  the  condition  bccoracit  Hggravatcd  when  the  lips  and  bac- 
cinftiors  arc  mmiiltanoonsly  pomljrsed.  But  the  diiiieuUjr  of 
masticatioQ  is  greatly  augmorjtcd  when  tbe  motor  divisioo  ol 
the  trigeminuH  U  involved  iu  the  disease.  Tlie  pteiygoid 
muscles  are  lutually  the  first  of  the  masticatory  muscles  to  lie 
affeotaci,  &nd  paralysis  of  th^nn  abolishes  the  power  of  effecting 
the  lateral  movemeuls  of  the  lower  jaw.  With  the  advancing 
paralysis  of  the  remaining  muscles  of  nuuiticBtion,  the  power  of 
chewing  the  food  becomee  iocrea^iDgly  difficult,  feeble,  aod 
filially  impossible. 

The  dij^eiilty  of  defflutUumy  caused  by  paralysis  of  the 
tongue,  lips,  and  soft  palate,  is  greatly  augmented  when  the 
pharyngeal  lauscJcs  and  thoHo  which  close  the  larynx  ore  in- 
volved in  the  dieease.  When  the  pharyngeal  muscles  are 
paralysed  particles  of  food  are  apt  to  lodge  la  the  pharynx,  and 
this  increases  the  ri^k  of  foreign  particles  «nt«ring  the  laiyax. 
Ac  other  times  the  whole  bolus  gets  fast  ou  a  level  with  the 
glotti-t,  causing  danger  of  instant  snfTocatJon. 

But  when  the  muscles  which  close  tho  glottis  are  paralysed, 
the  danger  of  swallowing  either  fiolida  or  fluids  becomes  greatly 
iDteosi6cd.  Particles  of  food  passing  into  the  lar}mx  prodaoa 
diiitressLng  paroxysms  of  cougbing  and  dy8pQ(»a,and  by  pwiting 
into  the  bronchi  often  cause  pneumonia.  When  the  paralyns 
extends  to  the  ceeophagus  deglutition  becomes  impossible,  and 
to  survive  the  palteut  must  be  fed  by  the  stomach  pump.  When 
the  nucleus  of  the  npinal  accessory  nerve  is  involved  in  the 
disease  the  laryngoscope  reveals  pareeia  or  paralysis  of  the  voc^ 
conls,  the  voice  becomes  hoarse  and  feeble,  until  finally  there  a 
complete  aphonia,  The  power,  uot  of  articuiatinn  only,  but  of 
phooation  also,  is  now  abolinhed,  the  loss  of  this  function  betng 
manifested  by  ioability  to  pronounce  tho  vowel  <k  The  loss 
of  phooation  does  not  necessarily  interfere  with  the  reepimtory 
functions,  but  as  the  disease  advances  disorders  of  respiration 
and  circulation  supervene,  which  soon  prove  fatal. 

Not  much  in  known  with  respect  to  disorders  of  the  cinmU- 
tion  in  the  early  stages  of  the  affection.  There  is  no  trustworthy 
record  of  retardation  of  the  pul»o  which  eould  with  probability 
be  referred  to  irritation  of  the  vagus,  but  a  pulse  riEing  b<>fore 
death  from   130  to  loO,  or  even  higher  per  minute,  has  beeo 


SPISAL   CORD   AND   MRDULLA   OBLONGATA 


1711 


rrotfueDllj  recorded,  and  is  probably  caused  by  paralysis  of  the 
n^^tt.  In  tho  t«nDiDal  poriod  of  tbe  dtscftse  patients  often 
■nfferfniin  buoliog  fito,  sccumpaoiod  by  great  anxiety  and  a 
HOMtioD  of  iinpeadiDg  death,  ond,  indeed,  death  may  result 
frwB  an  attack  uf  syocope.  These  phenomena  ate  probably 
euued  by  tbe  cardiac  ceulres  of  Junerration  liaving  become 
iovolvcd  in  tlie  disease. 

When  tbe  rtspiratory  mechanism  is  affected  a  ffttal  lermi- 
natiuD  ti  near.  The  respiratory  tnoTcmeats  beoomc  feeble,  and, 
owing  to  the  implicatioo  of  the  fipinal  accessory  acives,  tbe 
aiixiltary  mtuclea  of  respiratJoD  ore  paralysed,  and  superior 
Iboracic  breatfaiog  in  impumible.  Tho  inefficiency  of  tbe  respi- 
imtocy  moremeot«  renders  the  breathing  shallow,  and  all 
atlemptv  at  coughing  or  blowing  the  Dotte  are  weak  and 
powerlcsa.  Patients  complain  of  a  fertlmg  of  constriction, 
accompanied  by  an  oppreft^ive  feeling  of  want  of  breath. 
Afier  a  time  tfae  pneumogsstric  nervo  appoars  u>  become  im- 
plioated  in  the  dtwoM.  Paroxysms  of  dyspnccs,  with  a  tendency 
to  lyncope,  supervene,  bat  theoe  must  not  be  confounded  with 
the  niffocatiTe  attacks  which  occur  at  on  early  period  from  the 
■eodoual  introduction  of  foreign  bodies  into  the  larynx.  Tbe 
Mtacbi  of  dyspotea  l>econie  more  and  more  frequent  as  tbe 
difOMB  pragreaaee,  and  the  breathing  power  feebler  and  feebler, 
until  nltimately  tbe  patient  dies  from  asphyxia.  Death  may, 
Intleed,  be  caused  at  an  early  period  of  the  affection  by  a  slight 
dbmM  of  the  respiratory  organs,  such  as  a  bronchial  catnrrb 
or  pneuDionia. 

Atrophffo/the  paraly«ed  ViWides  is  one  of  the  most  constant 
mad  sthktug  symptoms  of  (bis  affection.  It  is  usually  most 
maiked  in  the  tongue,  and  tbe  lips  also  become  emaciated  and 
thin,  and  both  are  oRen  kept  in  constant  movement  by  fibrillary 
cuolractioDS.  Atrophy  of  tho  soft  palate  baa  not  yet  been 
rcoordod,  and  cannot  probably  be  recognised  with  certainty. 

Atropliy  of  the  paralysed  muscles  is  not  an  early  symptom  of 
Uw  djiwuie.  And  does  not  run  a  parallel  course  with  tbe  paralysU. 
Th«  toogoe  may.  however,  retain  a  normal  appc-aranoo  and 
voluDM^  and  yet  exhibit,  on  micTOflcopicnl  examination,  exten- 
stre  ddgeDemiioD  of  its  muscular  fibres  (Charcot). 

JAVd  atrophy  and  fibrillary  contractions  of  tbe  smnll  muscles 


180 


STSTEH  DISEASES  OF  THE 


of  the  band  are  Bometimea  observed  indicatiog  a  complicatkie 
with  progressiTc  muscular  atrophy. 

71i6  electrio  exciiability  is  generally  said  not  to  undergo  aiijr 
Dotewortliy  chouges,  but  £ib  statee  that  be  found  the  woA 
marked  "reactioo  of  degcDeratiun"  on  direct  irritatioa  of  tbt 
muscles  of  the  chin,  tip»i,  aod  tougue.  The  electric  iiritatnlitj 
of  the  Dcrvcs  wus,  however,  uormal,  or  but  slightly  diminished. 

The  semibilit})  romains,  m  a  rule,  unaffected  throughout  lh» 
whole  course  of  the  disease,  and  even  taste  i<t  only  altered  on 
rare  occasions.  Affections  of  the  auditory  nerve,  conBistiog  of 
bumng  of  the  ears  and  doafnesa,  have  oocanooally  been 
observed.  The  trigemiQus  is  sometimes  implicated,  the 
(symptoms  observed  being  a  furry  feeling  and  anaatbeeia  oo 
both  Dideii  of  the  face,  and  want  of  common  seasation  in  the 
tongue,  and  in  some  cases  pain  has  been  fell  in  the  oocipitit 
and  upper  part  of  tbe  cervical  region  (Trousseau). 

7A<  intelligence  remaiim  quite  clear  to  tbe  Last,  the  temper 
is  mmewhat  excitable,  and  patienta  often  manifest  an  inclioa- 
tioQ  to  hiugh  on  slight  provocation. 

RejUx  irritalf'ditif  is,  as  already  mentioned,  eomeiimei 
greatly  dimiuiabed  or  abolished  in  the  tongue,  soft  paUie. 
pharynx,  and  even  in  the  larynx  before  the  appearance  of  aay 
other  Hymptoms,  but  on  the  other  bond  it  in  often  retained  in 
these  parts  until  a  late  period  of  the  diBoase.  Even  when  the 
reflex  irritability  is  lost  the  patient  can  feel  and  looaliiie  eaeb 
touch  quite  distinctly. 

V<uo-mctor  disturbance  have  not  been  recorded,  and  there 
is  DO  fever  during  the  whole  course  of  the  disease. 

Qtncral  nutritive  diwrdera  occur  sooner  or  later  in  the 
course  of  the  affection.  These  are  in  lai^e  part  due  to  tbe 
insufficient  quantity  of  food  taken,  and  which  ultimately  pn>- 
duces  a  HtAte  of  inanition.  The  helplesaQMs  of  the  patient  is 
greatly  aggravated  by  his  inability  to  doae  the  glottis,  and 
thus  all  forcible  expiratory  actions  are  rendered  impoasible 
Duchenne  thought,  probably  on  Insufficient  grounds,  that  tlie 
constant  loss  of  the  saliva  exercised  a  deleterluua  influeocA  on 
digestion,  and  consequently  contributed  to  produce  tbe  general 
debility.  But  whatever  may  be  the  causes  which  co-operate  lo 
produce  the  state  of  emaciation  and  marasmus  into  which  tha 


SPOiAL  COAD  AND  MEDIfLLA   OBLONGATA.  181 

it&n^  tbe  dobility  at  lut  becomcfl  so  great  that  be  is 
lie  to  get  up;  lie  aits  ia  bod,  with  the  apper  part  of  Ibe 
Lad;  propped  up,  sad  witb  the  bead  resting  on  piUows  uod 
iBcUuid  to  one  aide,  in  order  to  let  the  saliva  flow  oat  of  tbe 
mouth,  and  death  »ooo  superreaes,  cither  during  a  paroxysm  of 
dy^noea  or  suddenly  and  quietly  from  arrest  of  the  heart's 
actios. 

§  423.  CfauTK,  Duration,  awi  Terminationt. — ^Tbe  course  of 
bulbar  paralysis  is  always  alow  and  chronic,  but  surely  progressive. 
There  is  »eldom  a  remission  of  loug  dumlioa ;  aoy  degree  of 
tfflprorameDt  is  still  rarer,  and  recovery  has  never  been  observed 
when  tbe  diagnosis  of  a  primary  affectioD  was  beyond  questioo. 
Death  aioally  results  in  from  one  to  five  y«ar«. 

§  42*.  Complieation9. — Pro^e^t^emuxuUtr  atyophy  is  the 
most  important  and  frequent  complication  of  bulbar  paralysis, 
Labto-glosso-Iaryngeal  paralysis  may  either  be  tbe  primary afiec- 
lioo,  or  it  may  merely  be  a  terminal  phenomenon  supervening  in 
tbecoar»e  of  progressive  musctilar  atropby,  and  caused  by  exten- 
sion of  tbe  morbid  process  in  tbe  anterior  grey  boms  of  the  cord 
to  cbe  motor  nuclei  of  the  medulla.  The  two  afiWtioaa  are 
indeed  eaaentially  tbe  same  diseaM,  both  a^  regards  Uie  clinical 
symptoms  and  the  anatomical  changes  found  af^er  death. 

Amyotnyphie  tatenil  aderogU  U  another  important  com- 
pbcatioD  of  progressive  bulbar  paralysis,  and  the  latter  may 
•tiler  be  the  primary  or  secondary  aflfcction.  Amyotrophic 
lateral  sclercsis  occurs  not  unfrequently  ia  tbe  later  stages  of 
bulbar  paralysis.  The  disease  is  then  characteriited  by  the 
fljrraptoms  of  progresBive  muscular  atropby  in  the  superior  and 
Ihoae  of  spastic  spina)  piualysis  in  tbe  infmor  cxtremitjca.  A 
MBbar  fk  cas«s  described  as  bulbar  paralysis  or  progrcttivc 
aaamUr  atrophy  belong  to  tbis  clasa  The  diseaae  is  no  doubt 
dne  toesteosian  of  the  morbid  prooess  in  tbo  medalla  to  the 
interior  grey  bonu  of  the  cervical  enlargement  and  to  the 
aatero-lateial  eolumna  of  tbe  cord. 

$  425.  Martid  AruUirmy.—The  firat  ubservatiooa  with  respect 
to  the  OMicbtd  slteiatioos  uf  tbe  oervuus  tiystvm  wen  OQlultKted 


18S 


SYSTEM   DISEASES  OP  TBB 


witljout  careful  microscopical  extuninattoii  of  the  medulla 
pona  In  a  complex  case  uf  paialyeiis  of  tho  ton^u,  lips,  luul 
veil  of  the  palate.  ooEnbine<l  with  genoral  muscnilar  atropby, 
reconk-d  by  Dr.  Bum^nil,  the  roots  of  the  hypoglossal,  fiici&l, 
aud  sinaal  iicccsaoiy  ucrvca,  aa  well  as  the  aoterior  spiDol  roots, 
w«re  found  wasted,  the  atropby  abo  ext«D(liag  to  the  tniaka 
of  the  serves  tbetnseWes.  Troasseau  fouad  iucreased  consin- 
tcDcy  of  tbo  medulla  oblongatu  ond  thickening  of  the  dura 
mater  of  the  medulU ;  but  ho  regarded  the  atrophy  of  tbe  roots 
of  the  bulbar  nerves  as  the  eaaeotiol  morbid  alteration  in  this 
diseaue. 

The  dose  anatomical  connection  which  the  researches  of 
Lookhart  Clarke  and  othere  have  prov&d  to  eiUt  between  tie 
nuclei  of  origin  of  the  nervea  implicated  in  this  diiiease,  ax  well 
aa  the  discovery  which  had  already  be«n  made  that  the  allied 
atTectious  of  progreraire  muscular  atrophy  atid  iofautilc  spinal 
paralyfiis  were  duo  to  diseaao  of  the  ganglion  cells  of  the  ante- 
rior grey  horns  of  the  cord,  bad  led  pathologists  to  suspect  that 
the  estiential  anatomical  changes  in  this  ditrcase  would  be  found, 
not  in  the  roots  of  the  nerves,  but  in  the  ganglion  cells  of  their 
nuclei  of  origin.  It  was  in  reference  to  this  cipectatiou  that 
Dr.  Wilks  wrote:  "Tbe  anatomist  and  tho  physiologist  have 
in  fact  informed  the  clioical  phyucian  of  the  precise  spot 
which  is  affected,  and  it  only  remoiiu  for  tbe  pathologist  i^ 
prove  it" 

About  the  time  that  this  Dentence  was  being  uttered  by 
Wilkg  the  opportunity  for  making  the  neccsBary  verificalM] 
of  the  hypothesis  presented  itself  to  the  evor-vigilaot  eye  of 
Charcot,  and  liia  observation  waa  soon  afterwards  couSrmed  by 
Duchenno  and  JotTroy.  The  e»seDtiat  anatomical  chaoges  id 
the  affection  appear  to  consist  of  a  degenerative  atrophy  of  tbe 
ganglion  cells  in  the  grey  nuclei  ou  the  floor  of  the  fourth 
ventricle  Tbe  cells  shrink  and  become  tilled  with  yellow  or 
browu  pigment,  their  nuclei  disappear,  and  finally  the  cells 
themselves  are  only  represented  by  angular,  glistening  pig- 
mented masses. 

In  some  casea  tha  surrounding  tissue  was  found  to  oonUin 
GOipuscles  of  Gluge  in  varying  ciuantity,  increase  of  connective 
tissue  and  in  the  number  of  nuclei  and  of  Deiter's  cells,  and 


SPOfAL   CORD  AMD  MEDULLA.  ODLOKQATA. 


183 


hjrpertropliy  aad  Uttj  degeneration  of  the  vsscular  w&ltg.  The 
nerve  fibres  themselves  were  fouDd  alrophied,  the  medullar/ 
^tsth  had  dt&appcured,  and  m  chronic  caaca  the  axis  cyUnden* 

The  nucleus  of  the  h;p<^lo8»aJ  nerve  appears  to  be  the 
tUrting  point  of  the  duesHC,  and  the  nucict  of  thu  spinal 
aeo«**ory  and  ragus  are  next  attacked,  while  the  disease  doee 
not  extend  in  all  cases  to  the  nucleus  of  the  gloaso-pharyngeal 

Flo.  171. 


ftiw- 


f/» 


H 

FMl  171  (VfiiM  Lbt<ImI-  fwl^  of  Uu  Ortp  Su&ifanee  on  M<  ,«iior  o/  (A*  favik 
rwHUvtt  «it  •  Ifii  rw'S  (ir  aitUlt  of  Vtr  Uu/iovintnU  Ifueltiu,  from  a  aim  <^ 
fn^rtnin  Ma*""  "iA  BtiU^r  J^inttytw,  •kowiofr  ISt  dritmttiam  of 

KUJim  npb^  ,         -.  'i:>rM  ol  tiM  bjpcicliuaMl  nerrea.    Tbc  taixmorT 


nerrcL  The  nuclei  of  the  facial  aire  attacked  at  a  rery  earlj- 
ftage,  evpecially  those  which  are  connected  with  the  inferior 
braochM  of  the  nerve,  and  which  I  have  named  the  accessory 
nuclei  of  the  facial.  l*ho  annexed  diagram  {Fig.  171),  burrowed 
fnxn  Lejdea,  represents  the  morbid  changes  obBenred  in  the 
modulU  oblongata  in  bulbar  poralysia.  Remnants  of  the  fun- 
danental  celU  of  tho  hjpoglossal  nuclei  may  ttiU  be  observed, 
while  ever;  tiace  of  the  accessory  nuclei  has  disappeared. 

The  motor  nucleus  of  the  trigeminus  has  been  found  atfected, 
but  the  nucleus  of  the  abduceui  and  the  aoouatic  and  trigeminal 


m 


SYSTEM   DISEASES  OP  THE 


one  hy  Co9t«  and  Qioj«  in  1639,  md  h  w«U  miu-kod  cmo  by  He.  Partridga 
in  1S47.  Bat  Ur.  Ueryoo,  in  19M,  wu  tbe  fint  to  draw  attoation  to  t^ 
cluiicol  fM>ture«  «f  ttiis  aSoctioD,  and  Opp6nb»iia,  ia  1856,  d«*crib*d  a  w«U 
toarlced  group  or  cafiea.  The  disMM  va»  thoroughly  Javntig»t«d  by 
Uuchenne.  Uw  friend,  M.  Bouvier,  aeiit  to  hia  cliniqiu  in  1S&8  •  child, 
wUo  h^  baeu  siiffuring  from  aa  uutiaual  form  of  paralynta,  aud  during 
tbe  Bubaequeot  thrM  jean  DiuhAons  ooIlMted  other  caaes,  wbuth  -wen 
wimilar  to  th»  oqs  seot  by  Bouviar,  and  ynt  did  not  correaimnd  to  lb« 
dMcriptioo  of  any  feoows  diawso.  Duchtnno  deaeribod  tiie  principal 
clinical  oharnctera  of  the  diseaao  in  tbe  itccoud  edition  of  hb  troik  en 
l/ocalised  Electricity  (P&ri^,  ISfll),  but  it  wan  not  until  1&6S  tiuit  h« 
pu*bli»Iied  ill  tie  "  Archives  G^a^r&lea  do  M^ocitw  "  a  full  account  of  hia 
inveatjgatioDs  into  th«  nature  of  tho  aSMtion.  Ho  then  gava  dataiUd 
dsBcriptiona  of  thirteen  oaaea,  whioh  had  come  tiitder  his  owti  obMrratton, 
and  tDoorporat«d  with  these  fifteso  cases  puhlishod  up  to  tttat  data  tif 
other  obHerrers.  So  thon^ushly  waa  the  work  dona  by  this  diatiagoiabad 
pbynoian  that  nothing  easential  has  ainoe  been  add«d  to  oar  knowI»il|i 
of  the  coiine  and  iiroiirem  of  the  diaeaae.  Caaee  bavs  beoD  daacribed  in 
this  Guuiitrj'  by  Mr.  Wilitam  Adama,  Dr.  Langdon  Down,  Dr  Ord,  Mr. 
Keatttvvu,  Dra.  Ruwcll  and  Balthaxar  Poeter  (Birmingham),  Dr.  Barim 
(UaaoJlMtar),  Dr.  DatidaaD  (Liverpool),  Dr.  Clifford  AUbutt,  nhOe  Dr. 
OoHcra  baa  writloo  an  ablo  muuugraph  on  the  divoMc 


§  iSO.  Etiologi/. — Thisftffection  is  almost  but  not  eiclasivety 
confined  to  infAucy.  The  first  symptoms  are  frequDntly  noticed 
at  the  time  when  the  child  ought  to  begin  to  walk,  although  it 
is  Terr  probable  that  tbe  disease  is  established  before  chat  time. 
The  disease  begioH  in  a  cousiderable  proportion  of  cases  between 
the  ages  of  five  and  thirteen  ye-i-rs,  and  caftes  are  recorded  where 
adults  have  beoQ  attacked.  It  may,  however,  be  doubted 
whether  mauy  of  the  latter  are  gouuiae  examples  of  the  disease. 
Id  the  caao  Heecrlbi^d  by  Auerbach,  for  instaocc,  the  bypei^ 
tropbv  waa  Qrst  outioed  in  tbe  ligbt  arm,  and  microscopical 
examination  of  the  affected  muscles  showed  that  the  dtsoasB 
waij  more  like  true  hypertrophy.  In  the  case  described  by 
Eultuburg,  where  the  patient,  a  female,  waa  forty-four  jear»of 
«g«  whoD  tho  £r8t  symptoms  appeared,  tbe  paralysis  began  to 
tbe  right  arm,  in  the  form  of  progressive  muMutar  atroplij, 
and  although  there  was  apparent  hypertrophy  of  the  muBOlai 
of  tho  lower  extremities,  tbe  course  and  progresti  of  tbe  can 
vas  different  &om  those  of  a  case  of  true  pceudo-hypertropbic 
ponlyBiB.    Iq  an  undoubted  instAOCti  of  the  disease  under  my 


SriSU.  CORD  AND  UKbUUjk  dblohoata. 


187 


an  at  preseot  the  patieDt  is  forty-aeren  ymn  o?  age,  but  the 
ftffectioD  began  at  tbe  age  of  ten.  It  in  much  more  coiqdiod 
Id  boys  IhaD  girls.  Of  tho  thirteen  CAses  collected  by  Duchcnoe 
nolj  two  were  girls,  of  forty-une  cases  collected  by  Webber  only 
fire  were  femalefl,  aDil  of  twuaty-lliroo  cosffs  mentinoed  by  Dr. 
Oowcn  only  fire  were  females.  Out  of  a  total  of  330  caoes 
hitherto  published  190  were  males  a&d  thirty  females  (Qowcre), 
The  diseaae  also  appears  to  pursue  a  more  cbrocic  course  in 
girls  than  in  iMya. 

Hereditary  predispositioD  to  tho  disease  frequently  exists. 
Two  cbildreo  in  the  same  family  are  often  attacked,  as  iu  the 
eaaes  related  by  Wemicb,  Heller,  and  FCesteveu,  and  sometimes 
arm  eight  chililrcn  of  the  same  family  havo  been  affected,  as  in 
the  eases  relatud  by  Meryoo.  Lutz  met  with  two  sisters,  a 
mat(*mal  ancle  nod  aunt,  and  a  maternal  half-sister,  issue  of  a 
Snt  marriage,  alTected  with  the  disease.  In  another  example, 
three  maternal  QDcles  and  aunts  were  afiected  ;  io  a  second,  a 
maternal  uacle  and  a  halT-UQclc ;  in  m  third,  three  maternal 
half-brothers;  and  in  a  fourth  instance,  a  matoroal  half-brother. 
three  maternal  uncles,  and  other  members  on  the  mother's  side 
(Ftene).  It  is  curious  to  notice  that,  although  the  dieease  is 
mainly  oooGoed  to  the  male  sex,  yet  the  descent,  so  far  as  is 
kDOva.  is  always  through  tbe  mother's  side.  This  disease  is 
not,  ■•  a  rule,  tranamittod  directly  from  paroota  to  offspring; 
lioce  by  (u  the  greater  Dumber  of  its  nctims  are  attacked  at 
an  ««rly  age.  and  therefore  do  not  become  parents,  and  this 
eocuidcraliotk  also  precludes  the  idea  that  it  is  an  example  of 
■ntinmn.  A  oertaJa  predispositiou  is,  therefore,  transmitted, 
whidi,  with  tho  concurrence  of  othernnfavourablo  circumstances, 
socfa  as  an  eruptive  fever,  develops  the  disease. 

Tbe  exciting  caoaea  of  the  disease  are  by  no  means  clear. 
Kxpoiare  to  cold  and  damp  appears  to  be  occasionally  the 
dcAermining  cause,  while  at  other  times  it  has  followe<l  an 
amptive  km.  variola,  or  measles,  and  several  caaea  have  been 
udiered  in  by  convulsions. 


9  431.  ^yrnptonu.— FeeblenesB  of  the  lower  extremities  ia 
tMually  tlic  fini  iiymptom  to  attract  ultenlion,  and  when  the 
diaaaii  bsyias  during  infancy  it  in  ditficult  to  fix  the  exact  date 


188 


SVSTUH    DISEASES  OF  TQE 


of  its  ongiD.  Tlio  attention  of  the  poreDts  is  not  directod  to  tbe 
condition  of  the  c1iil<l  until  be  arrive  at  tbe  age  when  other 
cliiltlren  beg^n  to  walk.  At  this  petiod  it  is  noticed  tliat  when  the 
cliiltl  in  placed  on  bts  feet  he  does  not  iostinctii'el/  move  liu 
legs  to  walk,  but  immediately  falls  doM-u,  and  in  other  cases 
be  may  have  begun  to  walk,  but  is  soon  fatigued  and  can 
DO  longer  stand  steadily  or  walk  without  stumbling.  At 
other  times  the  child  may  be  late  io  attempting  to  walk, 
and  is  obliged  to  support  bimaelf  by  holding  on  to  the 
nearest  article  of  furniture.  Tbo  parents  arc  not  readilj, 
alarmed  at  tbe  inability  of  the  child  to  walk,  ioa»m' 
aa  the  limbs  appear  to  he  so  well  developed.  Wheo 
sttodiug  or  walking  the  feet  are  widely  »«p4rated  feou  ooe 
another,  and  when  they  ore  made  to  approoeli  each  oth«r 
walking  is  rendered  difficult,  and  the  child  may  fall.  In 
walking,  tbo  body  is  inclined  from  aide  to  aide,  so  that  the 
gait  reserabtes  tbe  waddling  of  a  duck.  When  the  feet  are 
kept  widely  apart  the  centre  of  gravity  at  each  stop  must  be 
carried  well  over  to  the  side  of  the  active  leg,  in  order  that 
the  liuo  of  gravity  may  pass  through  tho  centre  of  tbe  arcb 
of  the  foot  planted  on  the  ground.  Ducbenne  thought  that  tbe 
oscillation  of  tho  body  in  walking  depended  upon  we&kneia  of 

thegluteuamediua.  But  in  the  case  of  Charlotte  A .already 

described  (§  4-12),  tho  gluteus  medins  on  both  sidt-s  was 
paralysed,  yet  itiatead  of  the  waddling  gait  so  characteristic  oF 
pseudo- hypertrophic  paralysis,  tho  bead  and  body  were  moved 
forwards  during  locomotion  in  a  straight  line  without  the 
normal  lateral  inclioatioa  of  them  being  observed. 

Id  sevarol  caaca  of  pitcudo-bypertrophic  paralysis  which  I 
have  examined  with  reference  to  this  point,  on  placing  ouo  of 
my  hands  on  each  side  of  the  peh-is  immediately  above  tbo 
trochanters,  ihc  gluteus  medius  on  tbe  side  of  the  active  leg 
could  be  diatiucliy  felt  to  contract  at  each  successivo  «tep. 
Tho  patioats  also,  when  lying  on  one  aide,  with  legs  extended, 
are  able  to  raise  the  upper  leg  away  from  the  other,  without 
much  apparent  difficulty,  and  when  the  hand  ia  placed  over 
the  gluteus  raodius  during  th'u  movomont  the  muscle  may 
be  felt  to  contract  powerfully.  In  an  advanced  case  of  tbe 
diuftse  which  I  saw  recently  oJoog  with  my  friend  Dr.  John 


n'-iPr 'ri 


^ 


8ri:fAL   COBD  ASD   MEDULLA  OBLONGATA. 


189 


Burnley,  tbe  paltoot  eould  aot  stand  or  sit  erect,  j«t 
wbcn  lying  oo  bis  side  he  could  abduct  the  upp«r  leg,  and  on 
placiDg  my  band  nbore  the  great  tiocliauter  of  the  femur  the 
glnteos  medtus  was  f«lt  to  contract  Tbiit  muscle  wan,  therefore, 
out  likely  to  havti  been  affected  at  an  early  period  of  tbe  affec- 
tioa.  The  oscillation  of  the  body  in  walking,  therefore,  iostcnd 
of  being  cau»ed  by  paralyais  of  the  gluteus  medius,  hi,  in  my 
opinion,  mainty  effocted  by  contraction  of  this  musciv.  The 
luenl  inclination  of  Uie  body  appears,  lodvetl,  to  bv  rendered 
DcoeaBwy  in  the  early  stage  of  tbe  affection  partly  by  the  legs 
being  bold  widely  apart,  &nU  partly  by  tbe  inability  of  the 
patient  to  produce  don&l  dezion  of  the  foot  bo  u  to  allow  tbe 
pawTe  leg  to  swing  forward  in  locomotion. 

in  the  second  stage  of  the  diseiue,  when  doable  talipes 
•qnious  and  doreal  currature  are  established,  other  factors  co- 
operato  in  the  production  of  tbe  alternate  balancings  of  the 
body.  When  tatijM-a  cqtiinus  is  odim!  formed,  the  body  at  each 
tueeenive  Btep  must  be  delivau>ly  balanced  so  that  tho  tine  of 
gisrity  will  posK  through  the  ball  of  tbe  foot,  and  ounKequently 
the  aligbtest  dispIacemoDt  of  the  ccDttv^f  gravity  would  cause 
the  patient  to  fall  It  is  therefore  neceesary  thai  at  i>acb  step 
Uw  body  abould  be  inclined  well  orer  to  the  aide  of  tbe  active 
leg,  and  tbe  patient  aids  himself  in  balancing  the  body  on  the 
ball  of  the  foot  on  the  side  of  the  active  leg  by  moving  his 
atnu  about  like  a  rope  dancer. 

When  the  patient  is  laid  down  or  falls,  he  raises  himself  in  a 
chaiaeteristtc  mannor.  If  any  object  b«  near  which  he  can 
courenientty  groAp,  such  as  a  choir  or  other  article  of  furniture, 
be  drags  btmHelf  up  by  bis  arius.  Wheu  the  patient  baa  to  get 
up  willujut  extraneous  ud,  bo  fint  raises  him»clf  on  his  hands 
awt  feet.  lu  the  first  position  which  he  assumes  the  patient's 
leet  an  planted  on  the  ground,  tho  different  segments  of  the 
lower  extremities  are  slightly  Boxed  upon  one  another,  tbe 
body  is  Boxed  oo  the  lower  extremities,  and  the  head  directed 
dowowarOs,  and  tho  tips  of  the  fingers  of  both  hoods  rest  oo  the 
grpand  a  Utile  in  front  of  the  toes  (Pkte  III.,  1).  Tbe  patient 
next    raucs    his    hand,    say    the    left,    and    places    it    above 

now  drawn  over  to 


body 


oppost 


BO  that  iu  weight  rests  mainly  on  the  right  leg,  by  one 


190 


BTVTEK  DISBAflES  OP  TBB 


vigorous  push  of  the  left  arm  iho  left  knee-juint  is  thrust  backi 
wards,  and  the  log  and  thigh  are  thus  extended  oae  upon 
another,  while  tbe  body  ia  ut  the  same  time  thrust  upwards. 
The  feeble  extensors  of  the  body  on  the  thigh  are  now  brought 
into  action,  and  the  trunk  is  partly  nused  upwards  by  their 
contraction,  and  partly  punhed  upwards  by  the  left  uppcrj 
extremity,  while  tbe  right  may  not  require  to  be  placed  ovt 
the  right  knee  in  the  early  stago  of  the  aSectioo. 

But  even  in  the  early  iitage  of  the  disensc  tbv  action  of  the 
extensorsof  the  body  ou  the  thighs  is  greatly  aided  by  the  abduc- 
tors of  the  thighs,  and  the  potieat  muy  be  observed  to  elevate  tbe 
trunk  by  a  kind  of  rotatory  movement,  the  bodj  being  drawo 
tir^t  to  the  one  side  and  then  to  the  other. 

The  following  case  has  afforded  me  an  opportunity  of  studjiiig 
the  different  niovoments  n-hich  are  mado  in  the  act  of  ottaiauig 
the  erect  posture,  inasmuch  as  these  are  slowly  performed;  and 
ns  the  case  is  of  interest  in  other  respects,  I  shall  describe  tbe 
symptoms  in  detail  I  have  received  valuable  assistance  &om 
Dr.  A.  H.  Young  in  deticribing  the  different  groups  of  muitcles 
which  are  brought  into  action  by  the  patient  in  atUuoing  the 
erect  posture. 

Potflr  P ,fortj-fiv«  years  of  age,  was  admitted  to  the  Royal  Inl 

MaocliasUtr,  I'sbrunry  Ijtti,  t&St).  Ha  vaa  qu)t«  haahby  until 
yMn  of  agv,  when  bo  bad  as  attack  of  typhoid  hnr.  Daring  tb*  att*ck 
of  fflvw  he  juffored  from  bed-sorss,  and  his  recovery  was  Mow  and  p»o- 
traet«d.  SabMqiMiit  to  tliia  period  ht  oouM  aH^end  a  *tair  with4Ut 
diffioulty,  and  could  carry  weighta  like  other  people.  Re  thinks,  however, 
that  bw  mndo  of  walking  wm  peculiar,  and  Uiat  be  vne  wenlc  on  his  legs. 
Bo  could  not  joiu  iu  gamea  which  miulred  active  exerciae,  as  ninniog,  and 
the  other  boys  at  school  amtued  tbenuelves  bj  piubtng  agaiust  him  and 
tbrowiog  him  down.  At  fiftoou  yuars  vt  age  he  was  apprenticed  to  a  Joiotr, 
and  waa  then  able  to  oaoend  a  liutder  aud  parfurm  the  ordinary  work.  It 
woa  not,  indeed,  until  he  was  thirtj  yean  of  age  that  blrapreaauiHyinptMna 
iMgau  to  altmot  attention.  At  this  ttma  his  maater  observed  that  ha  waa 
unable  to  get  through  hiit  work  like  the  other  rani,  aud  ooiLsequeatly  be 
wa!4  the  lint  to  be  dijtchaiged  when  worlc  wu  aoaroe.  The  ftntt  Myniitem 
which  attracted  liia  atl«ution  was  that  ho  wan  utiabla  to  aaoend  a  etair 
without  placing  biH  baud  ou  bis  kiieu,  white  holding  ou  to  the  buiiator  with 
tbe  other  baad.  From  that  tLin«  up  to  tbe  pneont,  a  period  of  tbirteeo 
yaan,  be  baa  b«ooine  gradually  nod  slowly  wone.  He  was  married  thii^ 
leeo  years  ago,  and  baa  throe  cbildrvu,  all  of  whom  are  hoalthy. 

J'ritvM  Cvttdition.—  Tbe  patient  eeemabirly  veil  nourisbed  and  bealtliy. 


SPtllAL  OORD  jLKD  VKDVLLA  OBLOKGATA. 


m 


Tbm  is  »  ctoatrtx  two  iocbaa  in  diameter  on  lli«  [irominvnt  pftrt  of  tlie 
aKnuu,  luitl  a  smaller  0110  oirer  tlw  gnai  troch»nt«r  of  tho  femur,  on  each 
aula,  tluwe  being  left  b;  the  bed-MRfl  frooi  which  he  cuflbrad  wh«a  ill  of 
t/iibuid  fvrer. 

Am  tha  patteut  ■taiiibi  Du  Lho  tluor  in  tho  erect  jxiature  hii  feet  an 
4^  tuchoa  apiui  at  the  heela  and  10  iuclioa  at  tha  toca.  The  lieela  acaroalf 
touch  tlw  (nMiid ;  wImd  ht  itanda  on  hJJt  naked  Tevt  a  piece  of  oardboanl 
oMi  In  readil;  pasMd  botwtea  the  bvch  and  tho  Hoor.  Whea  ha  raiaee  his 
loot  off  th*  ground  it  MMunea  th«  poutioo  of  talipea  equino-Tarua,  aud  he 
Okoaot  prodiK*  doraal  fleuou  of  th«  fool,  but  there  m  110  defvnuity  of  th« 
toe^  Wb«D  the  patieut  ia  ataDdiu^  tho  inuaclea  of  the  calf  are  haxA,  teuse, 
OMDpanttrelj  large,  aod  woU  fonncd.  Th«  uutclea  of  the  tbigb  ate  auinll, 
■oft,  aad  Aabbj,  ao  that  the  oouipiiratiTal;  alvoder  thi|{ha  offer  a  atnkiitg 
ooBtrvat  t«  the  largo  kdI  ««U  formed  cftlvM.  Th«  buttooka  are  somewhat 
flattened,  aud  Gbrillarj  iDOTemeiita  are  obMrred  io  tlia  eroctor  aiilnn  aud 
tha  nuaclM  of  Uw  back  of  the  thigh.  The  ecapular  musclw  are  uuatloctodl, 
tilt  deltoids  are  |irotmneDt,  and  act  with  great  energy  on  roluntary  oSbrt. 
Tba  pacboral  mueclee  are  decidedly  atrophied,  aud  tha  triMjia,  bieepe,  and 
tka  Eotaoo-liraofaialia  are  vaatttd  to  no  marked  a  degree  that  the  aletidenieaa 
of  tha  ana  (>Sen  a  strong  eontnuit  to  the  foil  and  rounded  shoulder  caused 
bf  tlia  promineuoe  of  ttie  deltoid.  The  muiwlea  nt  the  forearm  an  nut 
atrophied,  and  tboy  etand  oat  promioently  under  the  skin,  and  feel  hard 
■od  teoso  whru  the  patient  frasps  aiijlhing  strongl;,  yet  his  grasp  is 
rwDukably  feeble.  I>r.  Leech,  who  has  nude  a  microsoopic  tzamiaatioD 
of  portiuus  of  thene  miucloi  withdrawn  by  his  trocar,  oBaurea  me  that 
the;  eihJbit  morbid  thUkgtM,  bat  he  is  onkblo  to  a^y  that  they  are  the  same 
ta  tbow  which  cbaraotariae  pseudo-hypertrophy  of  muscle. 

ThefoUowiagoMunrenienta  wore  taken:  Height  nR.7iQ.,drcuinfer«nac 
of  IbediuL  32in^  abdomen  aijin.,  u|»per  jiart  of  aich  thi([h  l(l|iii.,  middle 
at  aaeb  Uiigh  13ia.,  each  oalf  IS^iu.,  upper  arm  T^in.,  forearm  »}in.  The 
«iroanifn«Dc«  of  Um  calf  oioeeds  tluit  of  the  middle  of  Ihu  thigh,  while 
the  ctroomferttMe  of  tbe  forearm  ((reatl;  exceeds  that  of  tha  upper  arm. 
Vf\u\e  standiDg  the  pelris  ta  iuoliaed  weU  forwardi^  bia  ahdoman  la  aom»- 
what  pratvbemit  J  while  the  apper  part  of  bia  body  ia  dragged  backwaHa, 
to  that  a  deep  curve,  with  ita  ooucarity  dirvctod  backwards,  ta  formed  in 
the  tumt>odonal  ngioo.  A  plumb-ljue,  let  fall  front  the  toost  prominent 
of  Um  epiiwus  prooessea  vt  the  upper  doreaJ  T«rt«br»,  falla  thrae  inches 
behind  tbe  sacnim. 

WmUtiryf. — I'he  gait  of  the  patient  is  peculiar  aud  cbara«t<triatic;  the 

ly  la  alternatety  drawn  from  side  to  aide,  gi*tug  to  the  walk  a  duck-like 

vaddiuig  luvwtneut.  The  patieut,  eui  alt«ady  nniarked,  can  neither 
pbea  tho  two  hir«ls  Annly  on  the  ground  at  the  same  tune,  nor  elevate  the 
loaa  by  producing  dorul  flexion  nf  thu  foot,  and  oonseiiiienUy  the  pasive 
lag  earuiot  awing  forwards  with  the  Dormsl  pendulum  moreoient. 

The  dtf&culty  of  moviDg  tho  poMire  log  forwards  la,  indeed,  jnereaaed 
by  tba  fact  that  the  predoaiinaul  actdon  of  the  miiHloa  of  the  ualf  ext«nds 


192 


SYSTEM    DlSBiLSES  OP  THE 


tba  foot  on  tlie  leg  wben  onoe  It  is  ninei  off  the  ^und,  to  thkt  Uu  Umb 
u  IcDgtbcucd  iuGtDod  of  being  HhDrt«ned  hj  dntsal  floxjou  of  th«  fbot,  M 
in  Dormal  iocntDotia]].  Under  these  circunmtauctt  th«  tora  of  th«  pMtfra 
tog  am  nud«  to  clear  th9  gTouud  by  a  diSemut  ai*chaiiUni  froca  tfa«t 
wbioh  obtains  in  bealtb.  Tb«  feet  are,  u  alroaily  dcacribed,  b«lil  widel} 
apart ;  Lti<l  nhon  thn  pumWe  log,  say  tha  right,  is  bt  b«  movsd  fonraM* 
the  body  n  dragged  veil  oror  to  the  left.  Thia  moremeot  ia  mainl; 
sffiMtoct  by  tha  abducton  of  Uie  thigh  on  the  aide  of  tha  astir*  log,  and 
the  gluteus  medina  on  that  aido  is  fuh  titrouglj-  contracted  on  placuig  the 
hand  OTar  it.  Bat  the  centre  >>f  gravity  is  not  only  drawn  orer  to  tfea 
ffide  of  tho  acUve  leg,  but  it  is  also  drairu  somowltat  backwards  by  iba 
utioii  of  the  gluteal  and  probahly  also  the  hamstriug  mucelea,  and  the  liae 
of  grarity  lu  passing  through  the  arch  of  the  lift  foot  appnwobeA  tLebeel, 
and  tbe  latter  ia  now  felt  to  b«  firmly  pUot«d  od  the  ground.  Itafuf 
this  duubk  but  o»uibiued  movenidut  tbi:  line  of  gravity  ia  iu  datngar  «f 
being  oarried  too  far  to  tbe  left  and  backwaidi^  baoce  the  right  anu  ia 
tlicowB  outwards  ai;d  furwanla  do  ue  to  tuuutaio  the  Miitre  of  graTity  aa 
far  to  the  right  and  forwarda  as  po<>ail)]^.  During  tbe  lateral  movMBent 
of  the  body  toararda  tbo  tide  of  the  active  I«g  tbe  pelvla  ou  the  aide  of  tbe 
pamire  log  ia  elevated,  and  tbua  Ibo  Ivngth  bvlwaao  the  head  of  tbe  Uana 
Mid  ground  i»  incrcaiMd,  and  during  Ibc  biKkward  iDOv«tiK>nt  of  the  body 
the  pelvis  is  mmlo  to  asmme  a  moru  vertictil  pciaitioci,  m>  that  Die  B«u>n  of 
the  thigh  on  the  body  can  oot  more  of^jently  en  tho  paaaivo  lag.  The 
thigh  of  tbo  passive  leg  ta  now  Sexed  on  tbe  body,  the  abdaotoca  alaa 
oontraotiug  and  giviug  to  tbti  thigh  au  outward  inolinatioo,  tbe  leg  ia 
slightly  flexed  ou  tb«  thigh,  and  tlie  foot  is  moved  alowly  forwarda  and 
outwarda,  aud  wb«u  Ih?  at«p  ia  comploted  tbe  toe  coniee  6mt  to  the 
ground. 

The  fcnraid  and  outvord  prcjooUon  of  tbe  p«A*ivo  leg  teoda  to  oovstv- 
act  tbe  t4!ticlency  of  the  line  of  gravity  lt>  paiu  Inn  far  to  tbe  aide  of  tfca 
aotiv«  leg  and  bacltwarda.  When  the  paa«ivc  leg  ia  placed  on  tbe  growtd 
the  ahductorv  of  tbo  thigh  on  that  aide  oootroct,  tbo  body  ia  drawn  am 
to  thu  ri^ht,  and  tho  line  of  gravity  ia  alowly  traiufemd  to  tbe  lag  titkl 
wan  [ULiHtiTo  and  which  now  in  ita  turn  becomea  active. 

Attaining  the  Bnct  Pottwt. — Ou  rising  fruui  tbe  nvumbeut  poaiUeo 
tbe  patient  Unit  geta  aa  hia  handa  and  kaeeii,  aud  placing  hta  right  fooCen 
Ibe  ground,  he  reettbia  right  elbow  above  the  Icuee,  and  iucliuea  hia  tnmk 
to  the  right  so  tba.t  tiie  centra  of  gravity  paaaea  through  the  right  foot 
When  he  loana  well  forwards  in  this  position  and  praaaai  bie  right  elbov 
dowuwarda  and  backwards,  it  will  tond  to  drag  tbo  tninV  and  with  it  tbe 
right  hip'j^int  forwardv,  but  inasmuch  ta  tbo  right  ku«e  is  at  tbe  aanx 
tiiiM  prtvwd  downwards  and  backwards,  any  forward  movement  of  \ia 
hip-joint  must  bo  a«comi>aiiiod  by  ekvatioo,  'I  bo  weight  of  the  trunk  is, 
tlierofore,  ao  applied  that  it  tenda  to  drag  tbe  bip-joiat  forwards  and 
upwards,  and  thua  to  extend  the  trunk  on  tbe  thighs  and  to  push  tbe  right 
knev-Joiut  downwarda  aud  backwards,  and  thua  to  eitand  the  lagapoo 


SPINJLL  CORD  JlSD  MEDULLA  OBLOSGA.TA. 


ms 


tba  lUgh.  M>  that  Uw  traigltt  of  tha  tmnic  ia  ao  applied  u  to  ni  j  tb* 
ntnmm  In  erecting  Um  boiljr. 

The  «xt«oior  miuclM  an  now  brought  into  action,  and  th«  tninlc » 
■L»«lr  alevatcd  to  what  I  majr  call  the  aocond  ]Mattiftii.  In  ttiin  [Kaition 
tha  nriou  Mgnwnta  or  the  right  lower  oitromit/  are  alightly  DozmI  upon 
«■■  aoothier,  tlia  tntnik  ia  dirvctod  ri^r-nnls  honsonUII;',  and  th«  right 
■Ibow  reau  >bor«  t]i«  Icnrw,  whilw  the  l*(l  thigh  is  directed  retticall/ 
dowBwania,  tba  kit  1^  is  iDclin«d  don-owarda  and  backwarda,  and  the  toe 
reata  oa  ibe  giuuikl  on-iideraMy  bvhind  the  right  foot,  while  the  left  hand 
iwta  light]/  va  the  l«rt  thigh  innaodiBtoly  above  tiia  kn«o- 

Aftara  manMotarj  pause  the  patioiit  proceedn  toattain  the  thinl  poai- 
Tha  iMuetora  of  tbo  right  thigh  contract  and  rotiito  the  pelrle  ao 
.  the  l«fl  ht)i-joint  ia  slight!;  eluTatcd,  Thin  inovctDciit  hriaga  the  liDe 
of  ^kvity  Wfll  wtthiii  tba  right  foot,  and  taken  th>  weight  of  tho  trunk 
taXirAj  vfftbe  left  lovor  ottranitjr.  Thr  left  foot  is  now  drawn  forwardti 
aod  ^Jaead  tm  tha  ground  in  a  lino  with  the  right  foot,  but  alight! jr  mtiior«d 
tram  it  laterally,  while  the  left  hand  at  the  eamo  time  graepe  the  lofi  thigh, 
kawtiately  abo<re  the  knw  By  a  coiitrnvtiou  of  the  aUluctora  and  ex- 
l«B»Bfa  of  the  left  tbigb  the  lino  of  gnrity  ia  now  truisfvrrod  (roui  the 
rifht  to  the  left  foot,  the  ngbt  ahotdder  is  elevated,  aud  the  h^bt  hand 
ia  quidily  trauafcrred  to  the  poeition  prerioualy  occupied  by  the  elliow ; 
Um  abducten  and  extauaon  uf  the  left  thigh  now  relax,  uiitil  tliu  liiie  of 
gnrity  pamm  botweea  Uie  foot,  aud  Iho  third  potntiotj  a  attoinod. 

lo  thia  position  tlw  two  aides  are  aymmetiioJly  placed.  The  f««t  are 
phcei  ua  the  gniand  aod  aoinewhAt  nmvni  from  one  ooatber,  but  the 
beak  do  not  quite  touch  the  giound;  the  lega  are  alightly  Hexed  on  the 
fcat,  Uw  Ihigha  un  the  tegs,  and  the  tniuk  ou  tbo  tbigha ;  both  arnw  jmu 
domwaHa  and  baokwaidi^  each  band  graaping  tbe  thigh  of  the  oorre- 
^ooding  aide  clooe  above  the  kneoi.  When  the  patient  ie  viewed  laLoraUy, 
the  ihigh,  am,  aiid  trunk  are  mvu  to  form  the  tbre«  aidea  of  a  triangle 
(Plate  III  ,3),  aud  tlw  weight  of  tbo  truuk  applied  through  the  arum 
Buut  tend  to  puab  both  knees  downwanU  aud  backwartla,  while  at  the 
aanie  tine  tending  to  elevate  the  hijfjoiota.  The  body  is  incUoed 
fcrvmf^  aud  apwaids,  but  owing  to  Uw  deep  dono-lumbar  curv*  the 
TWteal  alia  of  the  pelvie  oocupioe  a  ntotv  horisontaJ  positiou  tbaa  might 
he  aopeeted  from  tbe  upward  incliuatioo  of  thu  bo<!y.  The  Une  which 
>)i«a  tba  anUcior  superior  spioe  of  tbe  ihum  aod  the  head  of  tbe 
faaar  fcnna  nearly  a  ri^t  augle  with  that  which  juina  the  liead  «f 
th*  tbnur  and  the  centre  of  the  arch  of  the  foot ;  and,  ean>*e<iueat1y,  were 
ibe  ^uteus  mediua  aud  mioicuua  of  both  eidca  tmw  to  contract,  they  would 
•M  ouiBly  aa  Aeiors  of  Lbe  pelvis  oa  tbe  thighs. 

Tbe  pstinit,  a{W  a  little  pause  Ut  take  breath,  propans  for  a  further 
elevation  of  tbe  body,  the  groat  difficulty  Iw  has  to  eoeouuter  ia  to  erect 
Um  palria  on  the  tlitgha,  while  at  the  same  time  exteading  tbe  varioua 
of  the  lower  extreinitim  upon  one  another.     By  tranaterriBg  the 

I  of  gravity  from  one  foot  to  tbe  other  be  takee  ttie  woijjbt  of  thu  body 


194 


STSTCK  DISEASES  Of  TBE 


off  each  foot  alternately,  asd  in  this  way  be  is  enabtod  to  slip  hy  tant 
oaob  baud  further  up  t)i«  thiKhn  until  be  granpa  tbnn  about  tbe  juoctioa 
of  the  middle  with  th«  lower  tbird.  Tho  tiunk  is  oow  drsggod  orn-  to  tbi 
left)  so  that  thci  Ud^  of  grarit;  paaaea  tbrough  tbe  loft  foott  and  tlK  ly^i 
band  iM  nmoTud  from  tho  right  thi^h  (Plato  III.,  4).  The  right  foot  li 
nbuSlod  outwards  and  biu;Warda,BoantoaIlowtbDlcj;  tobefuU/ezteaded 
OB  the  thigh.  This  iaoTea«at  is  [H*rrarm»d  vith  great  dcliboratton,  i 
■fler  it  is  eiTiiotcd  tbe  patieut  reota  for  a  luomeut  as  if  to  assure  bit 
that  tbe  right  foot,  which  nov  rests  on  its  inner  edge  constderabt/  belund 
Olid  removal  frotii  the  loft  foot,  ia  finulj  (>lanbed  no  aa  not  to  sLi|).  Tbe 
final  effort  now  bugina.  Apparently  b/  a  combined  action  of  the  inward 
roUtore  of  the  left  and  »f  thu  outward  rotatoni  of  the  right  thigh  tbe 
t)elviei  is  mtAtod  obliipioly  frvm  iiefora  bocltwardji  and  &oai  right  to  ItiL 
Bj  thia  muveiDiunt  tbo  right  bip-joint  in  brrjugbt  well  farwanl>|  aod 
palvia  ia  pru1>«l>l)'  oIno,  hy  a  aimultaueowi  actiiiii  of  tbe  exteoaon  oCJ 
body  00  the  tbigb,  made  to  anaume  a  more  vertical  ptwitioii.  But  wfa^ 
ever  ma;  be  the  tuiture  of  the  muacular  action  concerned  iii  thia  mart- 
ment,  when  it  is  ooutploted  the  bead  of  tbo  ri^t  fomur  is  pU««d  alowet 
vertically  below  tbe  anterior  aaperiur  ii|une  oT  tbe  ilium,  iiiatead  oC  baing 
on  this  name  horizontal  pkue  irith  it  as  in  the  third  poeitioo.  The  bat 
which  joins  tbe  Biiterior  superior  spine  of  tbo  ilium  and  the  gre«S  tto- 
obttuter  dow  forma  a  wry  obtuM  angle  with  that  joining  tbe  great 
trocbiiiter  mA  tbs  middle  of  the  arcb  of  the  foot,  aod  in  thia  poaitfan  tbe 
glut«ix3  rnminma  and  tuodius  will  act  naialy  as  extvoaora  o(  tbe  pelvit  on 
the  thighs.  Tbe  great  efiort  of  the  patiBUt  is  now  directed  to  tranrftr  the 
line  of  Kravity  from  the  left  to  the  right  foot  Thia  ia  eSected  by  the 
trunk  beiog  draggwl  over  in  a  diugoDal  manuer  from  befora  backwards 
and  bvoi  left  to  h^M,  partly  by  thecuujuiued  action  of  the«xt«usocaMiil 
abductors  of  tbe  right  thigh,  and  partly  by  tbe  left  sboulder  being  pusbed 
upwards  and  to  the  opposite  aide  by  forces  acting  upoa  it  from  bel«w 
thmugh  the  arm.  Tbe  elevation  of  the  left  ahoulder  ia  elTected  by  the 
azbennoD  of  the  diSoreDt  segment?  of  the  arm  npoii  one  anotfaet,  and  by 
the  elevation  of  tbe  bcel  and  consequently  of  tbe  knee  by  coiitnctlou  of 
the  muecEea  of  the  calf.  The  upward  movement  of  tbe  kft  ahookUr  i* 
not  ODO  of  simple  elevation,  but  is  indeed  a  very  onmplei  act  The  left 
knee  is  not  only  olevated  by  contraotiau  of  the  rhiscIm  of  the  ealf,  but  a 
stroitg  contraction  of  tbe  adductors  of  the  tbigb  preventa  it  from  betog 
thnwt  out  bttenUy.  Tbo  inward  rotators  of  the  left  am  {the  Ifititiimir 
donn,  terca  m^or  nod  minor,  and  iufraspinatua),  and  the  abducton  of  the 
arm,  especially  the  posterior  third  of  the  deltoid,  enter  into  atrong  oo»- 
tractioD.  Tbe  toadency  of  the  coiubined  ati^on  of  these  muacles  is,  the 
arm  beltig  fixed  by  tbe  baud  grasping  the  knee,  to  thrust  the  left  abooUer 
to  the  oppoeita  side,  aod  to  rotate  the  body,  so  that  tbo  loft  shoalder  i> 
pushed  forwards  in  advance  of  the  ri^ht  mm.  V>o  have  alrvady  seem  tM 
the  pelvis  was  rotated  in  tiucli  a  way  that  tbo  right  was  placed  In  advance 
uf  tlie  left  hip-joint,  and  iiuw  the  left  i*  pushed  forwards  in  advaooe  <' 


SPINAL  COBD  AND  MEDULLA  OBLOKOATA.  195 

tbt  riffat  sboaliler,  uid  coasequeDtly  tho  upper  part  of  ths  \xiAj  in  )m»g 
rot>t«d  in  tbo  «{>p9nt«  direction  to  the  lowor  put ;  «r,  in  other  n-orda,  the 
ptlris  is  b«ing  totaled  from  right  to  left  thioiigb  the  hip-juiiiU,  ami  frora 
l«ft  la  right  through  the  vertebr&l  colamn,  the  power  iii  the  latter  «a«o 
beuig  ^uplJed  on  a  Urel  wiUi  the  brim  of  the  pelvia.  If  iim  f»rc«H  which 
teed  U>  rotate  the  pelvi*  from  right  to  left,  uid  thoee  which  t«nd  to  rotate 
it  frota  left  to  right  were  tppliod  on  th«  atuao  \im\,  thojr  would  tend  to 
MulMliee  ooe  MMtJter,  and  the  pel^l*  would  remain  more  or  Iww  fixed. 

I  Bnti  iitfamiich  aa  the  forces  which  rotate  the  pelvis  from  right  to  bft 
a  afiptied  thmngfa  tho  ht[i-Joitit«,  atid  those  which  tend  to  roLute  it  from 

{ Ut  to  rixht  through  the  vertebral  coUmii,  the  oonaequenoe  ia  that  the 
temcr  will  tend  to  puah  the  hnad  of  tbo  right  feniiir  forwards,  whtLa  the 
kttsr  wiQ  tend  to  carry  the  brim  of  the  right  ilinm  backwanls.  It  will 
he  Ifans  aMQ  that  the  forward  rotation  of  the  left  shoulder  will  tend  to 
caiTX  tlw  aatcrior  n>iperi»r  epitie  of  the  right  ilium  baokwaida,  and  thnro- 
l«  iMiata  Uw  aetloo  of  the  gluteua  mediua  and  mioimuaof  the  right  side 
MoUnaMSof  the  bod^  on  iht  tbigih.  It  uaj,  itide«d,  be  said  t^t  the 
donhla  ratatioD  just  daaorlbed  twiata  or  secewa  the  pelvia  iuto  a  more  or 
■  enct  pontien  with  reforeuoo  to  the  right  lower  extromitj,  around  the 
tuf-joiot  of  which  all  the  BpoTemeDta  of  the  bodjr  at  present  oeutre. 
Am  ths  tioe  of  grarit/  spproachca  the  right  foot,  tbo  lof^  lower  sztrtmit; 

^b  beoooiiog  mora  and  more  inclined  forwardi!  and  outwards,  its  difliirent 
■l|iiHiii!ii  beeoiae  sxteoded  upon  «»o  another,  aud  the  toe  renrts  on  the 

I  jroond.  When  onoe  the  line  of  graritj  {laiutes  throiigli  the  right  foot,  the 
•steosofs  and  abduotoiti  of  the  right  thigh  relax  somewhat,  while  those  of 

I  the  lafk  DOW  suddenly  contract ;  tlie  pelris  tit  rotated  once  more  in  such  a 

I  waj  that  the  bead  «f  the  left  femur  is  brought  forwards  under  the  pelrn. 

I  During  this  moremvut  the  left  hand  is  remored  from  the  thigh,  the 
nnsdoB  of  the  calf  relax,  the  heel  comes  to  the  ground,  and  the  tine  of 
fjmwitf  is  rorn  mouient  trooMfcTTcd  to  tho  left  foot,  but  immodint«tjr  after' 
WBfds  the  weight  of  the  bodjr  is  borne  by  both  foet,  the  line  of  gn-ritj 
bSiat  betweeu  thorn,  and  die  erect  poeturc  is  attained. 

When  the  patient  reclines  on  one  side  he  can  raise  the  uppermost  leg 

I  awaj  from  the  other  with  a  ooosiderahle  degree  of  force,  and  during  this 
tetiaD  the  gluteus  mwjius  can  be  fielt  strongly  oontracted. 

Wbita  mtting  bo  cut  cross  one  log  orer  the  other  readily,  abduot  and 
•Mnet  bia  Isga  with  connderahle  force  agunat  a  resiitCiug  olijaat,  but  he 
an  eoJjr  produce  duraal  dexiuu  of  the  fool  to  a  alight  extent. 

Owing  to  the  fcebloDcas  of  ibc  gluteus  maximus,  the  patient 
riperieocen  great  dii&calty  in  getting  tipxtvps,  and  the  luaDQCr 
in  wbidi  be  aacentls  a  stair  is  aa  characterietic  as  that  iu  wbicb 
be  mttAiDS  the  erect  posture.  He  lays  bold  of  the  railing  with 
one  baoil  say  tba  right,  and  by  the  coutiactioa  of  tlie  nau8cl«a 
of  tbe  right  upper  extremity  be  drags  his  body  upvrarda  at  eacb 


196 


STSTEU  DISEiLae8  Of  THE 


etepi  The  right  arm  ia,  however,  assisted  by  the  left.  The  left 
haod  is  plaoted  above  the  left  knee,  and  each  time  the  loft  log 
ia  raised  a  stop  the  body  is  thrust  upwards  by  the  vanoiu 
BogmeutH  of  the  left  arm  being  exLeudihl  upon  oue  aiiother. 

One  of  the  xnmt  coDHtant  symptonu  of  the  disease  is  the 
exieteuce,  duriog  standing  or  walking,  of  a  remarkable  curra* 
ture  of  the  spine  iu  the  lumbo-sacml  region.  The  Hhoulden 
and  upper  part  of  the  vertebral  column  are  carried  backwards, 
80  that  a  plumb-line  let  fail  from  the  most  promineat  sjndous 
procbsa  of  the  vertebra*  fuUd  bchiud  the  eacruin.  I  hare,  b<iw- 
ever,  obeerved  an  undoubted  example  of  the  diaoaae  in  irbicfa 
the  plumb-iine  did  not  clear  the  sacrum.  Ducheone  attributes 
thia  iucurvutioQ  to  weakacba  of  the  erector  muaclcs  of  the  epioei 
but,  aa  pointed  out  by  I>r.  Gowers,  weakocsa  of  the  exteownof 
the  pelvis  oa  the  thighs  contributes  to  the  formation  of  the 
lordosis.  Weakness  of  the  extensors  allows  the  pelvis,  and 
with  it  the  lowcil  lumbar  vertebra;,  to  incline  forwards  in  the 
erect  posture,  and  a  compensatory  backward  inclination  of  the 
dorsal  spine  ia  oecpssary  in  order  to  keep  tbo  centre  of  gravity 
in  the  normal  position. 

Another  important  feature  of  the  diseas^e  is  that  the  patient 
ha.s  a  difficulty  in  bringing  hiH  heels  to  the  ground  ;  and,  ai  the 
caite  advances,  a  permanent  condition  of  talipes  equinux,  or 
equino-varus,  is  established.  The  foot  becomes  more  boUow 
frora  increase  of  the  plantar  arch,  while  paralysis  of  the  inter- 
ossei  causes  the  first  phalangea  to  be  maintained  in  a  state  of 
exaggerated  extension  on  the  metatarsal  bones,  and  the  two 
distal  phalanges  to  be  flexed,  so  that  the  toes  assume  the 
p«culiAr  clawlike  appearance,  which  Duchcnse  has  cftlled  ^riffe 

The  apparent  hypertrophy  of  the  musdeo^  which  is  Ibe  most 
characteristic  symptom  of  the  dise4W,  generally  begins  by  en- 
largement of  one  calf,  the  other  also  becoming  affected  before 
very  long.  This  is  the  uRual  mode  of  invasion,  but  sometimes 
the  muscular  enlargement  begins  in  the  muscles  of  the  upper 
extremities,  as  in  a  case  related  by  Duchenne,  where  the 
deltoids  had  begun  to  enlarge  many  months  before  the  gostio- 
cnemii  The  gluteal  muscles  become  affected  soon  after  thoei 
of  the  calf,  and  then  the  disease  eztendH  in  succesition  to  the 


SriNAL  OORD  1»J}  HBDULLA  OBLON01T^ 


197 


lambchcpina]  mtudes  ukd  to  some  of  tlie  muscles  of  the  thigh, 
tnink,  and  upper  extreiDities.  Of  the  muficles  of  tb«  upper 
extremities  tbe  deltoida  are  usiiall;  the  fint  to  mffer.  Id  one 
cue  related  by  Duchonoc  the  appiirc-ot  hypcrtroptiy  had  become 
■D  genenU  that,  with  the  esceptioD  of  tbe  pectoral  muscles,  the 
hiiaaiinus  dorei,  aad  the  stenio-maBtoid«^  all  the  muscles  of  (he 
IudIm,  trunk,  and  even  those  of  the  face,  cspeci&lly  the  tem- 
pomls,  were  successively  invaded.  Id  a  case  related  by  Weir 
Hitebell  not  only  tbe  muacUs  of  the  face,  but  eveo  those  of 
tb«  tongue,  were  hyportropbiod. 

The  affected  muscles  may  attain  an  enormous  volume,  and 
itaod  out  90  prominently  under  the  akin  that  Diicheane  uses 
the  term  "hernial  protrusions "  to  deseribe  their  appearance. 
Tbe  mnacles  also  feel  bard  and  resisting  to  the  touch,  so  that 
the  vbole  appearance  of  tbe  child  often  HUggealH  the  iilea  of 
Herculean  strength  instead  of  the  great  feebleness  which  in 
reality  ezistR.  But  even  amidst  all  ibis  apparent  development 
of  muaculBT  power  there  are  not  wanting  visible  indications  of 
the  rs«I  aattire  of  the  malady.  Some  of  the  musciea  are  always 
foood  atrophied,  their  wasted  condttioa  coulraating  alrougly 
with  the  exoeaaive  aixc  of  the  others,  l^ven  in  the  case  related 
by  Oachenne,  where  the  child  looked  like  a  young  Hercules, 
the  pectorula  and  latiiaimus  dorsi  were  atrophied.  lu  the 
majority  of  cases  the  muscles  of  the  calves  and  buttocks,  and 
probably  also  the  deltoids,  are  enlarged,  while  the  remaining 
otMclee  of  the  ann,  forearm,  shoulders,  and  trunk  are  atrophied; 
ia  that  the  slenderaeas  of  tlie  upper  part  of  the  body  offers  a 
ntDng  oontraat  to  the  abnormal  development  of  the  inferior 
attmnitiea.  We  see,  therefore,  ibat  all  the  paralysed  muscles 
do  not  undergo  augmeutatiun  of  bulk;  in  fact,  atrophy  of  some 
of  tba  muaclea  is  a  constant  symptom  of  tbe  diseose.  Another 
cutomstaoce  worth  noting  is  that  the  degree  of  paraly^in  lias 
DO  direct  rcUitioa  to  the  amount  of  hypertrophy.  This  is  veil 
iUnstiBted  in  the  leg  where  the  action  of  the  extensors  of  tbe 
foot,  although  theee  are  much  enlarged,  predominates  over  that 
of  tbe  flexon,  as  evinced  by  the  clovatiun  of  the  beet. 

Tbe  diaeaee  now  becomes  more  or  less  stationary  for  two  or 
three  years,  and  soutetimes  for  u  much  longer  period,  and  as 
the  getienJ  health  is  good  and  the  mascular  developc 


19$ 


arfflEM  DISEASES  OF  TBB 


*pparentlj  vory  powerFul,  the  parents  cannot  TjelJCTe  tb&t  (lie 
affection  is  incurable.  This  illusion  i«,  howcTer,  after  a  time 
destined  to  be  diapelled  The  feebleness  of  the  loirer  ertre- 
mitica  gnuIuiLlIy  iDcnjusca,  so  that  Uic  child  cannot  maintain 
the  erect  posture,  whilo  the  miisclea  of  the  superior  extremities 
alBo  become  both  paraljsed  and  atrophied ;  and  ereD  the  bjper- 
trophiod  limbs  bcgia  to  woatc,  aud  to  diminish  rapidly  in  sisK 
The  patient,  now  arrived  at  adolescence,  may  live  on  for  sereral 
yean  !□  a  condition  of  almost  complete  paralysis,  uotiJ  finally 
death  takes  place  from  exbaustioD,  impUcatioD  of  tbo  respiratory 
muBclfis,  or  more  usually  from  some  iatercurrent  affectioD. 

There  aro  still  somo  minor  features  of  the  dlseaae  which 
deserve  atteotioa  Tlie  statements  of  different  observers,  with 
respect  to  the  electro-mmcular  contractility,  are  somewhat  oon- 
tradictorj.  Except  in  the  very  early  stages  of  the  diseasie,  the 
faradic  contractility  is  diminished,  while  the  galvanic  ctmtrac- 
tility  may  be  normal  or  increaned.  lu  the  second  stage  of  the 
disease  the  quadricepji  tendon-reflex  is  completely  abolished. 

Very  frequently  the  akin  orer  the  affected  parts  preaenta  a 
[wcutiar  mottled  appearance,  the  colour  rarying  in  different 
cases,  and  in  tbu  same  caMc  according  to  the  degree  of  exposure. 
Sometimes  it  is  described  as  of  a  roseate  hue,  again  as  bright 
red,  and  at  other  times  as  consisting  of  patches  of  purplish 
colour  alternating  with  wliito.  All  of  these  phenonicDa,  how- 
ever, indicate  capillary  congestion,  the  result  of  vaso-motor  dis- 
turbance. This  supposition  is  still  further  atreogtheaed  by  the 
fact  that  the  superficial  temperature  of  the  inferior  eztremitut 
is  froquently  higher  than  that  of  the  trunk. 

This  disease  Is  often  associated  with  a  eortain  amount  of 
mental  incapacity.  In  several  instauces  the  subjects  of  it  haft 
been  noticed  to  bo  alow  in  acquiring  the  power  of  speech,  othai 
are  described  as  being  obtuse  in  intelligence,  and  a  conmderabte 
number  have  been  idiots.  The  disease  is  not  accompanied  by 
any  suffering,  there  is  no  alteration  of  sensibility,  and  the  fnne- 
tions  of  the  bladder  and  rectum  are  not  interfered  with,  while 
the  general  health  is  not  much  affected  until  near  the  tennioal 
period  of  the  affection. 


§  432.   CouTM  and  Duration. — Tbe  disease  is  easentially 


SPINAL  CORD  AKD  UU>VLIA.  OBLOyOATA. 


199 


AeMk.  It  begins  without  fever  or  marked  derangement  of 
the  fuDCtioBs  of  (ligeHtion,  respiration,  or  circulation.  Ai 
already  stated,  it  connisba  of  a  first  stage  in  which  there  is 
progreBsire  enfpcbicmcnt  of  the  lower  extremities,  saddle-back, 
and  woddliog  gaib  This  ntage  may  last  a  few  weelcn,  moaths, 
or  e*en  a  year  before  the  commeuccment  of  the  next  atage. 
nie  aecocd  period  is  cb&ractcriscd  by  apparent  hypeKropby  of 
ftMrtaio  number  of  muscles,  usually  begioniug  in  those  of  the 
cclf,  and  extending  gradually  to  other  muscles  of  the  trunk 
mad  Dpper  extremities.  lucrcase  in  the  volumo  of  some  muscles 
is  always  aoconopauied  by  atrophy  of  others.  This  stage  of 
muscular  hypertrophy  continues  to  increa.-Mj  progresgively,  and 
attains  its  roaximum  in  degree  ojid  extent  about  eigbteeo 
months  (rom  the  beginning  of  the  second  ntage  of  tlie  disease ; 
the  symptoms  then  remain  stationary  for  two,  or  three,  and 
wtnetimes  for  many  years. 

The  tbird  stage  of  the  disease  is  now  ushered  in  by  a  still 
fortber  enfeeblemitnt  of  the  muscles  already  affected,  and  by 
the  extension  of  the  paralysis  to  the  superior  extremities.  Ab- 
dnction  and  eleTation  of  the  arm  is  al  Rrsb  rendered  difficult, 
ihta  impossible,  and  by-and-by  the  paralysis  gnuluxdly  im- 
pbeatea  the  other  movements  of  the  arm. 

Tbe  child,  now  probably  arrived  at  the  age  of  puberty,  enters 
Qpoo  tbe  last  Blage  of  the  diseoaa  The  slight  power  of  movo- 
meot  of  which  be  was  capable  dxiriag  the  previous  period 
becomes  gradually  lost,  so  that  bo  can  only  sit  in  a  chair  or 
recline  on  a  couch.  The  patient  may  continue  to  live  for  a 
loag  time  in  this  condition,  but  eventually  death  6U[>ervenes 
from  exhaustion  or  some  intercurrent  malady. 


§  433.  Dittynoriif. — When  the  disease  is  thoroughly  estab- 
tiabed  ther<T  can  scarcly  bo  any  possibility  of  mistaking  it  for 
any  other  afleclion.  The  diseasi-B  which  are  most  nearly  related 
to  h  are  infantile  paralysis  and  progressive  muscular  atrophy 
In  tbe  infant.  True  muscular  hypertrophy  may  also  be  mis- 
takeo  for  the  disease,  and  a  likely  coudtlion  to  be  confounded 
with  it  is  a  late  development  of  the  power  of  muscular  co- 
ordioatioD  and  walking  in  children,  especially  when  combined 
with  a  oerobral  lesion,  m  in  cases  of  idtotoy. 


200 


STSTSU   DISEASES  OF  THE 


The  invaaioD  ofin/arUiUparal-^n*  U  sudden  and  accorapanied 
with  fever,  and  tbedUtributionof  the  paralysis  is  totallir  differem 
from  that  of  the  pseuJo-liypertrophic  variety.  Sonmtimes  the 
paralyKis  is  limited  to  a  few  muscles  or  to  aa  entire  limb,  at 
other  timea  it  i^  hemiptegic.  crossed,  parapl^c,  or  general. 
The  uiuack'M  which  are  least  injured  recover  completely,  while 
others  ntropliy,  aud  lu  the  latter  there  is  rcry  early  and 
decided  diminution  of  electro-muscular  conbractility. 

Progreasivt  viu^cuUir  atropfiy  in  the  child  usually  beg 
between  the  age  of  five  and  seven.  Some  of  the  fa 
muscles,  principally  the  orbicularis  orb  and  zygomatic!,  become 
atrophied.  After  a  stationary  period  of  some  years  the  atrophy 
extends  succosaivety  to  the  musclefl  of  the  upper  limha  and 
trunk,  and  the  lower  extremities  are  not  affected  until  a  more 
advanced  period.  The  muscteJt  are  invaded  irregularly,  attd 
as  tlie  degree  of  paralysis  is  always  proportional  to  the  amount 
of  atrophy  this  gives  rise  to  various  deformities  of  the  traok 
and  limbs.  When  the  atrophy  att&cks  the  exteasor  muBclea  of 
the  trunk  and  some  of  the  muscular  groups  of  the  lower  ex> 

tr«mitie8,  as  in  the  case  of  Charlotte  A ,  already  described, 

progreai^ive  masciilar  atrophy  is  by  no  means  easy  to  diatioguish 
from  paeudo-hypertropUic  paralysis. 

Id  making  a  diagnonis,  the  main  reliance  must  then  he 
ploocd  on  the  history  of  the  ceuse,  the  progress  of  the  symptoms, 
aud  a  microflcopic  examination  of  portioas  of  the  muscles  of 
tlie  calf  withdrawn  hy  the  trocar. 

Simple  tntiscular  hypertrophy  may  b©  distinguished  from 
pseudo- hypertrophic  paralysis  by  the  history  of  Uio  case,  the  ab- 
sence of  paralysis  and  of  the  special  symptoms  of  the  latter  diaeaM, 
an<l  if  necessary  by  &  microscopic  examination  of  the  mtutcle. 

In  late  development  of  the  muccular  co-ordinatioo  in 
children  the  feet  are  not  planted  widely  apart,  and  there  is  no 
saddle-back  or  waddling  walk.  Wheu  want  of  co-ordination  is 
combined  with  idiolcy  there  ia  a  flow  of  saliva  from  the  half* 
open  mouti),  and  the  tendinous  reflexes  are  generally  exag*. 
gerated  in  the  lower  extremitlea. 


§  iSt  Morbid  Anatomy. — The  firnt  examination  of  the  oon-i 
dltioD  of  tbe  muscles  in  this  disease  was  made  la  Qermaoy  by 


spisrjLL  ooan  and  uedvlla  oblongata. 


SOL 


OrcisiDgBr  aod  Billrotli,  who  excised  in  a  joang  living  sub- 
ject a  portioQ  of  tho  left  deltoid  which  was  completely  panljsed 
and  bypertrophied.  Diichenne,  however,  oot  llkiog  to  under- 
take auch  a  serious  opcraiioo.  invcotod  a  Hmall  iostrument, 
wfaid)  he  called  bis  "  Emporte  piiscc  bt8tologi(|uc,"  and  which 
enabled  him  to  obtaio  minute  portions  of  muscular  tissue  from 
the  tiving  Bubj«ct.  A.  modi6calioQ  of  this  instruiueut,  first 
proponed  by  Dr.  Ord  (Mod.  Chir.  Tiudsoc.,  vol.  Ivii.,  1874J,  aod 
nude  by  Hnwkslcy,  London,  is  generaily  used  in  thia  country 
fof  the  purpoiK-.  But  after  repeatedly  using  Dr.  Ord's  trocar  in 
variuua  diseases,  I  am  quite  sntistied  that  the  relations  which 
the  different  elements  of  the  diseased  muscle  bear  to  one 
aaocber  are  not  always  accurately  represented  by  the  fragment 
of  tusue  withdrawn  by  the  iuHrunient.  Charcot  indeed  Kug- 
geatfl  that  Ducbenne's  iostruinent  will  withdraw  islets  of  con- 
aectJTc  tissue,  inasmuch  as  it  will  seize  the  fat  cells  with 
greater  difficulty;  and,  judging  from  my  experience  of  Dr. 
Ord'a  trocar,  the  objection  is  valid. 

The  bappy  idoa  occurred  to  Dr.  Leech  tlut  an  inotrument 
mijgbt  be  constructed  which  would  withdraw  a  portion  of  the 
auade  by  cutting  instead  of  by  tearing;  and  Hawkaley  has 
le  one  at  his  su^estion,  which  answers  the  purpose 
tixably.  The  fitit  muBCular  change  which  takee  place  in 
tliii  disaaae  oonaists  of  an  increase  of  the  connective  tissue 
wfatcb  aeparatos  the  muscular  bundles  ftttm  one  another,  so  that 
tbe  ibvaths  of  the  muscular  bundles  become  greatly  thickened. 
11i«re  li  al»o  a  corresponding  increase  of  the  connective  tissue 
which  passes  between  the  fibres  thomselves.  The  compara- 
tivvly  thick  masaes  of  tissue  which  now  separate  the  fibres  from 
one  another  consist  of  fibres  arranged  parallel  to  tlie  long  axes 
of  the  muKular  bundles,  mixed  with  a  considerable  number  of 
ciabiyonic  cells.  In  this  early  stage  the  muscular  fibres  tbem- 
salves  do  not  appear  to  undergo  any  very  manifest  changes, 
exoepl  tbal,  aocoiding  to  Ducbennc,  their  transverse  sUriation 
becomes  fainter,  while  the  longitudinal  striatioD  becomes 
■Don  marked.  The  IranDversc  etriation  is,  however,  generally 
(|«il«  distinct  ontil  a  late  period  of  the  disease.  Ducbenne 
ngarded  lb«  proliferation  of  the  conncctivo  tissue  as  the  chief 
«MM  ot  the  iacreased  size  of  tbe  muscle ;  heoce  he  called  the 


SOS 


SYSTEM  DrSBASES  OF  THE 


JisBMC  "paralysis  ■myosd^rosique;"  bat  other  autliora  bcliere 
that  the  muscle  Joea  not  increase  niach  to  volume  tiotU  the 
aficoud  »tagfi  of  the  chauge  occurs.  This  stage  cemsista  of  the 
deTclopment  of  fat  celU  in  the  connective  tissue  and  aUo  in  the 
newly-formed  flhrous  tissue,  whereby  the  muKCular  fibres  become 
widely  separated  from  one  another.  The  muscular  Bbrca  oov 
become  atrophied  and  begin  to  disappear.  They  become  nar- 
rower, and  indeed  a  single  fibre  varies  in  diameter  at  different 
points  in  its  length.  The  transrerec  striatiea  may  »om«Umes 
disappear  in  ihc  narrower  fibres,  and  be  replaced  by  gnuiules 
diittributed  uniformly  through  them.  Mnch  of  the  fibrous  tiiisue 
surrounding  the  fibres  contains  oat-shaped  nuclei,  which  ore  sup- 
posed by  some  to  he  durived  flora  the  empty  ahealha  of  muscular 
fibres  (Clarke,  Gnweni).  After  a  time  both  the  muscular  fibres 
and  the  newly-formed  fibroid  tissue  completely  disappear,  and 
the  entire  muscle  is  represented  by  fat  cells  like  thoae  of  an  ordi- 
nary lipoma.  The  fat  may  subscciuently  become  absorbed,  aod 
connective  tissue,  with  perhaps  a  few  traces  of  muscular  fibres, 
is  all  that  is  left 

Condition  of  the  Xervoue  Sytiem. — The  brain  and  spinal 
cord  have  beea  examined  in  several  patients  who  died  Irom  this 
disease,  but  the  examinations  possess  no  real  value  except  in 
two  or  three  iuBtancea.  Even  in  tlic  case  reported  by  Kulenbuig, 
where  the  cord  was  examined  with  great  cure  by  such  a  com- 
petent oliaerver  as  Cohnhoim,  it  has  been  justly  objected  by 
Charcot  that  delicate  leinona  like  atrophy  of  the  motor  cells 
might  escape  dotcciion/inaamuch  as  tbo  cord  was  examined  in 
the  fresh  condition,  or  only  after  imperfect  hardoning.  If  this 
objection  be  valid,  when  urgod  against  an  examination  con- 
ducted by  Cohnheim,  how  much  more  true  does  it  become  when 
either  do  microscopic  examination  or  only  a  very  imperfect  one 
was  made.  In  one  of  the  cases  collected  by  Duchenne  the 
patient  died  in  February,  I87I,  and  his  brain  and  spioal  cord 
were  carefully  examined,  both  in  the  fresh  state  and  after 
hu^ening  in  chromic  acid.  Portions  were  forwarded  to  Charcot^ 
Yolpian,  and  Lockhart  Cl&rko,  and  no  abnormal  appeaivncea 
were  detected.  A  huge  number  of  sections  of  the  cord,  at 
difTereut  levels  of  the  cervical  and  dorsal  regions,  were  made  by 
M.  Pierrot,  and  coloured  by  carmine,  but  neither  Cbaroot  Qor 


'%«  could  detect  an;  trace  of  disease.  M.  Bartb  examined  tlie 
cofd  in  tbe  case  of  a  man  forty-four  yeani  old,  who  suffered 
from  mtiKular  pseudo-hvpertrophy,  and  found  partial  de- 
generalioo  of  the  antero-latcral  columns,  and  diminution  of  the 
number  of  ganglion  cells  in  the  anterior  horna  of  the  cord. 
Charcot,  howovor,  justly  points  out  that  the  clinical  characters 
of  this  case  were  more  tike  amyotrophic  lateral  sclerosia  than 
pseudo'hypertrophic  par&ly&is. 

Tbo  most  important  case  hitherto  examined  is  tbe  one 
reported  by  Drs.  Lockbart  Clarke  and  Qower^  In  which 
"  varied  and  extensive  "  lesions  of  the  cord  were  found.  These 
lemons  wore  so  numerous  that  only  the  most  important  of  them 
can  be  mentioned  here.  The  changes  hegan  on  a  level  with 
the  origin  of  tbo  second  cervical  pair  of  nervoa,  and  consisted 
of  "disintegration  of  the  lateral  grey  network  which  ia  so  ooo- 
spicuous  in  the  region  between  the  caput  oornu  posterioris  and 
the  tfBctns  iDtermedio-lateralie,  and  through  which  the  spinal 
accesaory  nerve  makes  its  way  into  that  tract."  "  One-half  of 
the  autcrior  white  commissure  was  entirely  destroyed."  In  the 
lower  part  of  the  cervical  region  there  was  disintegration  of 
vome  of  the  "  posterior  nerre  roots  near  the  entmuce  iuto  the 
caput  oorau  postenons,"  and  both  the  lateral  and  pottUtrior 
wbito  columns  were  tn  many  seRllons  damaged  hy  sclerosis. 
Id.  the  tipper  portion  of  the  dorsal  region  "the  changes  were 
IcM  frcquttnt  and  extensive,  but  here  and  there  the  anterior 
white  commissure  was  partially  deetroyed."  The  lesions  were 
"  most  extensive  and  striking"  at  the  lower  part  of  the  dorsal 
r^on  and  the  commenceinent  of  the  lumbar  enlargement. 
The  ceotral  and  lateral  parts  of  the  grey  substance  on  each 
side  were  severely  damaged  by  softening  and  disintegratioiL 
In  the  middle  part  of  the  lumbar  enlargement  the  lesions 
were  less  serious,  but  lu  the  lower  portions  and  in  the  conus 
medullaris  the  lenions  of  the  grey  substance  were  again  more 
exteoiire  and  severe.  "  The  central  part  of  the  anterior  cornu 
sad  the  outer  part  of  the  cervix  coruu  poaLcrioria  were  very 
much  damaged  by  conttDUOUS  diaintcgratioo."  The  largo  ncrre 
calls  in  the  anterior  comua  were  much  diminished  in  number. 
and  the  few  reraaining  celts  were  atrophied  and  contained  an 
excee»  of  pigment. 


SOi 


SYSTEM  DISUSES  OF  TBI 


Tbe  foltowiug  abstrucl  of  ao  importaab  com  of  this  discue, 
ia  which,  a  poBl-mortem  examinattoa  wma  obtained,  I  owe  to 
the  kiaJDeiis  of  Dr.  Leech,  who  is  proparing  a  series  of  in* 
tcrestinj^  caaea  of  this  diisease  for  publication. 

R.  J ,  ogod  Mvva,  oKtne  ander  Dr.  LMah'H  otre  at  tlu  Mui<liMt«r 

Infirm  try  on  tho  iOth  of  Soptombor.  1977,  irith  tiu>  ToU-knowa  BTtupMnu 
of  pMudo-hjp«rtro[>liic  pantljeis.  UU  mdtc  ajii  mttboA  of  riaiag  £mta 
the  recutabeat  posture  w«re  quite  ofaanot«riatic,  and  U)rd<»is  was  mU 
mtrkeil  The  oalr&s  of  tha  l^gt  were  unduly  Urge  and  Ann,  the  anna 
aad  ILighathiQ,  dUUiiutl;  atrophii^d,  the  other  parta  of  tha  body  wan 
badly  nouriihad  though  not  dcflait^ly  ivatl«d.  ThepMtonl  niuelea  were 
thff  most  rwlttced  in  nize  and  ntruiixth,  whilnt  the  deltoids  «ere  firm  and 
lugs  as  oompand  wltli  tha  other  mtuuloa  of  the  ahonldfir  and  ana. 

The  boj  oould  Htand,  titough  not  without  difSoulty,  for  tli«  hw^  could 
only  be  brought  to  the  ground  witlietftirt ;  hU  powor  of  loooiuotion  wm  of 
cO'Une  limited,  yet  he  oould  caiily  walk  acraan  a  wide  word  without 
falling.  The  boy  had  apprarodtpiitohealthy  tillho  began  te  walk,  Whm 
two  joon  old  it  wa.'s  nottocJ  that  ho  was  not  ao  firm  tm  Uia  Icga  a«  hia 
brotheni  and  niiUin  hwl  Iwin,  A.9  he  advanoed  ia  age  mu.<tuiiUT  weakne— 
became  moro  appartot.  IIo  foil  coastantly  aud  had  difficulty  ia  riaiiig ; 
be  oould  only  get  apatairs  with  the  aid  of  his  amut.  At  three  yeara  of 
ag*  the  bay's  limbs  bad  Lost  their  t'lumpuaaa.  The  iuereue  in  the  riat 
of  tbe  calves  of  the  legs  waa  not  noticed  till  aii  maaths  before  he  came 
into  tbe  luGrmary.  It  doee  not  appear  that  auy  other  member  of  the 
family  had  been  similarly  affected. 

The  b'ty  contiuued  uuder  my  care  two  yeare,  aud  then  died  of  breo- 
ohitis.  A  alight  amount  of  wasting  went  on  in  all  parts  of  tbo  body  during 
this  time,  and  the  loes  of  mu»cular  power  was  coaaiderablp. 

Eighteen  moatbs  before  he  died  ho  hocams  unable  to  walk  or  stand, 
and  tha  re«t  of  his  life  wu  pasaed  in  a  fhair  or  lying  down.  For  the  last 
nix  months  he  was  unable  bo  extend  fully  his  logs,  and  sat  in  a  bowed 
positiuQ  owing  to  the  we>a.kiie38  of  tbs  muscles  of  bU  back.  The  ealrea 
of  his  legH  deureaaed  alightly  in  aize,  bub  continued  lar(;o  a«  compand 
with  the  other  parts  of  the  body, 

A  po«t-mortem  vaa  made  thirty-six  hours  after  death.  The  uuaoloa 
had,  for  tbe  mo^  part,  lost  their  uoi-mul  appearance,  and  were  of  a  light 
yellowish  brtinn  ooluur.  In  Mime  placet  it  was  difficult  to  diatingoiali 
them  from  eonueotivu  tiMuo.  This  ttas  apecially  the  case  with  the  peetoral 
inuaoW.  The  f,iketrDoaeaiiuB  looked  on  oevtiou  like  dark-cclourett  fatty 
tiaaiio.  [»  talcing  out  the  spinal  eord  a  very  <li«tinct  diOeniiMM  waa 
noticed  botweoQ  the  condition  at  the  erector  vpinie  in  tfao  lumbar  and 
upper  donil  re^on.  In  the  former  the  musclaa  had  a  cotu»ctav»-ti«a^ 
Uke  appearance  :  towards  the  mid-dorsal  region  thoy  bcoaiM  datfcar  anl 
redder,  nod  in  the  upper  donal  region  had  the  ordinary  appearance  of 
muMular  tissue, 


SPINAL  COBD  .LSV  MEDITLLI   OBLOIfQATA. 


906 


Thr  muaclM  in  the  cerrkkl  region  bad  tbe  Mino  itppcuviioe  u  tboM 
JD  ths  ui)p«r  doratl.  Tbe  rbomlMida,  levatcr  anguli  scct^iuliv,  utd  tn- 
podoB  w«n  dutioctl;  alt«nd  in  oolour  tai  testorc,  tbo  upper  paK  of 
tbe  tnpaiaB  bring  tbe  Istst  Kffifctod. 

Tbm  mienaoopt  onmad  U>  sbow  tbat  nvarly  all  tb«  mascular  tiaeue  in 
tlw  body  WM  ftflHt«d,fi)r«Teii  in  that  takaa  bom  the  upper  doraal  regiou 
*hidk  looked  bealtbj  «  diatioct  inomwe  of  ooaoective  ttsaue  b«tw««u  tbe 
fibrw  WM  erident. 

In  tbe  moades  wbicb  ^pctred  to  the  Doked  ef  e  oaoat  cbwiged,  auob 
••  tbe  pectonU,  tbe  new  coaoectin  timw  grotrtb  was  rer7  mticb  more 
•itetuive,  el)  tbe  6brea  of  (be  pnauUre  (iueicoli  b«iDg  wpemtod  b;  it, 
«Ulii  beie  eod  there  atngle  ftbroa  »d  ilooe  videl;  aeparated  by  coDueo- 
tive  ttane  fmn  their  eompuiiaiu. 

Here  and  tbtire  mm  of  bt  oalU  appeared  Mtnetimee  betveen  muacular 


Ftu.  172. 


I 


_  .  MY<ma0-  MmMcmlaf  nbrtt  in  tariMu  itagm  of  tfipHwutfaa.  fnm  m  mm  «f 
ttrwth-hfiiartnpltic  PanlfiU.  -a,  MoacoW  filca  oolr  rilfliilT  ihM^nl, 
ihfwiMgUiim  of  Itw  BiB»d»  cocpn»da»,  swl  in  lulled— i  i*lln  iiwiiim 
MilUiMi  Ui  eoWa  iwu  of  iu  Nngtb;  t,  tha  mow  aa  a,  bnt  m«*«  atro- 
pUad  ;  ^  BHiaciihr  ibre  cnatly  abopUed.  and  vamtmOa^  andel  at  latwak ; 
A  atvopbivd  amaeular  flbra,  wtA  ila  Uaaaremi  atriatioa  ^naoaUv  dhlieca  t 
«,  airapfai«<l  flfan  ntrooiidad  br  a  BbfUUt«<l  oobomK**  UaM*  iM  b 
McWi  fitais.  iBnaoiikr  Bbra  f run  Um  anctor  qifna.  wUd  naaif Nlad  Ibe 
■mAwt  ahanflta  to  tbe  naked  «ji.  Thaaa  flbraa  appear  to  bare  ndariMta  a 
kjralbM  efaaaB<s  Imt  UiAlMaaianaatrlatioD  Uatlll  falatlj  *inbU.  TU  tbra* 
ahealaiNnRlMapalliK  aooMliBaialiMoaiKlacractiiDaaaibaUanda. 


S06 


STbTEM   DISBAMB  OF  TUK 


fibrw,  wnwliiDOB  surrouiMlM  bjr  cotmactire  Uanw,  mmI  Id  plftcc*  wcwiiu* 
UUou  of  f»t  oslb  mrt  tiui  viUi  iiwUad  «r  dagU  rents. 

Id  th«  gutnomoiiiw  omaolfl  tbs  nns  ooaditioa  iru  prCMot.  bnt  t)» 
TaI  ccUs  ««•  much  mora  abui>d*iit  aod  formed  loou  MCumaUtiao*  of 
adipoM  twoe  amid  the  muACulu  fibns  atid  comwctire  Ucsue. 

In  All  th«  musclas  the  fihras  wen  dittioctly  narrowed,  aod  tb«  ddcIn 
of  the  aaicolamma  wen  greatly  incnued  in  number,  but  tha  atnatkm  of 
the  fibres  ww  Ibrtb*  moat  pot  not  interfered  «nth  oud  w&aoftan  oQaaoaQj 
diatiuct,  enn  in  fibrea  wbicli  had  undergone  a  high  degras  of  atnfhj 
{J^.n2,e,d].  The  annexed  diagram  {Fig.  t72J  repraaeote  tti»  mot* 
uaual  KpfouanotM  prcnented  bj  tbo  altered  muscuUr  fibroa. 

In  T«r;  few- of  th«  fibpc*  wa«  granular  ohanga  met  with,  vhilat  hardly] 
any  good  cxam[>lu  of  tme  fattjr  ohaagc  were  ae«D. 

Tha dNTMU  in th«  iliam«tor  of  tha  munculiu-filiniaecmed  moat  tnarlced'] 
io  tbe  miuolaa  which  were  moot  changed  to  the  naked  eya.   In  the  cnwtatj 

Fia  US. 


rn 


Tig.  173  iToanB)-   Traiurtrte  Stttian  fn»  Oi  lamr  half  «/  Oe  ImwAv  Manw ' 
nifnl  v/  lAe  ^pinat  Ci>ri,Jntn  a  out  4/  Fwetd«-h)fpertntaUe  PmrtimU.-A, 
AutvtVTr  grvf  hnm  ;   P,  PoaUrioir  gNj  Lmii  ;  M,  e«ikuaf  oaaal ;   i,  BrinoBl. 
a,  anUrior.  nf.  anteru-lateial,  ;?<,  portwvlaMal,  c,  MBlral  povp  ol  ftaupitm 
c«U» ;  m,  median  area. 

Kpiuo  from  the  upper  dorul  regioD,  for  ei&mpls,  it  waa  bardl;  manifest : 
vbibt  maay  of  tbo  £brM  of  the  pectoral  moaule  wen  nduced  to  os«-aixth 
of  thnr  normal  dJam«t«r.  The  uarrowiiig  of  the  munoular  flbraa  Bcenwd 
indeod  proporttooato  to  tb«  ostoat  of  tha  dcTalopmaDt  of  tho  ■am  oon- 
nectiro  liasue. 


SFIKAL  COBD  XSD  MEDULLA  OBLOKOATA. 


207 


Pr.  L«ecb  kindly  ^nt  th«  Ki>inal  oonl  to  mo  roroxaminatioi).  In  tho 
lumbar  ngioo  ths  Dortool  loom  and  ii[iODg)r  bciturs  of  th«  oentrnl  coIucid 
ma  nplaced  by  «  Botaewbat  itaav  vid  Sbrillatcd  tiaeue,  in  which  no  trace 
of  ganglion  oeila  could  be  foiiud.  The  blood -TeEaela  were  enUir^oiI,  and 
tb«ir  mlk  thidnotd.  In  Ibo  anterior  grej  h«riis  Ui«  giuiglimi  culln  had 
eompleMy  dUainwwwd  from  the  medUn  ajieo,  the  Anterior  fi]Mii{i,  And  the 
maiguib  of  all  the  other  groups  {Fin.  ''^X  "^^^  gao^iou  celb  gould  be 
dioUnctlj  BMD  in  tbe  intenial  ^^up  (Fig.  173,  i  j,  but  they  won  strophiMt, 
•nl  only  4  few  of  tbeir  prooooBeii  oould  bo  diacovervd,  *ml  thu  coutrAJ 
groapiFiff.  173,  c)  |irewDted  one  or  two  cells  oidy  wliich  wan  not  diKtinotlf 
•tropbied.  Thv  centr*]  pwiioDa  vt  tbo  tntcro-latcnd  uid  poetcro-latenl 
{Fif.  173,aX,j>()  gruupi,  bowever,  contained  tome  oeUn  which  K{)peared 

Pio.  1T4, 


Fto.  IM  lYoont).  fnuurrrtc  Srction  Jrvm  Uit  midiUt  u/  tkt  Dartai  Btfiion  «/  tiu 


•Mlnin  (vf  ClarltB. 


TBe  otaar  lelUin  indioate  Lb*  Hitn*  aa  th*  eorrvaponding 


hi  enrif  reaiwct  nornia],  but  othera  coQta.inGd  au  eiceaa  of  |iisiiieat,  while 
the  tuArKinil  «9U»  were  decidedly  atrophied. 

In  the  daraal  n^poo  tbe  oeutnil  coluiun  preaetitod  tbe  aame  Reneral 
appeanmoea  aa  is  Ibe  laubar  entargenwat.  The  diaeaao  extended  into 
tbe  aoterior  grey  born  in  tbe  dorval  rcgioa  chiefly  in  tbe  area  which 
baa  iNrtwMQ  ibe  ant«ro*iat«ral  and  ixiat«n>-Ut«ral  grcupa  {Fiff.  1 74,  ai,  pi) — 
Um  awUo-Utcmt  area.  Tbe  gauglioD  cells  of  the  posbero-Iatcral  group 
*we  atiophMd  and  dtctitute  of  prooosMB  to  a  re^  marked  dognae.    The 


206 


sy?TEU  DISK&SBS  OF  THE 


oolUocniIdiiioit)«  seeu  iu  tb«  uitcnor(/^.  174,  ii)Rin'iatbeociitnlgnu(^ 
but  thoM  of  tli«  iiibtrnal  and  lutAra-Ubml  groupa  «er«  ili*Uiictlf  TiMbb: 
Mauf  of  tbe  Utt«r,  bowevn-,  ooutaiiiod  an  exoMa  of  [n{^«Dt>  uid  appMnd 
u>  haT«  lowt  a  conaidarable  numbn-  of  Uieir  procwui.  Tb«  oalla  cif  th» 
TancoUr  eolomn  of  Ouka  app«ti«<l  normal  or  mUj  aUghtlr  aJUnd 

In  the  ccrfiul  ngioo  tbo  ceutnU  culrnun  abo  prManted  th«  bum 
gtotnl  apiManneea  a«  tb6  other  portiiuM  of  tha  oord  joat  «zaiaicM<L  la 
th«  l<>wer  half  of  the  o«rt-ical  eulargaiDeat,  bonvTer,  th«  tosJiaa  ana  of 
th«  ai)t«rioT  hi^rnn  ci.ntAiiied  beKutiful  heal th;  cells,  &ck1  it  ooiitrwrtaj 
ntroagly  in  this  rcajjcct  witb  the  moUaQ  ar«a  ia  the  lumbar  anlarfitSMot 
Tlia  internal  group  of  oella  vnn  $X*'>  bealtli;,  while  healthf  oalla  w«r« 
aeeu  in  the  auleriLir  srouit.  Tlie  umr^nal  cvUa  of  Uie  central.  aDt«n}' 
lateral,  and  pMt«ro-!atenU  grou^m  wera,  however,  atrophied,  wltile  uwo^ 
of  tHeiD  had  diaappeared.  In  tba  uppar  end  of  the  otfrioal  ooUrgNiaiit 
the  MDtral  and  antoro-lateral  groups  appeared  to  have  been  OMtra 
than  any  other  portion  of  tbe  aiiteritir  horn  (Fig.  lib,  e,  at). 

Tut,  in. 


Flo.  ITS' Voanel.  Tf^nrtrrttStttitnt  from  lie  upptrkai/iiflJuCrrtitiUliml^roitm 
of  tilt  BpiaS  Cant,  fnm  a  oew  V  /Vnuio-AjipfrtPapAic  Fanlftii,  Tbelrllen 
ioUi««t«  iJv* euM  ^  til*  oonecpuD ding  loUan  m  JV-  ^'^ 

§  435.  Patftologi/. — This  dtseAse  is  so  frequently  aieooiatcd 
witb  obtaafacaa  of  the  meatnl  facuUies,  or  with  idiotcy  and  crr- 
tiaUtn,  that  Duclionne  was  nl  first  inclined  to  bolii^ve  that  the 
muscular  cliaages  resulted  from  cerebral  diseaae.  More  esteoiltKl 


SPDCAL  COBD  AND  MEDULLA  OBLOKQATjL 


200 


(^MTTation.  howerer,  w>od  sbowetl  that  tbis  aJfecttoo  frcquontly 
«xutA  indcpeDdcDtly  of  any  cerebral  lesioa.  Tliu  JilatatioD  of 
the  capilUhM  of  tb«  «kio  over  tbd  nffocted  raiuclefl,  acd  tbe 
finqaeot  eleration  of  tbe  superBcial  temperature  of  tbe  limbs, 
Moompiirect  witli  that  of  thg  trunk,  bave  le<I  nome  pathologists 
lothiolc  that  tbe  primary  tc«ioD  is  eitunted  in  tbo  vaso-motor 
BVfoOB  ^jvteu,  but  no  additional  facts  Uave  been  disGOvered 
to  Terifj  thu  suppodiliou.  Tbere  Htill  remains  tbe  question, 
wbetber  Ibfl  diaeaae  U  primarily  in  the  muscles,  or  in  that 
put  of  the  ii«rTotM  ajateru  which  coutroU  their  uulritioo. 
Oharoot  and  Fneilreich  regard  tbe  muscular  leiion  as  tbe 
eaKOtial  ooe.  Friedreich,  however,  looks  upon  progresajre 
■oamUr  atrophy  also  as  primarily  a  mu8cu]fir  disojLse;  and. 
ladMd,  ho  conaiders  the  two  diseases  aa  essentially  tbe  «amo. 
■Jtbough  each  ia  aomewbat  modiGed  by  circanutauceB. 

Charcot,  on  the  other  haml,  who  believes  that  progresuTe 
moacoJar  atrophy  is  primarily  a  nervous  diat-aso.  regards  pseudo- 
bypvrtropbic  paralysis  m  a  primary  dioeose  of  tbe  musoular 
tMKia  Charcot  grounds  bis  opiuion  mainly  on  tbe  fact  (bat  he 
eoald  delect  oo  lesion  in  the  cord  which  he  ba<l  examined  for 
Dadienoe  ;  and  conaidering  how  thoroughly  compoient  he  is  to 
decide  such  a  point,  it  must  be  admitted  that  tbo  objection 
a^uoit  regarding  the  disease  as  of  nervous  origin  is  an  ex- 
oaedtDgly  strong  one: 

Punag  over  the  case  ubserved  by  Barth.  aa  not  being  an 
oodoabted  example  of  tbo  disease  under  coosidemtioo,  tbe  caae 
ofaMiTed  by  Dnt  Luckhart  Clarke  and  Oowers  speaks  strongly 
in  Ikroar  of  tbe  nerrous  origin  of  tbe  affection.  It  is  evident, 
from  the  deecripUoD,  thai  extenttve  changes  bad  occurred  in 
tbe  oaotnl  ootamD.  and  tbe  postero-laieml  group  of  cella  of  the 
•Dterior  coraoa,  (hroughout  the  greater  part  of  the  lumbar 
ODlarienciit  aod  lower  dorsal  rv^iou  of  the  cord.  I  observe, 
bcnraref;  that  eraD  Dr.  Oowcra  has  abaudoued  the  nervous 
theory  of  p«tido-byperuophic  paralysis,  and  wo  murt  leave  tbe 
<|tiflnioQ  Ao  open  one  at  preeent. 

lo  Mty  aubaequeot  e«4«  the  condition  of  the  ganglion  celts  of 

the  jHetero-biberal  and  medio-lateral  groups  in  the  lumbar  and 

dooal  regions  of  the  conl  should  be  carefully  examined.    Id  the 

qMsal  cord  which  I  examiued  tbe  chaogea  found  in  tbe  central 

o 


212 


3TSTEU  DISUSES  OF  THE 


publiabed  bis  memoir  in  185S,  mi  ao  profaaDd  was  ths  inpraMion  pto- 
duoed  by  Um  esliat»ti*«  anftljns  aud  aecur&t*  dowriptiotis  of  this  Mitbor 
that  ho  was  for  a  hug  tixao  rogardod  aa  tbo  diwxitr«nr  of  tbe  diaaaae. 
Tli«  trritiiiga  of  I>aeh«nna  aod  T^oaaaMQ  oootiilKited  mora  than  auj 
otbera  to  obtain  for  thin  amotion  Uis  rraoenitioa  of  tha 
DnelwiiDa  did  not  make  my  coatributioa  to  the  patlio]p^c«l  anatonj  i 
tbo  diaease,  but  be  thought  that  tbe  daficienoy  of  motor 
muat  be  dependeot  upon  soma  atnictatal  or  fnoclioiial  leaton  of  Utal 
wnbellum.  He  anggealed  that  the  cseutral  morbid  pioceaa  began  iu  tbe 
motor  nervea  of  tha  eye  aod  tbe  oorpora  qiudrigeoiina,  &om  whicli  itj 
eiteoded  to  the  sup«ri(>r  peduDolea  of  tha  oerebeUum,  and  lastjjr  to 
oerebellum  itaelt  This  riev  waa  combated  bj  Eiwnmaan,  and  a  li« 
diaoDesioii  eusued  whU-li  had  the  efioct  of  aettUag  de&sitelr  tbat  tbe ; 
eonatant  aoatomical  kaion  in  locomotor  ataxj  ia  grejr  degeneration  or 
aderoala  of  tha  poaterior  oolumtw  of  the  spioiU  oord.  Amoogit  tlw 
autbora  who  contributed  to  eatabliih  thin  view  may  be  mantwoad 
Dumenil,  Bourdon,  Oulmont,  Uamfcte,  Charcot  and  Vulpl&n,  Lnja  and 
Cam!  iu  Frauce  ;  Rimlfleiacb,  Weatpbal,  Frirtlreich,  nud  Lefdaa  in  Ger- 
many  ;  and  Lockhort  ClArkd  in  England.  In  ita  clinical  relationa  tbe 
(lincBMe  liM  Iweo  inveMLif{at«d  amon^t  othera  hy  Jaccoud,  To|ntMud. 
Axonfeld,  RemAlc,  Spnetb,  Cjron,  Benedikt,  and  maay  other  authoraL 

The  name  of  the  diaeua  has  aba  ondergono  freqoent  obangea  in  aooor- 
daiicc  vith  tli«  prcTiuliiijdoctriiica  with  r«gard  to  Ha  oattmu  When  it 
waa  ragatded  aa  being  due  to  atrophy  of  tbe  »piiial  cord,  it  received  tJi« 
name  of  "Atrophia  Uediillau  Bpinalia,"  a  namo  which  had  to  be  abaodoned 
on  more  noountc  hLttoIogic^l  invoatigation.  WuDderlieb  called  it  "  Pn»- 
greeaive  Spinal  ParalysiB,"  but  this  name  beoanio  untenable  when  it  waa 
found  that  the  symptoms  did  not  depend  upon  paialyaia  bot  on  want  ef 
co-ordination.  In  the  preaeot  day  threenamfa  are  employad  indiOerratly 
to  deaigimto  the  diseaae.  Thsae  are  "  Grey  Degeneration  or  ScUroaia  of 
the  Posterior  Cohimnn  of  the  Cord'TrograsaiTD  Locomotor  Ataxy,  "and 
"Tabea  Dorulii."  Nonn  of  thoa*  oaraaa  ara  entirely  fi«ft  from  objeetiofia, 
but  they  hnTO  got  iKwteoaion  of  the  fluid,  and  it  would  occupy  apaoe  to 
very  little  admitaga  to  diaooas  hvre  all  objectiona  which  might  be  niged 
i^aiuitb  them. 


§  440.  Etioiogy. — The  etiolog;  of  tbe  diseane  is  very  obacure, 
a.Dd  in  manj  cases  no  defioito  cauae  of  it  cao  be  traced. 

Hereditarj  predisposition  undoubtedly  ezercisea  a  oenaiD 
amount  of  influence  in  its  production.  Locomotor  ataxj  ii 
fre^jueotly  met  with  in  individuals  whose  Dearest  reUtivee 
are  liable  to  suffer  from  other  nervous  diseases,  such  aa 
monomania,  hypochondriasis,  epilepsy,  mignuQC.  mental  dis- 
MBM,  or  vlolvut  tite  of  anger  and  diunkeDDeos.     Tronasoaa 


SPmiL  CORD  AXO  MEDULLA  OBLOKGATA. 


21S 


meatioos  the  case  of  a  patieot  finlfcriag  from  advaaced 
locomotor  ataxy,  whose  ODcle  and  aunt  vera  iosaae,  and  wbo 
had  one  brother  ataxic  and  auother  bismiplogic.  He  also 
mentioDs  the  case  of  aaotber  patient  who  had  been  ataxic 
for  upwards  of  twenty  years,  but  whose  intelloct  was  perfectly 
clear.  His  father  cominittcd  suicide;  and  hia  two  Bona  laboured 
UDder  peculiar  aenrou-s  affecltons,  one  baring  singular  muscular 
spaams,  and  tlie  other  being  irresistibly  compelled  to  shriek  in 

moflt  extroordiaary  maoDer  nearly  all  day.  lo  other  cases 
'  the  in6uencc  of  heredity  is  direct  (rom  the  parent  Friedreich 
mot  with  three  different  families  in  wliich  several  brothers 
aad  naters  were  attacked  with  the  diiseoso  at  almost  the  same 
Bge,  vbile  the  parents  themselves  were  healthy.  Carrd  was 
informed  by  an  ataxic  patient  that  seventeeo  other  members  of 
ber  family  were  affected  by  tho  same  diseasa  Dr.  Dreschfeld 
bu  recorded  an  inEtance  of  a  family  in  which  fivo  out  of  6ftcoD> 
and  Dr.  Oowers  one  in  which  five  out  of  nine  chiidreu  were 
affected  with  locomotor  ataxia.  In  many  cases  of  tabes  no 
hereditary  ucuropathic  tendency  can  be  trac«d. 

The  male  ia  much  more  liable  to  bu  uffL-cted  with  the  dis- 
MM  than  the  female  sex,  no  doubt  greatly  owing  to  the  fact 
that  men  are  much  more  exposed  than  women  to  the  most 
powerful  exciting  causes  of  the  affection,  such  as  exposure  to 
cold  and  sexual  ezoenea  Out  of  149  caaes  coUvcted  by 
Ealenbnr]?  128  were  males  and  21  only  females,  ao  that  thu 
number  of  the  latter  aSected  in  proportion  to  the  total  number 
was  barely  14  per  cent  The  following  table,  givun  by  Eulca- 
borg,  shows  not  only  the  proportion  betweea  the  number  of 
■lalfls  and  females,  but  the  Dumber  which  occumnl  alrarioua 


Md*. 

Foiwlt. 

From    U  to  10 

feaia 

"T 

**w        ■^^        -■- 

...       1 

,.     10  .,  SO 

...      2    ... 

...     — 

«     20  „  30 

...    35 

...     li 

..     »0  „  40 

...     39     ... 

...       7 

„     W  „  M 

...    47    ... 

...       1 

„     W  ,.  60 

...       8     ... 

...     — 

AAer  00  jwa 

... 

.  ^  .          ■■» 

...     — 

1S8 


II 


II 


Fnna  this  table  it  will  be  readily  seen  that  locomotor  ataxy 
a  disease  of  youth  and  middle  ago,  by  far  the  largest  Dumber 


su 


STSTBM  BISEASBS  OP  TUB 


of  cases  occuiriug  from  thirty  to  fifty  years  of  ag&     The  i 
is  rare  before  the  tweotieth  and  after  the  fiftieth  year. 

lliose  who  from  the  nature  of  their  occupation  are  obliged  tol 
expose  themBelvee  to  cold  and  wet  aad  to  other  bodily  bard«hipi^ 
Buch,  for  iLstance,  as  commerdaJ  traTsUers,  engiDeera,  soldiers, 
and  aailora,  ore  very  liable  to  be  affected  with  locomotor  ataxj. 
It  is  DotoriouB  that  soldiers  are  particularly  liable  to  be  affected 
with  the  di&eaae  after  bivouacing  dd  damp  grouDd. 

Severe  bodily  and  mental  exertion  both  predispoM  to  the 
disease  and  act  as  excitiag causes  in  its  production.  Tbo  severe 
struggle  for  existence  to  which  the  inhabitants  of  large  towns 
axe  subjected  explains,  perhaps,  why  the  dieease  in  relatively 
more  frequent  in  large  cities  than  in  the  country.  The  larfjeit 
number  of  co^es  of  tabes  are  probnbly  caused  by  excessive  bodily 
exertion  and  subsequent  exposure  to  damp  and  cold,  hence  the 
frequency  with  which  tabes  occurs  in  soldiers  after  foroed 
marches  in  cold  weather. 

Emotional  disturbances,  such  as  sudden  fright,  continued 
anxiety,  and  rtpeiitfid  anger,  appear  occasionally  to  be  ca|iAble 
of  being  the  starting  point  of  tabes. 

Locomotor  ataxy  is  an  occasional  sequel  of  acute  dinnaim. 
such  as  typhus,  articular  rheumatism,  acute  pneumonia,  and 
above  all  diphtheria;  but  it  ia  difficult  to  determine  whether 
theae  affections  act  as  prcdisposiDg  causes  or  whether  they  take 
a  direct  part  in  setting  up  Dutritire  changes  in  the  cord. 
Difficult  labours  and  repeated  abortions,  severe  puerperal 
affections,  copioua  biemorrtu^cs,  and  long-continacd  lactation 
are  mentioned  ns  other  causes  of  this  affection.  Syphilis  is 
a  frequent  cause  of  locomotor  ataxy,  although  probably  not  sa, 
frequent  as  was  at  one  time  supposed. 

At  one  time  sexual  excess  and  onanism  wore  rogard«l 
almost  the  only  causes  of  tabi>s,  and  the  unfortunate  victims  of 
the  disease  were  often  unjustly  suspected  of  leading  secretly 
immoral  lives.  That  sexual  excess,  however,  is  a  very  important 
exciUng  cause  of  the  affection  is  shown  by  the  frequency  with 
which  it  occurs  in  men  during  the  period  of  tbuir  greataat 
sexual  activity,  as  well  as  by  the  fact  that  the  diseaAS  baa 
been  known  to  follow  immediately  upon  ^reat  sexual  exceSMft 
Frequent    pollutions  and    spermatorrhcea  often   precede 


tin) 

IP 


outbreak  of  tsbe*,  but  whether  tbeso  are  tho  causo  of  tbe 
^iaeasQ  or  man  results  of  the  pricoary  seosory  disturbances 
whicb  are  so  oootmon  in  tbe  earl;  stage  of  the  afiection  Is 
difficult  to  detanniDe. 

Vuious  traumatic  iojuries  may  be  the  starting  poiot  of  loco- 
motor a.taxy.  and  instancea  are  recorded  in  which  the  disease 
nan  followtid  a  fracture  of  the  thigh,  a  fait  upon  the  belly,  the 
■bock  of  a  gunshot  wound,  and  concumion  of  the  spinal  cord 
(Sohulze).  Some  think  that  the  disease  may  also  be  cauM'l  by 
exconre  tobacco  smoking,  but  the  atatumuut  appean  to  be 
anfoojuW.  laagreatnumber  of  cases  of  tabes  do  recognisable 
oauM  can  be  traced  after  tbu  moet  careful  inveatigatioD. 

$  441.  Symptoms. — Locomotor  ataxy  generally  begins  with 
a  pmaoDitory  stage,  whi«h  may  extend  over  months  or  years. 
The  mosiconstant  aad  characteristic  prcmonitoty  symptoms  are 
ptMU  of  a  veiy  pecnliar  and  distressing  kind,  which  are  not  only 
present  daring  the  initial  stage,  but  usually  accompany  the 
disease  throughout  its  entire  courec,  and  which  may  last  for 
yean  without  any  other  symptoms  being  present. 

These  pains  hare  been  deaerihed  under  the  names  of  general 
oeuralgia  or  neuralgic  rheumatism,  and  are  compared  by  the 
patieots  to  forked  lightning  darting  through  the  body  (Light* 
niog  PaioM)  §  53).  The  pains  aie  at  other  times  of  a  burning 
chaiicter,  and  are  not  unfrequently  confined  to  a  small  well- 
defined  spot  of  tbe  skin  (Hypenesthetic  Spots,  §  52).  Some- 
times tbe  pains  may  be  deeply  aitaated  in  the  soft  parts  or  in 
bones,  or  Uiey  may  follow  oortaio  definite  nerve  tract.s,  and 
ofiisa  regarded  as  rheumatic  The  nerve  tranks  may  he 
Mwitive  to  pressure  daring  m  paroxysm.  The  intenaity  of  the 
ipaia  taries  in  diSeceot  flaMS,  and  at  times  patients  suffer  the 
fraatest  torture  from  them. 

Fain  in  the  back  is  met  with  occasionally  in  tabes,  and  at 
tunes  poiats  painful  to  pressure  may  be  found  on  the  spinous 
«r  tiiDsvene  processes  of  individual  vertebra,  but  those  are 
me,  and  appear  aba  to  be  quite  unimportant.  Wheaever 
thete is  prolonged  or  severe  pain  in  the  beck,  it  may  he  auspeoted 
that  tbe  dtsease  ts  complicated  by  spina]  meningitis. 

The  feeling  of  a  tight  girdle  round  the  thorax  or  abdomen. 


£16 


STSTEH  DISEASES  OF  THE 


wkicbissofrcqueut  a  symptom  of  many  ttpinalaffoctioDS,  is  also 
a  frequent  symptom  of  locomotor  ataxy  (Qinlle  SensatioD,  §  51). 
Girdle  pains  may  also  be  felt  round  tha  jointd  of  tbc  lower 
uxtrumilicii,  aad  it  U  sometimes  described  a&  a  feeling  like  tbat 
caused  by  a  gartor  tied  tigbtly  below  the  kaeo.  Seiu&tiaitB 
of  formication,  aumbness,  or  of  bumiDg  or  coldness  of  the  akin 
are  frequently  compliUDod  of.  Some  patients  feci  as  if  tbey 
were  walking  on  vool,  cork,  or  felt  soles;  while  others  feel 
as  if  they  were  walking  on  bladders  of  water.  These  panes- 
tbesia'  belong  to  tho  earliest  stage  of  locomotor  ntnxy,  and 
one  or  other  of  them  is  almost  constantly  found  in  tbe  initial 
stage  of  the  affection.  Hyperesthesia  of  the  skin  is  not  un- 
common in  tabcB ;  and  nt  times  there  may  be  byperapstliesia 
towards  impressions  of  temperature  and  anaasthesia  of  touch. 
aud  at  other  ttme«  an»>stheaia  of  the  sense  of  touch  may  be 
accompanied  by  a  high  decree  of  hyperiesthesia  towards  im- 
pressions of  pain. 

But  auoathcaia  is  a  much  more  common  symptom  of  1oo<k 
motor  ataxy  than  hypern-»thcsia.  There  may  be  a  high  degree 
of  anicsfhesia  without  (lie  patients  being  aware  of  it ;  but  after 
a  time  they  Bnd  that  tfaoy  no  longer  fcuA  the  floor  distinctly, 
that  all  articles  which  they  touch  have  a  velvety  fee!,  or  tbat 
they  c&nnot  hold  small  objccta  in  their  fiogcra  If  Lheie  is  a 
high  degree  of  ansestbesia,  the  patienta  cannot  judge  of  tbd 
position  of  their  legs  when  iu  the  dark.  Anfesthetic  patdiet 
may  be  found  on  the  soles  of  the  feet,  tho  toes,  and  back  of  the 
feet,  and  they  may  be  so  limited  that  they  can  only  bo  recog- 
nised by  the  most  careful  examinatioa  Aa  a  rule,  however, 
the  diminution  of  Benaation  extends  to  tho  thigh,  and  even  the 
trunk  and  portions  of  the  upper  extremities,  although  it  is 
generally  most  marked  on  the  legs,  fiut  the  cutaoeoos 
ann:>KtbeMa  in  locomotor  ataxy  hardly  ever  reaches  the  high 
grade  observed  in  the  later  stages  of  transverse  myelitis,  and 
slow  compreasioD  of  the  conl. 

Every  variety  of  paralyses  of  sensstion  and  every  combination 
of  them  are  tnet  with  in  the  later  stages  of  the  affeotian; 
but  probably  analgesia  is  the  most  frequent  Occasionally, 
however,  the  sensibility  to  pain  is  retained,  or  even  increaaed. 
vbilfl  tbero  is  a  diminution  of  sensibility  to  some  or  all  varieties 


I 


3PUIAL  UOKD  Ann  UEDULLA  <XBS/>SQkTA. 

of  touch;  and.  again,  partial  paralyab  of  the  sense  of  touch  may 
be  combioed  with  analgeaia  and  hyperalgesia,  or  with  byp«r- 
■atboia  lowarda  impreeBiocui  of  temperature.  At  a  late  period 
of  the  disease  a  distinct  retardation  of  the  conduction  of  ocnsa- 
tiooa,  aspecially  of  ituprcsdioos  of  pain,  is  observed,  and  this  may 
abo  be  found  in  the  earlier  stagee  of  the  affection.  The 
prick  of  a  needle  frequently  gives  rise  to  a  double  sensation, 
the  first  being  one  of  touch  which  w  conveyed  with  nonnai 
rapidity,  and  the  wcond  of  pain  owing  to  the  slowneu  with 
which  the  iotpression  is  conveyed.  Hertzberg  has  demoDStrated 
that  in  iome  cawM  the  sensations  of  touch  and  of  temperatore 
are  aUo  retarded,  although  to  a  less  degree  than  that  of 
pain.  The  nensatioQ  of  pain  also  oontinuea  for  a  relatively 
loog  time,  even  when  the  cause  nluch  h&»  Induced  it  haJi  been 
of  momentary  duration,  and  the  highest  degree  is  not  reached 
mitil  Mveral  seconds  after  the  pain  has  begun  (§  40).  Fischer 
baa  recently  observed  that  in  certain  circuniBcnbed  cutaneous 
ams  of  the  foot  the  patient  may  feel  two  points  when  one  only 
ii  touching  the  ^io,  nnd  when  two  points  are  in  contact  with 
it  four  or  live  may  he  fult  (FulyojHthcsiu,  §  5U).  DisturbADces 
of  the  uusculor  ijcnsibility  and  mu^Kolar  sense  are  frequently 
obaerved  Ln  tlm  affection.  In  the  first  stages  the  alteration 
of  the  muacuUr  setisibillty  conaisu  of  a  feeling  of  unre«t  io 
tb«  limbs,  which  prevents  the  patient  from  lying  down  or 
KUing  still  for  any  length  of  time,  a  feeling  which  has  been 
giBphjcally  called  the  fidgets.  It  is  probable  that  the  feeling 
of  fjatigae,  which  is  so  fretjuent  at  the  hennaing  of  the  disease, 
ii  a  panuthesia  of  the  scosttivo  nerves  of  the  rauRctes.  It 
moM,  however,  be  remembered  that  even  in  the  early  stage  uf 
the  diaeaso  the  locomotive  movementii  require  a  greater  amount 
of  attention  en  the  part  of  the  patient,  and  that  a  much  greater 
effort  is  expended  in  walking  than  in  health. 

As  the  disease  advances,  the  muHCular  sen»o  becomee 
diminiihed.  and  consequently  the  power  of  recognising  what 
muaoles  arc  thrown  into  action  is  lessened  in  oorrospondiug 
degm.  When  the  panilysts  of  the  muscular  sense  attains  a 
high  degree,  the  paUent  does  not  know  the  position  of  hie 
lower  extremities  when  his  eyes  are  closed,  and  isalso  uncertain 
with  regard  to  the  extent  and  direction  of  the  movements  he 


sift 


8TSTEU    DISEASES  OP  TBB 


undertakes;  henco  these  moTements.  not  beiog  under  due  coo* 
trol,  become  excessive.  TbU  condition  miut,  however,  be  cue- 
full;  diatiuguisbed  from  tlie  ataxic  moTements  about  to  be 
described. 

Although  distarbances  of  seDEibility  are  much  more  ooniitaat 
and  marked  la  the  tower  than  in  the  upper  extremities,  yet  the 
latter  are  frequently  involved,  especially  in  the  advanced  period 
of  the  disease.  Casea  of  pronouoced  ataxia  have  been  described 
by  competent  obscirer*,  in  which  the  mort  coreful  invoatigation 
failed  to  detect  the  slightest  traco  of  any  disturbance  of  cuta- 
neous or  muscular  sensibility.  On  the  other  hand,  caaea  have 
been  oh»erved  in  which  a  high  degree  of  aniosthesia  was  prcHoV 
but  in  which  the  ataxic  symptoms  «ere  either  entirely  abaaBt 
or  little  prououuced,  aa  that  it  may  be  concluded  that  there  is 
no  constant  relation  between  the  degree  of  ataxy  and  that  of 
cutaneous  or  muscular  anai-sthesia. 

The  vwtor  dvilu,rf>anceH  constitute  by  far  the  most  charac- 
teristic features  of  locomotor  ataxy.  The  motor  distarfaaacet 
were  for  a  long  time  thou){ljt  to  be  of  a  truly  paralytic  natoret 
but  Todd  and  suboequently  Ducbeane  sbgwed  that  the  cliano> 
terifltio  gait  of  ataxy  was  due  to  a  want  of  certainty  and  pre- 
cision in  the  execution  of  movements,  especially  of  oonibined 
and  complicated  movements ;  while  the  strength  and  certainty 
of  simple  movements  h  not  at  all,  or  only  slightly,  dimimsbed. 
Duchennc  indeed  gave  the  name  of  ataxy  to  the  (Usoase  fron 
the  recognition  of  the  circumstance  that  the  characteristic  gait 
depends  on  a  want  of  co-ordination  of  muscular  action  and 
not  upon  true  pamlysis.  The  motor  dLsturbanoee  almost  always 
begin  in  the  lower  extremities,  and  are  at  firet  so  slight  that 
they  can  only  be  recognised  by  careful  examination. 

Static  Ataxia. — During  the  early  stage  of  the  disease  spedal 
tests,  which  have  the  power  of  increasing  the  motor  inoo- 
ordination,  are  very  valuable  in  enabling  us  to  determine  the 
true  uature  of  the  affection.  If  the  patient  be  asked  lo  stand  up 
and  keep  his  feet  closely  applied  together  along  their  inner 
edges,  he  may  manage  to  maintain  the  erect  posture  with 
moderate  steadiness  when  his  eyes  are  open ;  but  when  they 
are  oloeed,  he  immediately  oacillates  from  side  to  side,  and  wotdd 
fiUl  unless  be  open  hia  eyea  or  be  supported.    Aa  the  diaocder  flf 


iDDMniUr  eo-ordioaUoD  increases,  st&Dding  vritliout  support,  ctcq 
wfaeo  the  ejea  are  opeo,  becomes  iccreasingly  difficult,  and 
■UtioD  becomes  bj-and-b;  impossible  without  the  aid  of  eticJcB 
orcnitehca.  Wbea  at  Ibis  stage  the  patient  stands  by  the  sup- 
port  of  two  sticks,  it  nay  be  obeerred  that  all  tbe  exteosor 
mttsole*  of  tbe  body  are  in  a  state  of  poworTuI  tonic  ooDtractioD. 
The  (DDScloa  of  the  calf  are  strongly  oontmctcd  anJ  extend  the 
leg  upon  the  foot,  bo  that  they  form  au  obtuse  angle  with 
the  other,  the  exteiuors  of  the  leg  are  contracted  and  ex- 
tend the  thigh  00  the  Ipg,  the  flexors  of  the  thigh  are  also 
eootcacted,  and  tbe  foot  being  fixed,  they  tend  to  extend  the 
Cnuk  on  the  thigh,  this  tendency  being  greatly  increased  by 
cootnction  of  the  gluteal  muscles  and  of  the  erector  spins.  It 
is  erideot  that  if  the  contractious  of  these  muscles  were  uo- 
astagoaUed.  the  patient  could  not  for  a  moment  maintain  the 
erect  poatore  but  would  fall  backwarde.  The  tendency  to  fall 
backwards  is  counteracted  by  what  appears  to  be  a  voluntary 
eoolneitoo  of  the  muscle*  which  flex  tbe  trunk  on  tbe  thighs. 
By  this  mcaos  tbo  body  is  bent  forwards,  and  the  lino  of  grarity 
fisUa  iu  front  of  the  line  joining  the  centre  of  the  arches  of  the 
_lwt,  while  the  tcndeacy  to  fall  forwards  is  counteracted  by  the 
.  of  the  two  sticks.  The  attitude  assumed  by  tbe  patient 
tbeee  eireumstancea  is  cbaiacteristic,  llio  legs  are  drawn 
so  as  to  form  an  obtuse  angle  with  the  feet,  the 
thighs  are  extended  on  the  legs,  and  a  plumb-line  let  fait  from 
each  trochanter  falls  considerably  behind  tbe  heel,  while  the 
forward  inclination  of  tbo  body  causes  the  buttecks  to  project 
fasekwanb  in  a  marked  nunnei:. 

Ataxic  Gait. — In  the  early  stage  of  tbe  disease  the  patient 
may  be  obserred  to  stagger  a  little  on  getting  up,  especially 
after  sitting  for  a  long  time,  the  staggering  being  greatly  io- 
creassd  when  the  patient  is  in  the  dark,  closes  his  eyes,  or  has 
to  tan  abraptly  round.  These  phenomena  were  demonetrated 
to  mo  in  a  striking  moaner  a  few  weeks  ago.  I  was  walking 
«B  a  mooolight  nigbt  in  a  garden  with  a  friend  who  biu  suffered 
fervpiranU  of  twelve  years  from  the  lancinating  pains  of  tbe 
fiiMiB,  and  who  is  now  manifesting  slight  ataxic  symptoms, 
Oar  walk  tennin&ted  under  the  shadow  of  a  high  nail  and  tree 
eoTvrsd  with  thick  foliage.    So  long  as  my  friend  was  in  the 


sso 


8Y9TEU   DISEASES  OF  IBB 


oiooDligfat  he  walked  steadily  enough,  but  when  ooce  we  got 
under  the  deep  shadow  the  staggering  became  veiy  appaieni, 
and  was  much  aggravated  when  we  tarned  roaad. 

In  order  to  teat  at  thin  early  stage  the  degree  of  preciitioa 
with  which  the  muscular  adjustments  of  the  lower  extremitica 
oao  be  performed  the  patient  maj  be  asked  to  stand  on  ooo  leg, 
to  ran,  or  to  hop,  the&e  movemcnts-bciDg  more  diJficult  to  execate 
than  simple  walking.  He  may  also  be  requested  to  perfono 
aome  complicated  movement  with  the  eztremiQr,  such  at  to 
describe  the  outliae  of  a  circle  oo  the  floor  with  the  toa 

When  the  ataxia  becomes  more  pronounced,  the  gait  beoomes 
so  characteristic  thai  it  can  be  readily  reoogDised  without  the 
application  of  any  special  iesU.  The  patient  ha«  now  to  direct 
hift  eyeii  to  the  ground  and  to  his  feet  while  walkil^,  and  were 
he  to  close  them  the  movements  of  the  legs  would  become  dis- 
orderly, and  walking  would  be  impossible.  The  patient  assamee 
in  the  erect  posture  the  attitude  already  described,  in  which  the 
trunk  is  bent  forwards  ou  the  bhiglu,  the  feet  are  held  well  in 
advance  of  the  buttocks,  and  the  legs  are  extended  on  the  thtf^ 
It  is  impossible  id  this  position  to  advance  the  panive  leg  with 
the  pendulum  movemeob  characteristic  of  normal  locomotion. 
And,  indeed,  owing  to  the  Btrong  tonic  contiaction  of  the  muaclei 
of  the  thigh  and  the  extensors  of  the  foot  which  is  praseot,  the 
various  aegments  of  the  pwsive  leg  cannot  be  flexed  upon  oM 
another  so  as  to  enable  it  to  clear  the  ground  durii^  its  forward 
movement.  Under  these  circumstances  the  passive  1^  is  pro- 
jected forwards  in  one  piece  by  strong  coutraeiion  of  the  flezon 
of  the  thi^h  aa  the  trunk,  aidcil  by  contraction  of  the  abductors 
of  the  tbigb.  The  consotiuenoo  is  that  the  paaiive  foot  is  flung 
forwards  and  outwards  with  a  rapid  jerk,  being  subeoqaeatly 
brought  down  with  a  thump  During  thiti  movement  the  heel 
is  generally  the  last  to  leave  the  ground  and  the  first  to  touch 
iL  The  heel  is,  however,  sometimes  lifted  from  the  grouad 
before  the  toe,  as  occunt  in  a  caw  under  my  care  at  preseot 
As  the  passive  foot  is  being  elevated  a  slight  flexion  occun  at 
the  knee-joint  and  the  heel  is  elevated  before  the  toe,  but  »■> 
sooner  is  the  latter  removed  from  the  groutid  than  the  leg 
becomes  suddenly  extended  on  the  thigh,  the  foot  is  projected 
forwards  and  outwards,  and  the  heel  is  subeetiuently  bcougbt 


SPIXAl.  COmO  AND  KKDirUJL  OBLOlCCATi. 


SSI 


down  with  ft  thamp  in  the  usual  duuuct.  Id  onler  to 
t-jiah\e  tbc  puiive  l«g  to  clear  the  grottod  dnriag  its  ronrard 
movement,  Ute  abdaet«r  muMlfic  of  tbe  thigh  on  the  mile  or  tbe 
aetire  l«g  enter  into  atroDg  cootnctioo.  aad  coowqaently  clerate 
cbe  pdrit  on  tbe  itde  of  th«  passive  1^.  So  strong,  tndfl«ii 
does  tbo  eonlractioQ  of  the  abductors  of  the  thigb  on  the  side 
of  Ihfl  active  }eg  become  tliat  the  patient  is  in  danger  of  eanyiog 
hii  ecntre  of  gnvitjr  too  far  to  that  ndei.  In  order  to  counteract 
this  tendency  tbe  upper  part  of  tbe  body  U  cnrred  to  the 
oppiMile  side  by  contnctioQ  of  tbe  er«ctor  apln^,  and  when  the 
I  |aAi«Dt  U  able  to  walk  without  sticks,  by  tlie  ami  on  the  side 
«f  tbe  pa«ve  l^  being  thrust  out  laterally,  and  during  tbe 
altemale  Ixnnaference  of  the  line  of  gravity  from  one  foot  to 
the  other  in  walking,  tbo  truuk  is  mond  from  side  to  side  and 
tbe  arms  Bung  aboat  like  tboae  of  a  rope  dancer  in  order  to 
•Hist  the  patieot  to  maintain  his  equilibrium.  When  the 
patiMt  walks  by  the  aid  of  sticks  tbe  tendency  to  too  great  a 
lateral  displMeneot  of  the  centre  of  gravity  towards  the  nde  of 
the  active  leg  Is  counteracted  by  the  patient  giving  an  outward 
adlDation  to  the  sticks,  ao  that  bo  obtains  a  lateral  support  from 
k«B.  Patiaite  who  have  suffered  from  a  high  degree  of  ataxia 
han  bean  known  to  walk  long  distances  without  fatigue. 

When,  bowe^mr,  the  disease  has  made  considerable  progress, 
the  irregularity  and  violence  of  the  moremeots  soon  exhaust 
the  patient's  strengtli,  and  he  cannot  take  many  Kteps  witbont 
paottng  and  being  covered  with  profuse  perKpiration.  After  a 
tioM  the  want  of  oo-ordination  bKomes  so  great  that  the  main- 
tanaooe  of  the  erect  posture  and  walking  become  impoaaible. 
If  the  patient  be  supported  by  two  persous  under  tbe  arms 
whilst  he  tries  lo  walk,  his  legs  are  thrust  backwards  and 
fcrrwards  10  the  right  and  to  the  left  with  the  utmost 
Atdnlmr,  so  tbat  they  are  incapable  of  giving  the  least  support 
tt  Ik*  body ;  they  move,  as  Trousseau  remarked,  tike  those  of 
a  poppet  or  a  marioonotto.  Tbo  muscles  of  tbc  trunk  m&y  now 
bMOOe  offscted,  tbe  patient  is  unable  even  to  sit  in  a  choir, 
and  noMUOS  confined  to  bis  bed.  But  even  in  these  advanced 
CMis.  tbe  patient  wben  laid  down  may  bo  able  to  resist  passive 
moveoients  of  the  Hmbe,  and  to  perform  the  simple  movements 
of  flexion  and  extension  with  scaieely  diminished  power.    When, 


SS2 


STSTHM   DISEASES  OF  THE 


under  thee«  circum^taacea,  the  patieot  attempte  to  touch  as 
object  with  the  tip  of  tho  foot,  th«  Uoe  of  motion  is  irrogalu 
and  zigzag,  &Qd  disturbed  b;  tat«ral  movements,  while  it  ia  quite 
impossible  for  him  to  exooate  more  complicated  movements — 
SQch,  for  iDst&nce,  as  are  required  in  describing  an  imnginu; 
circle  with  the  tip  of  the  great  toe. 

At  a  later  period  the  ataxy  appears  in  the  upper  extremities, 
and  cases  have  been  dascnbod  by  Friodreicb  in  which  the 
ataxy  appean  in  the  upper  simultaneously  with  or  soon  af^ 
its  first  mauifeBtatlon  iu  the  lower  extremitiea  In  the  more 
usual  form  of  the  disease,  however,  ataxy  of  the  upper 
extremities  is  rare,  and  belongs  to  the  later  manifestations  of 
the  affection.  Ataxy  of  th«  upper  cxtremitiei  first  maoifeite 
itself  in  complicated  and  special  movemenle.  such  as  tbon 
required  for  writing,  playing  the  piano,  and  other  morements 
requiring  delicacy  of  Djanipulation.  These  morementa  become 
difficult  and  uncertain,  and  tbo  irrcguhtrity  boDomm  greater  if 
an  attempt  is  made  to  perform  the  necessary  actions  without 
the  guidance  of  the  eyed.  At  a  later  stage  the  simpler  move- 
ments also  becomo  irregular  and  ataxic.  If  the  patient  no* 
attempts  to  grasp  an  object  before  him,  it  can  only  be  reached 
in  a  roundabout  way  and  with  jerky  interruptions,  ami  the  act 
of  grasping  in  performed  in  an  uncertain  snd  spasmodic  manner. 
The  slighter  shades  of  ataxy  of  the  upper  eztremiUes  may  be 
tested  by  inslnicllng  the  patient  to  touch  with  closed  eyea  nme 
part  of  the  siir&ce  of  the  body,  8uch  as  the  forehead  or  tip 
of  the  nose  by  the  point  of  the  forefinger  of  each  band  alter- 
nately, when  the  ataxic  symptoms  declare  themselves  by  the 
inability  of  tho  p»tient  to  touch  the  intended  spot  until  after 
repeated  IriaU  A  similar  uncertainty  of  morements  ia  observed 
when  the  patient  is  asked  to  transfer  a  small  object  fixim  one 
band  to  the  other.  Static  ataxy  at  a  later  period  may  be 
present  in  the  upper  extremities,  so  that  the  patients  can  no 
longer  hold  their  arms  still  when  stretched  out  horizontally, 
and  are  unable  to  exert  uniform  pressure  with  their  hands. 
In  a  still  higher  grade  patients  can  no  longer  dross  nor  Feed 
themselves,  inasmuch  as  they  cannot  perform  such  simple  move- 
ments as  are  requisite  for  carrying  a  spoon  to  the  mouth,  bat 
even  under  these  circumHtances  they  may  be  able  to  exert  great 
muscular  power  in  resisting  pasuve  movements. 


SPDTAL  CORD  AKD  MBD17LLA  OBLOHOJkTA. 


323 


The  atjucy  may  also  iovade  the  masclM  of  the  trunk,  bo  that 
the  body  makes  irregular,  swaying  moveaients,  owing  to  the 
impOMibility  of  maiatainiog  the  due  balance  betweea  the 
Tmrioiu  muaclcd.  contracUoa  of  which  is  neccsaary  for  muiataiD- 
bg  the  erect  posture.  The  musoles  of  the  ucck  may  also  be 
ttoplicated,  and  the  bead  become  the  subject  of  irregular  and 
shaking  movementa.  Speech  is  sometimes  also  interfered  with. 
At  fint  the  ataxy  declares  itself  by  a  somewhat  indiatina  pro- 
nottciation  of  worda,  but  when  the  affection  ia  more  ndraoced, 
there  U  an  irregular,  stuttering  intcmiptioo  of  speech.  At 
tiaace  whole  sentences  are  uttered  rapidly,  and  then  there  is  A 
•light  stuttering,  and  this  ia  repeated  in  an  irregular  manner; 
while  the  voluutary  movementii  of  the  Iip3  and  tongue  ore 
apparently  i^uite  unaffected.  Id  the  highest  grades  of  the  affec- 
tion articulatioQ  may  become  m  defective  that  speech  beoomw 
almost  ineomprebeosible. 

The  third  and  final  stage  of  the  disease  is  characterised  by 
decided  psialysia,  although  a  certaiD  amount  of  motor  weakness 
Biay  be  shown  to  be  present  in  the'  majority  of  cases  of  tabes 
oTcu  at  a  moderately  early  stage  of  the  ataxic  period.  Partial 
aod  temporary  paralysis  in  the  domain  of  single  nerves  id  the 
•xtranities  is  not  of  rare  occurrence.  In  the  Inter  stages  of  the 
dif  PIC  true  motor  paralysis  increases  and  ultimately  becomes 
the  predominant  symptom.  The  muscles  undergo  atrophy, 
or  contracture:!  set  in,  and  they  finally  become  more  or  less 
ooiDpletely  paralysed.  With  the  appearance  of  the  paralysis 
the  ataxio  symptoms  are  thrown  more  and  more  in  the  back- 
ground. 

Symptonu  indicaUre  of  motor  irritation  are  not  promiDent 
features  of  locomotor  ataxy.  In  the  earlier  stages  of  the  disease 
fibnUary  contraction*  and  spaems  of  ainglo  uosclea,  with  slight 
jerking  of  a  limb,  may  be  observed.  At  times  twitebJngs  of 
BOtireextremitiea  may  occur  in  connection  with  the  hmcinating 
pains,  and  are  doubtless  reflex  in  nature. 

Muscular  tension  is  alao  entirely  absent  from  true  cascB  of 
tabes;  the  limbs  are  limp  and  do  not  offer  the  least  resistance 
to  puBiTe  moTementa.  When,  however,  the  paralytic  symptoms 
■Qperrene  muscular  tension  and  contractures  also  arise,  and  may 
oltinuUt:!/  reach  so  high  a  grade  that  the  limbs  remain  im- 


iu 


STSTBU  DISEASES  OP  THE 


movable  in  the  position  of  exteosioD  or  flexion  as  they  do  ii^ 
the  later  stages  of  other  chronic  spinal  diseases. 

The  olectrica)  reactioDS  vary  at  different  stages  of  the  dii 
and  the  statemenu  made  by  diBurcnt  authors  with 
to  them  ore  not  ia  accord  with  odq  another.  Erb  foimd  the 
faradic  and  galr&tiic  excitability  to  be  qiiit«  normal  ia  respect 
both  to  quality  and  quantity.  In  another  series  of  cases  he 
found  a  Hiight  increase  in  the  faradic  and  galvanic  excitability 
ID  the  anterior  muscles  of  the  1^,  without  any  qualitatir^ 
alt«ratioi}8,  while  in  other  oasc^  he  found  a  more  or  leesdistiDot 
dimioation  of  electrical  excitability  in  the  autcrior  moeclw  of 
the  leg,  without  qualitative  cbaoges.  From  tbeee  case«  Srb 
draws  the  general  couclusion  that  in  tbe  earlier  stages  of  the 
disease  there  is  an  increase  and  in  the  hter  stages  a  diminution 
of  the  electric  contractility.  But,  as  Erb  confessea,  no  great 
advantage  in  to  be  gained  either  for  diagnosis  or  prognons  frcaa 
elcctricnt  examinatioos. 

Rejlex  Action. — The  cutaneous  reflex  ia  usually  unnR«cled 
iu  locomotor  ataxy,  at  least  until  a  late  period  of  the  diaeaae. 
In  some  cases,  however,  the  normal  interval  between  the  cuta- 
neous excitation  and  the  resulting  cootntction  may  be  gretuly 
prolonged  (Fischer).  The  absence  of  the  reflex  action  of  tbe 
tuodons  (§  7^)  cousUtutcs,  aa  haa  been  poiuted  out  by 
Wetstphal,  oue  of  the  most  remarkable  fc&lurea  of  the  aflectioD. 
The  putcllar-tondon  rcHcx  is  usually  abwnt  iu  the  prenioiutoiy 
stage  of  the  disease,  and  often  long  before  the  ataxic  syuptODU 
make  their  appearance,  and  it  ia  consequently  one  of  iha  moft 
valuable  signs  of  tbe  disease  which  we  possess.  It  must,  how- 
ever, bo  remembered  that  the  absence  of  the  patellar  reflex  is 
not  absolutely  pathogonoTnic  of  the  disease.  Erb  found  this 
retlez  absent  in  forty-eight  out  of  forty-nine  cases  examined  by 
him,  but  in  the  one  exception  the  reaction  was  very  lively,  I 
have  at  present  under  my  care  a  woman,  who  developed  symp- 
toms of  ataxia  somewhat  suddenly  two  years  ago  after  a  mis- 
carriage, and  in  whom  the  petellar-tendon  reflex  is  in  excess.  I 
have  seen  another  case,  which  will  be  8ubBe<)uently  mentioned, 
where  symptoms  of  ataxia  were  utsodated  with  exoesmVQ  reactJOD 
of  the  potellar-teudoQ  reflex,  but  the  subaequeut  course  of  tbe 
case  skowed  that  it  was  one  of  insular  sclerosis.     I  thought  for 


SPIXJIL  CORD   AND  BfEDULLA  OBLOKOATJL  tl5 

mtat  time  tb&t  Uie  case  of  the  womau  just  alluded  to  would 
toni  oat  to  be  of  the  same  cliaract«r;  but  after  watcbiiigtbe  pn> 
grm  of  ber  cue  now  for  eight  or  nine  montba,  1  can  come  to  no 
other  cooclusioQ  tban  that  it  ia  one  of  tnie  locomotor  ataxy.  The 
ataxic  gait  aad  swaying  movemeQts  on  olosiug  the  ejrefl  are 
wcU  [oarktxl  in  her.  it  is  true  that  sbo  has  not  suffered  much 
from  laocioatiDg  paiiu,  but  there  is  decided  dioiioution  of 
uctite  ii«t»ibility  in  the  akin  over  the  eictenwl  aspect  of  both 
Ugi,  there  has  be€n  aomc  dribbling  of  urine,  and  there  in  cora- 
pleu  abaeaoe  of  paralysis  and  tnusculnr  tension.  But  not  only 
doai  the  pAtellar- tendon  reflex  remain  unaffected  or  even  in 
•xows  in  csseii  of  true  tabes,  but  it  ia  iioinetimes  alisent  in  those 
«ho  an  otherwise  typically  hpnltby,  bo  that  nomc  degree  of 
caution  m  necessary  lu  accepting  the  absBDoe  of  this  pbenomenoQ 
ai  m  sign  of  ataxia.  With  thcBo  reseTvationB,  however,  the 
abaenoe  of  this  reflex  is  a  most  valuable  sign  of  locomotor 
ataxy. 

§  HZ.  Oaiasional  Si/mjttonu. 

Contraction.  —  Attention  has  recently  been 
^rawn  hj  Wetttpbal  to  a  curious  phenomenon,  which  may  he 
regsrled  aa  the  oppottilo  of  the  tendon-reflex  contraction  of 
tbe  nauacle.  Aa  Uhh  symptom  was  anfortuDately  overlooked  by 
me  when  the  first  volume  of  tbta  work  was  passing  through 
tbe  pre«»,  (  ifbaJl  deicribe  it  in  detail  ia  thia  place: — 

It  MMuuits  in  tbe  coDtmction  of  a  muBcl«  induced  bj*  suddeoly  ajiproxl- 
laatiiijC  tta  poiuts  of  orijpu  &ud  inwrtiot).  Tbe  Ciir'iowi  dicunutniicie  tbsfe 
«  aodden  relkution  of  a  rauada  oatuM  it  under  oert&iD  cirouinatauoea  to 
«onm«t  bat  I«d  Wwtpbal  to  name  tbia  pbenoDenou  paivdithrieul  «»«• 
ItmtiiM  Thia  aymptom  i»  bwt  «ta(li«il  in  tho  tittivlln  itnticiiD,  nhich 
naqr  ta  ontain  dUeawo  of  tbecmtral  u«rvoiu  ajKtvm  b«  inkdo  to  contmct 
b^  pfuluciiig  Hiidrieii  or  Kia)etim«s  a  gndual  doml  dezion  of  tba  foot. 
Wlwa  tbe  patieut  is  Uid  on  bis  tack  in  b«d,  and  thtt  louadaa  ar«  r«Ux*d, 
HjiMially  if  tb^  be  |uinUyaed,  tbe  feet  occupy  the  p<«itioD  of  eit«iniou 
or  plwitar  (leiioii.  If  donal  deuou  of  ooe  foot  b«  now  prodncod,  ttw 
UibUlla  anUcuk,  qnilar  certaiu  cinstmatanoea,  ooatracta,  its  tendon  bcoomea 
lavnltwut,  aud  tlie  foot  ia  mkiotaiDod  Tor  aomo  minut«a,  aometioaM  evM) 
aa  loog  aa  twmty-Mvsa  miuut»s  in  the  poaition  of  doraa]  flaiiuii  aud 
adduction,  Wbao  tbe  maM^l•  ia  mada  to  coalruct  hy  direct  or  iiKlir«ct  ex- 
iriian^pfi  or  by  volonUry  eBurt,  the  foot  may  ram&iD  in  a  atatc  of  donal 
■nlM  long  aftar  tba  Mtjoialua  baa  ceaaed  to  act,  and  a  (Xtaataiit  ourreut 
P 


S26 


SYSTEM  DISUSES  OP  THE 


iwuwd  throujjb  it  does  uot  |»roduca  relaxatioii.    Outiiict  roMtaoo*  )«  slw 

ofieredto  tho  pomtve  productton  of  iilaiitu-fftixioii.  After  a  Tuubto  Im|Ui 

of  tiui9  tho  cdumIo  rekiM,  ottbcr  gnduiltj  knd  coutJnoouBlj,  or  vrith 

several  iut«rtaiMioa»,  act!  Ihe  foot  fiilU  by  ita  own  wcdgbt  to  Uia  |KMiLiod 

of  iikotM*  Boxiaa.    Tho  p(U-*dojdcAl  coatrMtioD  m>iii«t)iu«ii  estvntU  to  Uw 

extensor  commuaia  digitaruut  and  extensor  bref ia  pollicta.     lu  mm  ctM 

obMrvtid  t;  WoatpliiJ,  tint  bioep*  fistnuria  wm  smo  W  coatnct  on  Uh  li| 

betn^  auddeni;  Seieil  ou  the  thigh.    This  land  of  eoutnctjoa  toaj  l» 

prMwt  when  tbo  Uodou  r«flex<»i)  «re  ^xeai  or  ddtouU,  uid  probAbl;  sIm 

when  they  Me  Blightly  oxnggirnilvd ;  but  th*  pnMmin  of  disttuct  ankU 

clonoB  will,  of  cMine,  pr«Ti)ut  tho  fout  b»m  bMombg  fixed.    Th«  plMdo- 

mwiiou  luuy  also  bo  absonrGd  wtivti  tbo  cutaDaous  MOHibiUtj  of  tbs  low 

«stniiuitios  is  Donnitl  or  loff«r«il,  and  \a  th«  (klM«nc«  of  soy  axceaa  of  U» 

outftiuiouH  reflex  excitability.     Paranloxiul  coatroctioo  is  generally  aMO- 

elatvd  with  p«u«ais  of  tha  l^war  •xtremitiM,  but  a  &pMtto  tigidity  of  tbt 

mtualM  in  iiavsr  preMtit,  althouKh  a  alight  degreo  of  nnlaUaoa  may  hi 

felt  (0  paaaivo  movomftatA  of  tho  l«g  a»d  foot     This  form  of  contrastiM 

miy  vxtCDd   to  thu  uiumUki  of  tbo  ii[i|)er  «streuiiti«.t,  auil  in  ■  atm 

oWnved  by  Wiiotpbal,  in  wbioh  Bara«  a(  th«ro  M«re  tSaetoA,  a  ocrtain 

UDOUDt  of  rigidity  HubHtfiiiontly  apiwarcd  in  tho  muscles  of  both  uppvr 

AiiA  lowtr  «xtMmit]«!i.     It  ia  a  rarnnrknbla  ctrcntDiitanoc  that  th*pan- 

doiical  cantmotton  ooctin  in  mujicira  Uko  tho  tibialis  aatkua,  which 

probably  never  coatnct  wb»u  thuir  taudous  m  stniolc ;  and,  Movowly, 

tbe  paiailiixical  ooiitniation  Iibd  Dover  boou  obaeired  Id  rauadn  lik«  the 

qu&>lncei»  femoris,  which  mauifeat  readily  the  t«ndoa-Mflex  eonfaraetiaa. 

WlieLberlljeparailaxicBlcaEitraation  in  caiiaed  by  reflex  or  direct  Kzcitatian 

is  not  IcuowD.    Thif?  phenomenon  is  aometimoa  a  ayinptotn  of  locoiuotor 

ataxia,  but  probably  oaver  of  miconipllcat«(l  caaes  of  tfae  Hii-irr     Ita 

prcMitce  uxy,  perhaps,  be  regarded  as  a  sigii  that  ths  luinn  in  the  poa- 

terior  oolumos  in  oxtending  to  tho  lateral  oolumns,  and  that  the  paralytie 

ataga  of  the  disnaso  in  npproitchitig,      This  contniction  haa  alao  ban 

oluervod  by  Woetphal  in  parolyain  ai^tans,  and  in  a  oaso  of  bannatomydl 

at  pnaeut  under  toy  cari),  in  which  both  loner  cstramiliss  are  ooiDpMaty 

paralyaed,  paradoxical  oontraotiaa  ta  readily  iutiuced  in  tbo  tibialiii 

of  the  right,  but  not  in  tliat  of  the  left  leg. 

Paralysis  of  fJie  Octdar  MwkIcm. — One  or  more  of 
ocular  miiscL'fl  nre  iiot  iinfrequeatly  paraljsed  in  tabes  donaliak 
and  this  Hymptom  also  is  of  grcut  value  'because  it  may 
precede  by  many  yeais  the  motor  inco-orvli  nation  of  tlie  lower 
extremities.  The  motor  oculi  andabducenaare  more  frequently 
aHecLttd  Uiau  the  troclilear  nerre.  The  paralysis  of  tbe  ocular 
Derre*  ia  usually  transient,  aoU  gonerallj  lasts  for  a  faw 
day«  or  months.  Tbe  paralysis,  however,  often  rccun  afiei 
a  longer  or  sboiter  time,  aad  may  beoomo  penuaDeDt  t<nranii 


SPINAL  CORI)  AND  MKDULLA   OBUI-VQATA.  227 

tl)£  later  etages  of  the  dtaease.  The  temporary  pAralmt  of 
the  ocular  muscles  in  locomotor  atasy  often  do  not  give  rise 
to  any  apparent  aquiot,  but  cause  double  vision  (diplopia), 
which  ifi  either  constantly  present,  or  only  when  the  ryes  are 
lurned  in  partictilar  directions.  Distinct  sqitict  and  ptdsia  are, 
hovever,  present  in  some  caaea.  Out  of  64  cbhcb  reconled  by 
Euleabtii^,  25  had  etrabiamua;  of  the»e  35,  10  Lad  div<>rgent 
nrabtinaiu,  and  4  bad  in  addition  paralytic  ptoaiH,  while  6  hrtd 
convergent  alrabismus.  When  p.imlyslii  of  the  third  or  sixth 
nerve  ucxrura  sypbUis  is  generally  euspocted  to  be  the  cause, 
atxl  if  the  paralysis  disa[^tear  in  a  fuw  dayn  or  weeks  under 
tnatuent,  the  diagnosis  seems  to  be  placed  l>eyond  doubt 
Famlyinii  of  tbeso  nerves  may.  huwevcr,  be  ibe  firat  symptom 
of  locomotor  ataxy.  In  a  case  of  my  own,  paralysis  of  tbe 
aixth  nerre  i^ipeared  to  have  been  promptly  cured  by  iodide  of 
putasaium,  and  it  was  not  until  cighteun  montbii  afterwards 
that  tbe  ataxic  symptams  dcclarc<l  thcouelves  and  the  true 
oatore  of  the  case  was  made  apparent. 

Mydruviis. — Dilatation  of  tho  pupil  was  obaorved  by  liulen- 
bufg  in  9  out  of  Qi  case^.  In  3  the  dilatation  was  double,  in 
4  nogle;  and  in  2  accompanied  by  myosis  of  the  other  eye. 
There  i^  no  defect  of  accommodation  occompauying  Ibis  con- 
ation; hence  it  would  seem  that  the  pupil  is  ditnte^l  not  from 
panlysin  of  the  third  nerve,  but  from  irritation  of  tbe  cilio- 
•pioal  nervra.  The  pupil  frequently  dilates  during  suvere 
panNtyams  of  lancinating  pains  (C)iaroot)  and  during  gaelralgic 
attacka  (QraJager  Stewart). 

ili/oais. — Euleuburg  found  contraction  of  the  pupil  in  23  out 
of  C4  caves^  21  showing  iloubh:  and  7  ninglc  myoaia.  Tbe  two 
pupils  are  indeed  seldom  of  the  same  iiize,  aud  the  degree  of 
contraction  varies  greatly  in  different  cases  and  in  tbe  same 
caae  at  different  times.  Inequality  of  the  pupils  is  common  in 
tho  early  stage  of  the  disease;  jiuU  ou  tbe  side  on  which  tbe 
cootracttou  of  tbe  pupil  is  the  moro  nuirked  there  may  be 
redness  of  the  cheek,  congestioit  of  tbe  coDJunctiva,  and  local 
deration  of  temperature  (Charcot).  Thcec  symptoms  indicate 
vaso-motor  pantlyets,  and  prove  that  tbe  myosis  is  due  to 
paralysis  of  the  cilio-apinal  nerves. 

Thi  Argjflt-ItvOerUon  Symptoni. — ^Tliis  symptom,  as  already 


S28 


8T8TBU  DISEASES  OF  THB 


meatioDed  (§  S2ff,  ll},ooDsiBte  in  the  abtwDce  of  aoj  oontraet 
of  tbe  pupil  OQ  exposure  of  tbe  ejre  to  tigbt,  while  coDtractioo 
with  the  acooramodation  ia  normally  retained.  The  symplom 
is  generally,  Although  not  invsrtahly,  associated  with  myosia. 

K'l/sUignm^  h,  aa  Friedreich  has  shown,  oocasionatly  present 
in  locomotor  ataxy;  altbouKh,  coDtraryto  what  occurs  lu  muUifile 
sclerosis,  it  is  au  exceedingly  rare  symptom.  The  aysti^mus 
only  appears  wtitiu  attempts  iiru  madu  totixthc  eye  oqod  objecL 
The  movements  of  tbe  aystagmus  in  tabes  do  not  sucoeed  one 
another  with  the  same  rapidity  as  the  rnovemeDle  in  ordinuy 
nystaj^mus,  depeiiduut  upon  di»ua»c  of  tbe  eye.  Tbe  move- 
meats  arc,  indeed,  purely  ataxic,  and  only  occur  on  a  roluntaiy 
cHbrt  at  fixation  being  made.  Ataxic  nyatagmus  only  oocun 
in  eertfiin  caaeB  which  possess  miirked  clinioal  peculiarities,  aod 
it  ia  alnay»  a  lato  symptom  of  the  disease. 

Atrcphy  of  the  optU  nerm  ia  a  frequent  and  diitreadng 
complication  of  locomotor  ataxy.  The  affection  begiiu  with 
elowly  or  rapidly  advancing  diminution  in  the  aotiteoesi  of 
viaioQ,  which  soon  tenniuntes  in  amaurosis.  Colour  blind- 
neM  can  usually  be  demouHtrated  prior  to  any  ItmitatioB 
in  the  lictd  of  vision.  The  perception  of  grcon  is  first  loit, 
then  that  of  red,  yellow,  and  blue  in  sucfossiou.  althoagh 
deviations  frum  this  order  may  occaaionally  occur  (Krb).  Tb« 
pupils  are  usually  contracted  in  such  cases  and  they  do  nut 
react  to  light.  Tbe  hlindneKK  is  caused  by  white  atrophy  of  th« 
optic  nerve.  The  rapidity  with  which  blindness  supervenei 
is  very  variable.  At  times  total  blindness  may  superTene 
in  R  few  weeks,  while  at  other  timrft  years  may  elapse  before 
the  loss  of  Bight  ia  complete,  and  occasionally  the  affection  may 
cease  to  progress  after  it  baa  lasted  fur  a  comparatively  long 
time.  The  diacaee  may  be  limited  to  one  eye,  hut  usually  both 
eyes  are  simultaneously  attacked,  Atrophy  of  the  optic  nem 
ftppean  in  about  thirty  per  ccat  of  all  casoa  of  locomoiot 
ataxy,  it  i<  frequently  one  of  the  initial  symptoms  of  th« 
disease,  and  sometimes  even  precedes  the  lancinating  poiu 
Tbe  amaurosis  has  been  known  to  have  existed  ten  years  before 
the  other  symptoms  of  tabes  have  mode  their  appearance. 

Disiurhaiices  of  hearing  are  occasionally  observed  in  tabe& 
Tbe  defect  of  hearing  is  somoCimee  a  paraly  accidental  circutn- 


stance,  but  at  otber  tiraeH  it  probably  depeodfi  upon  atrophy 
of  the  auditory  iterve,  aDalogous  to  tLat  of  the  optic  nerve. 

i>u(ur6aiMeit  of  tatU  a-nd  smell  bare  also  occanio&ally  bcca 
obmrved.  but  are  of  fluborditiate  importance. 

Tlu  trigmiinxM  at  times  manifesto  aigna  of  irritation,  giving 
riw  to  pain  and  panesthense,  or  it  may  be  either  partially  or 
completely  paralyiied,  giving  riso  to  a  sense  of  numbDens,  or  to 
aomtlieaia.  Disturbances  uf  tasto  and  smell  are  always  asso- 
ci«t«d  with  an  abnormal  couditioo  of  the  trigotniuuB. 

The  faeiixl  nerve  ia  rcry  rarely  implicated,  but  irregular 
twibchiugs  of  the  fociul  muscleii  bare  occa^Ioaally  been  observed. 

3%0&jl|)Oj;{oMaZncrTohiu  teen  rarely  affected.  The  pncumo- 
jMtnVi  ■nrttlfrrwn  phurynflrnl  nTrrn  nrr  very  seldom  impHcAtcd, 
■Bill,  iiidMd,  the  gaitralgio  troubles,  which  are  bo  frciiiueat 
aad  digressing  in  tabes,  ore  the  result  of  irritation  of  the 
poeomogaatric*. 

Pmf^uxd  disturbaruita  oro  but  seldom  observed  Wcstpbal 
has,  indeed,  showu  that  the  majority  of  patients  whu  sufTer  from 
give  paralyiiiii  of  the  insane  appear  to  have  degeneration 
^ibe  apiBal  cord  chietly  limit«d  to  the  poslBrior  culumnB.  The 
aymptonis  of  progressive  paralysis  of  the  ioitano  may  precede 
the  tabes  for  many  yeaiH,  or  may  becomo  associated  with  it  after 
it  baa  exi»t«d  for mnny years,  or  may  notarise  until  the  terminal 
period  uf  jooomotiir  ataxy.  In  all  those  cobm  the  tabes  is  only 
COS  of  the  manirestAtions  of  a  more  widely-difTuKed  degenerative 
pcooBia.  juat  as  ataxia  may  be  one  of  the  symptoms  of  multiple 

are  other  njrmptoms  of  locomotor  ataxy  which  do  nob 
such  promineat  featares  of  the  disease  as  those  already 
ribod,  but  are  not  oo  that  account  less  remarkable  ur  of 
loM  importoDoe.  Tbeoe  arc  what  may  bo  denominated  viaoeral 
tympUoM, 

J^cUiotu  of  the  Bladder  and  B^ttum. — During  the  early 
HAge  of  the  disease  the  patient  often  suffers  from  frequent  and 
jfuL  nuclurilion.  along  with  neuralgic  pains  in  the  depth  of 
pelvis,  in  tlie  pcrinnuDi,  or  the  neck  of  the  bta<lder.  At 
ft  hUr  stage  of  the  disease  signs  of  paresis  of  the  bln^Ider  make 
their  appeaniuce,  so  that  empljiug  the  bladder  takes  a  longer 
time,  and  i^|u^^ie  nibsecjuent  dribbling,  or  there  maybe  a. 


280 


SYSTEM  DISEASES  07  THE 


moderate  degree  of  iuoontinenoc ;  but  complete  paralyBu  ofUie 
bladder  ia  exceodingly  rare,  aud  ouly  occurs  in  the  laxt  stage  of 
the  disease.  A  certain  degre«  of  vesical  catarrli  ma}'  be  prewot 
duriDg  ihe  termiaal  stages  of  tabat,  but  it  K  Heldom  of  a  aeren 
cbaracter. 

Patients  alno  compIaiD  during  the  earlj  stage  ot  tabes  of 
ver/  peculiar  sensntions  in  the  rectum.  These  aensatioRs  are 
at  times  described  by  thu  patient  a*  a  fevling  Biiuilar  to  that 
which  might  be  produced  by  the  forcible  introduclioD  into  the 
anus  auil  rectum  of  a  long  and  volumiuuu:^  bo«ly  (Cliarcot)- 
This  sensation  appears  suddenly  and  noon  dinappcara,  aati  it  iit 
usiiatly  accompanied  by  a  strong  desire  to  evacuate  tbe  contenu 
of  the  bowels,  and  occasiooally  an  invoIuiotAry  evaeuatioQ  of 
fecal  mattcra  occ^urs.  At  n  more  advanced  period  of  the  diseaae 
antesthetia  of  the  anus  may  be  present,  so  that  tbe  patieou 
lose  the  feeling  of  approaching  evacuations,  and  hence  not 
ttofrequcntly  dirty  thems*o!ve».  True  pnralyi^is  of  the  tipbiocter 
is  rare  and  only  occurs  iu  the  terminal  period  of  the  disesM. 

DiviuTbancmt  of  the  SexiLut  FimHion«.' — A  certain  amount  of 
disturbance  of  the  genital  otgaus  is  rarely  absent  io  tabes.  In 
the  early  period  of  the  disease  Rymptomti  of  irritatioa  are  preseDt 
Trouiuieau  obser^'cd  in  cortaiD  cases  a  singular  aptitude  for 
repeating  the  venereal  act  a  great  many  timCK  within  a  Rbort 
period,  and  he  mentions  the  case  of  a  man  who  was  able  to 
have  connection  as  many  as  eight  or  nine  times  io  oue  night 
Iq  these  copies  the  appearance  of  excesaive  virile  power  is  already 
ooQJoioed  with  symptoms  indicative  of  weakness.  Very  oftea 
this  excessive  desire  has  been  preceded  by  a  certain  ajoouot  of 
inoootincnce  of  urine  and  involuntary  tiominal  omissions,  tad 
the  erections  arc  often  imperfect  and  accompanied  by  premature 
ejaculation.  Charcot  and  Bouchard  have  obecrvcd  ayroptoms  of 
gcoital  irritation  in  voToeD.  As  tbe  ataxic  symptoms  mmiifaift 
themselvtrii  wcakooss  of  the  sexual  ftmctions  set  in,  which  sooq 
develop  into  complete  impotence,  although  some  tabetic  patient* 
retain  their  sexual  power  undiminished  for  a  very  long  time. 

A  permanent  acctUmtum  oj  th«  pvlw  has  been  mentioDed 
amoDgat  tbe  symptoms  of  locomotor  ataxy.  Tbe  temperature  of 
the  body  U  often  increased  during  theattacka  of  lightning  pains 

GoBtralgie  attaeht,  desoribcd  by  C^rcot  under  the  name  of 


8P1HAL  CORD  AND  MCOUU^  OBLONGATA. 


231 


criMs  gciHriqvM,  are  rrcqueoO^  obscrTcd  id  the  early  stage  of 
tsbcA.  t  IcDow  a  geotlemao  wbo  suffered  rrom  tbe«e  attacks, 
anit  laociaatiog  pains,  ten  years  before  tlio  appearance  of  the 
ataxic  symptoms.  The  goatralgic  attack  generally  begins  sud- 
denly during  a  paroxyam  of  the  laQcinating  p»n&  The  patient 
cooplaiiui  of  pua.  which  starta  from  tbu  groins  and  appears  to 
^^aUB  op  cadi  aide  of  the  abdomen,  so  as  to  become  Bsed  in  the 
^^pigutnc  region.  At  the  same  time  severe  paios  are  felt 
'  dtuAt«d  between  the  shoaldcrs,  which  radiate  round  the  base  of 
tb«  thorax,  under  the  fono  of  lightning  paina  As  a  rule,  the 
action  of  the  heart  is  violent,  and  accelerated  during  tlie  attacks, 
vlucfa  are  generally  aooompanied  by  extremely  poinful  and  in- 
CMHOt  vomiting.  The  food  is  rejected,  then  a  quantity  of 
mteiy  mucus,  which  is  at  first  colourless,  but  may  ultimately 
become  mixed  with  bile  and  blood.  A  profound  malaise  and 
vertigo  are  conjoined  with  the  vomiting,  while  the  lightning 
pains  are  unusually  severe,  ito  that  the  HufFeriugs  of  the  patient 
may  become  truly  agonising.  These  attacks  may  last  without 
rapite  for  two  or  three  days,  and  may  recur  every  two  weeks  ; 
bat  usually  the  interval  between  the  attacks  is  not  less  than  a 
month.  During  the  interval  the  fiinctions  of  the  stomach  oro 
entirely  unafTected.  The  gattralgic  attacks  may  begin  at  an 
eaxly  stage  of  ibo  diacMe,  and  may  con8titut«  for  many  yean, 
along  with  the  lightning  pains,  the  only  symptom  of  the 
appraoehing  malady.  These  atta«k0  do  not.  however,  always 
dittppeor  on  the  ataxic  symptoms  being  established,  but  may 
eantinue  to  recur  until  the  fatal  termination  of  the  disease. 

ycphT\dqie  atUick-a  have  recently  been  described  by  Raynaud 
which  present  symptoms  almoHt  entirely  similar  to  renal  colic, 
only  that  there  is  entire  absence  of  calculi,  gravel,  or  blood 
from  (he  nriue. 

fininciiia]  attacks  have  been  described  by  F^reol  ander  the 
nune  of  "bnmehial  crms"  consisting  of  paroxysms  of  spaa- 

Eio  ooagh,  difficulty  of  breathing  and  swallowing.     In  cases 
ribed  by   Friedreich  vertigo  has  been  a  very   prominent 
ptooL 
T<uo-motcT  IHdurhancea. — Voso-motor  disturbaucM  are  nob 
pTDminont   features  of  locomotor  ataxy.     Patients  not  unfrc- 
qa«stly  oonplain  of  cold  feet  i  and  aometimea  there  is  a  great 


S3S 


SYSTiCM    DISEASEi  OF  THE 


tODdeacy  to  the  formatioQ  of  etUia  aiutfriTia.  The  skin  ix : 
times  mottled,  and  ther«  may  be  iooreafted  or  diminished  cuta- 
DCoiiii  Becrction.  A  curious  case  has  rooeotly  boca  described  by 
£.  Remak,  in  which  the  ataxio  symptoms  began  iu  tlie  right 
upper  extremity.  The  muscles  of  the  forearm  were  aomevbat 
wasted,  but  there  was  do  distiDCt  loss  of  motor  power,  yel 
band  waH  rendered  practically  useletw  frum  the  ttisurderly  moi 
meuts  which  oocurred  when  any  attempt  was  made  to  use 
Serious  sensory  disturbaiicen  were  obaerred  in  the  extremity 
afr^cted  with  ataxia,  and  slight  analgesia  of  tlie  sole  of  the  right 
foot.  There  were  also  slight  swaying  movements  on  closing  tbs 
eyca,  and  the  patcllar-teudoa  rcfleses  were  absent,  but  there 
wore  no  lancinating  pains  and  no  ataxic  or  paralytic  symptoms 
in  the  lower  eKtremities.  Id  addition  to  these  syraptoins.  the 
patient  suffered  from  unilateral  byperidrosis  limited  to  the  right 
side,  rcdncas  and  alight  relative  increase  of  teropenUurc  of  the 
right  half  of  the  face  and  side  of  the  head,  and  myosis  of  th« 
right  pupil,  tho  latter  becoming  more  marked  with  the  increaBe 
of  the  secretion  of  sweat,  and  froquentlydisappearing  altogether 
with  complete  re»t.  The  secretion  of  sweat  was  increased  on  the 
right  side  when  the  patient  took  any  acid  substance  into  his 
mouth,  and  also  by  faradic  ozcitation  of  the  tongue  and  mucous 
membrane  of  the  mouth,  or  of  the  skin  of  the  cheek,  and  tmuk 
of  the  fHcinl  nerve.  The  conjunctiva  is  »aid  by  Trousseau  to  bo 
frequently  congested  in  locomotor  ataxia^ 

Trophic  Dieturhances. — The  most  common  trophic  affectic 
are  eruptions  of  the  skin,  such  as  herpes,  lichen,  or  the  forma- 
tion of  buliie,  like  those  of  pemphigus.  Bed-sores  usually 
belong  to  the  terminal  period  of  the  diseoso  only.  Dr.  Buusard 
reports  a  case  of  lucomutor  ataxy,  in  which  an  eruption  of  hcrpet 
occurred  in  the  right  gluteal  region  during  every  paroxysm  of 
lighlDing  pain.  The  patient  stated  that  he  must  have  suffered 
from  fifty  or  sixty  attacks  of  herpes  during  the  four  yeara  pre- 
vious to  the  report  of  his  case.  Tbe  nutrition  of  the  mu»oles 
remain  for  a  long  time  iinafTocted;  and.  indeed,  the  inuwlo*  of 
the  lower  extreraitioe  may  undergo  a  certain  amount  of  hyper- 
trophy during  the  early  part  of  tbe  atoxic  stage,  owing  to  the 
excessive  activity  to  which  tliey  are  subjected.  During  the 
[PStrAlytIc  stage  the  muscles  may  waste  rapidly,  simply  from 


SPINAL  CVRO   XHt>  UKDVILA   UBLONOATA-  233 

dl«iua.  uiJ  not  Troni  tatj  active  atropli/.  Occasionally,  how- 
ever, tbe  iliufwe  becomes  oompUcatvil  at  a  oomparulively  early 
period  with  atrophy  of  oertaio  miudea,  such  as  those  of  llio 
OAlre*  of  t^e  legs,  or  tho&e  of  the  thighs,  bull  of  the  Uiumb.  or 
of  ODe-bftlf  of  tbo  tOQgitc;  aod  ia  iIicm)  cusch  the  atrophy  coi)> 
sbta  of  active  degeaeratioD,  and  not  merely  of  tbo  postivo 
degt&eration  which  ia  causetl  by  fuDctiunal  inactivity.  The 
noU-  nmaikftble  trophic  diaturhaDces  which  occur  in  ubes  are 
the  affectiofia  of  tbe  joiots,  which  haro  beoo  described  by 
Clharoot  under  the  name  of  arthroptithies  des  cUaxiquet.  It  ia 
poidbto  to  meet  with  joints  deformed  with  rheumatic  gout,  and 
di;  arthritis  coiocideDtly  with  tabes,  but  the  artbroputhiea  of 
Igoomotor  ataxia  develop  themsolves  quite  independently  of  any 
gMuiia]  afliKtloa.  Tliia  atfectiou  always  appears  during  the 
flwly  stage  of  tabes,  URually  during  the  stage  of  the  lightning 
paiiM,  although  many  canes  seem  to  contradict  this  nile.  The 
joiutsoflhe  upper  extremities  raay.for  iustauce,  hecome  affected 
at  ao  advanci^  period  of  the  diseoAe.  The  disease  bait,  however, 
Doly  reached  ad  aJvaaced  stage  in  the  lower  extremiliesi  while 
tbe  upper  extremities  are  only  just  beginning  to  manifest  the 
initial  stage  of  the  affection.  The  joint  tnoHt  fr(>queutly  affected 
is  the  koee-joint;  and  then  in  a  deacendiog  order  of  frequency, 
the  abouldcr,  elbow,  tbu  hip-joint,  and  the  wrist  in  BttCcessioD. 

Vahouii  luxattoQa  of  the  joints  ensue,  producing  notable 
deform  itieo. 

lo  locomotor  ataxy  tbe  bones  also  lometimes  become  abnor- 
mal ly  friable,  so  that  spontaneous  fractures  may  occur,  a  change 
which  is  no  doubt  of  similar  origin  to  tbe  joint  affection. 

Tbu  follDwing  case,  reported  by  Dr.  Drenchfeld,  will  illustrate 
tbti  actbnipatbies  of  looomotor  ataxy: — 

&  "W- — ,  agwl  fif^,  toMhanlc,  nuriMl,  witli  no  hwtory  of  either 
ayphOi*  •«■  sjoobolisia,  bad  alwAja  BDJoired  good  health  ItU  fiAeea  juara 
«|ci,  vben  Um  &nl  symptonis  of  locomotor  ataxy  cftme  ocl  Tbeoe  symp- 
toina  eoaaiatod  ia  the  inability  to  mlk  iu  the  dark,  and  in  tbe  |)cwaea«e  of 
b^taiiif-tilie  paine  ia  ttw  legs,  ia  oonaequanco  of  whioh  ha  waa  aoon 
aUfid  to  gira  up  his  work  8ov«d  yaara  ago  the  poioa  in  tbe  right  thigb, 
■ftboot  loaing  their  Ughtiiiii{:-tilcs  obanoter,  becsms  auddeoly  mueh  mon 
pswrialtnt,  and  obhgwl  the  pktient  lo  take  to  hia  bad,  aad  to  raaiaia  in  bed 
far  ft  mnaUi,  wb«Q  Uwy  left  bioi  aa  aoddeoly  as  they  came.  On  trying  tn 
C«t  up  be  Ivuad  aow  that  his  right  leg  waa  much  sliortor  tbau  the  left, 


S94 


SYSTEU   DISILUil&J  OF  TDS 


and  tliat  ibero  was  a  projection  aa  the  right  hip,  which  occaNouall;  woold 
suddenly  dis^iieiur  with  a  )>eculiiu-  Doiaa.  Anj-  tnovemeDt  of  the  thigh  or 
leg  iTould,  however,  make  this  projection  verjr  aooti  raap[>ear.  Three  ymn 
ago  tha  left  Icuee  begau  to  give  my  without  any  exacerhatioD  of  pain,  or 
auy  t'lddea  aweilliig  of  the  jviut,  aud  very  gnulually  assumed  tta  ]jrMsnl 
jioaitiou,  that  of  extreine  baokward  ditdocalioti.  la  coiitaqueuoe  ot  Hum 
jeiut  aiTectious,  wAllcing,  which  was  alroady  difficult  l>«fore,  became 
ocjly  [KHuiiliLu  with  tliu  h«l|i  of  two  sticks.  The  geueral  hvalth  of  the 
patient  had  rmoaiued  tct;  good  throughout,  his  eyesight  had  been  bad 
for  some  yetan,  but  he  had  never  miQend  from  vomitinj'  or  aoy  bladdCT 
troubloH. 

Oo  admiasion  p&tieot  looked  well  and  healthy  ;  tha  thigha  wei*  oon- 
aiderab)/  waatod,  but  the  root  of  the  body  was  uot  emaeiated.  The  cheet 
aiid  iLbdotniuol  nrgaos  were  perfoutly  lioalttiy.  Then)  was  ito  afliictioii  of 
atiy  of  the  oerebral  uerve*,  oaccpt  oiarked  white  atrophy  cf  both  of  the 
discs.  The  [}upiU  were  coutractsd  and  reacted  to  acoommodttUoir,  but 
not  to  light.  Tho  upper  cxtrenutics  wore  perfectly  Dcnual.  The  lower 
extremities  showed  the  chief  symptoms,  and  here,  as  regards  (I)  aeuaatioii, 
there  were  dluiinutioa  of  tactile  seueibility,  atialgeeia  of  oertaio  ^Ota, 
aud  retardation  of  Heiiniliility.  Tho  aetiae  for  teuperature  aitd  weight  WM 
Dormal ;  thu  tuuauuW  eeuaa  waw  coitaiderably  affected.  The  |>ateUar-tM- 
doii  reJei  wax  (luite  absent  Both  lower  eitremitiea  were  often  the  seat 
of  the  lightuiug  ptuna.  Aa  regardt  (S)  trophic  changM,  (a)  the  museln 
of  both  thighs  were  flabby  and  abropbieil,  but  es[)eci]i1ty  the  muiolea  of  the 
left  thigh.  {(/)  There  waa  marked  dielocation  backwards  of  tho  left  thigh, 
80  that  wheo  the  patJeut  stood  the  upper  surface  of  the  tibia  oould 
distiuctly  be  felt  under  the  skin.  Thare  was  no  atrophy  of  either  of  the 
articnlaliug  aurracoM,  niir  any  new  deposit  of  bono  round  the  joint  as  far 
M  ouuld  be  mode  out  on  manual  examiuatiou.  The  head  of  tho  right 
femur  was  dlalocat«d  ou  to  tho  dorsum  of  the  ilium,  and  could  be  felt  as  a 
distinot  ronnd  pcojeotion  ;  it  was  freely  morakle  and  could  easily  bo 
reduced,  but  rery  aoou  slipped  out  again  from  the  acetabulum  uu  to  the 
dorsum.  Owing  to  thin  duilooatioii  the  left  knee  waa  altuated  four  Inehes 
lower  than  tho  right  kuoo,  which  diSbnouce  disappeared  m  aoon  aa  the 
reduction  of  the  headof  the  femur  was  effected  (Plata  rV.1,S}.  The  head 
of  the  dialocatod  fomur  did  not  seem  bo  bo  atrophied,  nor  were  there  any 
bone  deposits  to  be  felt  about  the  joint  cavity.  A  man  of  bone,  however, 
uf  uiore  than  cue  inch  iu  length  was  felt,  situated  in  the  aheath  of  tbe 
MrtoriuB  muscle,  totally  unconnected  with  the  joint,  but  moving  freely 
with  tliu  miiaolfti  during  tbia  coutraction.  Aa  ret,'artls  (3)  motility,  tbore 
was  ooueiderable  diminution  of  motor  power  in  both  legs,  but  more  in  the 
right  than  iu  tha  left ;  the  patient  wan,  however,  able  to  stand  aud  to  walk 
with  the  help  of  two  sticks  ;  his  walk  was  characteristicaUy  ataxic :  he 
WW  unablo  to  walk  with  his  eyes  ehut,  and  with  hie  eyea  opoo  his  g«il 
waa  very  unsteady,  owing  to  the  atuy  ai;d  the  dialocatioos. 


23C 


STSTEU   DISE&aES  OF  THE 


(■li)  ParapUgic  Fom. — Id  »  oertaia  nomW  of  cmm  mudfeitetkiu  of 
motor  weakneM  coma  inlo  pntmineDW  at  mi  eu-l/  porioil  or  ti)«  diw—. 
NO  tbftt  the  Ubetio  »jrm{>toma  become  olMcured.  The  «;TO|>toEii]i  ma;  In 
iiucli  ciues  auggwt  panplegia,  and  ecnaciatioii  aud  atrophy  of  tb«  1^ 
\0Ay  ettDui  it>  ounArtn  tliia  opinion.  In  theM  cuea  the  degesentire 
chsngn  haT«  no  doubt  exteuded  to  the  pjrranndal  flbcm  of  Ibo 
columoa  n»d  to  the  aDtsrior  horns  of  the  gnjr  mbatAiico. 

(S)  Newiil'^c  Fom.—lu  oilier  casea  the  bnclaaUsg  paina  oooatit 
tfa«  mo«t  promitietit,  oiid  Tir  a  Inng  time,  aometiiae«  apmnta  of  twentj 
7«ani|  tho  oul;  s/mptoma  of  the  dueoso.  This  form  haa  be«a  called  "tabes 
dolorosa."' 

(8)  Mmin^iic  Farm. — At  times  locomotor  ataxy  beoomu  oomplkstad 
wiih  apia&I  uieiiiusitia,  and  such  oasee  may  offer  a  rerj  nriable  oomhina- 
tioD  of  B/mptoma.  OircutUBCribed  or  diffused  eutaaeoiu  by peneatbeata, 
paiu  ID  the  back,  aud  s[:nualt«uderiiensareeoueof  ttieaymptontairbicltars 
moat  oDiumonlv  present.  Lcwomotor  ataxy  may  alao  be  oomplieated  witfa 
TAriou9  psjiaiiical  duturbutoM,  aad  these  must  be  tulyeated  (0  a  i 
iuTestigatiuD. 

§  4414.  Ctmrae,  Dttntti&ti,  and  Tennination.  —  The 
ilevelopment  of  the  locomotor  ataxia  is  alow  aad  cliroDi^  ex* 
teuJiHg  over  raontba  or  years,  although  cases  havo  been 
describeJ  under  the  Qnme  of  aeute  cUaxia  which  run  a  rapid 
couriw.  As  &  rulo,  stugle  symptoms  arise  which  remain  isolated 
for  a  long  time,  and  with  which  othen  become  afUr  a  time 
associated  uulil  iu  the  cotirae  of  moathn  or  yean  the  picture  of 
the  diBcase  ia  complete.  The  ataiic  symptoms,  as  already  men- 
tioned, ii&ually  begiu  in  the  lower  extremities,  but  a  few  cases 
are  reported  id  which  the  upper  extremities  were  first  affected. 
Occasioually  a  unilateral  development  has  been  obaervoiL 

When  the  disease  is  fully  developed  the  intensity  of  tfae^ 
symptoms  progressively  incroaeds,  now  symptoms  arise,  and  the 
oondttioQ  of  the  patient  gradually  grows  wotse.  The  diMMt 
may,  however,  rema.iii  statiocary,  or  even  undergo  a  marked 
improvement  for  months  or  yeftra;  but  after  n  time  ad  on- 
favourablL'  chan^  usually  takes  plac&  The  patients  feol  better 
in  summer  arid  worse  in  winter,  but  they  generally  lose  more 
in  cold  than  they  gain  in  warm  weather.  In  rare  cwob  the 
improvement  may  progress  to  complete  lecovery.  The  duration 
of  tlie  disease  is  always  to  he  cutiuted  by  yean,  and  eomeUmes 
hy  decades.    Even  the  initial  stage,  with  laucioating  paioa,  mi^ 


SriKAL  CORD  AND  JIEDCLU  OBLOKOATA.  237 

Ust  over  twenty  yean;  Id  the  nwjority  of  typiaU  cues  of  the 
ilisMUW  the  avenge  duration  of  life  appears  to  be  from  eiglit  to 
twdve  jenrs.  aod  in  tbeso  canes  death  is  caused  bv  bfM]-eore8, 
cyBtitia,  or  bulbar  sjrmptotns,  or  the  spinal  affection  renders  the 
pAtieot  lesB  capable  of  snrriving  iutercurreot  attacks  of  discatse, 
■ucfa  as  pneamoiiia,  the  exanthemata,  or  other  fcvent. 

BeooTery  is  not  unusual  io  the  initial  stage  under  appro- 
priate treatment;  and  even  wUco  tbe  dieeaae  is  fully  developed, 
recovery,  or  an  improvement  bordering  on  recovery,  may  take 
pUee.  Often,  however,  patients  must  be  content  with  a 
modentfl  iraprovemcnt,  or  an  arrest  of  tbe  malady.  As  a  rule, 
tbe  disease  is  of  a  progreesive  character,  and  the  most  judicious 
treatment  may  foil  to  bring  about  <-ven  a  temporary  improve- 
QMOL  A  fntal  termination  may  be  brought  about  in  various 
wayi.  The  disease  may  lead  to  paraplegia,  cystitis,  and  bed- 
aorea,  and  the  patient  dieR  from  tbe  usual  aymptomti  of  severe 
■llilial  paralysis.  During  tbe  laet  few  days  (»>rvbrai  symptoms, 
■a  mma  and  delirium,  may  supervene.  The  morbid  proc^Ks 
may,  in  prt^essing  from  below  upwards,  involve  tbe  medulla 
oblongata,  and  cause  death  by  interfering  with  respiration  oi 
with  the  act  of  degluittioo.  Very  frequently  some  intercurrent 
aflectioD.  such  as  typbus,  pneumonia,  diphtheria,  and  phthisis, 
causes  a  fatal  tcrminatioo. 

§  ii5.  Morbid  Anatomy. — The  spinal  pia  mater  is  often 
ibickened,  cloudy,  and  oonnected  by  numerous  adhesions  to  the 
dura  uiaier.  The  change  in  the  pia  mater  is  generally  conSnetl 
to  tbe  posterior  aspect  of  the  cord,  being  {nrcumscrtbed  by  the 
iterior  roots  on  each  side.  Occasionally,  however,  tbe  pia 
appears  altered  over  a  larger  area,  and  the  spinal  Huid 
U  almoaC  always  increased  in  quantity.  Tbe  spinal  cord  is 
»Mr^ly  altered  in  form,  being  flattened  from  iK'fore  back- 
over  a  eonndorable  portion  of  its  Piieiit,  caused  by  a 
dimioalioa  of  the  volume  of  the  posterior  column.  On  making 
rane  sections  at  difierent  levels  of  the  curd,  a  grey  or 
^•yellow  discolouration  may  be  observed  along  llie  poH> 
median  fissure,  extending  almost  the  entire  length  of  the 
The  consistence  of  the  cord  is  usually  increased,  but 
rsoMMonally  it  may  be  diminished. 


238 


SYSTEU   niSEASES  OF  THE 


The  posterior  rooti<  are  di»co[oure<I,  grey,  traoslucent,  and' 
atrophietl,    this  coadilioa  beiug  particulurly  well    marked  in 
the  Cauda  equina.      Dr.  Carter,  of  Liverpool,  exUibiled  tti« 
spinal  cord  from  a  case  of  locomotor  ntnxy  aC  a  recent  medic 
mooting  in  Maocbeater,  in  which  the  gang]  ia  of  the  posttcrio 
roota  of  the  aacml  and  lumbar  nerves  were  greatly  eotarged. 

The  degeDeration  ig  not,  as  a  rule,  unifonnlj  distributed  ovvi^ 
the  whole  tranaverse  sectioa  of  the  posterior  cotntnas.  Thi 
columns  nf  Goll  are  usually  affected  orer  their  entire  leogtJi, 
and  the  postorior  root-zoucs  are  always  atTected  to  a  mere  or 
\ess  extviil,  alihuugh  they  are  not  oft«o  degenerated  tbrougboul 
the  entire  length  of  the  cord.  In  the  iDferiur  portion  of 
lumbar  enlargement  there  ia  frequently  only  a  alight  grey 
discolouration  in  the  external  half  of  the  posterior  columoai 
but  on  ascending  it  iticreuea  in  width,  ao  that  iu  the  upper 
half  of  the  lumbar  enlargement  the  discolouration  embraces 
the  entire  trausvursu  auction  of  the  pi^ittterior  colunioa  The 
whole  of  the  posterior  columns  are  usually  Eificctcd  tbiougbout 
the  entire  length  of  the  dorsal  region,  but  its  extent  dliuiuishes 
again  in  the  cervical  portion,  and  the  degeneratiou  bccomca 
limited  in  the  upper  cervical  regioa  to  tbo  oolumos  of  GoU. 
M  a  rule,  the  iatonsity  and  extent  of  the  morbid  proceed  is 
greatest  in  the  upper  lumbar  and  the  dorsal  portions,  duni- 
utttbing  both  upwards  and  downn'ards  from  these  points, 

The  morbid  change*  may  extend  upwards  into  the  me- 
dulla obloDgatA,  aluug  the  ascending  root  of  the  trigeminui 
(Pierrat).  The  posterior  horns  of  grey  matter  often  appear  of 
a  dark  grey  colour,  shrivelled,  and  diatorted,  and  the  vesicular 
columns  of  Clarke  have  been  fotind  altered.  The  diw»>lDUTati<ni 
may  also  extend  furwanis  from  the  posterior  boms  to  the  direet 
cerebellar  fibres  and  the  pyramidal  libres  of  (be  lateral  column 
Such,  then,  are  the  morbid  appearances  which  arc  fouad  iii 
fully Hlurt-'lopud  caeeH  of  the  disease,  but  in  canes  which  have 
died  from  an  intercurrent  affection  during  the  early  stages 
locomotor  ataxia  tbv  morbid  appearancee  mot  with  are  son 
what  different.  Cbarcot  and  Pivrret  have  shown  that,  although' 
the  columns  of  Qoll  ore  usually  implicoted  in  locomotor  atAxy, 
the  ataxic  Bymptoms  may  be  present  io  a  high  degree  in 
the  entire  absence  of  aoy  affeotiou  of  these  oohimint.    Sclewai* 


SPINAL  COIU)  AND   MEDULLA   OBLOSOATA. 


S$9 


of  the  posterior  root-zones  is,  accordiog  to  tbese  autliora,  tbe 
aaMOtial  morbid  aJtciatioQ  of  lucomotor  aluxto,  aud  even  the 
wtiole  widtb  of  these  xonea  need  cot  be  impUcaled.  A  cerlaia 
amount  of  altcntiou  of  these  zonoa  m&y  ba  dutectcd  b;  micro- 
floopic  examiiuilion«  if  not  by  the  naked  eje,  evea  io  thorn  cases 
that  bftvc  died  hy  aq  intcrcurrcat  diaiuise  during  the  stage  of 
th«  Iftnciaatiog  paios  before  the  alAxic  syinptoms  bnd  nutde 
th«ir  appeamtva  And  oa  the  other  hAod,  m  &  womoo  lu  whom 

Fio.  ire. 


if  -\ 


i 


/^j 


'<%.-'^i 


^^ 


^^- 


11V  iCbuvot  Mtd  Pbmc).    TrxuiMnm  SKtiom  «f  lAt  Imcrr  juaiitm  nf  iXe 
FXmmII tr  Vw/arytjwnit  >vn  a  tewc  c/  Loc«Mo4or  AUtia.     A,  Toetoriar  noUi 
B,  Iat«n>l  nJicuUr  ludtuliM,  iKs  aisUmiw  being  limiUil  to  it*  cgun« ;  C. 
milu  aauflur  any  bom  in  •  nUAf  o(  »mpby. 

thR  diiieue  app«ftred,  in  a  generalited  form,  tlie  superior,  an  well 
u  the  inferior,  extremities  beiog  the  subject  of  the  HghtDioji 
pAiiu  u)d  motor  ioco-ordinaliuD.  the  posterior  root-zones  were 
fooud  AffL-cled  the  whole  length  of  the  cord,  while  there 
wu  complete  Abseoce  of  may  afFectioo  of  the  columns  of  Qoll 
{Pig.  176.  B). 

Id  rrry  old  And  protracted  eases  long  portious  of  the  spinal 
corJ  appear  banlened  ftod  atrophied  iu  its  entire  thickoetp. 
On  nalliog  a  transverae  section,  the  whole  is  found  transformed 
into  A  grey  transluceat  maM,  io  which  it  is  difficult  to  recogniee 
eren  tfae  distiaction  between  grey  and  white  matter. 

Tbe  mi<:toKopical  choaget  in  the  cord  oonriBt  in  the  early  stage 
of  Uiickcuiug  of  the  luleratitial  tisftue,  increase  in  the  number 


S40 


SYSTEM  DISEASES  OF  THE 


of  nuclei  ftlong  with   the  formation  of  enlarged  and  liigblj- 
developed  Deiter's  cells. 

The  norvc  6brcs  dwiodtu  gmduall;  and  ultinuitely  disappeu. 
The  medullary  sheath  (loe^i  not  usually  undergo  fatly  deguDCra- 
tioD  or  breaJc  down,  and  no  swelling  of  the  axis  cylinder  » 
obscrrtid ;  tbcru  ia  simplu  atrophy  and  dtsappeantnce  of  tlie 
nerve  Bbres,  and  niimerotis  granuU  cells  ara/ound.  lo  rec«Dt 
ca«e8  the  vessels  are  generally  thickened,  the  nuclei  are  increased 
in  number,  aud  corpora  amjlacea  are  scattered  throughout  the 
tissue  in  greater  or  teaser  number.  In  the  later  stages  tha  prin- 
otpal  mam  of  the  strucluro  is  composed  of  a  firm  fibrillar,  ofujn 
WAvy,  connective  tissue,  which  contains  numerouti  nuclei  and  tg 
di^eiiiiauttid  with  innumentblo  corpora  amylacen.  Moslof  tfae 
nerve  fibres  have  disappeared,  but  even  in  advanced  cases  some 
well-preserved  but  isolated  fibres  may  still  be  scon  scattered 
through  the  firm  connective  tissue. 

The  posterior  rooto,  in  their  passage  through  the  posterior 
loo(-Eone«  to  the  posterior  grey  boms — the  inner  radicular 
fasoiouLoB— ore  involved  in  the  degenerative  proceM>  Their 
fibraB  are  broken  down  and  atrophied,  some  are  completely 
destroyed,  while  the  remaiaa  of  those  left  are  separated  from 
one  another  by  hnmd  baudti  of  connective  tissue. 

The  posterior  horns  of  grey  matter  are  also  implicated  is 
tb('>  degeneration.  There  is  thickening  of  the  connective  tissue, 
disappearance  of  nerve  fibres,  aud  the  ganglion  cells  are  pig- 
mented but  not  much  changed  in  other  respects.  Clarke'i 
columns  are  also  frequently  implicated,  although  their  ganglion 
colls  remain  tolerably  intact. 

Sometimes  the  degenerative  process  extends  to  the  anterior 
horns  of  grey  matter,  injuring  the  large  ganglion  cells,  and 
then  the  mui^cleu  innervated  from  the  diseased  grey  matter  are 
always  in  a  state  of  atrophy.  Thin  alteration  stnnrfs,  nccordiag 
to  Fierret,  in  connection  with  sclerosis  of  the  inner  radicular 
friwiculuH,  and  extends  from  those  along  the  bundles  of  libros 
thatmdiate  into  the  anterior  grey  homa  In  tbo  annexed  diagram 
the  ganglion  cells  of  the  right  anterior  horn  (Fig.  177.  D)  are 
in  great  part  destroyed,  and  the  muscles  of  the  upper  and  lower 
extremities  of  the  same  side  were  atrophied. 


BPIIfAL  OOIID  ANO   UBDULLi.  OBLONOATi. 


241 


unMOt  obaervera  are  of  opinion  that  the  degenerative 
wjibin  tlie  cord  itself,  and  uot  id  the  posterior 
rootA.  Loydco  tbiDlcn  that  the  process  from  beginnitig  to  eod 
oooMfttaof  a  degeneratioii:  while  Ciiaront,  Friedreich,  and  otbers 
look  npoD  the  degenerative  ch;uigtrs  as  the  result  of  cbroaic 
inflammation.  All.  bowerer.  are  agreed  that  tbo  pcoceaH 
begiiw  in  the  nerve  elenaents  themsclvc!i,  an<l  cxt«nda  from 
them  to  the  iatentitial  tissue.  The  disease  may.  however, 
begin  at  times  in  the  pia  mater,  and  spr<-*a()  thvuce  lo  the 
poatvmr  root^zooeB  aod  oolumus  of  OolL 

Fjo.  177. 


\ 

.Mi 


V 


Fm.  IT(  (Chww*  Uid  pMmt).     JVsajwTW  SietUm  «/  iJu  Lumt>ar  Biffum.  fron  a 


Tbe  poftvrior  nerre  roots  are  atrophied  in  the  late  stages  of 
ths  diaeaae.  Tbej  appear  as  flat,  gT«jr.  tramilucenl  boada,  utd 
exhibit  degeneratire  atrophy  of  the  nerve  6brea  and  prolifera- 
tioG  of  coDsectiTe  liasnc. 

Tbe  peripheral  nerves,  the  anterior  nerve  roots,  the  sjnnpa- 


S42 


STSTEU  DJSBASB.S  OF  THB 


thetic  syetem.  and  the  miisctes  are  genenJly  qtiite  nomud.  Tlu 
spinal  ganglia  of  the  posterior  roots  lisve,  bowever,  beeo  foniid 
disensed  (CWtor).  Some  of  tlio  crauial  nervea  b&ve  abo  beea 
found  dii>Piu)eil,  grey  dcgeoeration  of  the  optic  oerres  betogthe 
most  frequent  change  observed.  Morbid  chaogeo  have  been 
found  on  rare  occaeiona  in  the  ocuto-motoriiut,  abducf^na.  aod 
bypogloasua.  The  Quclet  of  these  nerves,  on  the  Boor  of  the 
fourth  TCQtriclc,  also  appear  sometimes  to  be  affect«d. 

When  arttiropstbies  form  a  pare  of  the  disoaeo  tber«  i» 
disappearance  of  the  articular  cartilages,  and  the  articular  ends 
of  aome  of  tho  bonea  are  eroded.  There  la  little  or  no  tendenqr 
to  exostosis.  In  more  recent  coses  the  amount  of  articular  fluid 
is  greatly  increased,  points  of  thickeuing  and  fungaiiiiea  are 
found  OQ  the  Rynovial  membrane,  the  BUrroundiag  soft  pwrU 
are  swelled  and  suffused  with  fluid. 

The  t'hauges  in  the  akin  and  viscera  are  tbe  nme  as' 
chronic  myelilis. 


^  44(J.  Mtrrh-ul  Plajntnl/Kfif. — ^The  general  opinion  am< 
patbolugisLs  at  present  is  ttiat  sclerous  of  the  posterior  root 
of  the  up)  nal  cord  for  ft  contiidcrable  portion  of  their  loDgitadlnal 
extent  ti>  the  esiential  morbid  alteration  in  locomotor  ataxia. 
As  the  disease  extends  horiiontally  towards  the  posterior  mediaa 
tisvurc,  the  columns  of  QoU  become  implicated,  aud  when  ooce 
the  fibres  of  these  columns  become  intemipted  io  any  part  of 
their  course  the  portions  above  the  seat  of  lesion  undergo 
degCD'oration,  bO  that  sclerosis  of  tho  columni  of  Goll  throtigl)- 
out  tbeir  entire  length  is  usually  present,  although  it  does  aot 
appear  to  constitute  a  necesuury  part  of  the  morbid  chaogOL  Ax 
the  sclerosis  spreniU  outwards,  tho  inner  radicular  fascicahu 
and  posterior  grey  horns  become  occasionally  affected;  and  in 
many  cases,  as  already  remarked,  the  disease  extends  to  the 
anterior  grey  boms  and  lateral  columns. 

The  lancinating  pains  may  be  explained  by  irritation  of  the 
posterior  nerve  roots,  and  their  proloDgations  through  the  pos- 
terior columns,  white  the  subsequent  anavtbeaia  is  caused  by 
destruction  of  the  posterior  root  fibres.  Tbe  ahaeDce  of  tlu) 
patellar- ten  don  reflex  is  caused  by  disaaae  of  the  affsrent 
portion  of  the  reflex  aro  ia  its  passage  throagfa  the  posbsrior 


PIXAL   COBD  AXO   XEDULLA  OBLOXQATA. 


ZiS 


rt  is  proli&blo  Chat  iiritatioD  of  these  fibres  mtkf  in 
vtage  of  Uiu  disease  give  rtue  to  excems  of  the  tendou 


iticmof  pftinTuI  impreesione.  and  anAtgfesta  aro  caused 
of  the  gttj  substance  of  tLe  posterior  borns.     JrritA- 

'  the  grey  eabitaaco  of  tbe  posterior  horns  occasions  the 
leottt  trophic  disturbances.  When  tbe  morbid  cbuig«  cx- 
1 1»  the  gaogltOQ  oeUs  of  the  anterior  horns,  atrophy  of  Ibe 
let  npplied  from  the  disewed  part  resulte.  and  it  is  also 
Mt  that  the  arthn)palbie>i  of  locomotor  ntaxia  are  caUBcd 
•BMe  of  the  ganglion  cells  of  the  anterior  horns.  Difieaae 
19  ADtomaitc  centre*  in  tbe  lumbar  region  occaeions  tbe 
il  and  texiuU  diHtijrbaDo>>!i.  When  the  pjramidal  tract 
■us  unplicat«d  in  the  morbid  change  tbe  paralytic  Htage 
9  Blfection  becomes  established.  Implication  of  the  direct 
isUar  tract  is  not  known  to  produce  any  Hymptoms. 
tvinmiaa  ooir  to  connect  the  svayiog  movemetita  on  closing 
ijras  and  the  ataxia  with  the  morbid  changes  in  the  cord. 
r«  to  coonect  tbe  laotor  disturbances  in  locomotor  ataxy  with 
peof  tbe  posterior  root>zoncs  thomselvcs,  or  with  disease 
IB  fibres  of  tlie  posterior  roots  and  of  tbe  posterior  grey 
■  with  their  consequent  sensory  and  reflex  disturbauvea  ? 
irdt  aod  Ueyd  haro  shown  that  wbca  tbe  soles  of  the  feet 
inltby  persons  are  rendered  aiut-sthctic  by  chloroform  or 
ibtt  amplitude  of  tbe  oscillations  of  tbe  body  is  increased. 
•bowB  that  lose  of  eutaoeous  sensibility  must  exercise  some 
mpb  io  tbe  production  of  the  motor  disturbances  of  loco- 
Btua,  aod  this  influence  becomes  still  greater  wboD,  as 
Kody  happens^  the  seogibility  of  tbe  muscles  aod  articula- 

is  lost. 

It  there  is  no  constant  relation  between  tbe  degree  of 
a  aod  tbst  of  cutaneous  and  muscular  oniBBtheaa.  Nume- 
rasre  are  lecorded  in  wbicb  a  hi^h  degree  of  ataxia  was 
iDt  la  the  absence  of  any  disonler  of  cutaneous  or  muscular 
htHly,  aud  when  both  symptoms  are  present  they  do  not 
m  a  parallel  counia  It  muKt,  therefore,  be  concluded  that 
xaxia  is  out  caused  by  disease  of  the  fibres  of  the  posterior 
ai  the  posterior  grey  born,  and  that  it  is  caused  by  disease 
•  poetcnor  root-sones  tbeBiselves.    These  zones,  as  already 


S44 


STSTEM  DISEASES  OF  THE 


mentionec),  conaUt  of  )cx)p«d  fibrea  whicli  co-ordinate  a£E«rent 
impulnes  before  they  are  transmitted  upwards  to  the  cephilic 
gnngtia.  But  the  motor  disturbances  of  locomotor  atAxii  do 
DOt,  ott  we  ba?e  just  teeo.  result  from  arrest  of  cercbro-aSerent 
impuUen  (anaisthesia),  and  it  may  tburefore  be  concluded  that 
it  is  caused  by  disease  of  cerebellu-aifercnt  fibres. 

§  447.  DiagnoaU — Typical  cases  of  locomotor  atAxy  ar«  caqr 
to  recogoise;  but  in  tboee  cases  in  which  the  morbid  pnwen 
extends  beyond  its  muaJ  Umits,  the  diagnosis  is  surrounded  by 
many  difficulties,  ^nd  it  can  only  be  made  by  on«  who  hu  k 
dear  and  distinct  knowledj^  of  the  history  of  the  cam  and  of 
the  BymplomH  which  impltcntion  of  each  segment  of  the  conl 
oGcasioDg.  It  is  also  very  ditlicult  to  diagnoae  tabes  at  ila  com- 
meucement,  and  yet  it  is  of  great  importance  not  to  overlook 
the  true  nature  of  the  case  in  the  iuittal  stage.  The  most 
trustworthy  symptoms  are  the  lancinating  pninn,  the  feeliog  of 
a  tight  girdle,  parulysis  of  (lie  ocular  muscles,  myods  with  the 
Argyll -Robertson  njmptom.  amaurosi»  with  while  atrophy  of 
the  disc.  paruj!ithesia>  in  the  region  of  the  uluar  nerre,  jrreit 
aenw  of  fatigue  on  slight  exertion,  slight  swaying  of  the  body 
oil  the  eyes  being  closed,  failure  of  the  pateUar>teDdon  reflex, 
slight  weakness  of  the  bkddcr,  and  disturbances  of  the  sexual 
oigaoA, 

The  following  are  the  chronic  spinal  affections  wbicb  are 
most  likely  to  be  mistaken  for  tabes: — 

Common  tran^wrae  myditia.  as  a  nile,  preeentd  oo  diSBcalUea 
Paralysis  of  all  the  spinal  functions,  both  motor  and  sensoiy, 
characterises  this  affection>,  and  there  are  uo  lancibating  pains 
in  the  initial  stage. 

MtUiipie  v^erona  may  sometimes  be  very  luiiular  in  tto 
symptoms  to  locomotor  ataxy.  The  following  symptoms  may 
be  regarded  as  significiint  of  multiplo  sclerosis:  Great  dizzineea, 
headache,  psychical  disturbances,  early  nptagmus,  the  chiiv- 
terietic  tremor  on  voluntary  effort,  paralysis,  muscular  tcnaioDi, 
contractures,  increased  r«flex  actions  of  tendons  in  tbo  lower 
extremities,  and  apoplectiform  and  epileptoid  attacks. 

i^Kurnudic  ^jAnal  fiarnlr/gui  (lateral  nclerosis)  is  chamcterised 
by  paresis  and  paralysis  with  muscular  tension  and  contractum 


SFIKAL  OOBD  AVD  VEDVLLA  ODLOKGATA, 


243 


eolum&B.  It  ii  prubaUe  tliat  irritatioD  of  th«s«  6bres  may  in 
the  early  etage  of  this  dtB«as8  gire  rise  to  excess  of  tbe  toodou 
retler. 

KotaittatioQ  of  paiDful  imprenions  and  analgesia  are  caused 
by  iliaeaBe  of  tlie  grey  sut»UDc«  of  the  posterior  horns.  Irrita- 
tion of  the  gray  sabctaoco  of  the  posterior  horns  oocasions  the 
cutaneous  trophic  disturbances.  Wlien  the  morbid  chu.uge  ex- 
.teod*  to  the  gauglioo  cells  of  the  anterior  horns,  atrophy  of  iho 
lascles  supplied  from  the  diseased  part  results,  aud  it  U  also 
>b*ble  that  tbe  aitbiopatbie»  of  locomotor  ataxia  arc  caused 
'  diiBMB  of  the  gaogUou  oella  of  tho  unturior  boraa.  Disease 
tbe  automaUc  centres  in  the  Inoibar  region  oocasioQs  the 
and  Mkzual  disturbaocos.  When  the  pyramidal  tract 
implicated  in  the  oaorbid  change  tbe  paralytic  stage 
'the  affection  becomes  established.  ItapUcatioo  of  tbe  direct 
ebellar  tmct  is  not  known  to  produce  any  symptoms. 
It  remaios  now  tu  connect  tbe  swayiug  movemeuta  on  closing 
'  ^ee  mnd  the  ataxia  with  the  .morbid  changes  in  tho  cord. 
Ar«we  in  connect  tbe  motor  disturliuncea  in  locomotor  ataxy  with 
itttiWT  of  the  posterior  root-zones  themceWes,  or  with  disease 
of  tfa«  fibres  of  the  posterior  roots  and  of  tbe  posterior  grey 
boras  with  their  consequent  sensory  and  reflex  disturbaiices  ? 
Viarordt  and  Heyd  have  shown  that  when  the  sotes  of  the  feet 
in  healthy  peraons  are  rendered  amesthetic  by  chloroform  or 
ioe.  tbe  amplitude  of  the  oscillations  of  the  body  is  increased. 
This  shows  that  loss  of  cutaoooaa  sensibility  must  exercise  some 
influence  in  the  production  of  the  motor  disturbances  of  loco* 
iBMtor  ataxia,  and  this  ioflueoco  becomes  still  greater  when,  as 
lucntjy  happens;  the  sensibility  of  tbe  muscles  and  articula- 
iooa  is  lost. 
But  there  is  no  constant  Tolation  b«twccD  tho  degree  of 
tia  oad  that  of  eataneoua  aod  muscular  anamtbeeia.  Nume- 
caac«  are  recorded  in  which  a  high  d^ree  of  ataxia  was 
kt  in  the  abeenee  of  any  disorder  of  cutaneous  or  muscnlor 
ility,  and  when  both  symptoms  are  preHeat  they  do  not 
le  a  parallel  coorsa  It  must,  therefore,  be  concluded  that 
ataxia  is  out  caused  by  disease  of  tbe  fibret  of  the  posterior 
jts  of  the  posterior  grey  horn,  and  that  it  in  caused  by  disease 
tbe  posteiiai  rout-xoDjes  themselves.    These  zones,  as  already 


S46 


STBTEU  D1SB18E3  OF  THE 


pains  and  the  nexual  wealcoeiu  are  usaally  very  obstinate,  bat 
the  vesical  troubles  may  disappear.  The  progaosis  in  paralyni 
of  the  tnuHclen  of  tbe  eyo  in  favourable,  but  the  amaurosM,  doe 
to  atrophy  of  the  optic  aenre.  is  quite  hopeless. 

§  -1^49.  TVeatmont. — Wbeo  there  is  a  maaife&t  prcdispasitioo 
to  locomotor  ataxy,  the  members  of  the  family  should  be  sub- 
jected to  a  careful  regimen  with  the  view  of  provontiog  the 
development  of  tbe  disaaae.  Members  of  sacb  families  should 
be  cautioned  agtuaat  exposing  thomMlves  to  the  cxatiug  caoees 
of  the  disooso,  ftuch  as  cold  aad  dAiup,  veacroal  ex<«>8M«,  aod 
onaoism. 

Antiphlogistic  treatment  may  be  uacfut  in  the  very  early 
stage  of  tlioue  cases  which  are  complicated  byspioal  mcDiDgitit, 
but  it  does  no  good  in  any  other  case.  Counter-irritants  have 
b«en  greatly  emplitycd  in  tlie  treatment  of  tabes,  but  they  have 
never  been  found  to  be  of  any  use,  except  probably  lo  tfaoM 
Gssei  which  were  complicated  by  spinal  meningitis.  Thermal 
batbs  have  been  much  used  at  one  time,  but  they  are  probably 
injurious  instead  of  being  beneficial,  except  in  tboae  casea  wliicfa 
are  attended  by  lancinating  pains  of  unusual  severity,  and  in 
wbicb  there  are  general  excitability,  sleeplennftss.  soil  otber 
symptoms  of  irritation.  Tbe  temperature  should  never  be 
above  90"  F.,  and  the  patient  should  not  remain  in  the  batb 
lougcr  tban  from  6ftoen  to  twenty  minutes,  and  it  sbonld  be 
used  only  once  in  two  or  three  days  (Erb). 

Sidpkur  balhe  buve  boon  mucU  used  in  France,  aad  the 
effocte  obtained  from  thom  have  been  fovourably  reported  ob. 
They  have  only,  however,  been  used  as  a<]juncta  along  inth 
other  agents,  do  it  La  impossible  to  tell  bow  much  of  the  vS«i 
)i  to  be  attributed  to  them. 

Saline  thermal  baOis  appear  to  act  favourably  OD  the  discaw 
Rheims  has  long  enjoyed  a  reputation  in  the  treatment  of  taba^ 
and  Erb  reports  favourably  of  Nanheim.  Chalybeate  and  mnd 
baths  have  been  employed  in  the  treatment  of  the  diaaaae,  bal 
it  is  doubtful  if  they  possess  any  special  advantages. 

The  cold'waUr  care,  in  well-conducted  hydropathic  establisb- 
meota,  is  probably  one  of  tlio  very  best  methods  of  treating  tb< 
diaeasa    Almost  all  authoritica  oa  nerroiu  dUoMDB,  with  the 


SPSHII.   COaO  JLMD   MEDITLLA  OBLONGATA. 

Uocinotiog  paios  a  largo  number  of  remedies  bare  been  em- 
fiaytd  at  various  Umoa.  Amongst  thoae  maj  be  meDtioned 
sfctapisiiM,  blulers,  warmth,  Pricssnitz'a  cold-water  compresses, 
beUadoDoa  plasters,  rubbing  with  cliloroform,  faradi^tion  or 
(talmusation  (stabile  anode)  of  the  hyporo^sthotic  Epots,  sub- 
eataDMUi  iojectiooa  of  toorpbia,  lar^  dosea  of  the  bromide  of 
pirtMiium,  of  the  bjdro-bromide  of  quiaiuo.  and,  wbea  tbero  ia 
nMniogitifl,  large  doses  of  tbe  iodide  of  potassium. 

£lectneilif  is  the  only  remedy  for  cutaneous  annstheBia, 
tnobor  weakneH,  and  atrophy  of  the  muscles. 

In  vesical  weakooaa  faradisatioa  of  the  bladder,  either 
wilfa  or  without  the  aid  of  the  bladder  electrode,  is  ueefuL 
Cjrvtitis  mu&l  be  treated  in  tbe  same  way  as  chronic  myeliUs. 
For  die  amauroeis  no  treatment  appears  to  be  of  any  avail 

CongtipiUion  is  sometimes  a  very  troublesome  symptom. 
Tbe  diet  slioold  be  carefully  regulated,  with  the  view  of  acting 
apoD  the  bowels,  and  enemata  may  be  employed  as  aids  to 
troabDeoL  If  necessary,  mild  apenents  may  be  used;  but  all 
porgatirai  should,  as  fur  as  posiubto,  bo  araidod. 

Ia  ■^rrtinn^fl'  cases  faradisation  of  the  bowels  may  be  of  great 


8l  Sclcroeis  of  tUe  ColumTw  of  GolL 
(■)  P&DLiBT  ScLXDuBia  or  m  Coll-mxs  or  0»u- 

§  450.  Tbo  most  ootable  example  of  primary  sclerosis  of  the 
eoluoiDs  of  Qoll  is  n  ease  obwrved  by  Fierrct  The  folloning  is  a 
brief  abumct  of  the  symptoms  recorded  : — Margaret  Magnaignt, 
siL  80  years,  experieoced  numbness,  furmicatioa,  sensatiooa  of 
hmt,  and  de«p-«ent«d  pain  in  tbe  limbs,  more  eepecially  in  tbe 
oppsr  extremities.  There  were  also  obstinate  beadache,  pains  in 
tbe  loins,  and  a  sense  of  conxtrictioa  of  the  thorax,  In  1860  she 
did  not  feel  the  ground  distinctly  with  her  feet,  and  she  was 
obligod  to  walk  with  a  cane,  and  three  years  later  she  entered 
the  SalpdtrillTe  under  the  care  of  Charcots  Tactile  senaibility 
was  then  diminiabed  to  tbe  sole  nf  tbe  fcvt,  which  she  detached 
»itb  difficulty  from  the  ground.  These  symptoms  were  especially 
mariced  in  tbe  lefl  footv  and  she  could  not  walk  without  tbe  use 
rf  a  cmtcb  under  the  right  axilla.  When  she  wished  to  advance 
■be  kit  aa  if  »be  were  being  diuwa  backwards,  but  onoo  started 


2^0 


ST8TE3I   DISEASES  OF  TBE 


she  was  impelled  fnrwarda  by  a  force  she  could  not  control    Sh«\ 
could  Qututaia  the  eraob  posture  with  closed  oyea,  but  fch  ttoAj . 
ti»  fall  at  every  inatant     fn  1866  «he  compUioed  of  girdle  sen- 
sations, aud  ligbtoiiig  p&iDS  pasaiog  round  the  body  uid  dowa 
the  anterior  part  of  the  thighs,  while  she  was  readily  fati^ed, 
but  the  muscular  eensewas  uaaffected.    She  died  in  1871  from 
an  attack  of  pueumonia.    At  the  autopsy  Pterret  found  sclenwa 
of  the  colunuiB  of  Qoll,  and  bo  tbitiba  that  diKaso  of  Uuw* 
columns  explains  the  tendency  to  propuJston  and  retropropoUiooi 
experienced  by  the  patient  as  well  as  the  uncertainty  fell  ia- 
maiotaiDLng  the  croct  postura     Tho  posterior  root>9!oncs  were 
to  some  exteut  implicated  in  the  lesion  m  the  dorsal  region,  and 
I  should  Kay,  from  the  careful  drawings  whicb  accsompany  tlie 
case,  in  the  lumbar  region  aUo.     Implication  of  the  posterior 
root'zonea  doubtless  explains  the  lightning  paina  and  olber 
sensory  disturbances  present  during  the  progress  of  the  case. 
A  case  of  primary  sclaroais  of  tho  columnii  of  GoU  baa  been  re- 
corded by  Ducasbcl  and  another  by  Gkfwers,  but  in  Deitb^were 
there  symptom-)  during  life  which  could  wiUi  probatulity  be 
attributed  to  disease  of  these  columiu. 


\b)  SMOHDAHT  SoLKBOnS  OP  THS  COLDWra  OP  OOLL. 

§  451.  Secondary  sclerosis  of  the  columns  of  Goll  occurs  lo 
coDoection  with  trunsvunte  myelitis,  and  it  is  thou  called  ascend  - 
ing  sclerous  (§  390,  a).  It  is  also,  as  we  have  just  ■eeo.^DsuaUy 
associated  with  Bclerosis  of  the  posterior  root-zone*  in  looocoolor 
ataxia,  nnd  i^  often  ob«ervod  id  many  of  the  oompouod  losiocii 
of  the  cord.  In  none  of  these  cases,  however,  has  tbe  affection 
of  the  columns  of  Goll  ever  boon  cooDOOtod  with  any  deiioite 
symptoms. 

3.  Seleroai£  of  the  Direct  Cerd/ellar  Traatg. 

§  452.  SclorosLs  of  the  direct  cerebellar  tracts  is,  ao  far  aa 
ia  known,  always  secondary  and  ascending'.  It  occurs  in  tnuie- 
Terse  myelitis  along  with  Rcleroais  of  the  oolunuu  of  OoU 
(§  S90,  a).  Th«se  tracts  are  also  diseased  in  cases  of  meninges 
myelitis,  or  what  is  called  cortical  or  riog*«baped  sclenw& 
Diseosu  of  these  traotn  baa  never  been  oonnccuid  wiLb  aoy 
symptoms  during  Ufa 


SnSKL  CORD  AXD  UEDULLl  ODLOKOATA. 


2:)i 


4.  Latertd  Sdtnro»i$. 

(a)  Pkimart  LjirRKAL  SounoMS. 
IWm  fvrMlb  Bpumirilta  (Ckw<iM>    ft)>m>rfi«  CptooJ  Aivt)^. 

§  4S3.  Z^^ni7to».  —  Tbo  dUeatiO  is  characberised  by  & 
propewiTB  paresis  advancing  gradually  from  below  upvards, 
aeoompoaiod  by  muscaliir  lonsioo,  ooatracturcs.  aod  iocreaw  (ri* 
tbe  tendiDOus  reflexes,  aloog  iritK  eatiru  absoDce  of  seosory  aod 
Dutritiro  duturbaoees. 


§  Ifif  Etiology. — No  very  decided  hereditary  teDdeocy  to  the 
afliectioD  bas  a*  yet  be«n  made  out.  It  appears  to  occur  rather 
more  freqneotly  in  malos  than  females, 

Willi  respect  to  aqe,  by  far  tbe  largest  number  of  c&see  begin 
betweeo  Ibea^osof  thirty  and  6fty.  Tbe  diseaw  is  occaKioDally 
ofaoerved  io  childhood,  a  fact  which  might  suggoit  tho  oxlstence 
of  a  congenital  defect  of  !iomt>  parts  of  the  <tpiant  cord. 

Tbo  OKcitiog  causes  of  tbe  aifection  are  unknown,  although  it 
is  rery  probable  that  exposure  to  oold,  iojuriea  to  tbe  spioe, 
XmA.  poisooing,  and  xypbilis  may  coKiperate  as  &ctoni  in  the 
ptoduction  of  the  diseasat. 

9  4&S.  SymifHofM, — The  first  and  for  a  long  time  tbe  only 
ajrmptom  ia  a  psrests  of  tbe  inferior  extremities,  wbioh  may  be 
oqttal  io  both  or  more  pronounced  in  one  of  them,  and  the  only 
efleei  of  which  ia  to  render  walking  somewhat  difficult,  especially 
iin mediately  DD  getting  out  of  bed  in  the  morning.  Tho  patients 
oumplain  that  tWy  are  soon  latigued,  that  their  limbs  are  heavy, 
and  tbeir  gait  becomes  dragging  and  difficult.  It  is  only  in  tbe 
later  stages  of  the  a0eclioo  that  the  paresis  iocrease^  to  com- 
plete paralysia.  MaaifestationB  of  motor  irritation  now  ally 
tbemsdrea  with  tfae  motor  weakness,  Ou  lying  down  and 
e^Kcially  in  bed  at  night,  or  after  being  fatigiiei),  tho  It^ 
baooon*  subject  to  clonic  or  tonic  Hpasms.  Tbe  former  produce 
teemoTB,  which  sometimea  remain  limited  to  the  cxlremitiea 
bisi  are  at  other  times  so  violent  aa  to  be  communicated  to 
the  eatiro  body.  ThMe  may  hb  rMdily  excited  by  pughiog 
afSuut  tbe  toea  so  as  to  produce  dorsal  fl«xion  of  the  foot 
(lAkle  CloouB,  §  HQ),  After  a  time  dUtinct  muKvlar  tmaUm 
is  davcioped.    On  passive  raovemAats  of  tho  lower  extremities 


2$2 


SYSTEM  DISEASES  Of  THE 


the  muscles  become  tense,  but  in  the  eiirly  stageg  of  the 
atTectioD  the  muacular  tensloa  can  be  readily  orercome  by 
iocreasiiig  the  pressure,  while  it  can  be  considerably  diiniaished 
by  repeated  movcmeota  Tlie  muscular  teosioa  soon  showa  itself 
OD  voluutary  mOTemvnts  bciug  made,  rendering  them  difficult 
aud  uncertain,  and  making  the  degree  of  parcsiti  appear  greater 
than  it  is  in  reality. 

After  a  time  the  muscular  tenftioa  increases  to  pernoaoeiil 
rigidity,  and  a  high  degree  of  caUi-acturc  resulbi  The  legs  aw 
maintained  in  a  position  of  rigid  extension,  the  thighs  being 
aiao  held  rigidly  together  by  contracture  of  the  adduetora,  the 
feet  are  in  a  position  of  extreme  talipes  equino-varus,  and  the 
toeg  are  generally  strongly  flexed.  The  rigid  immobility  of  the 
feet  is  now  and  then  interrupted  by  clonic  trembling,  which 
may  extend  to  the  entire  leg.  The  trembling  may  appear  to 
arise  spoutaaenuKly,  but  i.i  nearly  always  caused  either  by  a 
reBex  or  voluntary  movemeut  of  the  foot. 

The  Spasmodic  Oait  or  Spastic  Walk. — The  combined 
parcttis,  KtilTneiis,  and  tremors  of  the  lower  extremiljes  render 
the  gait  quite  characteristic.  The  fout  seems  to  cUng  to  the 
ground,  from  which  it  in  detached  with  difficulty,  and  as  it  is 
made  to  slide  forwards  it  produces  a  cbaTACtenstic  scrapit^ 
noiae;  while  the  toes  find  an  obstacle  in  every  cleration  of  the 
ground,  aud  the  patient  readily  stumbles  and  falls.  Owiog-to 
the  contracture  of  the  extensors  of  the  lower  extremity  the 
limbs  are  held  in  a  rigid  condition  at  all  the  articulations,  so 
that  tho  Qcccasor}'  eleration  of  the  poasirc  leg  is  obtained  by 
an  upward  rotation  of  the  peUis,  caused  by  contraction  of  the 
abductoFA  of  the  thigh  on  the  side  of  the  active  leg.  The  body 
is  con!)c([uently  strongly  inclined  at  cAch  step  to  the  side  of 
the  active  leg.  The  movement  of  the  pasgire  foot  is  not,  how- 
ever, directly  forwards.  The  preduminaot  contraction  of  the 
adductora  of  the  thigh  over  the  abductors  causes  the  legs  to  be 
drawn  energetically  towards  one  another,  while  the  foot  is 
sometimes  though  not  always  inverted,  owing  to  the  strong  con* 
tracture  of  the  iuwonl  rotators  of  the  thigh.  The  couxequenoe 
is  that  the  toe  of  the  leg  about  to  be  moved  forwards  often  gets 
e&t&Dgled  ogaioBt  the  boel  of  the  active  leg,  and  the  trunk  has 
to  he  strongly  iacliaed  towards  that  side  so  as  to  give  additional 


SPfKAI.  COUD  and  MEDtTLLA   ODLONOATA. 


253 


parcbase  to  ibe  sbductore  of  tbe  c^posite  thigb,  ani)  thus 
eDJLble  tfaara  to  move  the  foot  outwardH  auit  awity  from  the 
other.  The  passive  leg  is,  therefore,  moved  ontwards  und 
forvards  in  a  semicircle,  aud  wheu  it  ia  brought  to  the  ground 
it  g«aeralty  crodaes  over  to  the  opposite  side  in  front  of  the 
other  foot  It  will  be  observed  that  at  each  step  tbe  body  is 
strongly  iocliDcd  towards  the  side  of  tbe  active  leg.  an<l  cod- 
sequeotly  Ihc  gait  is  xomewhat  "  watldliog,"  and  in  in  this 
respect,  as  UammoDd  reiQitTks,  like  that  of  a  woman  with  a 
wide  poWi*.. 

At  this  period  tbe  woight  of  tbe  body  suHiccs  to  arrest  tb« 
olooic  cootroctions  of  the  muscles  of  tbe  calf  of  the  active  leg, 
bat  tbe  passive  teg  is  often  agitated  by  treroors,  which  greatly 
add  to  tbe  difficulty  of  progression.  As  the  disease,  however, 
iDcreasea,  the  spasmodic  rigidity  of  the  muscles  of  the  calf  be- 
oontea  so  gront  that  the  patient  rests  upon  the  tips  of  his  feet; 
wbUo  the  body  is  inclioed  forwards,  tbe  arms  being  propped  up 
by  cratches,  or  supported  by  two  stickii,  which  are  held  wrII  in 
front  of  tbe  patieat  with  an  outward  inclination.  The  coulrac- 
taro  of  the  muscles  of  the  calf  in  now  so  pronounced  that  the 
Weight  of  tbe  body  does  not  suffice  to  prevent  ankle  clonus  from 
taking  place,  and,  cooaequently,  when  the  patient  first  attains 
tbe  erect  posture,  bis  hccla  become  strongly  elevated,  probable 
to  tbe  extent  of  S  ioches  from  the  ground.  After  the  Brst 
deTattoa  the  beel  is  lo  some  cases  almost  immedtately  towered 
to  tbe  extent  of  about  1  to  1}  iDcbee,  and  this  in  its  turn  is 
mcoeeded  by  aaotlior  elevation  and  bo  on  in  rby  tfamical  sequence. 
ThftheeU  and  with  them  the  whole  body  are  thus  elevated  and 
depwwad  7  or  8  times  or  more  in  rapid  suceesaion,  the  number 
of  tbeee  elevations  which  take  place  in  a  socoad  of  time  corre- 
■pooding  to  those  of  the  ankle  clonus  already  described. 

After  a  time  the  upward  and  downward  movements  of  the 
body  ceiise,  Lho  heels  come  closer  lo  tbe  ground  nllbough 
thoy  do  not  come  in  contact  with  it,  and  tbe  patient  now 
endeavours  to  move  forwards  one  leg,  say  the  right  The  first 
st«p  may  be  performed  with  tolerable  facility,  but  when  once 
the  right  foot  is  projected  forwards  it  crosses  over  to  the  other 
aide,  and  is  brought  to  the  ground  in  front  of  the  tefi  foot. 
When  th«  left  has  now  to  be  advanced  tbe  greatest  difficulty  is 


254 


SySTEU  DISEASES  OF  THB 


cxpcrieuccd  in  diaeogagiag  the  toe  from  die  beel  of  tbe  right 
fbot,  and  in  the  effort  to  do  no  the  muscLea  ot  the  calves  of  both 
legs  become  strongly  contracted,  tbe  patient  is  elerated  on  tip- 
toes, and  every  effort  to  ubduct  the  left  foot  ao  a«  to  move  it 
away  from  the  other  raiiy  induce  clonus  of  the  right  uiklc,  and 
coneequent  (^evatiooa  and  depresaiooa  of  tbe  body.  When  at 
last  the  left  foot  is  disengaged,  and  is  being  mored  forward* 
ID  the  semicircular  maoDcr  already  described,  it  is  generally 
seixad  with  trembling  (partly  constating  of  ankle  donua  and 
partly  of  teudinuus  reflex  contrnctionsi  of  the  muscles),  which 
extends  te  the  trunks  and  tbrowti  the  wholo  body  into  I'ioloDt 
agitation.  This  description  only  applies  of  course  to  the  severer 
caHes,  »ud  if  the  muscular  contracture  increases  beyond  this 
point  walking  becomes  imposMbla  In  less  aggravated  cam 
ooe  sudden  etevatiou  of  tbe  beel  of  the  active  leg  may  be 
followed  by  a  depression  without  subsequent  elevation,  so  that 
the  gait  boa  a  peculiar  bopping  character. 

The  disease  extends  slowly  and  gradually  upwards  until  the 
superior  extrcmiiicH  are  implicated  The  lumbar  and  alKlominal 
miiacies  arv  alsu  allTected,  thi:  abdumeu  bvcomes  promiDvaL,  hard, 
and  separated  from  the  base  of  the  thorax  by  a  faorizoatal  fold 
of  more  or  less  depth,  while  at  the  tsame  time  a  kind  of  lordoeia 
is  produced. 

When  the  upper  extremities  are  affected,  the  paretic  ooo- 
dition  of  the  bands  maaifoBts  itself  by  the  iuuptiludc  of  tbe 
patient  to  seize  small  objects.  The  digits  from  time  to  tioM 
become  flexed  iavoEuntariLy  into  the  palm  of  the  band;  while 
at  fl  later  period  of  the  disease  the  fingers  become  penoA- 
nently  flexed.  The  muHclea  acting  on  the  wrist  and  elbov 
are  succ^aaively  affected,  and  the  forearm  and  baud  become 
rigid  in  a  coudition  of  extension  and  pronation.  The  superior 
extrernitiea  ore  now  rigid  aod  immobile,  and  more  or  less 
strongly  drawn  to  each  side  of  the  body,  but  the  txetnon  are 
never  so  pronouDOed  io  them  as  in  the  lower  extremitiesL. 
Although  thi«  is  tbe  usual  course  of  the  disease,  yet  occasionally 
the  symptoms  are  developed  in  a  difierent  order.  At  times  the 
affection  passes  first  from  one  tower  extremity  to  the  upper 
extremity  of  the  same  side,  and  this  hemiplugic  condition  may 
persist  for  many  years  before   the  other  lower  extremiiy  is 


SPIMIL  COKD  AKD  MCDITLLA  OBLOKQATA. 


2S5 


attacked.  Sometimes  the  disease  Ih^^iiu  io  the  upper  extre- 
mities, progrenes  downwards,  and  doei  not  iovolre  the  lower 
extremities  until  a  later  period. 

The  paralysis  after  a  Umebecomesooiiipiete.  tbeoontractares 
incrsase  in  intensitv,  the  paticata  grow  HtiBT  and  immovable, 
and  are  doomed  to  keep  tbeir  ImmIa.  But  eveo  in  patients  who 
are  bedridden  for  years  Ibe  general  health  is  good,  and  it  does 
oot  appear  that  tho  diKCatic  ever  dircsclly  cuuses  death,  which 
^oeially  results  from  an  iotercurreot  afiectioo. 

The  teTulinoua  »7ui  penoHe<U  rtfi^xM  are  greatly  exaj^rated 
in  Uiis  disease.  The  patellar-tcDiioo  reHex  and  ankle  cIoqub 
can  be  elicited  in  the  usual  way  witb  undue  readineaa.  The 
quadrioDps  fontoris  and  the  adductors  of  the  thigh  nmy  be 
excited  to  contract  by  tapping  the  broad  upper  cud  ol'  tbe  tibia, 
and  the  contractions  may  extead  even  to  the  adductors  of  the 
i>ppoaite  thigh.  The  adductors  of  the  thigh  may  also  often  be 
mad*  U>  contract  by  tapping  over  the  region  of  the  lumbar 
vettebrffi.  Tendon  reSexes  also  occur  io  the  tibialis  posticus, 
■omi-tendiDoeus,  and  other  muscles. 

The  tendon  r^cxes  are  in  like  mananr  increased  in  the  upper 
extremities  when  they  become  implicated.  Tbey  can  be  elicited 
in  the  bicepsand  triceps  by  striking  tbi*  tcndous,  vrbilc  the  former 
may  be  made  to  contract  by  tapping  tlie  lower  end  of  the  radius, 
Ktid  the  latter  by  tapping  the  tower  end  of  the  uluii.  The  poH- 
terior  portion  of  the  deltoid  often  oontracta  along  with  the  triceps, 
when  the  lower  end  of  the  ulna  is  lightly  struck.  The  flexors  of 
the  fiogen,  the  extenaont  of  the  wriat,  and  the  supinator  loo^nis 
con  each  be  made  to  contract  by  tapping  tbeir  totidoDs  at  the 
wri»t;  while  the  interos&ei  may  sometimes  be  msdo  to  contract 
by  lappiog  the  ends  of  the  metacarpal  bones.  The  deltoid  may 
be  nude  to  contract  by  tapping  the  spine  of  the  scapula,  and  the 
pectoraljH  major  by  tapping  the  sternum. 

The  euianeout  refiez  appears  to  bo  occasioually  increased, 
bat  it  is  generally  normal  or  diminiBhed. 

The  eUctrical  excitability  of  the  motor  nerves  may  nmnifest 
slight  quantitative  but  never  any  qualitative  ckangen.  The 
bradic  and  galvanic  excitability  of  the  muaclvs  ia  generally 
diminlebed  (Erb). 

Sentory  di^u,rbancu  are  entirely  absent  in  ihin  disease. 


256 


SYSTEM  DISEASES  OF  THE 


tbo  various  forms  of  cutaDooiu  and  muscular  sensibilLly  beii^ 
normal.  Tho  pnticot  <loe«  not  complain  of  panestfaenic,  girdle 
ReuHatiouu,  laucin&tiug  paioB,  or  tbe  affdctiODS  of  the  cranial 
owes,  wfaich  are  so  commoa  in.  locomotor  ataxia.  The  func- 
tioDs  of  the  bladder,  rectum,  aad  sexual  organs  arc  entirely 
uoafieuted.  Vaso-uiolor  diBturbaacos  are  abseiit,  anil  there  are 
no  Qutritire  aflfectioiis  of  tbe  idukIcs  or  skiu,  and  uo  bed-sorea 

§  456.  Couree.  Duration,  and  T«rminatwn«. — The  courw  of 
the  disea«c  is  generally  rery  cbrocia  It  comes  OQ  ia  a  vciy 
insidious  TnaDoor.  and  moDthu  or  yean  may  elapse  before  ^e 
affeciioa  can  \}s  recognised  with  certainty.  QccBHionally  the 
symptoms  become  developed  in  a  typical  raanoer  in  a  com- 
paratively brief  space  of  time,  and  it  may  tben  remain  atationaiy 
fur  a  luug  period. 

The  duration  of  tbe  disease  is  nearly  always  long,  extending 
over  many  yeara.  Complicated  cases  may  run  a  oomparatirely 
rapid  courau. 

The  disease  occasionally  terminates  in  recovery.  Heuck 
reports  a  case  of  spastic  apinat  paralyaia  which  began  suddenly 
with  acuto  and  violent  pains  in  tbe  back,  and  terminated,  afwr 
a  duration  of  five  weeks,  in  complete  recovery.  Death  geoc 
occurs  from  uccidotilal  causers  or  iut^jTvurruut  diseases, 


(£)  CoHPOLiSD  Lateral  Scukwuh. 

{i.)     AMTOSROPHIO     LATtHAL     DOLIKiiStS. 

§  457.  SympUnra. — Spasmodic  spinal  paralysis  may  be 
plicated  with  every  degree  of  progicseive  muscular  alrof 
but  tbe  highest  degree  of  tbis  combinatioa  i«  presented  by  thii 
oases  whicb  bare  been  described  by  Cliareot,  under  the  naOK 
of  sdirvm  lat^raU  aitiyoii-ophique. 

The  disease  generally  begins,  according  to  Charcot^  in  the 
tippor  extremities  by  motor  weakness,  accompanied  by  n  rapiJ 
tuuHcular  wasting,  which  extends  uniformly  to  all  the  muscie* 
of  the  ftlTected  limbs.  The  aymptomB  of  paresia  may  be  pre- 
ceded by  formication  and  numbness  in  tbe  upper  extromities, 
and  tho  atrophy  is  accompanied  by  fibrillary  twitchings  of  the 


SPENAL  COKD  AND  MBDin.rjl  OHLONOATA. 


257 


affected  mtueleL  Uosoalar  tension  and  contra^uree  are  soon 
superadded  to  the  paresis  and  atrophy,  an<]  the  affected  es- 
tremities  are  brouj;ht  into  permanently  defortned  positions. 
Tbo  arm  is  applied  to  the  trunk,  tbo  forearm  is  seml-llexetl  and 
pronated,  aad  it  is  not  powible  to  supinate  or  extend  it  without 
emplojing  a  considerable  degree  of  force  and  causing  pnin,  the 
band  is  flexed  on  the  forearm,  and  the  different  segments  of  the 
£ngen  are  flexed  upon  one  another  and  upon  the  mcLacarpal 

F10.17& 


/ 


Tia.  ITS  (Aitn  Owreot).     Attibidt  a}  Ai  UanU  and  ffriaiim  m 


booea.  When  the  patient  elevates  the  arm  bj  a  voluntary 
efibrW  the  extremity  becomes  agitated  by  tremors,  not  tmtike 
Uiow  which  occur  in  sclerosis  io  patches.  In  advanced  cases 
th«  Ihtnar  and  Sypothenar  eminences  hecomc  flattened,  the 
palm  of  the  hand  bccomc-s  excavated,  and  the  muscular  atrophy 
nwj  proceed  so  far  that  the  forearm  and  ann  are  reduced  almost 
to  a  skeleton.  Under  these  drcumstanceii  the  apaatnodic  rigidity 
beoomee  leas  pronounced,  but  the  limbs  may  even  then  main- 
loin  the  forced  attitudes  in  which  they  have  buou  hi^ld  80  long. 

In  some  p«tJeQt<  the  head  is  fixed  by  HpaHinodic  rigidity  of 
the  muscles  of  thu  neck  so  that  they  cannot  move  it  in  any 
dtrectioQ.  The  contracture  nuiy  also  extend  to  the  temporal 
muscles  ao  that  the  mouth  can  only  be  opened  to  a  limited 
degCM  (Charcot).  The  muscular  atrophy  may  oocasioDally  be 
— — t'H  hj  a  pseudo-hypertrophy  of  the  affected  muBcle& 
R 


258 


SYSTEll   DISEASES  OF  THE 


After  a  period  of  from  two  to  nix  or  nine  moDtba  tbe  lower 
extremities  beoome  affected,  firat  by  poresiB,  whicli  maj-  be  pre* 
ceded  or  accompanied  fora  longer  or  shorter  time  by  formiaaioa 
and  numbnc&s  of  tho  Hmba.  The  pareiue  of  the  lower  cxtremi- 
tied  ia  not,  as  occtirs  in  the  upper  eztreraitiee,  necessarily  aocom- 
pulled  by  atrophy  of  the  mu8cle».  It  ia,  however,  aooompaDitxi 
by  niiiBCular  teiuuon,  permajicot  coatracture&  which  maintain 
the  extremities  rigid  in  the  position  ot  extension,  by  ttcuora. 
ankle  clonus,  and  increased  reflex  action  of  tendons.  These 
symptoms  are,  indeed,  those  which  have  already  been  described 
as  belonging  to  primary  lateral  sclerosis,  and  they  soon  increoM 
to  such  a  degree  in  the  amyotrophic  varietiM  aa  to  midar 
walking  imposBiblc.  At  first  the  muscles  of  the  lower  extremi* 
ties  are  tease  and  firm,  and  do  not  shon^  any  trace  of  atrophy, 
but  after  a  time  fibrillary  cootr^iclious  occur,  diffused  atrophy 
of  tho  muscles  imperveue,  uud  the  coutractutes  diininisli. 

The  third  stage  of  the  dineaHe  is  characterised  by  the  appear' 
ance  of  bulbar  paralyaiK,  consisting  in  paralysis  of  the  tongue 
and  lips,  and  of  the  pharyngeal  and  laryngeal  musclea.  Tbe 
nuclei  of  the  pneumogastric  nerves  appear  finaity  to  be  in- 
vadcd,  giving  rise  to  disturbaucee  of  circulation  and  respiration 
vrhicli  before  long  induce  death.  Tbe  diauutc  develops  rapidly, 
and,  acconiing  to  Charcot,  always  causes  death  in  from  one  lo 
three  years ;  differing  in  this  respect  greatly  from  progreaaiTe 
muscular  atrophy,  which  may  extend  over  a  period  of  froin 
eight  to  twenty  years. 


(ii.)  ODUBINED  noLinoftit  or  rni  kktxuo*  amd  utssal  cOLnyo. 

§  +58.  The  symptoms  of  locomotor  ataxy  aod  of  primary 
laternl  sclerosis  may  be  present  in  every  possible  combination; 
thuee  of  Uie  former  predomioiiting  at  one  time  njid  of  the  latter 
at  another.  The  bympiums  which  indicate  that  the  Utorsl 
columns  are  being  gradually  invaded  in  locomotor  ataxy  are 
•pODtaacous  jerkioga  in  the  loner  extremities,  gradual  loss  of 
power  to  perform  simple  movements  of  extension  and  flexion, 
muscular  teusiou,  and  contractures. 

Wlien,  on  the  other  hand,  the  sjrmptems  of  lateral  soleroM 
predominate,  the  signs  by  which  a  oomplicatton  of  locomotor 


8P1XAL  CORD  AND  HBDULLA  OBLOKQATA.  239 

UMxy  may  be  wispected  are  tbe  preseuce  of  lancinating  paina, 
girdle  paios,  uiil  otber  sensory  disturbances,  vesical  wcakneiis, 
sK^t  twayiog  on  clonog  the  ejes,  and.  abore  all,  the  atwenoe 
of  tba  patellor-temloD  reflex  and  aukU-  cEodiul 


(«l  SsoMiom  Latsiui.  Soucbouh. 

§  459.  [Ateral  sclerosis  occurs  as  a  secondary  (li«ease  iu 
UEDCTsne  myclttia  and  ia  various  ■Ii8caa«s  of  tbe  medulla 
oUoQgata.  pons,  and  braio.  It  always  occurs  below  the  seat  of 
Um  loioQ,  aad  pursues  a  deaoeiuUng  course  (§  390,  b).  The 
symptoina  caused  by  secondary  lateral  sclcrDei.i  are  the  same  as 
tboie  CAUsed  by  the  primary  form  of  the  aflfectioo,  being  only 
imldiSctl  by  the  symptom:!  of  tJjo  primary  luiiuD  with  which  it 
isaaKkdate^  Tbetie  symptoms  are,  brieSy,  voluntary  paralysis 
onisealar  uo^ioa  and  contracture,  excess  of  the  deep  reflezea, 
and  generally  also  of  the  cutaneous  rcflcxos.  Tbe  symptoms 
of  seeondary  degeoeratioD  of  the  pyramidal  tracts  will  be  mare 
nioately  degcribed  when  tbe  primary  lesions  with  which  it  is 
aMociated  are  under  discussioD. 

g  460.  Morbid  Anatomy.— The  morbid  anatomy  of  primary 
luaral  sclerosis  has  given  rise  to  a  good  deal  of  diHCusxiou,  and 
no  poflt>mortem  examioatioD  of  an  uncompHcaled  cose  of  the 
ihieaae  has  hilherlo  been  publiehcd.  But  what  we  know 
of  tbe  fanctioQS  uf  tbe  lateral  culunuis  r«adur!4  tl  prubahlu 
that  the  analomiail  basis  of  tbe  affection  consists  of  sym- 
metncal  sclerosis  of  tbe  lateral  columns.  Leyden  has,  however, 
advaaoed  powerful  arguments  against  this  opinioa.  Two  cases 
b«ire  been  published  by  Cha.rcot  and  Pitrea,  one  of  which  was 
diagDOsed  during  life  aa  amyotrophic  lateml  sclerosis,  and 
Ibe  otber  a»  primary  lateral  sclerosis,  and  the  post-roorteui 
uanuoaCioa  showed  that  bglb  were  auomalous  cases  »S  sclerosis 
in  palcbes.  The  t'reoch  authors,  however,  ackoowledgo  thai 
ID  tbe  case  which  was  disposed  during  life  as  primary  lateral 
tdanm  ttie  symptons  were  not  <\nii6  charjtcterietic.  Symptoms, 
for  uutance,  of  vesical  weaknesH  and  alight  setutory  disturbaDces 
warn  present,  and  the  authors  think  that  had  sufficient  wei|{ht 
b«ea  given  to  the  presence  of  these  symptoms  tbe  diagnosis  of 


260 


SYSTEM   DISUSES  OF  TOE 


primary-  lateral  sclerosis  would  DOt  have  been  made. 
again,  although  a  focus  of  disease  waii  found  in  tbc  postenot 
coluinn*  in  thu  cervical  region  of  the  cord,  the  other  foci  were 
founil  in  the  pyramitlal  iracto  in  tliuir  panago  through  Uie 
cruala,  anterior  pyruuiiiJs  of  the  medulla,  and  lateral  columni 
of  the  cord.  Charcot,  thcrufore,  thiuks  that  this  case  confinns  to 
Eotne  extent  the  theory  of  symmetrical  scluroais  of  lUc  lateral 
columna  Dr.  Cart  Ritter  von  Stofella  has  published  a  case  u 
which  the  typical  symptoms  of  spasmodic  panvlysift  were  prc^eni 
during  life.  The  autopsy  was  conducted  by  Prof.  Klob,  who 
found  symmetrical  scleroaJti  of  the  posterior  portion  of  the 
lateral  columua.  Prof.  Klob,  however,  mentions  that  the 
sclorogis  extended  in  the  thoracic  and  lambar  regions  to  tbc 
pia  mater,  so  that,  as  pointed  out  by  Leyden,  the  direct  ceie> 
bellar  tract  must  have  been  affected,  and  the  case  cauDOCbe 
<luoted  as  an  example  of  symmetrical  ficlerosis  of  the  pyramidal 
tracts.  No  microscopic  examination  of  the  cord  was  made,  wd 
this  fact  of  itself  would  render  the  case  almost  valueless  with 
respect  to  the  morbid  anatomy  of  the  affection. 

Dr.  R.  Schulz  communicates  three  cases  in  which  the 
symptoms  of  Hpa.smodic  paralysis  were  present  during  life,  but 
]n  which  the  post-mortem  examination  decided  againstn  primaij 
Kclurusis  of  the  pyramidal  tractti.  In  the  first  case  a  tumour  of 
the  medulla  obtongatn  wan  found,  accompanied  by  desoendiog 
sclerosis  of  the  pyramidal  tracts;  in  the  second  a  tumour  WM 
found  between  the  right  lobe  of  the  cerebellum  and  pons,  but 
without  a  trace  of  descending  sclerosis;  while  the  third  case 
was  one  of  chronic  hydrocephalus  internus,  also  without  a  trace 
of  descending  sclerosis  of  the  cord. 

A.  patient  under  the  care  of  Dr.  Morgau,  io  the  Hsmcbesler 
Ruyal  Infirmary,  who  presented  the  typical  symptoms  of  prlmarj 
lateral  sclerosis,  died  from  some  intorctirroDt  disease.  TU* 
spinal  cord  having  been  hardened  in  bichromate  of  ammonia, 
symmetrical  sclerosis  of  the  pyramidal  tracts  of  the  lateral 
columns  of  the  cord,  from  the  medulla  oblongata  to  tfaa  eoaui 
medullaris.  was  found. 

Dr.  Dreschfcld,  who  mode  a  microscopic  examination  of  tha 
cord,  assures  me  that  no  other  lesion  exists  in  the  oorcL 
Aufrecht  has  recorded  a  somewhat  similar  case: 


SPINAL  OORO  AND   ireOtrU,A  OfiLOSQATA. 


S&l 


la  tbo  Mnyotnipliic  variety  of  Iho  affectioD  Charcot  hit» 
MTenl  timea  proved  tbo  presence  of  symmetrical  8cton>«iH  of 
tbe  pjramidaJ  txuctfl  of  the  lataral  columns  of  the  cord,  and  of 
tiM  aoterior  pyramids  of  the  m^Iutla  obloogata,  along  with 
degeiwntive  atrophy  of  the  luatorior  grey  boms  and  loss  of  the 
bug*  gaoglion  colts  of  tbe  cord  and  of  tb«  motor  Duclei  in  the 
nwdalla  oblongata.  Tbe  condition  of  tbo  bnlbar  nuclei  in  this 
aflectioa  is  represented  in  Fiff.  179,  borrowed  from  Charcot,  tbo 
diNBaw)  Duelei  b«iog  shown  to  tbo  loft  of  A  lielitious  lino  (R,R'], 
and  tbe  hvaltby  one.  Tor  the  sake  ofcomparifiuo,  to  the  right  of 
that  lino.  The  port  which  Charcot  caltii  the  fasoicutiu  teres 
nmlly  consists  of  a  group  of  amaU  celts,  and  is  the  same  aa  tbat 
vfaioh  I  have  called  tbe  external  aocenory  nucleus  of  the  facial. 
Il  i«  aeen  to  be  disea:^  on  the  left  nde  (!>)  of  tbe  Bgure.  The 
JwatTnl  acoenoiy  bctal  nucleus  is,  howerer,  apparently  bealtby. 
Haie  obocrvations  have  also  been  confirmed  by  Joffroy, 
Gooiboalt,  and  others.    Valuable  cootribatlons  to  the  morbid 

Fio.  17S. 


A 


V 


•  /y 


,^fe-Hi-^,  ■ 


ITHi.  17*  <  FnW  I'hAfCot).      IVaMr<r*c  Stdioa  «/  Vt4  fStAuiU  fUliMfftJa  on  a  Urft 
Mtt  Bk  midiKt -^ Ikf  Xvfirm  nj  Ou  SyptylfliMiil  — K,  ](',  iomIiui  n[>li^  ;  A.  B, 
tWOtmtmU  ibc  tuirnul  cim<liiLuii,  ukd  A',  B"  (Im  pwU  h  iboy  >|>|ieu  in  juujn- 
\t  Ulmd  MtkTMM ;  C,  C,  th*  floor  <•(  ib«  (oarth  v>niiiel«  i  V.  t,  *mmL 
fcowdi  th*  noeUiu  of  Um  hypegtcMnl  uMriorhr  Hid  •xlorullf  i  D, 
Xm  tvM  i  MtA  D".  Um  onrT«wpi>iii>linK  invI  am  uw  dbeMnl  Me ;  A, 
\j  BBMlntt  «<  Um  krp^KloMU ;  and  A',  ib«  diwvHHl  kucUoa.     B,  tbs 
iiiiil»Mi  ^  lb*  pHMUnoeutric  dmtv*  ;  uid  K,  Uie  ntnUw  oo  ttii  dia- 


CHAPTER  V. 


U.— MIXED  DISEASES  OF  THE  SPINAL  CORD  AND. 
MEDULLA  OBLOKOATA. 


a  )  PARALYSIS   A3CKNDBN3    ACtTA- 


Acaie  Ascending  Parcdysis— Landry's  Paraljfii».'i 

§  465.  Definition. — Ac\ite  ascending  paralysis  iscbBractcmed 
by  a  motor  paralysis  wlilcb  geuerally  licgios  in  the  lower  ex- 
tremities,  BprcatU  pretty  rapidly  over  tho  Lniuk  to  the  oppor 
extremities,  and  usually  iDvolve»  the  medulla  oblongata,  the 
general  sensibility  and  alao  Klightly  the  functiaoa  of  the  bladdw 
and  rectum ;  but  there  is  no  decided  atrophy  of  the  miu^^ 
oud  uo  alteration  of  their  electrical  excitability. 

Ei  46$.  Hittory. — Cases  of  thia  diiieaM  wera  de«nbed  by  OIlivMr, 
Wolford,  hckI  nthcrei,  uid  it  appear*  th&t  Cuvier  dJed  or  It  lo  1S31 
The  di«>;AAo,  however,  was  not  r«cogDtM«l  m  a  noporatA  aSbction  mtfl 
165EI,  yrbeii  LkikIi^  diMwribcd  some  cues  uudor  th«  nane  of  "  Pwrtlyrit 
AM«iiduit«  Aigiw."  KuMmaul  aim  described  twoonoaio  Ihe  Mine  year. 
SioGo  Laodry'a  pnblioation  rvports  of  oasee  have  molUpIied  ;  altboo^  at 
times  iostaooes  of  other  diseasea,  such  as  of  acute  centra)  myetitia,  aiid  of 
eubacnte  aDtnior  poUomyeUtts,  bsre  been  described  uudor  tbis  naiaa. 

g  +67.  Etiolwpj. — Very  little  is  known  with  respect  to  tli( 
cauMLtiou  of  this  disease ;  and  at  timea  il  arises  iu  the  abeeoc 
of  recognisable  predisposing  or  exciting  causea  Moat  of  tho 
reported  oases  have  oocarred  t>etween  the  ages  of  twenty  and 
forty,  and  men  are  more  frequently  attained  than  women. 

Exposure  to  cold  is  probably  the  most  frequent  exciting  cauae. 
Some  cases  have  oocurrcd  daring  convalosceooe  from  acate 
di«ftsca,  as  typhoid  fever,  pleurisy,  or  variola,  and  a  few  have 
followed  suppression  of  the  menaes.    Various  authors  te^guA 


Bjphilia  M  a  frequent  cauM  of  the  disease,  but  it  is  doubtful 
Itow  far  this  opioiou  U  oorrect  lo  the  case  of  a  woman  of 
twenty  years  of  age,  who  died  of  the  disease  in  the  Royal  In- 
fimuuj,  within  a  week  &om  the  commencemecit,  there  were 
dsep  cicatrices  lo  the  left  groin,  but  no  further  evidence  of 
^philis  could  be  detected.  The  interior  of  the  uterus  was  lined 
with  a  layer  of  blood.  I  did  not  see  the  cose  during  lifu,  hut 
the  sjmiptoms  as  reported  to  me  were  very  characteristic. 

§  46S.  Stfmptoms. — The  paralytic  phenomena  are  generally, 
though  not  always,  preceded  by  various  premonitory  symptoms, 
such  as  sliglit  fever,  shooting  pains  in  the  hack  and  limbs, 
fonnication  and  Dumboess  in  the  feet  and  finger  tips,  and  n 
feeling  of  great  weorineea,  debility,  and  general  discomfort 
Tbeae  may  last  for  one  or  several  days,  and  tbcy  have  occa- 
sionally existed  for  six  weeka 

The  cbaraoteristio  s3rmpton]8  of  the  disease  now  ranke  their 
qipearance.  Great  weaknees  of  the  lower  extremities  is  soon 
complained  of,  which  increases  to  such  an  extent  as  to  render 
■Undiog  and  walking  impossible.  The  patient  can  for  a  short 
tioM  execute  when  lying  down  the  individual  movements  of  the 
le^  bat  tliis  power  is  soon  lost  The  paralysis  appears  Brst 
ID  the  musclet  which  move  the  feet,  then  in  thutto  which  move 
Ibe  legs,  and  at  last  to  the  muscles  of  the  thighs,  and  thus,  in 
the  oouise  of  a  few  days,  the  lower  eitroniitiea  may  be  com- 
pletely paralysed.  The  legs  now  lie  flnocid  and  powerless,  there 
i»  DO  resistance  to  passive  movements  of  them,  and  there  is 
eomplete  absence  of  muscular  tension  and  contractures. 

The  paralysis  advances  steadily  upwards,  the  mui«clp.a  of  the 
tniuk  are  invaded,  and  sitting  up  is  rendered  impos.'iible;  while 
tb«  actit  of  ooaghing,  sneezing,  and  defecation  arc  weak  and 
inaffective  through  paralysis  of  the  abdominal  muscles. 

The  muscles  of  the  upper  extremities  are  now  attacked; 
they  are  implicated,  indeed,  before  the  abdominal  muscles,  and 
soon  become  oomfdetely  paralysed.  The  h&niin  first  grow 
weak,  and  finer  actions,  as  writing,  become  impo.ssibIa  The 
movemenla  of  the  forearm  become  more  and  more  difficult,  and 
those  of  the  shoulder-joint  nro  eoon  implioated,  the  arms,  like 
legs,  being  completely  relaxed  and  immovabL 


3Q6 


MIXED   DISEASES   OF  TUS 


Diaturbauccs  of  respiration  Don  appvor,  owing  to  pftral; 
of  the  intcrcostat  and  otiier  respirtitory  muaclea  of  the  truok. 

The  disturbance:!  of  senftibiltlj  oro  quite  eubordinute  to  the 
motor  paralysis,  although  they  are  not  entirely  wanting. 
Patients  frequoutly  complain  of  numbness  and  forratcattou  in 
the  fingers  and  toes,  a  diminution  of  feeling  in  the  soles  of  th« 
feet,  extcodiu^  iKcasiooally  orcr  the  whole  of  the  lower  extre- 
mities, and  pain  may  be  complained  of  at  the  bc^nning  of  Uie 
disease,  although  it  is  never  a  prominent  symptom.  Cutaneoas 
BCnnbiiity  is  usually  norm.i1,  but  occasionally  tt  is  distioetlj 
lowered  towanU  the  periphery  of  the  extremities,  and  in  socna 
few  cnnesi  there  ie  almost  complete  aniT'-iitheBia,  while  rarely 
hyperalgesia  has  been  observed. 

A  coiiaiderable  amount  of  emaciation  may  appear  just  as  OGCun 
during  the  course  of  any  otbor  acute  diseaHe,  but  the  paralywd 
muscles  do  not  undergo  lupidly  progreesire  atrophy,  and  the 
electrical  excitability  of  the  paralysed  nerves  aud  muscles 
remains  normal.  The  nutrition  of  tbe  skin  Is  not  affected,  and 
bed-sores  do  not  occur. 

In  a  case  reported  by  Eisenlobr  tranntory  oedema  of  the 
ulciu  witli  redness  of  the  integument  over  various  joints  is  men- 
tioned as  having  been  present,  and    in    some   other  cases  a      | 
profuse  secretion  of  sweat  has  been  noticed,  but  do  other  vaa{>^^ 
motor  disturbances  ^H 

Reflex  action  is  preserved  during  the  Brst  few  days  of  tbfi      ' 
disease,  it  then  diminiahea  more  or  less  rapidly,  and  is  finally 
extinguished.     In  Kisenlobr's  ca«e  an  increase  of  reHex  action 
was  observed.     In  one  case  examined  by  Westphal  the  reflex 
excitability  of  the  tendons  was  abolished  as  well  as  that 
the  skin. 

The  functions  of  the  bladder  and  rectum  are  usually  a 
affected.     In  some  few  cases  slight  disturbances  of  the  Uadd 
havo  boon  met  with,  but  the  severe  paralysiis  of  the  bladder  and 
rectum,  which  occurs  in  otlier  forms  of  central  myelitis,  has 
never  been  observed.    The  bowels  arc  uaunlly  constipated. 

The  general  health  is  as  a  rule  good,  nnd  in  the  majority  of 
cn.<<e8  there  Is  no  fever.  In  some,  however,  the  general  health 
is  disturbed,  and  febrile  symptoms  appear,  which  occasionally 
may  be  severe.    Tbe  brain  is  entirely  unaffected  tfannigfaon. 


RpnTAL  COBO  ASD  HEDULLA   OBUIKQATA. 


267 


the  whole  coureo  of  the  ilweiuto;  evcD  the  cciubml  motor  norTes 
•re  Dot  inipticateil  uatil  the  tenoitial  period. 

A»  tho  discaw  advances  upwards,  patieata  complain  of  paia 
uiil  Btiffness  in  the  neck,  and  the  miuctes  of  Ibai  region 
bMotuQ  paralysed,  *nd  sometimes  there  is  paresis  of  tho  facial 
nnsclea.  The  medulln  obloogtita  is  soon  implicated,  and  then 
tliA  fuDctions  of  articulation,  mastication,  deglutition,  and  ulti- 
Boaiflly  respiration  are  interfered  with;  evidences  of  bypcra-mia 
liid  faypoetatic  congestion  of  the  lungs  appear,  and  the  patient 
diea  from  asphyxia.  Sometimes  the  pupils  have  been  unequal, 
and  the  pulne  may  become  very  frequent 

The  duration  of  the  diiteasG  is  somevhat  variable.  In  some 
CHCB  it  miiB  its  coarse  and  ends  in  death  in  two  or  three  days, 
while  oocuionally  it  lasts  from  two  to  fourweeks.  Thearerage 
dantion  of  fatal  cases  is  from  eight  to  tweh'e  davs. 

Bat  the  disease  may  end  in  recovery.  It  may  ceaM  to  pro- 
ywatany  stage  of  its  development.  This  usually  takes  place 
hefora  the  nerves  of  the  mcdulhi  oblongata  aro  involved,  but 
noorrerj  baa  been  known  to  take  |^ace  even  afler  dirturbauccs 
of  TCS{nnt)on,  deglutition,  and  mastication  hod  commenced. 

lo  casra  which  run  a  favourable  course  improvement  takcti 
place  at  on  early  period  of  the  diseaBe,  the  ports  last  attacked 
by  the  pamlysis  being  the  Brst  to  ahow  signo  of  improvement. 
The  patients  Brst  begin  to  use  their  hands,  after  a  time  they 
uv  able  to  sit  up,  and  finally  after  another  considerable  interval 
tb«j  are  able  to  stood  and  walk.  The  period  of  recovery  oocu- 
pi«*  uany  weeks,  although  the  duration  varies  much  in  indi- 
vidwd  eases.  Fluctuations  and  relapses  may  occur  during 
reeoverr.  and  the  patients  complain  for  a  long  time  of  debility. 
TIm  disease  oooaaioaally  begins  in  tho  balbnr  nerves,  and  the 
paralysis  progresses  downwards  within  the  cord  Ciivier,  as 
fiported  by  Fellegnni-Lcvi,  died  of  this  acute  descendiDg 
jiaimlyna. 

The  following,  according  to  Landry,  is  the  order  in  which  the 
nnncles  are  affected  by  paralysis : — 

I.  The  muscles  which  moTo  the  toes  and  foot,  then  the 
|)osterior  masctes  of  the  thigh  and  pelvis,  and  lastly  the 
anterior  and  internal  muscles  of  the  thigh. 


L-. 


s&» 


MIXED  DI3BASK1  Or  THE 


2.  Tlia  muBcleB  wTiicU  move  the  Bngew,  thoge  which  move, 

the  hand,  and  the  arm  upoD  th«  tcapula.  and  lastly  ttx 
muscles  which  move  the  forearm  iipoo  the  arm. 

3.  The  muscles  of  the  tniok. 

4.  The  muscles  of  respirafcioD.  then  those  of  the  C( 

pharynx,  and  (Bsophag:as, 

It  will  thus  he  seen  that  although  the  paralysii  pui 
goneml  aaceading  course,  yet  the  various  groups  of  muscles  ar* 
not  affected  in  the  same  relative  order  id  which  they  are  in- 
nerva.ted  from  the  cord.  The  muscles  of  the  haod,  for  iiutanc«. 
are- paralysed  before  those  of  the  abdomen,  yet  the  former  are 
innervated  from  the  cervical  and  the  latter  from  the  dorml 
region  of  the  cord. 

§  469.  DiagnoKia. — It  may  not  be  poadble  to  arrive 
positive  diagnosis  diirinj;  the  lirst  days  of  the  diseaae,  but  n 
it  is  fully  developed  the  diagnosis  presents  no  difficulty. 

Acute,  anterior  jxtlioTnyditin  may  be  distinguished  from 
otfoctioQ  by  the  circumstance  that  it  baa  uo  progressive  cbaracier,^ 
rarely  attacks  the  medulla,  and  hardly  ever  directly  causes  death. 
It  is  also  ushered  in  by  fever,  and  there  is  rapid  masculir 
atrophy  and  loss  of  faradlc  excitability.  Even  the  temporary 
form  of  acute  aateriormyelitlB  may  he  distin^ishcd  front  acuta 
aflcendin^  paralysis  by  the  loss  of  reflex  excitability  and  lowering 
of  famdic  excitability,  and  by  the  fact  that  the  paralysis  is  do 
progressive. 

Stibacuie  anlttrior  poli&niyGUtis,  when  it  parsoea  a  tolerably 
rapid  ascending  course,  may  very  readily  l)e  mistaken  for  acute 
oecending  paralyRis,  but  the  latter  disease  is  not  attcnd«l  with 
muscular  atrophy,  and  electrical  excitability  is  preserved.  Id 
subacute  anterior  poliomyelitis  reflex  action  is  earlier  aholiahed 
than  in  this  affection,  there  is  olmoat  entire  absence  of  di»- 
turhances  of  sensibility  and  the  functions  of  the  bladder,  and 
huihar  symptoms  only  appear  at  a  late  period,  and  the  disease 
is  never  so  rapidly  fatal. 

In  amiie  cejaral  mytlitia  thcro  is  always  a  high  degree  of 
di.sturbanees  of  sensibility,  reflex  action  is  early  abolished,  and, 
in  addition,  tbers  is  paralysis  of  the  sphinctors,  fever,  acute  bed) 


SPTKAt  CORD  AND   MEDULU   OBLO.VOATA.  269 

■ores,  K  lowering  of  faradic  excitability,  and  a  rapidly  fatal 
tenuioatioa. 

Tht  ifpinal  form  of  s^iilia,  when  it  asmmoB  the  form  of 
acut«  osoeadiog  pamlyaia,  may  be  Uistioguiabed  b;  tbe  previous 
hutor;  or  evideocea  of  etilt  existisg  syphilis,  aod  by  tUu  rcaalta 
of  ootisypbilitio  tK&tiocDt 

AcvUe  muUipU  neitritts  may  be  distinguished  from  acute 
•wendiDg  paralysis  by  the  severe  paius  limited  to  siug^le  ut-rve- 
toota,  by  the  UmiUtioa  of  (he  aoa^slhe^a  aod  paraly&iii,  aad  by 
Um  npid  loweriog  of  electrical  ejc[;itab)Uby. 

§  470.  Morbid  Anatomy. — All  the  oxamioatioDs  which  have 
bitberto  beoD  made  have  yielded  completely  negatiTC  reaulta 
both  ai  regiLnIs  the  spinal  cord,  medulla  oblongata,  brain,  syra- 
pathetic  Derves,  peripheral  ueire  truaks,  aud  muscles.  The 
oamat  of  Vulpiaa.  Uoniil  and  Raovitjr,  Bcrubordt,  Wcstplial, 
O^eriae,  aod  Goctz,  who  have  conducted  the  examinaiioos, 
•afficieutly  attest  the  competency  of  the  observers.  D^jerine 
and  Qoatx  state  that  thoy  observed  chaoges  in  the  anterior 
roots  of  tbe  nervea  The  altered  fibres  preseoted  the  ordi- 
nary cbaraoCcrifltics  of  parencbymatouii  ouuritiB  or  degenerative 
abopbjr,  such  aa  are  observed  in  tbe  peripheral  segioent  of  a 
o«nr*  after  lectioo. 

Th«  following  caae  appears  to  me  to  bare  been  &n  eiample 
of  Landry'd  paralysisi  but,  as  I  did  not  see  the  patient  during 
life,  tb«  diagiKisus  must,  perhaps,  be  recorded  as  somewhat 
doubtful.  Thai  symptoma  ivere  reported  to  me  by  Mr. 
Wartenburg,  who  was  then  House  Ijurgeou  at  the  Royal 
In&rmwy,  and  who  took  charge  of  the  case  ia  the  Bbsence  of 
the  Bouse  Physician  : — 

Hnirietta  R ,  uL  tw«at^-oo«  pan,  wu  Mliniti«<l  tat»  th«  Rojral 

to6niiar7,  unrler  tbe  cu*  of  Dr.  BioviM,  on  Jaooaiy  28tb,  lt)77,  aiul  died 
tba  HaQtiwiiig  limy.  On  admiadoa  tbe  lower  eskfvtnitJM  won  coEopleUl; 
pwsljsail,  mul  Uiere  was  pkrUal  |»ral]-Htti  of  tbo  upper  eitrouiitieit.  Tbe 
pwaljaw  »f  tfa4  tip)i«r  ettromitiM  IxicAine  tatndljr  toon  pronoDooMl.  th« 
rM|>iraturf  miuclea  were  mxmi  la^kat«d,  aud  tbo  pfttieut  died  trota 
Mplijxia  about  thirty  hoars  after  adrnkaidD.  Ko  wnsorjr  diiturbauoM, 
aaio^mj^ilmTj  {ibaxaaum,  vmiciil  troubim,  or  bed-Aorca  wen  uoted^  The 
Uatoff  nbtaUMil  oa  adminioD  iru  that  tho  i>*Ui!nt  hid  had  a  alight  l>Io« 
aa  ffav  bwh  of  the  drIc  loor  days  prvriaiiBl;,  aud  tbal  -^he  auuii  n/terwunls 


S70 


MIXED  DI 


THB 


bMUM  pualjrj<«l  in  the  lower  «itreniiti«t.     There  vers  no  contuaiona  or 
other  Bigua  of  injury. 

Thu  autopsy  wm  conducted  by  me  thirty-ais  boun  aft«r  <lcatfa,  and  Xh» 
following  la  uD  abstntct  of  the  ra|>orl :  Tltre«  liuear  hu6  deep  cic*trioai 
are  observed  in  the  ten  grain.  TIi«  nkin  over  tha  aacnim  and  trochaoten 
in  not  uloontt«d )  the  muoulM  ara  plnmp,  aod  none  o(  them  preneiit  ao; 
aigna  ofatro^iliy.  The  Hpjiml  onrd  n-as  flomewhttt  xriftT  thaii  oaaa]  ia  tlw 
loTtr  tutlf  of  tho  cervical  aad  dorsal  regioue,  and  in  thu  lower  half  of  tlw 
lumbar  flaUigomsot  aad  coaim  m«dullaha,  the  remaining  inrtimu  being 
Dorcual.  Th*  other  morbid  appoiu«n);««  noted  w»re  uRimportant  [  bam 
repeatedly  ejcamined  seotiona  of  tbs  spinal  oord,  and  alwaya  found  the 
graator  portion  of  tiio  ganglion  coUa  of  the  antorior  honia  ao  bwuitifnlly 
deflnocl  and  healthy  that  1  came  to  regard  the  cord  as  being  typicsUy 
hoalthy.  I  obiwrvAil  iliMidud  patholo^caJ  cbiuiges  in  the  oeDtral  ooltuon, 
but  regardod  them  as  accidental,  or  at  least  of  no  iropnrlanee  so  far  aa  the 
fuDotioDttl  disturbanoea  prsaent  during  life  were  cone*Tned.  U'beo,  botr- 
ever,  emb^y()^lKiclll  conttiderntionn  foronl  upon  me  the  oonolusiou  that  the 
c«ntnJ  columns  xiere  endowed  with  important  ftuietiona,  my  jttdgtnttnt  of 
the  aignlftcance  of  the  morbid  cbangee  obwrvoci  in  tLU  oord  bocaicr 
alcarod.    A.  section  of  th«  dorsal  region  ta  repmont«d  is  fXg.  ISO ;  the 

Pio.  ISO. 


■\ 


P>^ 


./ 


FiO.  180  ( YoungV  Stditm  ^  tin  Upper  Donal  Rtfitn  of  M(  SpiMtl  {Xmf,  from  • 
tan  tfJLevU  Aiffaitinff  t^ralftU.-A.  Anterior  lif>m* ;  P.  pnatatiar  boeM;  tf, 
oentral  canal:  rt,  vniciilarculuinn  of  Clarko;  <,  ii]tFniKl.  at,  aiitiu  bleial. 
pt,  p«mcTi>-later«i  urnati  vt  cvUn  |  n,l,  tbe  mrdi'i  Utrtai  area.  Tlie  dlinawd 
jKntiofi  c*  rvprMcnud  hy  lh«  liirbllyihBclMl  ana  wbieh  otcayitmthv  orniral 
gimy  aolanin  and  iU  eiUtiainttii  iHitwuan  tb? anlmvlaUral  aail  poaierolaUial 
IfTOupa,  and  betweoa  the  iaKiaal  and  autar»-Ut«**l  groaiA 


SPIHiL  CORD   ASH  MEDTTLtA   OBLOMGATA. 


271 


iDteriMl,  Mitero-Utentl,  Kiiil  po»t«ro>bitenl  groupH  an  normal,  whlla  tbe 
«Mtnd  cfllumrt  tad  nadia- lateral  ana  nro  diMaaod.  A  aaotion  of  tho 
nidJlo  of  tbe  oervkal  onUrgcDioob  ia  repreooDtwd  in  Fig.  181 ;  tbc  luternal, 
MitMkr,  •at«r»-Ut«ral,  and  poat«ro-]«t«ral  groupa  ara  normftl,  while  tho 
oantnl  OQloaan,  tlw  uudiaa  arWi  anH  the  ceatral  groap  of  ganglion  calls 
an  cfiaaaaed.  The  diaeued  anaa  ehmreil  gnumlar  degen«Tatton  of  0«r- 
Ucb'a  aerva  network,  c«tn[ilnt«  dinppearancc  ot  the  gaiiglioa  cella,  inareaao 
of  ooelal,  afid  dtUtation  and  oongMttion  of  bloml-vraaelB. 

Pie.  181. 


in 


k/\ 


Pta.181  iTouBs).  St^^m  «f  iKc  mMU  tif  *>•(  Vcrrin^  Enlarftntaii  <if  tkt  Spiital 
O&r^  fr«m  a BMit  if  AeuUJttnding Ftral joi*.'  e,  t.'cjilnlgroo|i,Mid^aiti«nor 
map  o(  f  aoBtloB  oelU :  n,  DMdka  ana.  Tb»  rf nn^Ding  letwia  liidl«ata  tba 
•anMa«lM««nMMailbsU(tonln/'v.  IM.  TbvdiMMadanaUnpnanrtad 
bf  tkt  H|bllr-«baid*d  poHiaii  wUcb  rtprMcaU  th*  cnttml  eraf  ooltran  and  iia 
ulMNfaaa  into  tba  ■■dian  an«  (n).  twtvwn  the  anltroaatital  and  poalwu- 
bwral  sMvpa  of  ealh,  aad  roaad  (b»  notral  xroupb 

§  *71.  Morbifl  Phynology. — ITie  pathology  of  this  ttffcclioQ 
[  eiCMdingly  ol^scure,  aad  Weslpbal  coosiders  it  probable  that 
diMtM  it  due  to  some  iotoxicatioD,  and  a  sUnUar  opinion 
btd  be«a  maiataiDed  hy  Laodr;.  In  many  respects  this  ditease 
'»  like  ietoMU.  Acuto  aaccnding  paralyeia  manifests  itself,  as 
iU  name  implies,  by  Iom  of  motor  power,  wbil«  tctaoua  is  mani- 
fwted  by  symptoms  of  motor  irritatioa,  but  both  affections 
anatmilar  in  th^ir  mode  of  ioTasion,  in  tbeir  rapid  oourse,  and 
fnqueDtly  rapid  fatal  termination. 


tTS  MJ.^£D  DISUSES  OF  THE 

§  473.  ProifnoaU. — ^The  pro^osis  a  always  rerjr  acriout. 
The  more  rapid  the  asceading  course  of  the  disease,  the  earlier 
respiratioa  lias  been  attackeJ,  and  the  more  prooouoced  Qit 
signs  of  Liulbar  parnlyds,  tliu  graver  docs  tlic  prognosis  become. 
When  oDCti  tbi!  progress  of  the  disease  is  arrested  and  ImproTe- 
•ment  begins,  the  prognosis  booomes  moro  hopeful,  bat  even 
then  tUure  U  danger  of  a  relapse. 

§  473.    Treniment. — At  an  early  ittagc  of  the  afioctioa  Cbi 
mau'i)  ic«-bsg  may  be  applied  to  the  spine.     The  coiuU 
current  has  been  employed  in  the  lat«r  stages  of  the 
which  have  terminated  favourably. 

(tt]    ACUTE  DIFPrSKD  itYELtTia 

AetUe  Difueed  In/lammation  of  the  Spinal  Co 

§  474.  Definition. — Acute  difTused  myelitis  oompriiies  all  tlM 
atteclioQH  of  the  iipiual  cord  which  are  attended  by  fever,  and 
which  lead  in  a  short  time  to  serious  functional  disturhancefl, 
with  the  exception  of  the  acute  system  diseases  of  the  cord, 
which  have  juat  been  considered. 

g  475.  Ktiatogy.—VLsMy  cases  apparently  originate 
taneouijly  wilhoui  any  recognisable  excttiugmuse.  The  inalew^ 
appeiirs  to  bu  more  subject  to  tlie  disease  than  the  female  sea. 
The  greater  number  of  cases  occurs  between  the  ages  of  ten  and 
thirty,  with  the  excepliou  of  infantile  spinal  paralysis.  Snaal 
excesses,  and  severe  bodily  exertion,  act  as  predisposing  cauaas 
of  the  diseuse. 

The  moHt  usual  exciting  causes  of  the  affectioo  are  injuries 
Buch  aa  those  produced  by  puncturiog  and  cutting  insu-umeou, 
fractures  and  luxations  of  the  vortebru,  contusions,  slow  coni' 
pression  of  the  cord,  and  inflaoiniatory  processes  Lraiumiltccl 
from  neighbouring  organs.  Kxpuaure  to  cold.  espc>cially  when 
the  body  is  ovcthuatcd,  or  after  severe  bodily  exertitm,  and 
sleeping  ou  the  damp  earth  or  in  snow,  arc  the  moBt  IreqiMiii 
causes  of  the  affection. 

Acute  myelitis  is  not  unfroq^uently  developed  as  a  complic 


SPINAL  COBD  AXD  MEDULLA   OBLOKOATA.  273 

or  leqnel  of  acute  diseasei,  siicb  sa  typhng,  the  acute  exantJbe- 
mBU.  acaU  rfaeumatigm,  severe  puerperal  dbeaaes,  anil  more 
especially  of  roriola. 

Ujrelitts,  rnDDing  a  very  rapid  courae,  is  observed  with  un- 
usual frequencj  amongst  syphilitic  patieDta.  Suppression  of 
tbe  metuns  and  boj-morrboidaL  bleeding  play  a  more  or  leis 
dovbtful  r^e  in  the  etiology  of  the  disease. 

Violent  emotions  appear  sometimes  to  have  caused  the 
affection,  and  several  cases  are  recorded  in  which    the   first 

iplomfl  of  myelitis  showed  themselves  immediately  afler 
it  fngbt,  anxiety,  or  anger. 

Irritative  ledons  of  peripheral  organs  give  rise  to  acute 
myelitisL  A  proportion  of  the  so-called  reflex  paraplegias,  which 
■ra  developod  in  oonoectioo  with  diseases  of  the  digestive  and 
graito- urinary  organs,  or  tbe  joints,  sbould  be  classed  m  acute 
mysUtia.  Feinberg  has  recently  succeeded  in  exciting  an  acute 
inflammalioQ  of  the  apioal  cord  in  rabbits  by  varnishing  tJie 
■Ida,  bat  the  mecbanuim  of  ita  production  is  uuknotrn. 

§  476.  Symptoma. — The  symptoms  of  acute  diffused  myelitis 
£ir«r  greatly  in  each  individual  case,  so  that  it  is  difficult  to 
deam'be  tbe  generic  featuree  of  the  uOection.  Tbe  onset  of 
^tfi  disease  is  very  variable.  It  ia  sometimes  preceded  by 
^IpienU  malaise,  sligbt  pyrexia  with  or  without  a  feeling 
'  of  ditUinesB,  and  the  usual  febrile  oocompauiments,  headache, 
gaoeral  depreasion,  acbing  pains  in  the  limbs,  and  loss  of 
^tpettic.  In  m&oy  cases  the  spinal  symptoms  make  their 
appearance  at  once,  disturbances  of  seosatioa  being  those 
which  uaujilly  first  attract  the  attention  of  the  patient.  Tbe 
symptoms  of  sensory  irritation  assume  tbe  greatest  prominence, 
bot  in  some  few  cases  they  are  entirely  wanting,  and  tbe  vio- 
tmt  shooting  pains  of  meningitis  are  rarely  present.  The  pains 
of  myelitis  consist  of  neuralgic  paiuH  surrounding  tbe  trunk 
at  a  variable  height  like  a  girdle,  dragging,  tearing,  boring, 
or  bunuDg  scnaatioos  Lu  tbe  limbs  which  are  not  increased  by 
pfMKun  or  movement,  and  pain  in  the  back  extending  over  a 
moK  or  less  extensive  area.  Several  of  the  spinous  processes 
an  often  tender  to  pressure.  The  tender  spot  can  sometimes 
be  best  elicited  by  passing  bot  and  cold  sponges  or  the  catliode 
s 


S74 


UIXED  DISEASES  OF  THE 


of  the  galvanic  curreDt  along  the  vertebral  coIamiL  Vaiic 
p&neslbeaise  are  almost  coaBlaotly  preeeot  m  the  disease,  tbe 
mo9t  commoa  and  constant  of  these  beiag  the  seusation  of  con- 
stricUon,  like  &  girdle,  which  is  felt  both  in  the  trunk  and  in  tbe 
extremttiea  end  joints.  Feelings  of  tension  or  swelling,  and  of 
cold  or  beat,  or  pricking  sensations  and  formicattoo  ore  eJipari- 
enced  over  more  or  lesa  extensive  aresn  of  skin,  enpeciall;  that  of 
tbe  lower  extremities.  True  byperiDatliosia  is  rarely  prewDt  a 
acute  myelitis,  aod  when  it  occurs  it  is  probably  duo  to  a  cots- 
plioatioQ  with  meningitis.  It,  however,  occure  on  tbe  some 
aide  as  the  motnr  paralysia  in  unilateral  circumiichbed  myelitit. 
Aa  tbe  disease  advances  the  feeliagg  of  numbness  and  farriii«« 
become  more  and  more  prominent,  and  these  are  soon  followed 
by  the  ditfuBed  painful  and  vibratory  Rensatio&s  which  Charcot 
has  n».med  dy5.-esthcsin),  and  which  are  produced  by  tooebing 
the  skin  of  circumscribed  areas,  or  of  the  entire  surface  of  one 
or  both  extremitiett. 

As  the  disease  advances,  the  feelings  of  numbnesa  and  furri- 
DV8S  give  place  to  coinplule  luaa  of  scnsatioD.  Tbe  auEU8lh««a 
may  be  partial,  or  may  mAnifest  itself  in  the  form  of  retardation 
of  acnsory  conduction.  At  other  times  it  may  be  more  or  lets 
diffused  and  complete,  although  the  parts  deprived  of  sbdkip 
tion  may  be  subject  to  severe  pains — anisstkceia  dohnaa. 
SUootuig  pa.iiia  and  spoKmodic  twitcbings  of  tbe  mosdea  an 
veiy  common  iu  the  paralysed  parta.  PaticutD  complain  at 
times  of  paioful,  dragging  sensations  in  the  bladder  and  rectum, 
gastralgic  attacks,  and  neuralgic  pains  in  tbe  other  viscera  In 
all  severe  cases  there  is  complete  aDa'«thesia  of  the  lower  half 
of  the  body  up  to  a  oertain  height,  the  anajsthetic  being  marked 
off  from  tbe  normal  Rbin  by  a  pretty  sharply  defined  lina 

The  motor  diaturbanee^  couaist  ofboth  irritative  and  paralytio 
pheaomcna.  In  children  the  onset  of  the  duiease  is  marked 
by  general  coevulsions.  Tbe  symptoms  of  motor  irritatioo  of 
spinal  origio  are  twitchlnge  of  individual  muscles  or  of  eotiie 
extremities,  while  at  times  the  Hpoamodic  contractions  of  the 
muscles  msiy  increase  to  a  condition  of  tetanic  rigidity.  Tbe 
paralytic  symptoms  are,  hovever,  much  more  constant  and 
important.  They  may  wmetimea  be  tlcrclopod  with  euek 
rapidity  that  we  speak  of  a^Q^la^i/onn  myelitis.     In  MOM 


SPUUl  CORD  AND  HEDTTLU.  DBLOKOITA. 


S75 


OMN  tho  poraljrsu  tn&y  be  developed  in  tfae  course  of  a  night, 
or  wen  in  IdM  tbao  ao  bour.  while  id  tli«  liitmorrbagic  form  it 
SMj  d«v«lop  in  tbo  courso  of  a  {qw  minutca.  Whon  tbe  para- 
IjtM  sympunnB  are  rmpidiy  developed  tbe  muscles  are  perfectly 
flaocid,  and  offer  no  re«istanc«  to  poseivo  rooTMUQDta  of  tbe 
joints,  and  when  tbe  limbs  aro  raised,  tbey  fall  like  those  of  a 
dtad  body.  Symptoms  of  motor  irrilatioii  may  reappear  in  the 
aAsotcd  timba  at  a  later  period  of  tbe  disease,  if  tho  patioat 
■■rriT&  Isolated  Bpontaoeoiu  twtt^bings  of  tbe  mu»cl««  may 
tb«D  b«  obsOTVed  in  th«  paralysed  limbii,  these  being  geaeTally 
aacocnpaDicd  by  severe  abooting  poioA. 

Spaamodie  tonic  contractions  of  the  muscles  occur,  which 
are  excited  by  a  voluntary  effort  to  move  tbe  afft'Cted  limb, 
or  by  itritatioD  of  tbu  senaitive  Dervee.  Ultiiaately  severe 
eontrvctures  are  produced,  which  fix  the  legs  in  an  extended  or 
6cxed  position,  and  are  frequently  rendered  more  intcQHo  by 
■tt«mpt«  at  active  or  pasaivo  movements  of  the  paralysed 
limbi.  Tbeae  symptomB  are,  however,  more  frequently  ob- 
scwed  in  tbe  subacute  and  chronic  than  in  tbe  acute  forms  of 
nyvtitU. 

The  most  common  forms  of  paralysis  are  paraplegia,  hemi- 
pamplegia,  monoplegia,  and  paralysis  of  tbo  eorvical  muMles, 
■bile  complete  paralysJs  of  all  four  extremities  and  of  the 
greater  Dumber  of  the  muscles  of  tbe  trunk  not  unfrequentJy 
ciecun. 

Tba  r^/Uoi  excitability  varies  aooording  to  tbe  seat  of  tho 
disMSB.  The  reflex  activity  of  both  tbe  skin  and  ransclea 
maj  b»  diminished,  d««troyed,  or  increased.  In  some  oaaea 
it  is  abolished  at  an  early  period  of  tbe  diiw^ase,  and  im- 
medifttely  alter  the  development  of  the  patnlynia,  so  that 
nifl«x  actions  cannot  be  excited  even  by  severe  irritants.  Ab 
ottMT  Umea  it  is  mA  ealircly  uhulishcd,  but  a  lon^r  time  is 
i»q aired  {or  the  production  of  reBex  Diovements;  while  in  other 
OMes  it  undergoes  a  conaidcrabte  increase,  so  that  slight  irri- 
Maooa  eall  forth  active  reBcx  muscular  twitchings,  which  may 
JBoaase  lo  *  convoUive  jerking  of  tbe  paralysed  parts.  la 
«th«r  oaaM  tbe  n&tx  excitability  is  unaltered,  or  it  is  sligfatly 
ivcmsed  for  a  time  and  then  begins  to  diminish  and  gradnally 
beeonM  WMk«r,  and  finally  disappears. 


£70 


UIXBD  DISEASES  0?  THE 


The  Bphiocters  are  frequeatly  inTolved.  Vesical  paralysis 
be  one  of  tbe  earliest,  or  even  a  premonitory  Kjmptom  of  ac 
myelltia.  Id  severe  cases  complete  retention  of  urine  is  usuailj 
present,  so  that  the  use  of  the  catJicter  is  rendered  Dcceiaaiy. 
In  other  cases  there  la  merely  incontinence  t^  urine,  while  is 
tbe  heginmng  the  Hymptoms  are  those  of  irritaUoo.  such  u 
spasmodic  closure  of  the  sphincter,  with  Lacreaaed  desire  to 
urinate.  In  scvcro  caHcs  tlie  urine  after  the  sotoqUi  or  eighth  day 
becomes  alkaline  and  eometimeB  bloody ;  it  contaiaa  numerous 
crystals  of  tbe  triplc-pbosphatcs,  and  there  a  a  muco-puralent 
deposit.  Paralysis  of  the  sphincter  ani  is  generally  prescsL 
Priapwm  is  a  not  uncommon  symptom  in  acute  myelitis,  the 
erections  generally  being  incomplete,  but  often  pereistiog  for 
days,  with  alight  variations  in  degree. 

Tlie  vaso-motoT  dtaturbances  arc  variable.  Engelken  found 
in  one  case  a  nee  in  the  temperature  of  the  paralysed  part^ 
but  moat  auiliors  speak  of  the  extremities  as  being  cold. 
Diffuse  oedema  of  the  paralysed  lower  limbs  is  often  ob- 
served. The  perspiration  is  sometimes  increased,  somfr- 
times  dimininhed.  Tbe  trophic  dislurbances  consist  of  gan- 
grenous inflammatioQ  of  the  flkin  over  the  sacrum,  trochanten. 
and  other  exposed  situations,  and  these  usually  progren 
r«pidly  and  prove  fatal  by  septic  fever.  When  Uie  losiofi  is 
unilatLTul  tlto  Lcd-sore  Is  situated  on  the  oppoaite  aide  of  the 
body  to  tbe  motor  paralysis.  Acute  bed-sore  uuty  make  its 
appearance  as  early  as  from  the  second  to  the  fifth  day  of  U^J 
disease.  ^H 

Tbe  case  may  lennioate  so  rapidly  that  there  is  no  time  * 
for  the  development  of  trophic  changea  in  the  nerves  ami 
muscles,  but  traces  of  degenerative  atrophy  have  been  fouad 
even  in  rapidly  fatal  oases  of  central  myelitis.  Tbe  atrophy  uf 
tbe  muscles  is  generally  well  marked  when  the  disease  has  beea 
of  somewhat  longer  dumtion.  In  these  cases  there  is  loss  of 
faradic  IrritabiLty  of  tbe  muscles  and  nerves  along  with  the 
development  of  tbe  reaction  of  degeneration.  There  are  caaes 
of  acute  myelili.<),  however,  in  which  there  is  no  change  in  the 
electric  irritability,  and  others  in  which  only  slight  quantitative 
changes  suck  as  slight  increase  or  diminution  can  be  demon- 
strated. 


SPISAL  CORD  AND  MEDULLA  OOLONOATA. 


iBS 


pneamoni&;  tbd  pleune  and  pericardinm  aro  generally  studded 
witii  stnall  bsmorrhagic  npoU.  ^ 

The  Urge  sIoughR  characteristic  of  acute  bed-Boraa  are  maally 
found  oa  the  parts  expottcd  to  mecbaaical  praasure,  as  tite 
MCrum.  nates,  and  trocbantera. 


§  481.  Morbid  Phygiology. — ^The  ioitial  Bjmptom)^  of  irrita- 
tioo  moit  bo  ascribed  to  the  increase  of  tlie  irritability  of  tbe 
nenre  cells  and  fibrea,  cauued  by  iQcreaBed  oatritive  activity 
daiiog  Uie  early  stages  of  tbe  inQammatory  procees,  aatl  tbe 
btcr  symptoms  of  paialysia  to  the  dostructiou  of  tbese  elfituoata 
mod  tbeir  compreasioa  by  the  intlanimatory  exudation.  Tbe 
girdle  pains  depend  upon  impHcatioa  of  tbe  posterior  loota  in 
tb«  isHatsed  focus,  and  tbe  partestbesi^  and  neuralgic  pains  of 
Ibe  ioferior  half  of  tbe  body  by  irritation  of  tbe  sensory  tracts 
ataiU«d  in  the  grey  etibstance  and  ia  the  posterior  white 
colanutt  of  the  cord.  Since  the  sensory  tracts  either  lie  within 
t^  grey  subetanoe  or  pass  through  it  for  a  oertaiu  diiitaDCd  the 
inteaae  siuutbesia  in  acute  centra]  myclitin  may  be  readily 
aeooanled  for.  In  tbe  circumficribed,  ilisseminated,  and  cortical 
fonns  of  myelitis,  the  degree  of  diiiturhance  gf  senitatioa  will 
dapeod  solely  ou  the  extent  to  which  Oie  posterior  roots  and 
tettaorj  tracts  are  involved  tn  pathological  changes. 

Tbe  rooter  disturbances  are  tinit  caused  by  irritation  and 
snbeequently  by  loss  of  function  of  the  motor  centres  and  con- 
ducting  fibres  in  the  conl.  When  Uie  anterior  boms  of  grey 
oasU.ter  are  affected,  piLralysis  ensues  with  complete  flaccidiiy  of 
tha  Umb&  When  the  pjrramidal  tract  is  affected,  loss  of  volun- 
tarj  power  ensues,  followed,  if  the  patient  surrire  aome  weeks, 
by  muscular  tension  aad  cmtraclurci. 

Tbe  condition  of  the  reflex  exdtability  furnishes  a  valuable 
iftdicstion  of  the  state  of  tbe  grey  substance.  So  long  as  the 
pay  rabetance  is  unaffected,  so  long  h  there  a  continuance  of 
reflex  actions,  nnlesa  indeed  tbe  reHez  arcs  be  interrupted  in 
tlwir  pwnge  through  the  posterior  an<l  anterior  roots  and  their 
Wfttinnatiotw  through  the  white  columns  to  reach  the  grey 
■UMtanoe.  When  a  portion  of  the  grey  substance  is  separated 
Avid  its  connection  with  the  brain  by  a  myelitis  utuated  higher 
np  the  cord,  reflex  actions  become  increased.    In  transrerae 


S78 


3IIXED  DISEASES  OF  THE 


before  death.  Id  other  cases  the  fever  i»  sHght,  never  ettabs 
a  high  grade,  and  mar  disappear  entirely  durm);  the  lobseqaent 
oQuree  of  the  ditteaae.  Ad  exhaustive  symptoniatic  fever  oocan 
in  the  latter  Htages  of  tlio  afTection,  caiiHed  bj  the  bed-sore^ 
cystitis,  pjelo-nephritia.  and  ooneequent  septic  infection. 

§  477.  Course,  Terminationa,  and  DttToHan. — ^I'hc  ooune 
of  acute  myelitis  is  exceedingly  variable,  but  it  is  alwaTV 
rapidly  developed,  and  it  is  this  feature  which  cDtitle*  it  to  be 
regarded  as  as  acute  affection.  Cases  which  take  more  tlian 
ten  days  to  develop  may  be  regarded  as  subacute.  11m 
paralysis  luay  at  timoft  be  developed  in  an  apoplectiform  manmr 
almost  without  premonitory  eymptoma,  and  it  may  attain  con- 
siderable intensity  in  an  hour  or  even  lexs.  As  a  rule,  however, 
there  is  a  premonitory  stage  of  variable  length,  and  days  ouy 
dapae  befora  the  paralyitis  develops  into  prououoced  pampl^gijL 
At  times  tbe  development  of  the  disease  ih  iutemiptei]  bjr 
remissions  instead  of  bemg  continuous. 

la  central  myelitis  and  ha^matomycHtis  the  paralysis  r^aidly 
ascends,  symptoms  of  asphyxia  appear,  and  death  cakes  place 
in  a  few  days ;  or  the  fatal  termioation  is  Inrought  about  by  the 
violent  fever  and  septicaemia  caused  by  the  acute  bed-sores  and 
cystitis,  and  life  may  Iheu  be  prolonged  for  a  period  of  a  few 
veeku.  Id  the  Less  severe  cases,  particularly  when  the  eatiie 
lumbar  enlai^emeut  i^  oil'ected  with  or  without  the  dorsal  por- 
tion of  the  cord,  the  course  is  somewhat  slower.  There  ia  oom- 
plete  paraplegia  with  paralysis  of  the  bladder,  cystitis,  deoabitiM, 
fever,  cachexia,  and  exhaustion,  and  the  patient  succumbs  after 
several  weeks  or  mouths. 

Id  all  other  oases  chronic  myelitis  is  developed,  and  tbe 
symptoms  are  then  complete  motor  paralysis  with  incomplete 
paralysis  of  sensation  and  of  the  bladder.  The  ^mptoms 
may  then  remain  stationary  for  mouths  or  years.  After  the 
disease  has  persiHted  for  a  vatiable  time  cystitis  and  bed-«orM 
may  develop,  but  tbey  never  become  very  severe  and  are 
BuscepLtble  of  being  at  least  partly  cured.  Death  finally  remit* 
firom  cxhaustioD  or  from  some  intercurrent  diaeoae. 

Id  other  cases  the  disease  ceuees  and  the  gencml  heolib  ts 
•ODD  oooiplclely  restored.     The  disorders  of  son&alioD  aad  of 


SPtNAL  OOBD  AND  MEDULI^  OBLOKOATA. 


27E) 


the  bladder,  aad  the  tropbic  disorders  of  the  skin,  are  usually 
entirely  wantiug.  Tho  disoaae  then  terminates  in  imperfect 
ncovery,  the  only  traces  left  being  paralysis  and  atrophy  of 
ooe  or  more  muscular  groups. 

Complete  recovery  takoB  place  in  rare  cases,  and  in  these 
eyraptous  of  improvement  set  in  early.  After  paralysis,  fever, 
afld  otbor  symptoms  of  a  mild  attack  of  acute  myelitis  have 
pemsted  for  one  or  two  weeks  they  undergo  a  shv  aad  gradual 
retrogfeeMon,  and  in  a  few  weeks  all  the  functions  of  the  body 
■re  eomplctoly  restored,  although  convalescence  is  somewhat 
proCnict«d. 

^§  478.  iforbid  Anatom>/. — After  acute  iuflammatioa  thd 
spinal  oord  is  gcuemlly  softened,  but  tho  appearances  presented 
by  the  diBcased  parts  difler  according  to  the  stage  of  the  tnye- 
Htu.  Leydea  divides  the  inflamtDatory  softenings  of  the  spinal 
cord  into  (1)  red,  (2)  yellow,  (3)  white,  (4)  grey,  and  (5)  green 
or  purulent  softening. 

(1)  Red  Softening. — ^Tho  stage  of  hypertcraia  and  com- 
meneiDg  exudation  is  not  oflen  met  with  post  mortem.  It 
may,  however,  be  observed  in  cases  of  traumatic  ami  cetitral 
myelitis  which  run  a  rapidly  fatal  course.  The  affected  spot 
may  be  found  swollen,  the  transverse  markings  on  section 
being  blurred  and  indistinct,  and  tbe  cut  surface  presenting  a 
variegated  marbled  appearance.  Tbe  colour  may  vary  Irom  a 
msy  injection  to  a  deep  red,  reddish  brown,  or  chocolate  colour, 
and  nnmerouB  capillary  bajmorrhages  may  be  observed.  Tbe 
inflamed  spota  are  moist  and  softv  and  swell  up  above  tho  level 
of  tbe  cot  surface,  and  at  times  the  tisane  becomes  diffluent 
In  rare  instances  a  slight  increase  of  consistency  is  observed  la 
tbe  stage  of  bypencmia.  Tho  membmnes  in  the  neighbourhood 
of  tbe  affected  spot  also  frequently  present  the  signs  of  hyper- 
SIIU&  and  inflammation. 

(2)  Yrlloiv  Softening. — M  the  disease  progresses  tho  affected 
psixu  become  paler  and  softer,  hence  t\m  stage  may  be  called 
tbat  of  yellow  softening.  The  ohango  of  colour  from  red  to 
yellow  is  due  partly  to  tbe  diffusion  and  allcmtion  of  the 
colouriog  matter  of  the  blood,  and  partly  to  the  fatty  degene- 
ration of  the  medullary  sbeatb^  and  tbe  formation  of  mo-sses 
of  fat>granule& 


266 


MIXED  DISEASES  Of  THE 


an  nflTocted,  oaei  two,  or  all  four  nxtrotaitica  may  be  panl^rsed,  ortixrt 
may  he  ooruplete  abseuoa  of  ixufalysw  of  tba  limbs.  Tlw  pstiaBl  dm^ 
«oiD|iliu[i  of  iHuua  uiil  furuiitiatiou  iii  tlio  liiaba,  but  then  ie  oo  aiMMUaMifc 
Tb*  bladder  and  recUtm  may  b«ctitae  paralynd  towards  tte  *■—*—' 
psnod  of  the  diaeatia.  Tlie  Uiaturbaoces  of  circulatiou  and  nepiratna  ia- 
cTCWo,  tbo  iiatient  becomtM  uDcouftoioua,  aiid  deatb  ramlta  froin  aai>byxia. 
JtorbuJ  Anatomy.— lu  Uir««  com*  qT  aoute  bulbar  myelitU,  obwrrud 
by  l«»;<lou,  miiiUi  ouutru  uf  Moftsniiig  without  dafiiilt«  boaodariaa  mn 
found  iu  tho  aa«dulU  oblongati^  la  two  caao«  the  ooutna  of  noAoniag 
oooupiaJ  the  internal  [Kurtion  uf  th.o  tnednlia  from  tba  floor  of  tba  foartk 
veiitrkle  to  lli^  auterior  pyraniida;  vtulo  ia  tin  third  a  aiaall  oeatt*  of 
Huftaiimg  wail  found  situated  between  tlw  reatifonn  and  ottvaiy  bodias 
and  roota  of  Uiu  hyiwglotHMtl  uen'c. 

4.  AtiUt  Tmntvtrtt  JfjfcHtit. — Thia  rariety  of  acute  i't'**""r"*T'MT  of 
the  copil  ia  rapraMnUid  by  tba  form  of  tbo  dixoaM  wliicb  darelopa  alUr 
Mvera  iujuriw  of  tba  spinal  oord  and  vertebral  column.  Tba  ayiuptcma 
vary  gn^aUy  according  to  tbo  levol  at  wliieli  tbo  cord  ia  dinaaed.  For 
prautiual  purpottc*  acute  traonvonw  inyolitis  may  be  subdivided  into: 
(a)  Acute  doreo-lumbur  tmasverae  myabUa ;  (6)  Acuta  danal  tianavana 
uiyelitis;  and  (c)  Acute  cervic&l  transverse  myelitis. 

(h)  Acuu  Dorto-lumitar  TrantDtne  ifye^iru.— Tbia  rariety  uxaaSy 
bagina  by  fever,  fonoioation,  uiunbueas,  aod  pain  in  ti»  lovaraittaiaitiM. 
Thaw  Rf  mptuma  are  acuimpiuiied  or  aooti  followed  by  atarUuga  «t  tba 
limU,  l*ut  thu  pLieuomcuu  nf  ntuAory  and  motor  irritation  aoou  i;\vp  pboe 
to  those  of  puniyai*.  The  iwralynod  limba  ara,  rigid,  and  the  redeioi 
both  cutanooua  and  deo[>,  aro  czo^jpirotod,  and  tbare  i«  a  t«aic  apaam  of 
the  aphinctora.  After  a  timo  the  uriuo  becomea  attoml,  aouta  bed^Mraa 
apiwar  oi-«r  tbo  aocnim  a»d  trochanten,  iatenmttent  ferer  aapertaoaa, 
aud  the  patieut  iliw  fruui  runraomus. 

SometimoH  thu  u:i--«ut  aiid  |imgre«a  of  the  diseaM  ia  m  rapid  that  it 
dewrves  to  bo  caltod  ii^ftr-^icuie  or  apopUcti/vnn.  Uayem  hasni|)oited 
two  cases,  iu  which  dsath  occurred  in  the  oua  iu  five  days,  aad  ia  the 
other  in  twelve. 

(ft)  AeuU  Donal  Traiutertt  MyAitU.  —This  form  of  the  diaeaae  ia  Um 
least  daogcruua  of  the  tUree.  The  eenaory  and  motor  diaturbaaoaa  are 
more  or  lutw  utmilar  to  tltiMe  which  oecur  iu  the  doiw>-lumbar  form,  ia 
acute  dorsal  traasvane  uayi^litka,  however,  there  la  completo  abaeoeaot 
bed-Boroa,  tJio  bladder  ia  unaffuutad.  xuil  uoiiawiuauUy  the  BeptiMMiiJa  aai 
matatimuaareabMiDt.  Caaoi  of  this  kind  may  completely  raeofw;  bat. 
■a anile,  the  afiection  a«« Limes  the  chrouic  form.  A  lac^  aombW-* 
caaun  of  chrouic  far^lt^ia  belong  to  Uiia  variety. 

The  paliout  may  at  tiiuea  recover  troia  a  Ant  attaclc,  aod  maj 
partially  recover  from  a  aecuud  aud  third  attack,  and  tUtimalely  i 
to  the  ditu.-ai!U9  many  mixiUia  after  the  &rat  attack  ( Piemt). 

(c)  A<mt*  Cwioai  Tntunrm  ifjieMtM— Tbia  lotaa  of  the 


SPINAL  CORD  AND  UEDULLA  OBLOKOATA.  283 

paeaoKniui;  the  plcun^  aod  pericardium  are  generally  atudJed 
with  loull  faa-morrbngic  spota 

The  larg^  slougbH  cli&racteristio  of  acute  bed-sores  are  usu&Ily 
foand  OD  the  poxu  exposed  to  mechanical  pressure,  as  tha 
BEcrQin,  nates,  and  trochaolera. 

§  4S1.  Aforbid  Phxfwyloffij. — The  ioittal  tiymptomit  of  irrita- 
tioo  mtut  be  ascribed  to  the  increase  of  tbe  irritability  of  the 
oerve  cells  and  fibres,  caused  by  increased  nutritive  activity 
diirii^  the  early  staged  of  the  ittdainmatory  procetm,  aod  the 
lAt«r  symptotna  of  paralysis  to  tbe  destruction  of  these  elements 
aod  their  compression  by  the  inflammatory  eiuJatlou.  The 
girdle  paius  depend  upon  implication  of  the  post«rior  roots  in 
tbe  iofUoied  focus,  and  the  parwsthesi.'p  and  neuralgic  pains  of 
tbe  inferior  half  of  the  body  by  irritation  of  ttie  seniuiry  tracts 
aitoolod  in  the  grey  substance  and  in  the  posterior  white 
columos  of  the  cord.  Since  tho  sensory  tracts  cither  lie  within 
tbe  grey  substAnce  or  pass  through  it  for  a  certain  distauco  tbe 
ifttean  aoijcsthesia  in  acute  central  myelitis  may  be  readily 
MODontod  fur.  In  the  eiicumscribcd,  dissvininated,  and  cortical 
Jmas  of  myelitis,  the  degree  of  disturbance  of  scnsattoD  wilt 
depend  solely  on  tbe  extant  to  which  the  posterior  roots  and 
•eosory  tracts  arc  involved  in  pathological  changea 

Tbe  motor  disiurbances  are  first  caused  by  irritation  and 
nibseqaently  by  toss  of  function  of  the  motor  centres  and  con- 
docting  6brci;  in  tbe  cord.  ^Vhe^  the  anterior  horns  of  grey 
matter  are  aifected,  patalyus  ensues  with  complete  flaocidity  of 
tbe  limbs.  When  tlie  pyramidal  tract  is  affocted,  loss  of  volun- 
tary power  ensues,  followed,  if  the  patient  survive  some  weeks, 
by  muscular  tension  and  contractures. 

The  condition  of  the  reflex  excitability-  furnishes  a  valuable 
iadicatioQ  of  the  state  of  tbe  grey  substance.  So  long  as  the 
grey  substance  is  uiiaflcctcd,  so  long  is  there  a  continuance  of 
rtflcx  actions,  untese  indeed  the  reflex  arcs  bo  interrupted  in 
tbeir  passage  through  the  posterior  and  anterior  roots  and  their 
eoDCiADAtioDS  through  the  white  columns  to  roach  the  grey 
rabstance.  When  a  portion  of  the  grey  substance  is  sepamted 
ftom  its  connection  with  the  brain  by  a  myelitis  situated  higher 
up  tbe  oord,  reflex  actions  become  increased.    In  transverse 


288 


HIXBD  DiaCASBS  OP  THE 


6.  Acutt  yiftlo-MeningitU. — Acuta  m7«litu  ia  freqamtl;  eomplioUd 
irith  ueDlD^tis.  Wo  shall  honaft«r  speak  of  tboae  o«»m  ia  niucli 
myelitis  is  (tevelopod  mmulUowMuljr  vitb  or  aa  a  oomplication  of  aoato 
meDingitis,  but  at  prsMnt  wa  mnh  to  limit  our  renurks  to  thacMM  is 
vhiob  meningeal  <ihangai  are  superadded  to  Bcut«  mjelitU.  This  oompti- 
Mtion  is  not  very  importaot,  aiuce  the  addition  of  meningitis  U>  an  neat* 
iitilAmniAtoTf  uffiKtbti  of  the  cord  iluca  uot  uppear  to  add  to  the  gnrit; 
of  the  latter.  The  a^ptoms  wbleli  tiidlc&te  meningitis  are  pua  aad  atiff- 
uess  in  tho  back  aud  neck,  prououticed  b^rpenastbeeja,  and  dJffuaod  palm 
Whei]  tlivHe  H^mjitoius  ure  aupcnulded  to  time  of  acute  m/^ti^  Uie  caia 
is  likvly  to  be  niia  uf  uij'ulo-iDuuiui;itis. 

Moriiid  AntUomy. — Wliou  the  membranas  are  alfocttMl  they  beootae 
cougoBtvd,  Bud  sotnetimea  capillarjr  oxtraTaaatioDs  najr  bo  ofaaervad  ia 
them,  or  they  ana  iiifiltratad  with  serum  and  ceUtiUr  elamqnts,  Um  s{»iial 
lluid  ia  increased  io  quantity,  is  cloudy  or  reddish,  aud  in  mora  firotnciad 
GSsas  the  m^ubrsuw  becoioa  tbiakeoed  and  loosely  adhereot.  On  micro- 
acupical  examiuution  the  u^juibranna  are  found  tbickeued  asd  tufiltratail 
with  cellukr  elemeota,  irbil«  iu  the  cortical  layer  of  tba  apiosl  oord  itself 
a  large  tiumb«r  of  the  uervo  £hroa  are  tlestrajed.  tba  oooaeGtira  tiana 
aapta  being  thickened,  and  a  great  iucrease  in  the  nnmber  of  Daitac's  mUs 
havtiii;  tukou  plftce.  Iti  canniiie  preparations,  nft«r  hardening,  tb»  cod 
is  surrtHitided  by  a  highly-ataiued  border  which  ezt«nda  into  the  sabstaon 
of  th4  cord  to  a  £Teat«r  or  lector  deptli,  aoeordiug  to  Uw  utent  of  thi 
diaeaite.  Thii  form  of  dlsaus  has  ooosequeutly  been  called  perij^mccr 
rm-tical  myelitis. 

7.  AcuXs  DiaHminaltd  JfytUtia.—T\K!  symptoms  of  this  affection  ait 
paraplegia,  samotiisos  a8soci.it«d  irith  sputic  symptoms.  The  bladder 
IB  generally  poralyaed.  Tho  atato  of  the  aciinibility  is  variable,  bat  it  is 
gaaerally  more  or  l«ss  impttired.  The  reflex  and  electric  excitability  ia 
also  variable,  both  being  generally  dimiiiiahad.  Tbe  groupiDg  of  the 
symptotoH  aud  tbe  eiaoerbatiaas  show  sometimes  during  Ufe  that  Mvml 
oeDtiOB  of  disease  eiibt.  The  disease  may  be  auapeobed  if  Uw  Bjaptotna 
of  aoute  myelitas  supervene  during  au  attack  of  variola,  or  if  they  denldp 
suddoiily  iu  pbthiaiual  patieiitti. 

Murbiii  A  wttottij/.  ^Thia  form  of  myelitis  occurs  in  smaD  spola  asatland 
through  the  aulMtauoe  of  the  cord,  and  appears  to  form  an  istennediabt 
grftde  betweuu  the  «cut«  aud  cbrouio  fomu  of  myelitis.  Tbe  MSSalM 
charoeterivtia  of  the  morbid  proowM  appcara  to  be  «□  incnom  in  tfaa  iriw- 
■titial  Umuo,  which  becomes  unusually  dense,  and  rich  in  nuclei  TItt 
aepta  are  swollen,  the  irolhi  of  tb«  vesaehi  thickened,  aud  some  grauob 
oella  are  observed.    Tbe  coniistence  of  tbe  cord  is  oftea  increased. 


§  493.  DiagnoM. — ^Typical  cases  of  acute  myelitis  are  easil/ 
recogoiset!,  but  the  less  pronounced  cnstaa  and  those  complicated 
by  tbe  presence  of  otbcx  affections  are  difficult  to  uoraveL    Tbe 


SI'IHjU.  cord  UTD  MBOtTLLA  OBLONGATA.  289 

cbanctenstic  tytnptonu  are,  the  stiddea  onset  of  the  afTectiou, 
Uw  prcMoce  of  more  or  leas  marked  agaa  of  sensoiy  and  motor 
irhtatioa,  ttio  rapid  development  of  complete  paralvsis  of  Mmo 
of  the  limbs  and  of  tho  bladder,  tbe  rapid  formation  of  bed- 
vona,  and  tlie  presence  of  fever 

Acate  myelitic  may  be  mistaken  for  ttie  folloving  diseases: — 

«titt  tueendiny  pattU^na  roaenablefl  diffuse  central  myelitis 
dosely  tbal  it  ia  acaroely  possible  to  distin^isU  the  two 
afiectioDS.  lADdry'a  paralysis  is  characterised  by  the  abseocc 
of  ooaTnUive  mo7eioents  at  the  onset  of  the  affection,  abseoice  of 
trophic  diBturbancea,  slight  degree  of  soDSory  diKturbaoces,  and 
the  preservation  of  the  faradic  contractility  of  the  paralysed 
mtudeflL 

AeuU  mtnintjUis  of  the  cord  is  chamcterised  by  high  feTer, 
•even  pam,  doraal  and  corvical  rigidity,  contractures,  slight 
•ynptoms  of  paraly&ia,  especially  of  the  sphincters,  absooco  of 
MTCTfl  trophic  disturbances,  and  pronounced  hyperesthesia. 
Tbe  two  disease*  «r«  oft«D  oombiaed,  and  then  the  difficultieB 
of  dUgooBia  become  greater. 

HinimtomyeUa  or  liiuple  hsemorrhage  into  the  spinal  cord  in 
Tcrj  difficult  to  distinguish  from  coutral  myelitis,  especially 
finnii  tbe  haemorrhagic  fonn  of  the  affection.  In  the  fonnur  the 
pumlyais  is  developed  sudtlenly  witbont  fever  or  protlromato, 
eihI  the  paralysis  is  statiooary  instead  of  being  progressive  as 
ia  ihe  latter. 

KmmatOTThaehis  or  hemorrhage  into  the  meninges  of  the 
ia  chaiactciised  by  a  very  abrupt  derelopmeul  without 
Moitory  symptoms  or  fever,  symptoms  of  severe  mcuiugeal 
tnilalioD,  violent  pains,  donul  rigidity,  a  comparatively  slight 
■^gree  of  paimlysis,  and  particularly  by  the  slight  intensity  of 
tbe  aaoisthesia. 

lijfp€TtKmia  of  the  cord  is  characteriied  by  the  abaenoe  of 
fever,  the  slight  intensity  of  the  sensory  and  motor  diiituibanoes. 
ibe  frequAnt  and  rapid  variations  in  the  symptoms,  and  tbe 
■faMOcs  of  vesical  weakness  and  of  bed-sores. 

Tbe  diagnosis  of  hysterical  paralysis  from  acuto  myelitis  will 
bereafler  be  coDsidcrcd.      Several  poisons  produce  symptoms 
wbidi  renmble  doeely  Ihoee  of  acute  central  myelitis. 
T 


290 


MJXSD 


IBB 


The  seat  of  tbo  discoM  in  the  cord  and  iU  attnnon  in  the 
tr&aavcrse  and  vertical  directiODS  cad  be  detenniaed  from  the 
area  of  the  paralytic  phenomeDo,  the  state  of  the  rodcx  iirita- 
biltty,  aud  the  trophic  disordeia 


§  484f.  Progiioais. — The  prognoais  is  generally  unfavoarsbi^ 
but  there  are  exceptions  to  this  rule.  Perfect  recovery  is  rare. 
Id  cnaoy  cases  a  chronic  disease  is  iailuced;  vhilst  in  othen 
there  is  arrest  of  the  disease,  hut  incurable  defects  remain. 

The  prognosis  depend:^  on  the  locality  and  extent  of  the  ia- 
flammabory  process.  T}ie  higher  up  the  Hiiiease  in  situated  in 
the  dorsal  and  cervical  regions,  the  greater  the  liability  of  the 
respiratory  tracts  to  heoome  affected  and  the  greater  in  the  danger 
to  Ufe.  Duntal  layelitis  is,  however,  other  things  being'  eqatJ. 
more  favourable  than  dorso-lumbar  myelitis,  because  tiiegenlto- 
urinary  automatic  centres  are  unadected  in  the  former. 

The  prognosis  is  the  more  unfavourable  the  greater  the  extent 
of  the  transverse  section  of  the  cord  involved  in  the  process.  U 
ia  rendered  very  unTavuLimhlo  when  the  central  and  poiterior 
portions  of  the  grey  substance  are  involved,  owing  to  the  coe- 
eequent  eyetitiu  and  acute  bed-sores.  It  is  doubtful  how  te 
implication  of  the  white  columus  influences  the  prognosiH. 

The  proxQosifl  also  becomes  worse  in  proportion  to  tlw 
longitudinal  extent  of  the  disease.  A  ciFcumscribM)  traosfcnw 
myelitis  is  not  so  daiigeious  as  the  same  affection  when  H 
extends  over  a  greater  length  of  the  cord.  The  progressive 
ascending  forms  of  the  disease,  and  parucularly  oT  cential 
ascendiDg  tiiyclitis,  have  a  piurticularly  unfavourable  progoosia. 
A  loDgitudioal  extension  of  the  diseaae  in  Uie  white  columniu 
not  BO  dangerous. 

A  rapid  development  and  great  intensity  of  the  parolysis, 
complete  paralysis  of  tbo  sphincters,  early  formation  of  acute 
bed-sorea,  progressive  advance  of  the  disease  upwards,  high  fever, 
impairment  of  the  general  health,  dyspnoea,  eyaaobift,  and  oUiar 
disorders  of  respiration  influence  the  prognosis  unfavounbly* 
A  moderate  degree  of  paralysis,  abeeuce  of  trophic  and  maaory 
disturbances,  implication  of  the  bladder  to  only  a  slight  exteDt» 
absence  of  fevor  and  of  marked  impairment  of  the  genenl 
bealth,  aud  oommeuciug  improvement  of  some  gf  the  nervous 


SPtKAL  COftD  AKD  UEDt'LLA   ODLO.^GATA. 

^unct^ftic  Kfmptoms  are,  the  sudilen  onMt  of  the  afTection, 
tbe  presence  of  more  or  less  marked  ngns  of  aentoTj  and  motor 
irritattDo,  the  rapid  developmeut  of  complete  paralysis  of  some 
of  the  limbs  and  of  tbe  bladder,  tbe  rapid  rormation  of  bed- 
»ons,  aod  the  presence  of  fever. 

Acate  raycliUs  may  bo  mistaken  for  the  following  diseases : — 

Acute  aacending  pai-^Uysia  resembles  diffiiHe  central  myelitia 
ao  dueely  that  it  is  scarcely  poasible  to  disttngulsb  tbe  two 
■fiixtiODS.  Lo-adfy's  paralysis  is  cbantctoriscd  by  the  absence 
of  oonmlsive  movements  at  the  onset  of  the  aflfcction,  absence  of 
trophic  disturbances,  slight  degree  of  ««nsory  disturbsDces,  and 
the  preservation  of  tbe  faradic  contractility  of  the  piuuljeed 
tousclea. 

Acute  meningUU  of  the  cord  in  cbamctcrised  by  high  feTer, 
teTero  paio,  dontal  and  cervical  rigidity,  cootracturcs,  slight 
symptoms  of  paralyats,  especially  of  tlie  sphincters,  absenco  of 
■BTere  trophic  disturbanoeu,  and  pronounced  hjiwnesthesia. 
The  tvo  diseases  are  often  combined,  and  then  the  difficulties 
of  diagnosis  become  greater. 

Sixmniomyetia  or  simple  haemorrhage  iato  the  spinal  cord  is 
Tery  difficult  to  distinguish  from  ct-utral  myelitis,  especially 
bom  tbe  hivmorrhagic  form  of  the  affection.  Id  the  former  the 
pM»lyiis  is  developed  auddeoty  without  fever  or  prodromata, 
»&d  the  paralysis  is  stationary  instead  of  being  progressive  as 
io  tbe  latter. 

IfcBmutorrhadtis  or  haemorrhage  into  the  meninges  of  the 
cord  is  characterised  by  a  very  abrupt  development  without 
prenumittny  symptomti  or  fever,  symptoros  of  sevcru  meningeal 
irritalioD,  violent  pains,  dorsal  rigidity,  a  comparatively  slight 
dogrb*  of  pwalyns,  and  particulurly  by  the  slight  intensity  of 
the  aoKstbesia. 

Hjfpenvmia  of  the  cord  is  characterised  by  tbe  absence  of 
fner,  the  slight  inteosity  of  the  sensory  and  motor  disturbanoeov 
tbe  frecjucnt  and  rapid  variattoos  in  the  symptoma,  and  tbe 
absence  of  vesical  weakness  and  of  bed-sores. 

Tbu  diaguosis  of  hysterical  paralysis  from  acute  myelitis  will 
bere*fker  be  considered.      Several  poisons  produce  symptoms 
which  resenible  closely  those  of  acute  central  myelitiB. 
T 


292 


MIXED  DISEASES  OF  THE 


with  carbolicoil,  tn  order  to  prereDt  the  introdactioa  of  bacteria 
ioto  the  bladder.  When  the  disease  hax  become  sabecute  ot 
chroDic,  the  treatment  must  be  modified  accordingly. 

(III.)   CHRONIC   DlPFtTSED   MYELITIS. 
Ckronic  Jnjtaminaiion  o/  the  Spinal  CortL 

§  486.  Definition. — Cbixmio  diffused  myelitis  oompriaes  all 
those  slow ly-d«vel oping  and  diffused  processes  id  the  spinal 
curd  which  run  a  liugering  course  without  fever,  and  which  are 
at  preoeot  ascribed  to  clironic  inflammatioB. 

§  487.  Etiology. — It  is  very  probable  that  indiridoals 
huritiog  a  ueuruimihic  constitution  are  predisposed  to  myetilia. 
hut  DO  statintical  proof  has  as  yet  been  forthcoming.  The  other 
predisposing  causes  of  the  dtaeaae  are  mental  and  bodily  orer- 
exertion,  disiiipat  ion,  auxu&l  excesses,  syphitia,  emotional  exoite- 
meot,  etpecially  tlie  depressiug  emotions.  The  disease  is  iao«t 
common  during  youth  and  middle  age,  and  iu  the  male  sex. 

Chronic  myelitis  can  develop  from  the  acute  foroi,  although 
the  former  can  be  produced  primarily  from  the  same  cauaes  as 
the  acute, 

The  following  are  the  usual  exciting  causes  of  the  affection  :— 
KxpoRure  to  cold,  long  sojouTD  in  damp  and  cold  loealitiai, 
sleeping  on  damp  earth,  bodily  oror-oxertion,  especially  when 
combined  with  exposure  to  cold,  as  occurs  during  campaigns, 
Simpleconcusiiionof  the  oord,  without  direct  injury,  and  gradual 
(XHapreMioD,  may  also  give  rise  to  chrouic  tnyelilis,  and  sexual 
ezMM  may  act  both  as  n  prediHposing  and  exciting  cause. 

Syphilis  is  a  fruitful  source  of  chronic  myelitis.  Syphihtic 
neoplasms  are  not  here  in  qu«stioD, but  cases  of  chronic  myelitis 
which  arise  in  the  courae  of  secoodary  syphilis,  or  in  peraoos 
who  had  previously  suffered  from  the  disease,  and  where  no 
specific  lesion  can  b«  discovered  to  account  for  the  affection. 
It  is  probable,  therefore,  that  we  have  here  to  do  with  simple 
myelitis  in  persons  predisposed  by  syphilis  to  chronic  iu- 
flammationa 

Chrouic  myelitis  is  oocosionnlty  developed  aa  a  seqad  of 
various  acute  and  cbroDic  diaeasea,   such  as  lepra,  cbrouo 


'■PINAL  COBD  AXD  UKDULLA  OBLONQATA. 


293 


lolUm,  and  chronic  lead  poLioQiQg.  It  may  a3so  be  dereloped 
froiD  irritatioD  aod  iliseaaos  of  peripboral  orgaas,  and  most  of 
Uie  cases  called  reflex  paraJysts  beloi^  to  tbe  category  of  sub- 
Mid  cbronic  myclilk 


♦S8i  SyniptonM. — All  the  diseases  comprised  under  the 
^MD  chrome  my«Utis  caoDOt  be  included  in  one  general  rlescrip* 
^pL  Tbo  following  dMcHptioD  applice  more  particularly  to 
transveree  mvdlitia,  where  one  large  focus  of  disease  exists  at 
■oy  height  in  tbe  cord,  or  where  there  are  several  foci,  one  of 
wbieb,  however,  determioes  the  chief  clinical  features  of  the 
afbctioo.  Id  tbe  majority  of  the  caaect  belonging  to  this  claea 
'tbs  symptoms  develop  slovrly  and  gradually.  Sensory  disturb- 
tanoea  are  first  comphuned  of,  consisting  of  abnormal  seosalioDS 
>aitd  anjeatbesia  la  tbe  tower,  more  rarely  io  tbe  upper  extremi* 
'tiea,  and  these  may  entirety  dimppear  for  a  time.  They  are 
firequexitly  accompanied  by  a  girdle  seniatioD  in  the  trunli,  or 
Ipecbaps  also  in  the  extremitiea.  Painful  scnsutiona,  (severe 
[paiai,  and  bypenestbesia  are  rarely  oomplainpd  of.  The  symp* 
i  are  variable  aod  inoonstAnt,  nod  only  attain  a  high  degree 
Iteastty  very  nlowly  and  gradually. 
the  motor  diaturbaoces  which  occur  io  the  early  stage  of 
those  of  motor  irritatioa  are  of  subon^nate  toi' 
iporiaiic«.  IlicM  usually  consist  of  slight  twitching  moTements 
\of  the  legs,  or  tbe  patient  may  experience  slight  muscular 
leaatiaetiona  and  trembliDg  of  the  legB  after  prolonged  exertion. 
.The  paralytic  EymptomH  are  usually  more  prominent  and  im- 
Iportaot.  Tbe  first  motor  eyniptMns  to  attract  tbe  patient's 
:«tiealioa  are  a  feeling  of  weakness  and  heaviness  of  the  limbs 
And  an  undue  sense  of  fatigue  on  alight  exertioD.  These 
^^Morns  may  at  first  be  relieved  by  walking,  patients  often 
^Hig  Btiffer  and  more  fatigued  at  starting  than  siler  they 
^|b  walked  for  some  time.  The  affection  occasionally  begins 
liyresioal  weakness  manifested  by  slight  incontineuce  or  reteu- 
itioa.  while  on  rare  occasions  the  onset  may  be  marked  by 
|)rMotiQeed  paralysis  of  tbe  bbiddcr. 

As  tbe  disease  advances  the  symptoms  become  slowly  and 
iiTttly  aggravated,  or  become  suddenly  worse  under  tbe 
of  oDe  of  the  exciting  causes  of  the  affection. 


304 


MIXED  DISBASiS  OF  THE 


The  atiffbess  and  weakneea  of  tb«  lower  extremities  now 
become  more  marked,  the  legs  feel  m  if  the;  were  made  of  lead, 
uid  tbc  feet  ore  slowly  dragged  along  the  ground,  tb«  tow 
oatdiiog  readily  in  erery  ineciuality.  Tbe  moremeots  of  tbe 
tow,  and  of  tbc  fingers  if  the  upper  extremities  be  implicated 
ia  the  paralysis,  are  slowly  porfonned,  ench  of  them  being 
accompanied  by  a  large  number  of  associated  movomaDt&  Tbe 
paralyeia  generally  assumes  tbe  typical  form  of  spinat  ]Hirapl^ia, 
although  occasionally  it  appeani  as  spinal  hemiplegia,  and  stiQ 
more  rarely  the  anna  may  be  paralysed,  while  the  legs  remain 
very  little  or  not  aftV-ctt-d. 

AiKfetftefia  of  varying  forms  and  degrees  of  intensity,  osaally 
involving  tbe  lower  extremities  and  the  trunk  up  to  a  variable 
height,  is  rarely  wantiug.  Retardation  of  sensory  conductic 
and  various  partestbesiw  are  often  oboenrcd.  and  the  patient 
occasionally  coraplaio  of  dysoisthesite. 

The  reflex  actmttf  is  increased  in  the  majority  of  caaes, 
a  variety  of  reflex  movements  may  be  produced  by  irritatioo  of 
different  sensitive  surfaeca.  Ticttling  the  acAea  of  tbe  feet  caoses 
active  jerking  and  kicking  movements  in  the  paralysed  l«gi; 
while  the  introduction  of  a  catheter,  or  tbe  act  of  dreasiDg  a 
bed-sore,  may  also  cscitc  movements  in  them.  Kvactiatioa  of 
urine  may  be  produced  by  irritating  the  tiktn  of  (be  feet  at  by 
introducing  the  linger  into  tbe  rectum,  erections  may  bo  pro- 
duced by  rubbing  the  inside  of  the  thighs,  and  a  discharge  6t 
ftBCQs  often  occum  during  the  dressing  of  a  bed-sore. 

Tbe  tendon  rejleswa  are  as  a  rule  abnormally  active,  tbe 
reactioDB  obtained  being  similar  to  thone  described  endor 
spastic  spinal  paralysia  In  Home  cases  the  various  reflexesaie 
diminished  or  even  eutirely  ahullHlied.  Ia  these  cases  the  grey 
aubfltaoco  ia  extensively  involved,  or  tbe  conducting  fibres  of 
the  various  reflex  arcs  are  destroyed  as  tbey  pas»  through  the 
nerve  roots. 

Tbe  va«9-moCor' disturbances  are  as  a  rule  not  very  pramineat. 
The  patients  complain  of  coldness  of  tbe  feet,  and  the  Limbs 
are  often  of  a  cyanotic  or  bluish-red  colour. 

Tbc  elictrie  irritability  of  the  nerves  and  muscles  is  geaarallT 
preserved,  both  quantitatively  and  qualitativ^ely,  when  tbe  rc-fles 
actions  persist,  and  in  some  cases  both  faradio  and  galvanic 


SPIWAl   CORD  AND  MBDULIA  OBLOKQATA. 


29i 


irrittWIity  jsmj  be  increased.  When  the  reflexes,  however,  are 
kboliftliod,  in  coasecjnence  of  exteosiTe  destruction  of  the  grey 
matter,  the  muscJee  undergo  atrophy  accompiiniml  by  loss  of 
their  6inulio  cxcitabitily  uad  the  reaction  of  degeDemtton.  The 
ttirtribntioo  of  the  atrophy  is  very  vanahle.  At  timee  the  upper 
extremitiea  kto  alone  or  cbieHy  affected  by  the  atrophy,  the 
lower  IJmba  preeeotiog  eimple  paralysis  without  atrophy. 

Id  triLtuverflo  myotttla  bcd>!iorcs  are  sooner  or  later  developed 
ID  the  usaal  places.  The  bed-aores  usually  assume  the  chronic 
fona,  although  they  may  occasionally  pursue  an  acute  course. 
In  some  raro  cases  loi^e  sloughs  may  become  permaDentlj  cica- 
tiiwd,  ereo  though  there  be  no  noticeable  improvement  in  the 
oUier  symptoms  of  the  dieeose. 

The  tpbinrtcm  are  almost  always  involved  to  a  more  or  less 
ftxtent,  and  the  vesical  Functions  are  particularly  liable  to  be  im- 
pairc-d  at  ne  oariy  p«iod,  but  there  ore  some  exceptional  cases 
^^n  which  thi>  bladder  remains  unaffected  tlioughout  the  entire 
^^■ttne  of  the  disease. 

Sexual  power  is  nsoally  impaired  at  an  early  period.  It 
dtrainishes  with  more  or  less  rapidity,  and  finally  disappears 
entirely.  In  cases  of  incomplete  paraplegia  sexual  power  may 
be  preserved  for  a  long  time. 

The  general  health  may  remain  perfect  for  a  long  time ;  but 
io  all  the  more  severe  cases  a  oonstantly  increasing  dis- 
tturfaaooe  of  general  nutrition  is  observed,  which  becomes  more 
marked  as  soon  as  cystitis  and  bed-sores  are  developed.  Loss 
of  appetite,  feror,  progressive  emaciation,  and  exhaustion  con- 

Kte  the  fiiuU  symptoms,  provided  hfe  be  not  terminated 
er  by  some  acute  intercurrent  disease. 
The  cerebm.1  nerves  are,  as  a  rule,  not  implicated  in  coses  of 
dirooic  transverse  myelitis,  except  towards  the  termination  of 
the  disease.  In  some  cases  the  morbid  process  ascends  uotit  it 
ex  Ltst  reaches  the  medulla  oblongata,  giving  rise  to  disorders 
of  deglutition,  speech,  circulation  and  respiration,  and  ulti> 
nuuAy  ceodng  death  by  asphyxia. 

g  -489.  Coti-rse,  Ihiratum.  and  Tenninatiojia. — When  the 
chronic  ii  preceded  by  the  acute  form,  the  onHCt  of  the  disease 
ia  of  coinie  sudden.    In  most  cases,  however,  the  disease  super* 


898 


MIXED  DISEASES  OF  THR 


Tenos  slowly  aod  gradually,  so  that  the  first  eyraptonui  att 
little  or  no  attenUon.  The  development,  instead  of  being 
continuous,  is  »oioetime»  marked  by  intervaU  of  more  or  leas 
improveineDt,  which  atteruale  with  exaoerWttoaa  and 
roUpsea. 

The  diseaxe  oo  attaining  a  certain  heig-ht  may  remaid* 
tionary  for  mauy  montha  or  ev«u  year*,  or  it  may  slowly 
and  terminate  in  difTerent  ways.  The  duration  of  the  affection 
generally  extendi  over  many  years,  and  in  some  cases  it  may 
last  a  lifetime  without  producing  dangerous  symptoms. 

Complete  reoovory  ia  rare,  and  even  in  tboeo  rare  CMM 
Telapiee  arc  liablo  to  occur.  Various  symptonu,  such  as  pan- 
lysis,  atrophies,  partial  aufcsthesiie,  deformities,  vesica]  dis- 
orders, and  other  affections,  otbeo  remain  behind  permanently. 
The  usual  course  of  the  disease  is  a  slowly  progressive  ao«^ 
leading  gradually  and  in  different  ways  to  a  fatal  terinioaUoo. 
The  process  may  slowly  creep  upwards  until  disturbanoei  of 
deglutitioo  aud  respiration  occur,  and  death  results  frooi 
asphyxia.  At  other  times  the  secondary, afiectiona  caused  by 
the  myelitis,  HUch  as  bed>sores,  cystitis,  pyaemia,  and  septicsmis, 
destroy  the  vital  powers  of  the  patient  and  lead  to  death  by 
exhaustion  and  maranmua.  In  a  large  number  uf  cases  dcathi 
caused  by  an  intercurrent  aifectlou,  such  as  pneumonia. 

§  190.  Morbid  Anatomy. — ^Tho  morbid  appearanoes  pn-J 
sonted  by  the  spinal  cord  are  often  so  slight  that  they  cannot 
be  detected  hy  the  naked  eya  In  many  oases,  however,  changes 
occur  in  the  consistence,  colour,  and  form  of  the  cord,  which  can 
be  readily  detected. 

It  is  unnecessary  to  repeAt  here  what  has  already  been  Mid 
with  regard  to  sclerosis  or  grey  degeneration  (§  387).  It  will 
su£cc  to  remind  the  reader  that  in  subacute  caaes,  or  in  the 
earlier  stagen  of  a  chronic  myelitis  which  has  developed  frora 
the  acute  form,  the  tissue,  instead  of  being  found  in  a  state  cS 
sclerosis  or  grey  degeneration,  may  have  uudergooe  softeniog^ 
or  the  morbid  process  may  have  led  to  the  formation  of  cavities. 
It  must  alflo  be  lemembcrud  that  a  chronic  myelitis  often  ter- 
minalcB  hy  an  acute  attack,  and  that  sc^eoiag  may  bo  fouat^ 
associated  with  ederoais. 


I 

I 

I 


Id  chronic  tnjrelitis  the  cord  uodergoea  various  cbaages  of 
iotm,  according  to  the  extent  and  localiRatlon  of  the  leaion. 
An  iacTMuw  of  volume  of  the  whole  or  circuiriBCribed  part«  of 
tb«  cord  i«  rmre,  but  a  diminution  of  volume  or  alropliy  is 
eommoo.  The  atroph}'  may  be  general  and  affecting  the  tran»- 
vene  area  of  the  cord  equally  in  all  directions,  or  it  may  take 
pUoe  [Q  pariicuUr  directions.  The  cord  may  be  Jt&ttened  in 
the  antero-poaterior  direcUoQ,  so  tb&t  it  prcfieiitB  the  appeutuioe 
of  a  band,  or  the  surface  may  be  depresBed  the  ctitiro  length 
of  certain  ootumns,  u  the  posterior  columos  in  locomotor  ataxy, 
or  the  mifiskce  may  be  dejHresacd  in  isolatod  and  circumscribed 
*p0U. 

MieroteopU  Exainination. — Chan^  have  been  obnerved  io 
the^l)  ooonectivQ  tiaaue.  (2}  tbo  nervous  tissues,  aod  {ti)  in  the 
blood-veBsela. 

(1)  Ooniisctive  Tisfnie  or  tht  Ifmt/rogtia. — The  connective 
tMSoe  septA  become  thickened,  the  neuroglia  celltt  eularge  and 
their  Dodei  aodergo  proliferation,  while  Deiter'a  cells  become 
gieatlj  increased  in  giie  and  number.  After  a  time  the  normal 
iMoragiia  becomes  converted  into  a  dense,  fibrillated  connective 
wbhq  in  which  a  large  number  of  nuclei  may  be  obKcrved. 

(!)  ilTsrtotts  T'tMues.— The  nenv  Jibres  undergo  changes 
which  coneBpond  to  some  extent  with  the  secondary  degeneration 
ef  the  fibres  of  peripheral  DeTveA.  The  medullary  sbeatb  becomes 
imgnhtfly  thickt^ncd.  then  undergoes  granular  and  fatty  degeue- 
latioD,  nod  is  6nally  absorbed.  Tbo  usiu  cylinders  become  at 
fint  much  swollen,  so  that  they  may  attain  two  or  three  times 
ilwir  normal  dimensions,  bat  when  they  are  viewed  longitudi- 
sallj  they  are  seen  to  present  spindle-shaped  enlargements. 
Aft«r  the  disappearance  of  the  medullary  sheatb  the  naked 
axil  eyUtwloiB  may  often  be  observed  for  a  oouEiderable  time 
longer,  hot  after  a  time  they  also  undergo  atrophy  and  di»- 
•ppaar,  so  tliat  nothing  remains  but  a  dense  fibrillated  connec- 
tive tiani&  The  ganglion  cells  are  cloudy  and  swollen  at  first, 
bol  after  a  time  they  undergo  various  forms  of  atro[^y  and 
vafoolation. 

(S)  Chanffca  in  the  Vesstls. — The  walls  of  the  smalt  arteries 
■Bd  veina^  and  probably  of  tbi:  capillaries  also,  become  tbtckcoed, 
aUihre  is  lessened.    The  walls  of  the  vessels  ore 


298 


MnCRD  DtSBJLSRS  OF  TEE 


often  adherent  to  the  indurnt«4l  connoctive  tissue,  so  that  tln| 
lymph  spaces  are  dei^troyed.     la  other  cases  the  periva 
spaces  coDtain  collcM'tionH  of  fat  and  pigmeat  graualoa,  aaJ 
oecaxionally   granule  ceUx    a1«o.      Orsoute  celU  and   corpora 
amylacea  are  obsnrred  scattered  throngh  the  diaeasad  tiwuR 

§491.  Marhid  PK^stolorfy. — The  coonection  between  th 
morbid  lesions  and  the  symptoms  is  the  same  in  the  chronic  a6  , 
in  the  acute  varieties  of  myelitis,  so  that  it  is  aaneceasaTy  ti^^| 
repeat  what  hna  already  been  aaid  vitb  regard  to  the  morbid^^ 
physiology  of  the  disease. 

§  4d2.  Varieties  of  Clironic  Difftrnd  MyeUiis. 

The  following  variotiea  of  chronic  difTiued  myelitis  may  ' 
diatinguiiihed : — I,  Chronic  ceatral  myelitil;  2,  Chrooic  trani 
vente  myelitia;  3,  Uaiveraa!  progresaive  myelitis;  4>,  Chroi 
bulbar  myelitis;  5,  Chronic  myelo-raeningitia ;  and  0,  Cbroar 
disseminated  myelitis  or  multiple  Bclerosts. 

1.  CRROKtfiCEmRAt.  Utelitik.— (a)  Tkt  »\AacuU  j/mtrol  ^inai  pon- 
lyxi'ii  of  DiioliotiTie  in  jmilHibly  a  typical  example  of  InflasimatiOD  of  tb* 
central  gr&y  i-oliimu,  with  «xtaDaiOQt  of  the  prooen  into  the  aDtariQrhtm% 
and  puTBuinK  n  griiduftllj  asooudiDg  coursa.  Chronic  atni|)liio  par«l|aii  ia, 
indeed,  doewly  iiimiUr  in  Itn  nymptona  to  Landtya  [Huraljrns,  of  wbiek  it 
DU]r  bo  reRanlod  wt  tbo  ohronio  form.  Bullopeau  luui  shown  tlwt  thk 
torm  tif  iinmljmiH  aametiiaw  parauee  s  dmovnding  oouiml  In  Umm  om 
tho  up|>er  cxtnimitiM,  wptoUlIy  Vua  lausolw  of  tlia  fonano,  bttawaa  finl 
lianljaeii ;  tbn7  uudsrgo  citrvpby  soon  aftcrwaivifi,  and  tfa*  tiands  liwmw 
defonaed  pmrtpoma.  It  is  o(i«u  mvea  or  eight  montfaa  or  longer  bvfon 
rather  of  the  lower  eitremitiea  are  aflvctsd,  naA  it  maj  be  mtdthI  monthi 
loaf^  Iwfore  both  of  tbom  ura  implioi.t4)d  Id  th*  paralytia:  Bat  *v«ii  ia 
theoD  OUM  th«  diiwaBa  punun  an  ascending  ooone  ba  waU*  bailor 
qnnptMiia  KLp«T*D«  aft<r  a  tlcae,  and  death  reaolta  from  paralveis  of  tba 
respiratory  centros. 

(i)  Peri^ptndymai  Jfyflitit— the  "  my£Utt«  p<iri-<p«iKlyinair**  of  Ha3- 
Ia|XMu~ii)  another  variety  of  ohmnio  central  myeliUa.  The  ejinptoiiM 
an  ehAracterised  by  paroles  followed  by  diuinutiaa  of  tbe  fiuradie  ooa- 
tractility,  and  atrophy  of  tbe  affectad  niuadea. 

Th«  pamlyais  come*  on  aomswhat  auddenly ;  the  patient  finda  that  ha 
H  not  able  to  move  tho  Bngom,  hands,  or  more  rarelr  tin  entire  Ihab. 
AfUr  a  timo  the  muaelta  low  their  (aradic  centiactility  and  baeomt 
atrophiod,  so  that  the  alTDoted  oitramitiNi  aniime  defbnwd  pooitlcaia 
flbnllary  coDtraotknia  ate  uitliar  absent  or  only  pmant  ia  a 


SPINil.  COBD  AND  KBDVLLl  QhLQUQXTA. 


Sfll) 


4sgnb  TIm  pfttiont  nuj  MmpluD  of  Tigtu  pains  fttoog  {he  tert«bntl 
wilwn.  tint  otber  seiMciry  disturhuiow  tm  oanally  absont.  The 
^ihbcUw  klao  RSMiii  tunffecM.  Ttw  course  oT  the  affisction  ts  slov,  and 
R  aiij  te  tempocaiily  ureated  for  a  long  time.  Th«  muitolw  mwt 
baqoeotlj  affoeta]  are  the  flexoni  of  tha  foot  on  tlie  leg,  anil  of  tliu  tbifh 
Ml  Uw  pslTiB  in  tbe  lower  eitremitiea  ;  and  tlie  extenaom  of  the  flngiini 
and  of  tbe  haiid,  then  lb«  muedee  of  the  hiuiJ,  aud  luutljr  the  fi«xoR)  Mid 
attar  Bncloa  of  ttie  inn  and  shoulden*.  Thia  aiTeclfon  ranf  pumio  a 
teOMiAttC  or  «a  Hoeodiog  ooorac,  and  iu  the  latter  uwon  bulbar  panl^oa 
■ipwmai  and  de^ith  i*  caimd  b^  rtupiratorjF  pml^NiN.  Itlnn;  caxm  of 
■jriafMDjclia  aad  hf  drotajdia  an  only  fomis  of  chronic  c^utrnl  myolitja. 
hrl-«pnKtjiiial  myolitiH  is  cIomIjt  allied,  on  tbe  on*  band,  vith  tbe  sub- 
•«Bl«  gMtfvl  afMual  )>anjj«i*  of  Dttcbotme,  aud  with  progremive  mtiACnlar 
atrophy  on  tho  other.  AaA  if  <*e  corupar«  the  ^TO[)toms  of  Landry's 
tm^pi*,  mlmtnU  general  tpiatl  panlytiB,  pefi-epeodysQAl  myelitis,  and 
laM^iaaiva  muaooUr  atrophy,  H  is  impaaiible  not  to  b«  struck  with  tbe 
WMrtft]  ttalty  whieh  uaderties  them,  while  their  dtffereiioes  are  oo  Isai 
tulnciire. 

All  tbawdiMaMs  ar»  fhanKtariwi)  by  a  progTMaimly-iDvnding  para- 
lyiia,  iMA  OMJ  piinrae  an  aacefuUiig  or  a  dssoending  ooutso,  and  by 
■bMMt  aottn  abaanoe  of  seoaor^  diatnrbancea,  bed-aona,  and  paralysis  of 
tha  qtblcKtera.  The  tnnei  slrildDC  dlfflonnces  between  them  an  fouiul  ta 
tha  tka»  necapted  in  derelopmant  of  the  symptonui,  and  In  the  eooraa  of 
se.  Landry's  paralysis  is  sudden  in  its  onort  sod  r^nd  in  ite 
wlint,  on  tbe  conttary,  pvogreasive  muscnlar  is  undual  In  its 
«aaei  anil  slow  in  its  prognas,  and  the  other  two  dLscasoe  oocnpy  intor- 
■aiBata  poaitMOfl  betwiMo  these  with  respect  to  their  development  in 
Stme.  InLaodry^iMmlyBiBtliereiB  no  decddodniuBcaUr  atrophy, and  the 
1  OMitnetilit;  ia  nearly  normal ;  in  subaents  genenl  apanal  paralysis 
I  la  decided  amacukr  atrophy,  rapid  Ion  of  fivadio  oontrsotility,  sad 

I  fsaetiop  of  degeneration ;  in  peri-ependymal  myaUtis  tben  is  also  pro- 
1  atrophy,  and  tbe  faradic  contractility  boooaes  stowlyaodgrulaaQy 
],  wbilfl  in  ppDgreasire  muscular  atrophy  tbe  atrophy  and  para- 
I  [JTuutwl  usually  nds  by  side,  and  the  hrtdjo  oonttavtiUty  is  {enerally 
fMTW^l  se  lao(  as  any  rauaole  remains. 

W«  iiiall  faereafW  slraw  that  the  morbid  anatomy  of  theae  diaeassa 

ifti  to  BSplaio  tbe  difii»«neaa  jast  dsNOibed,  nn  tbe  suppoaitioo  that  all 
ooly  diffecwnt  loDds  of  inflamaatioo  of  tbo  oeutnl  grey  colnmns 
'  Uw  QOfd,  with  lutarior  and  ktaral  axtamicnu  of  tbe  diaeaae  into  tfae 
<Blariorgr*y  honu. 

(v)  ChnmsD  Cmtnd  Dono-Lnmhar  JTyelitu.— Iu  this  Toriely  of  tba 
danaaa  tbasymptonu  corrwpood  to  tha  a0«otioD  alratdy  deseribed  aa  ae«t« 
ooalral  myelitis.  Tha  knrar  extrenltiea  am  paralysed,  tlie  Itmbs  are 
taecU,  tb*  raiuKJea  ondergo  atrophy,  and  the  faradio  eootraetility  of 
tba  paralywd  mtuolas  ia  soon  lost ;  the  reaction  of  dcgonentiou  is  present, 
abi  tbs  pamlyaia  Biay  grtdaally  uoend  to  the  mosolM  of  tbft  tntalc  and 


800 


MIXED  D]SEA:4BS  or  THE 


tlliMgorthe  uppf r  eitromittv*.  Sofu-theti  UieiTroptomicf  tlmi 
oomapoad  to  ihoao  of  eabacuto  geuonl  »p\a$.\  pArtijm  of  Dnchtnnc,  M 
othflr  symploma  are  obnarved  in  the  fonoer  which  do  not  ocoir  in  Ub 
latt«r.  These  a^-uptoma  am  luJmu  of  the  lowvr  eit7«ioiti««,  puftljmU  of 
th«  Bpbiaot«ra,  bed-sores,  itrid  orthrapkthiM.  S^DSory  duttirbuicOT  ibo 
exist,  coDsuting  of  viuioiu  pwnsUioaiv  ao^  hrfMnlgMia,  foQow»d  bf 
vfu-y  I[i2  iluKreeN  of  analgMiii.  If  the  nifolttui  br  limitw)  to  the  gny  mb- 
xtAuoo,  tactile  Mosibilitf  tail  tb«  aomw  of  locftlitj  wid  of  tcapantoA 
niii»in  iiDKfrMtod.  If  the  lower  nartion  of  th«  cord  tw  not  loipllcatM]  Id 
th«  diMii>H>,  tho  rcQvs  of  the  wle  may  bo  mtggtinlUi  io  th*  eortf  aUg*  tt 
tho  di>iea«e.  This  (arai  of  mjvlitU  in  aeldam  if  «v«r  chronic  from  Ht 
eommetic^iuent,  and  rosulta  uawJlj*  as  the  sequel  of  ut  acato  fctta^lc 

MarhUl  A'VKomy.—li  tH  uim»c«HMT7  to  MJ  much  at  preaSDt  mtb 
Mgard  to  tha  morbid  anatomy  of  the  ohroaio  forms  of  oeotr&l  mj^litu. 
It  appeara  to  me  that  Landry's  paraljrais.  chronic  atropfaie  splunl  |Mtalfwi. 
pert-tpcmlfniiij  mj«liti(>,  progromive  tawioaUr  atrophy,  aad  what  1  han 
teniied  chronic  central  dorso-lumbar  myeliUa  am  uiiljr  different  fom*  of 
inflammation  of  the  oeutral  gro^  ooluma  of  the  coid.  In  l^aArf* 
paralysis  the  inflamniatory  i>roccBa  is  wey  acuto,  and  keepa  liaiited  to  ihe 
central  coluun  and  the  embt^oaie  areaa  (the  RWdiA-latATal  area  in  the 
dorsal  and  up]>er  wn'ioal  rexiona,  uid  the  median  areas  and  margioa  of 
the  j^ups  of  gaughon  cells  in  the  liunbar  and  e«rvieal  onlargesMobJ 
of  the  anterior  fr%y  horns.  Tha  musclea  kbna  otflt  maJnWn  Uuir 
eonnection  with  thn  fnndacoorttal  calU,  and  their  fiu^c  ontnetilitj 
and  niitriUon  r«mnin  comparatively  iiDaffout«(l.  In  chroiiic  atrvpUe 
patalTnia  tho  mnrbid  procniu  piinnies  tha  aame  aaoending  or  deaocadng 
oourse,  hut  thu  fuDdaiaontal  sanglioa  oells  an  landad  and  deatnyedl 
benoe  muscular  atrophy  and  )nm  of  faradio  contractility  reaulL  Peh- 
ep«ud;fmul  myulitis  piireuiM  a  somewhat  trimilar  course,  but  the  ftiMla- 
ineDtal  cells  are  not  invadvd  at  so  tu\y  a  period  as  in  tlia  cduwiio 
atroptuo  variety.  IVQgrouiro  moeeular  atrophy  puraum  a  etUl  note 
chronic  cooRfl;.  Tho  dlseaM,  indeed,  appuarH  tn  Ut  a  jMrenchyiiiabfui  ousy 
and  to  sprvsd  from  fibre  to  fibre  aud  from  cell  to  cell  It  apfwan  to  b«sta 
in  the  amall  ouUs  and  fiua  fibres  which  lie  near  the  central  artery,  and  to 
aptoad  gradually  upwards  and  d»wiiwan)H  aud  laterally.  In  ita  lalenl 
•xteoaion  the  ganglion  cells  which  were  last  developed  beoome  fint 
affected,  and  the  priwcoa  gradually  sprvads  to  the  more  fiindameiitel  oeUk 
It  will  be  apparaot  that  fu  auoh  a  grudual  prouraH  aa  Uiis  the  mueoohr 
paralysis  aud  atrophy  will  punue  a  parollDl  course,  aud  that  the  Earadie 
oootraotility  will  be  maintained  so  loag  ••  tlie  fUodainenlal  celU  are  able 
to  pettfwm  their  functiooa  even  imperfecUy,  and  loos  aft«r  they  ba« 
Income  partially  diitefuwd. 

la  the  form  of  the  diaoase  wbiuh  I  have  named  chronic  oeol 
doiso-Iumbiu-  luyirlitie  the  aSectioa  apparently  begina  as  au  aoole 
WDtnJ  injrelitbi,  and  then  assume*  a  chronic  form.  It  pur«u«a  an 
Moendbg  oofine,  but  is  not  so  surely  inrading  aa  Landry'a  paraly 


ot  the  oolitmioi  of  OoU,  and  tlie  direct  cerebellar  tmct  sud 
Klerona  of  th«  pjmnidal  tnwta,  irilt  be  foiuid  aseociated  witli 
jtppearuioett  luiulljr  obMrr«cl  In  cetitrul  luyolitis.  ijucli  were 
EtioiM  i>b*crT«d  in  n  cum  under  Ibo  we  of  Dr.  Sim|W)iJ,  ia  whiuli 
ttw  posUiDurUiii  «xuaiiD&tioii.  TLe  pruiuiiiout  Bymptonift 
pitral^su  with  S«cciditjr  of  Itmbu,  muacuUr  stropby,  uid 
Iknidio  Mid  n&ei  exdtabilil^,  ultimatelf  aaaocutcd  wiib 
aad  puaJjTtts  of  the  ^Uncton.  At  no  time  did  the  sjmptuKia 
■putic  cooditioa  of  the  muaclea.  On  microtica{iic  ex&oUutitiou 
dornl  r«gion  of  th«  cord  vu  disorguiiMd  ia  the  whole  of  iu 
diunet«r,  Uiere  was  aaoendlug  acleraaiH  uf  tbe  columim  of  (JtoU, 
direct  cerebellar  tmots,  while  the  |>}r»imdal  tnotn  mn^t 
himbar  regiou.  The  ceutrtkl  ff^y  cutimiii  wnn  diaou«d 
medulkriB  up  to  the  lower  end  of  the  modullK.  In  the 
Mill  oornool  regioiin,  however,  the  fuudamoDtul  oclla  appoamt 
h;,  vhilv  lbs  Moemoiy  colU  h4ul  diitiipjiejuwl.  The  cotiditioii 
■utxituMM  in  tliu  «ord  iu  tbu  oorvic«l  nsgion  is,  indood,  n\>n- 
rig.  146. 
of  what  I  nrnet  nganl  u  in  the  m^ia  a  ccutral  tayoUtia,  under 
Dr.  UoTgsu,  (he  morbid  appt-Hruicm  diw»ov«r«il  differed  f^<ou 
•d  iD  Dr.  Simpeoii's  cam.  The  patieat  uuder  Ur.  Morgan 
[  «ter  and  had  his  sciatic  nerve  iDJured.  This  woa  followed  by 
riaed  bj  fliwcicltty  of  liniba,  aud  niuocular  atrophy.  A 
Um  aoeiihuit  spontnueous  fracture  of  the  neck  of  the  rl  jht 
Afiar  a  tioM  then  was  auwathoaia  of  th«  lower  extro- 
of  the  BphiDctcm,  b«d-«orwt,  and  dnatJi  frr>m  p^wiuia  aod 
The  posterror  oolaouta  of  th«  cord  could  b«  iweu  with  the 
to  be  gelatinous  In  ap{)eisrsDc«.  Oa  microscopic  rxaminstiou 
of  BcleruaB  of  the  poat«nor  coluuua  of  the  cord  ws4  coo- 


802 


MIXED  UI8RA8BS  OF  THE 


usvial  lateral  exteiuiotis  into  tbo  tmbryonic  oreaa  of  ttas  ftDtorio^ 
boroa.    1  bavo  obMrved  KBoikr  morbid  ftpiwuttDoes — pcMUrior  sdiniii 
aad  cautral  myolitw— iu  acaaeof  tiuoaurprMaiagapoajtlMauidaaqiiiBi. 

2.  Citnome  TsAMfiTKiuie  MTXLms— The  mpnptooM  vtij  maearAing  to 
tbs  lovol  ut  wbkh  the  cmd  is  cliiiMMd.  Tbia  «9ocUi>d  inaiy  be  mbditidid 
into  (t)  chranii]  donto-lunabar,  {t)  chronic  dorwl,  {<)  chronic  ccnioal 
tnui;(Tenit)  myelitis.  «nd  (d)  coiiit>rDMi«u  tuyrlitiit. 

[a)  Chronic  Dorio-Lum6ar  TraiuKm  J/y^litU.—Tbe  ponUjtK  ajMp' 
tamn  atu  oflvii  j>rcvct;d«l  by  ^nllo  imiaa,  foruiicatJoo,  Dumbiicoa^  aai 
vuiou«  other  parroiithwie,  and  by  Loncinatiiig  paioi  in  tli«  \ofnt  txti» 
mitiee.  Tho  patioot  ofWn  cooiplaiiui  of  muscular  onmpa,  oapeciaUy  is 
th«  calvuM  or  the  logs ;  he  is  eooii  fatigued,  aod  tht  movetnentM  are  atiff 
aud  coafttmined.  After  a  timo  tho  lowco'  oxtrvmitica  booomo  rigid  by  ow 
iraotunM,  Lku  ^ait  luwumes  thu  liiiaKtic  forui,  aiid  both  iha  supoificul  tmi 
doop  rcflcxvH  am  ouggerated.  If  the  loaiou  be  aituated  below  the  origia  M 
tlie  siith  lumbar  Dorvsa  tho  patellar-teodoo  reflex  in  aboliabed.  Tb« 
MOAory  dUiurboBccH  aW  iscraaM,  the  patioot  caunot  fnl  ttw  8vor,al 
be  &nA»  it  iioc«saary  to  direct  his  eyes  to  tbe  graond ;  tactile  anTwihilJIj 
aad  tbe  aousa  of  locality  and  tompatmture  are  geovraUy  imi>ai»d,  whik 
1b  advBiHwd  cnnm  thorv  may  be  retardatioo  of  eeoaoiy  coaduction  ml 
anolgexia.  Tbo  g«ii«niL  health  may  bo  onaffaeted  for  a  long  tiwe,  but  b;- 
aud-by  the  paraplegia  becomea  complete,  and  the  Tarioua  Conoii  of  •eraa> 
biUty  become  more  profoundly  afiwted,  «o  that  at  laut  tliaro  may  b( 
complete  aiia-tthaiiia  of  all  forms  of  aoiisibility.  MukuIat  atra|ihfi 
accou)}iaiiiod  by  loea  of  tbe  rellei  aud  fantdio  contractility,  may  ntm 
auperreue,  tbe  spbiuct«ra  are  pitrolysed.  bed-soires  form  over  the  parti 
expoaei  to  mechauical  preosure,  aud  tbe  pAtient  diea  from  pyaaia  ui 
marasmus. 

(b)  Chrotiie  Dortai  Trvuviittt  Jfyditis, — In  thle  foim  both  the  aeoMrj 
attd  motor  panlyiiia  extends  higher  thaii  lu  the  darao-lumbar  I'ariety.  Tlie 
coDdition  of  the  lower  extromttiea  with  regard  to  paralysis,  ooiitracturaa, 
spastic  walk,  aud  exaggerated  rvflexve  is  tbe  same  as  in  the  dor«» 
lumbar  form  of  the  diseaae.  Wbon  tbo  lesioo  is  aituatod  iu  tbt  uppM 
portion  of  tbo  dorsal  region,  the  muadea  of  the  baclc  and  abdousD  art 
iuvolved  iathe  diaease.  The  paralysia  of  tbe  abdominal  muoclee  Kud«« 
uriiistioa,  defecation,  aod  forcible  expiratory  acta  difficult,  so  that  the 
{Mtieot  is  much  troubled  by  oouetipatiou,  and  he  cannot  clear  tbe  broo- 
cbikl  tubes  thoroughly  IWim  mucua.  Death  i«  theovfen  liable  to  be  caoeed 
by  alight  bronchial  catarrh.  Valuable  iiiforraation  may  be  obtained  with 
regard  to  the  level  at  which  the  curd  in  diseaned  by  an  ezamiualiou  of  tiw 
cremaatenc,  gluteal,  abdominal,  eptgaxtrio,  doraal,  aod  scapular  trSeaes. 
Erb  boa  recently  dcacribcd  a  caM  in  which  a  spoataiMOUs  aubacuta  Joml 
trassrene  myelitis  was  preceded  by  double  optJc  QBuritia. 

(c)  Chronic  Cenicai  Trantvrrst  Mi/ttitu.—Tht  initial  aympfcoma 
gBDerally  begin  in  the  Dpper  extremitiee  which  beoomo  paialyaod 


SPINAL  COU)  AND  HBUULLA  OBLONGATA. 


303 


tioM  bafura  tbs  lomr  «iti«aitiu.  A»  the  disease  JncreiMM  aU  the  four 
cxtnmitUB  boooBW  pwilyccd.  Tha  muscles  or  tbe  upjierextniiuitiui  After 
»  tinw  bceeme  atrofthied  and  low  tbedr  reflos  aud  Cuadic  coutnatilitj, 
while  tfavee  oT  the  lower  oxtroioitieft  are  iu  a  state  of  cuiitractim,  tlwir 
laradic  coDtraotilhy  being  |)tHMrT»d  and  the  eu|>erficial  and  deop  ivflaxea 
iDCTMCExi  VariouA  oculo-tni(ullarr  8jria|itauB  ara  aUo  cainiiuinlj  |»weut. 
Wh0D  tht  njyper  oarrical  legLoii  of  lli«  curd  in  dmeiUMid, all  Tour  estretuitjw 
•ra  afibcted,  but  the  nutniKH*  of  the  iniudtw  of  Llie  ti(>piir  an  well  a«  thoaa 
tl  tbm  lama  «Ett«nutaMi  rouuuiui  uoafbctad,  aud  their  rv&vx  aotirity  a 
iocnoBBil.  The  diaphragu  buoomoi  pafalTSvd,  aad  the  imticut  audcrs 
leom  dj^pooaa,  imjMuniieDt  of  speech,  voiuilitig,  and  hioonugb. 

JtoMd  Afiatomtf. — The  moibid  auatomy  of  chrooic  trouercTse  m^elilis 
wiee  aeoording  to  the  lenl  at  whiah  the  oord  ia  afiectod.  At  tite  level 
at  tba  prluiiipal  focw  of  disease  hoUi  the  gre/  ami  whito  auluUiii-ex  are 
allMt«d,  aod  thie  portioo  of  the  cord  may  be  BofteaeJ  iusbaad  of  boiug  in  a 
atata  of  acleiuaia.  Aboro  the  level  of  the  mala  leaioo  the  coluuuw  of  OoU 
and  the  diroct  canbeUar  travtw  undeigo  oacBudiug  HcleraatH ;  while  the 
pjTaudilal  Incta  uudni;^  dosoendiog  eclerosi»  helot*  the  level  of  the  leeiou. 
Utholaaim  utnituated  lowdown.thewiceiKlingaoleruiilanttybwUDutedto 
kb*  oohniin*  of  GoU  and  the  deBCoadiug  to  the  pyraiuidal  tracta  oftha 
lataisl  oohiiana.  If,  oo  Iho  othur  hiuid,  the  Inlon  be  situated  high  up  ia 
tha  oofd.  both  the  ooliumu  of  QoU  and  the  direct  cerebellar  tnota  ara 
aflectad  with  a«oeudLiig  eclvroMS,  aud  the  p/nuuitlal  trauta  and  the  coliimiia 
«f  Tiirck  with  dcsoeudiog  aclcroeui.  Id  ndditioD  to  these  ohuugua  traua- 
T«na  nyalitis  is  rrcquently  accompanied  by  coutral  luyvlitis,  which  may 
attend  u[>  iuto  tho  uedulla  ublou^ata.  Kear  th«  luftiik  loaiou  the  cautnl 
myelitia  may  oKteod  forwarda  lo  aa  to  dostroy  all  the  gauglioa  ceUs  of  the 
atiUrior  bonittfbat  iu  the  upper  purtioti  of  the  cord  aod  in  the  medulla 
ohloDgata  the  aooosory  gaogltou  cells  aro  aloae  destroyed,  while  the 
foadaiDeotal  «»lb  r«muu  more  or  less  healthy. 

{d)  Compnttion  Ifytlilu. — This  Is  a  vvrj  oommoalbtm  of  myelitis,  and 
may  oosor  along  with  aoy  dMase  of  the  Tertehral  columu  or  tamBSamaaB 
vfatab  aamiae  a  slow  ooin[inn»ioti  of  the  conL  Tlia  syrojitoms  of  tbia 
a&etiou  ootrvspand  ia  the  maiu  with  those  of  opoutauooua  trausrena 
myelitis^  Tbs  chamctshstic  festuro  of  the  al1'octi»u  in  the  aiintcDceof 
sytntitoDU  wbivh  indicate  local  disOMut  uf  tb«  conl  lor  aotac  tiuo  pi«Tioua 
to  tbe  derelopmeot  of  definite  paraplegia.  The  most  usual  of  ttiesa 
•ynfAoma  am  »ev«r«  paine  along  the  courui  of  iMrres  which  issue  from 
a  particular  level  of  tbe  cord,  crampa  iu  the  musclca  supplied  by  thoae 
local  panlyeis  aud  nuucular  atrot^y,  local  hypensetheaia  or 
,  aad  paiu  aud  atiffueaa  of  the  back. 

JfoWkxf  J  Mo/omy. — Tbe  morbid  anatomy  of  corapresuoa  myelitiii  is  tho 
wme  aa  that  of  the  trausTDTM  rariotio:).  The  structure  of  the  cord  ts 
d««lNycd  at  the  larel  wbera  th«  compressioD  has  been  applied ;  while 
tlun  is  aacending  sclemsiii  a1>o?e  tbe  level  of  tbo  leeiou,  aud  desceitdiug 
I  b*h>v  it    Oealnl  myelitis  is  li«i^u«ntly  preaeat  also. 


S04 


MIXKU   DLSBASES  OF  THE 


3.  Umivxrbai.  ruoaKxs&ivi!  Hteutib.— InUiisformortbe  diMCdael 
myaliti*  grailuaily  eitenda  until  H  inrolvee  tli«  wholo  brudtli  of  tUt  owl 
It  ia  charoctorioed  bj  |>rDgreiia)va  weakaeaa  of  thfl  muadm  of  th«  lomr  a- 
tnmitiea  foUov»l  hy  ootnplete  pimlytfii.  Tha  disMw  gmenllf  hegtna  n 
the  lower  estreiuitiM,  uid  purmuxi  an  ovoendlng  oouno ;  but  iwniuiirmiHj 
it  Itegins  l:i  the  u[i(>or  oxtramitlcN,  mid  th«a  tt«  oourM  t«  daMcndiag. 
Then  ui*;'  at  &rBt  W  cvittmcture  of  the  miuoha,  knd  thin  la  foUnred  ^ 
gradual  Alrnpby  ut  the  gny  HubHt4uice  tjocomM  inrolTed.  Tits  ntam 
and  tho  farsidic  ooutractilit;  also  groduaUjr  dimiEiisli  aod  ultuoatcl]'  dif 
aii[Hs«-,  Than)  may  ba  moni  or  bwiTiolant  inuas  in  ths  back;,  tmnk,  mi 
MtKuitioi,  th«  |>&ticDt  complikiu  «f  panoatbwiiD  and  dyBOwthMie,  mi 

,  «ft«r  a  tine  then  is  completa  anintlHaia,  paraljnis  of  tbo  sphinctara,  aol 
bsd-ftoroa.  , 

M%>rhiii  AnMnmy. — In  the  lumbar  aod  lower  doraal  rogiotn  tbe  eoti* 
tratiAvcno  nroa  of  tho  ccai  la  diMAMd,  bat  in  tlie  oppar  doraal  and  eanktl 
rogionii  tho  acloronu  may  bo  limited  to  tho  oalumna  of  GoU  aod  the  diivei 
corubolUr  tract,  uwrictAted  Hotnetineit  witli  nwro  or  Imk  of  obronic  etutnl 
myelitis. 

4.  Cbrokic  Bdlhar  Mteuti9.  -  The  mut  charactoriMtto  fqnn  «( 
ohraak  bulbtir  inyulilia  has  alitady  been  desoribed  aa  chrome  pnynmm 
bvibar  para!ifiu,  but  coHea  of  bulbar  paraljais  are  occaaJoDaUy  vbwrnd 
which  do  Dot  pomMEi  a  diatiiict]y  ]>rogru«siTe  character.  Whiui  the  Utte 
class  of  CASM  ie  caiuod  by  n  bulbftr  myelitis,  tb«  afiactioa  ia  prohahly  ia 
all  caaea  pruduoed  by  tho  citenitiaD  of  iaflaoiffiakion  from  morbid  cfasofH 
taldng  pleco  in  the  ndghhoiirhood  of  the  gray  noelai  of  Um  nadBlh 
oblongata,  luflaiumation  uf  tbo  bulbar  uucid  may  in  this  manner  b«  all 
up  by  tiimoura  of  th«  neighbourlDg  structtiivs,  or  they  may  Im  involTwl  il 
the  iiidaiaaiatory  ki^uo  which  frequeutly  surrouiids  hauDorrhagic  bci  aad 
oeutrea  of  necrotic  aofieniug. 

C.  Cbbokio  MTGtx)-MBSiN(;iTiti.—ThtBfarmofmyeUtIihaabaeu termed 
peripberiu  or  ixirticol  mjclitin  by  Vulpian,  beoauae  it  oonaiBbi  of  a  ehimic 
iudammation  of  tbo  cord  prt«udtDg  iowsnla  from  tho  pta  mater.  It  u 
not  eaay  to  reco^iai;  thin  form  of  uyelitia  durio^  life  ;  but  ite  pnaeiin 
m^  be  suapected  vhea  the  Kyiuptomx  of  chronic  meniiigitia  are  aocea- 
pMii«i  by  an  uavroutcd  dcgrev  of  both  aoaeory  and  motor  paralyats.  Th* 
ponlyida  la  geuerally  of  the  eiiasttc  Tariaty  and  muMular  atrophy  dua 
Qot  occur,  it  tu&y,  however,  be  aaaumed  that,  nhould  the  autcfior  tvoU 
beooniH  involved  In  the  disease,  luuMular  atfophj  will  iuentabl/  takr 
plaoe.  in  aorae  oaaea  the  i>i>ntvrioT  coltuuue  are  more  iavuired  than  the 
lateral  tract*,  and  theu  at&iic  symiitoma  predomtoate  over  tbcae 
pandysifl. 

Jforbid  i47iifomy  — The  moat  characteriatic  feature  of  the  morbid  i 
tomy  of  this  aSectioD  ia  that  the  affected  ijortieo  of  the  oord  it  i 
more  or  len  completely  by  a  hug  of  aclcnmis.     Sometimes,  koweref,  the* 
■obrwie  appeaie  t^  epread  inurarde  io  the  poeterier  colunuie  U>  a 


SPINAL  CORD   AND  HKnULLA  OfiLONO&TA.  305 

«t  Umo  ebewb«T«,  wbil«  at  oUmf  Utow  the  Autehor  tn  kfi'sotail  to  h 
'  degna  tbui  the  pcatarior  or  UUnt  oolumua. 

6.  Csamio  DnxBMliiATKD  UrEUTis.—Afl  thiit  diiiwue  \a  not  unuti; 
kautwl  io  the  •{>iu«l  ooni,  but  eitooda  aa  «  rule  to  the  corebruia  aod  oere* 
bdliitn,  its  doKTipUoQ  will  fall  tuure  uatunUljr  with  tha  enc^plialo^joal 
UiMi  lbs  apiiul  iliaMMo. 

J£  4!>3.  DiagTuma. — Simple  cbroDic  traoaversc  myelitis  is  cfaa- 
mdCTMed  \ij  slow  iIcretopmeDt  of  paraplegia  wilb  relatively 
kUgfal  irritative  motor  symptoms,  and  by  tbe  prvseuce  of  mora 
or  ]eai  marked  sensoijr  and  ve^cal  diaturbances,  cod  tract  urea,' 
incTMsed  rettexen,  and  bed-dore&  The  affection  ifi  but«]igbUy 
pngreasiTe  in  character,  and  ruo*  a  tedious  course.  TnuisverM 
nyditif  can  oa  a  rule  be  readily  distinguiebcd  from  tbo  syste- 
matic affectiona  of  tbo  cord.  In  some  cases  of  the  latter,  bow- 
erer,  the  lesion  of  one  of  tbc  fuactional  systems  of  the  cord 
axteods  to  neigbbouring  ayatema,  and  oombinations  are  thus 
pcoduoed  whicb  are  sometimes  veiy  difficult  to  diatinguitib  from 
timnaverw  myelitis.  Numerous  combinations  of  the  system- 
ifisoMMM  ar«  poe&ible,  and  every  case  of  tbe  kind  requires  aepa- 
rato  rtady  and  a  special  dingnom 

g  494.  ProffivtM. — The  prognosis  is  geaentlly  unfavourable  in 
simple  transverse  myelitis.  Tbe  affection  is  always  severe  and 
dangerous, and  tbe  most  that  can  usually  bo  hoped  lor  ia  anvst  of 
tb«  morbid  process  with  considerable  loss  of  power  in  the  lower 
nttremitie*.     Complete  recovery  is  exceptiooaL 

A  alow  progressive  course  must  be  lookod  far  in  the  mnjority 
nf  wnm.  and  tfaa  disease  generally  terminated  in  deatb  id  a  few 
yeuK.  Tb«  prognosis  will  be  determined  by  the  ascendiag 
Iflodency  of  tb«  disease,  tfae  occurrence  of  relapses,  and  by  the 
ptMBDoe  or  abneDCt!  of  cystitis  and  bed-aores. 

§  49S.  TreaimenL — Tbe  treatment  of  the  early  stages  of 
chronic  myelitis  must  be  oiHiducted  ud  the  same  general  prtn- 
djilBi  aa  ue  applicable  to  tbe  acute  varieties.  So  long  as  any 
actiTe  symptoms  of  irritation  are  preaent,  the  patient  should 
■MBJa'p  tbe  recumbent  posture,  while  all  the  usual  precau- 
tions against  tbe  fonaatioo  of  bed-sores  and  cystitis  must  be 
V 


806 


MIXED  DISEASES  OP  TBB 


adc^tetl.  Ergot,  belladonoa,  attd  the  iodide  of  potassiam  an 
Ihc  internal  remedies  which  have  been  fouod  of  tnosl  oae.  1/ 
K/philis  he  auHpoclcd,  active  autisypbilitic  treatrnvDi  mun  be 
employed.  Nitrate  of  silver  waa  first  recommended  by  Wt»- 
derlicli  in  the  trefttment  of  chronic  mjelitis,  bitt  it  is  pfoba1>Iy 
of  inoro  usu  iu  locumotor  atuxiu  thau  iu  auy  other  variety  of 
the  diocoau.  It  should  not  l»c  lulmiuistcrcd  in  caises  associated 
with  spasmodic  rigidity  of  the  muscles.  Arseotc,  pfaoepbonts. 
and  cod-liver  nil  may  sometimes  be  found  useful,  but  strycboioe 
)«  positively  injurious. 

Counter  irritation  was  at  one  tine  used  too  indiserimin&t^y, 
and  the  results  obtained  were  not  very  gratifying.  The  Dseof 
the  milder  counter-irritants  such  as  flying  blisters,  may  be 
employed  with  advantage.  Brown-Sequard  pnusea  highly  the 
s.pplication  of  a  hot  douche,  Crom  98"  to  104°  P.,  for  two  or 
three  minutes  at  a  time.  The  stream  should  lie  nearly  ao  iocb 
iu  diameter.  The  greatest  reliance  Diuet  be  placed  on 
hydropathy,  and  galvanism. 

Batlis. — Erb  strongly  recommends  the  thennal  brine 
(Rehme,  Nanheim).  The  temperature  should  not  be 
86''' — 78"  P.,  and  the  immersion  not  too  prolonged,  and  the 
-water  should  not  contain  an  excessive  quantity  of  cai-bunic  acid 
Ordinary  brioe  batba,  chalybeate,  and  mud  hatha  arc  mv 
extolled  by  many  authors. 

CoUl-xwittT  «ur0  is  very  useful.  All  e«vero  and  stroogi) 
exciting  procedures,  snch  as  the  use  of  water  at  a  very  low  t«a 
perature,  cold  douches,  and  sharp  aiappinge,  shoutd  be  avoided, 
and  even  wet  packs  of  tim  entire  body  hare  proved  injorioiu 
(Krb).  Simple  tubbing  with  wet^clolhs,  foot-baths,  gpoogiog  Ibe 
back,  hip-baths,  and  local  compresses  to  the  back  left  on  tUl 
they  become  worm,  apponr  to  be  the  moet  useful  measures.  Tbe 
treatment  should  begin  with  baths  of  moderate  tempemtutea 
(68°— 77°  F,.  never  below  60°— 53°  F,),  and  nbould  not  be  loo 
prolonged.  When  an  insufficieDt  reaction  followB  a  bath,  and 
chilliuess  and  discomfort  are  produced,  the  treatment  should  be 
diacontinucd. 

Thtgalvcmxcevirrtntxtoozol  the  most  important  therapeutic 
a(;eats  for  tbe  treatment  of  chronic  myelitis.  The  electrodes 
musk  be  applied  diflenmtly  according  to  the  differeuces  iu  xi 


SPISAX.  CORD  AND  MEDtTLLA  OBLONGATA. 


307 


oD  Aod  extCDt  of  the  fonns  of  dutf>ase.  It  is  best  to  let 
folm  act  BUGceasiTcly,  either  witb  a  etabUe  or  with  a.  slowly 
CDirent  The  currents  uaei  should  not  be  very  gtroog, 
■ch  application  should  bo  of  skuH.  duration.  The  treat- 
ihould  be  continued  for  months,  being  occasionally  intcr- 
d  only  to  be  recomaieDceil  aflvr  a  briul'  pause.  It  is 
lient  to  alternate  or  combine  galTauisatiuo  with  othcr 
kU  of  treatment.  Some  few  cases  do  not  bear  welt  the 
AtioD  of  gikaniam,  and  witb  these  the  aso  of  it  muat  be 

•  gMenl  manageinent,  the  diet,  and  the  mode  of  life 
IB  patient  are  of  the  otmost  consequeocfi.  Rest  and 
IuIkt  mode  of  life  arc  essential.  Over-exertion  of  any 
UMntal  at)  welt  as  bodily,  mtuit  be  avoided.  Sexual 
tonive  should  be  confined  within  the  strictest  limits  or 
lately  stopped.  All  excitement  and  violent  emotioua  must 
ercDted  as  much  as  pottsiblv.  The  diet  must  lie  simple, 
lioua,and  CMy  of  digestion,  and  cod-liver  oil  in  often  bene* 
Alcoholic  beverages,  cotfee,  tea,  and  tob.'icco  should  be 
ivilh  great  moderation.  Kcflidottce  in  a  mouiilainous  region 
Doderate  elevation,  or  at  the  sea-side,  will  be  useful;  and 
idviAttble  that  the  wintcre  should  bu  piissed  in  the  south. 
laa  the  patient  is  completely  paraplegic,  a  wheeled  chair 
Ik  nted  so  as  to  permit  the  enjoyment  of  fresh  air,  and  when 
tttM  are  bedridden,  cnrc  should  be  taken  that  the  rccum- 
poetttre  a  not  always  maiotaiDcd,  but  occasionally  replaced 
le  latsml  or  abdominal  position. 

in  moMi  also  be  relieved  by  various  means,  the  snboutanoous 
lioo  of  morphia  being  the  readiest  and  most  effectual 
od.  Other  serviceable  drugs  ore  bromide  of  poLaasium, 
ne,  bromide  cvf  quinine,  zinc,  and  valerian.  Cutaneous 
taaa,  electricity  either  in  the  form  of  thefiradic  brush  or 
siic  current,  Prcissnitz's  compreJSRes,  applications  of  chloro- 
,  mod  frictions  with  veratrine  ointment  and  Himilar  agents, 
I  do  good  service.  For  the  paralysis,  atrophies,  and  aowa- 
•,  which  persist  after  tfae  diaease  has  run  its  course, 
tidty  is  ttte  best  remedy. 


308 


MIXED   DISEASES  OF  THE 


{IV.)   HVELOUALACIA. 

§  496,  Simple  SofUniv^  of  th$  Spinal  Cord. — Softening  ti 
ibe  epiiial  cord  ma;  rusult  from  aQa-iaHftmmatoiy  procesMs. 


§  497.  Stfmptmna. — ^Tbe  symptanu  of  flimpla  sofleLiog  an 
ozceediugly  obscure.  Tho  paiiont  first  complains  of  feelingief 
DuinbDess  and  feebleness,  generally  of  the  lower  extremiti», 
which  gradually  increaiie  io  severity,  until  ultimately  uucathonA 
of  the  lower  extremities  aod  paraplegia  are  fully  establisbed; 
tbc  rcdex  excitability  is  also  gradually  climinished  and  ultimately 
aboliahed.  To  these  symptonas  are  addod  progressive  panlysis 
of  the  Kphinctera  of  the  bladder  and  anue,  and  to  the  fioal  stage 
bed-8ore«,  manuimtis,  and  pyaemia. 

Brown-S^quard  and  Hammond  assert  that  at  do  time  in  the 
course  of  the  disease  are  there  any  paLoa,  hypeieestbeaia,  spasm*, 
or  increase  of  tho  rodcx  excitability. 

§498.  Morbid  Ancdomy. — The  post-mortem  appearanees  of 
nmple  softening  are  eimiiar  to  thoee  of  white  eoftooiog  eaoied 
by  previous  inflammation.  When  fatty  degeneration  assoMM 
special  prominence,  the  softened  spot  may  assume  a  yellowish 
colour,  and  pres&iit  the  appearances  of  yellow  softening.  Tbt 
softened  spot  usually  merges  imperceptibly  into  tlie  DomMl 
tissue.  Tlie  microscopical  characters  are  not  well  known  ;  bal 
ib  may  l>e  presumed  that  the  nuclei  of  the  ueuraglia  do  ooC 
multiply  to  such  an  extent,  and  that  the  corpuscuUr  elements 
aud  gmnule  cells  are  less  abundant  in  simple  tbao  intlaromatacy 
softening. 

§  499.  HcThid  Physiology. — The  symptoms  of  simple  aoAcn- 
ing  are  caused  by  the  gradual  dcatructioa  of  the  nerve  elemeotl 
without  prcviouB  irritatioQ.  Softening  is  probably  io  all  cases 
caused  by  disease  of  the  vessels,  tbrombosis,  and  embolism. 

§  500.  The  diagnosis  must  rest  mainly  on  the  absence  of 
all  symptoms  of  sensory  and  motor  irritation  during  the  eotira 
course  of  the  aifection.     The  jyrognons  of  the  affection  is  d«- 
ctdedly  unfavourable  when  the  centres  of  soltening  are  at  ftfty 
eztemive;. 


310 


OHAPTEB  VL 


IlL— VASCCLAR  DIRRASES  OF  THE  SPINAL  OOBD  AKD 
MEDL'LLA  OBLONGATA. 

(L)    AK-fEMIA.  TUROHBOSIS.  AND  KHBOUSM   OF  THE 
CORD  AND  MEDULLA  OBLONGATA. 


1.  AruBmia  of  the  C&rd. 

§  50SL  Amcmia  of  the  »piaal  cord  coosiste  of  a  dimiuDtioD 
in  the  amount  of  blood  cootaiood  ia  it  This  oooditioQ  oujr 
be  dne  to  caaiea  special  to  the  card  itse\{,  and  then  it  is 
called  spinal  isekannia;  or  to  general  causes,  sucb  as  oLigtemia 
and  Iiyrd»«mia,  aad  then  it  ts  called  di/acraw  apvnaZ  ai 
(Jaccoud). 


§  o03.  Etiology. — ^The  prodifiposing  causes  of  spioal  ant 
are  coDgeoital  Darrownees  of  the  calibre  of  the  veaaela,  woakocM 
of  the  heart,  and  unduo  excitability  of  the  vo&o-motor  neirea. 
Tbo  female  eex  is  strongly  predisposed  to  spinal  aosmia. 
Diseases  of  the  veasela  of  the  cord,  such  as  atheroma  or  the 
fibrosis  which  aocompanics  Bright's  disease,  nl«o  prodnco  fpinal 
anspmia.  The  exciting  causes  of  the  affectioQ  are  atrest«d  or 
diminished  circulation,  as  may  be  produced  by  compresstoo, 
thromboKifl,  or  emboltJiin  of  the  abdominal  aorta  above  the 
point  of  origin  of  the  lumbar  arteries. 

Owing  to  the  numerous  anastomoses  of  the  spinal  arteries, 
thromboua  and  embolism  of  one  or  more  of  them  only  lead 
to  circam»cribed  ischfemia.  It  ia  probable  that  a  considerable 
number  of  the  eo-caltcd  redox  paxalyaes  are  caused  by  a  reBex 
spasm  of  the  apinal  arteries,  and  direct  irritation  of  the  rM»> 
motor  conducting  paths  iu  the  cord  may  likewine  produce  i 
of  these  TG«scl& 


SniTAL  OOBD  AND  MEDULLA  OBLONGATA 


81T 


^  npetitioD  of  exactly  the  same  group  of  ajmptoms  more 
^TODtly  in  coses  of  embolus  than  we  do  in  cttravaeatioa 
Striking  and  rapid  improvemeul,  with  total  disappcaniace  of 
ipl«te  gToupR  of  paralytic  sympUrni-s  seldom  occurs  Ju  caaes 
(wmoirhagG.  The  frequent  anoinalous  diHCributiou  of  the 
veoels  vflen  reDd«ni  it  impossible  to  diagooee  the  particular 
«rt«i7'  which  has  been  obstructed.  Other  Hytnptoms  may  hvlp 
at  to  a  diagnosis.  Ad  unusually  full  pulse  in  the  carutiiJtt  is 
Mid  to  point  to  ohHtniction  of  the  basilar  urt£ry. 

■  S  £15.  Protpions. — The  prc^nous  is  always  of  the  gravest 
star,  aod  sadden  and  complete  ohstmction  of  the  basilar  or 
"irf  both  vertfibral  arteries  is  almost  invariably  fatal.  A  slowly- 
dereloping  occluHion  of  one  or  more  of  the  large  vetaeU  in  this 
legion  ahu>  terminates  in  death  within  a  short  period.  Life 
nay  be  prolonged  and  partial  recovery  take  place  in  cases  of 
relatively  limited  obatruclion  which  bappeu  to  afiect  the  least 
ilaDgcroas  parts  of  the  medulla,  or  when  u  cocsidvnkhlc  collateral 
circulation  is  estabHahed. 

§  516.  Treatment, — Stimulants  and  tonics  are  plainly  ia- 
dkaled  when  one  of  the  bulbar  urtvries  are  obHtructed ;  but 
■afortunately  the  diagnosis  is  so  uncertaia  in  many  cases  that 
it  u  difficult  to  follow  out  any  definite  course  of  treaimenL 
At  a  later  period  electricity  may  be  applied  with  the  greatest 

ipe  of  succeas. 


W. 


<HT£EK«UtA  AND  n.£:k[ORRHAGK    0?  TDE  SPINAL  CORD 
AND  StKDlTLLA  OBLONGATA. 

L  Ityperwaiia  oftha  Spinal  Cord  and  it«  Membixtrtts, 

i§  917.  It  is  impoMible  to  Mparate  hjrpersDmia  of  the  apinal 
•ad  of  the  spinal  mcmVaDc«,  either  clinically  or  onato- 
ically,  hence  the  two  must  be  considered  together.  By  hyper- 
emia, of  the  cord  and  its  mcmbranet!:,  therefore,  is  understood 
an  iocreoaed  supply  of  blood  in  the  structures  contained  within 
vertebral  canal. 


§  518.  Etiology. — Hyperapmia  of  the  cord  ia  produced  by 
QIC— ive  functional  activity,  aucb  aa  occors  in  severe  exertion 


SIS 


VASCULAR  DISEASES  OF  THE 


tbesiiP,  pain,  hypeneBlhesia,  and  eveo  nligbt  aoEstlieda  maj 
occasionally  be  present  The  reflex  actions  are  oAen  exaggerated 
uad  tlic  jipbiQcten  oro  not,  as  a  rule,  affected.  It  is  i&xd  that 
tho  symptomR  improre  on  lying  down,  anil,  oo  the  oootnu)'. 
are  made  worse  nhen  the  patient  assumes  the  erect  povture. 
TUc  pamiyLic  Bymptoma  are  associated  with  the  uauaL  dgns  of 
general  ana>inia  or  of  chlorosis. 

§  505.  Course,  Duration,  and  Termination. — The  dis 
may  bc^in  Biiddenly  vhcn  it  is  caused  by  severe  htemorrha^  i 
embolism,  but  the  onset  in  more  gradual  when  it  results  ftoa 
thrombosis  and  chloraiis.  The  patient  often  recoven  rapidly 
by  the  establighment  of  collateral  circulation.  At  oUicr  tiioa 
recoveiy  is  slow  and  gradual,  and  in  casee  of  embolism  the  cord 
may  undergo  softening,  so  that  recovery  becomes  impoesibta 

§  506.  Palfu>logieal  A  natomy. — Anaemic  portions  of  tbe 
cord  look  pale  and  bloodless.  Tbe  grey  substance  b  dull  ia 
colour,  and  sinks  below  the  level  of  secttOD ;  while  the  white  b 
soft,  upd  protrudes  slightly  above  the  surface  of  the  sectioD. 
The  membranes  are  pale,  and  their  voiaela  are  empty.  The 
antemic  portions  contrast  strongly  in  colour  and  consiJtteocc  with 
those  which  ore  healthy.  In  thrombosis  and  embolism  of  tbe 
smalt  spinal  tcsscIs  it  is  often  poesibto  to  find  the  point  e( 
occlusion.  Ked  softening  exists  in  tbe  region  supplictl  by  tbe 
plugged  artery  and  collateral  Huxion  in  its  vicinity.  If  tbe 
iacbmmia  be  protracted,  white  and  yellow  Bcfteoing  of  the  «o^ 
responding  portion  of  the  cord  may  occur. 

§  507.  Diagnosis. — Tbe  diagnosis  must  reet  mainly  oo  the 
concomitant  symptoms.  The  symptoms  of  the  acute  iadiMlue 
form  resemble  those  due  to  spinal  bn^morrhage,  and  ansnua 
can  only  he  inferred  to  be  the  cause  when  the  aorta  is  known  to 
be  obstructed  or  a  great  loss  of  blood  has  recently  occurred. 

The  chronic  forms  of  spinal  antemia  resemble  chronic  myc 
or  chronic  meningitis,  but  wheu  severe  general  an»mia 
it  may  be  inferred  that  the  disease  is  caused  by  it.  The  fact 
that  the  horizontal  position  relieves  the  syuiptoms  may  afford 
valuable  aid  in  forming  a  diagnosis  (Hammond). 


8PUIAL  CORU  AfiD  HEDULUL  OBLONOATX 


81S 


§  508.  PmyiuMW. — Spinal  anft-'mia  is  not  &  iteriotw  disease 
taken  in  itnelf.  but  in  aumc  of  tho  .levorer  casca  Hortpening  may 
occur,  and  then  the  prognosis  becomes  unfaTourable 

§  £00.  Trtatmatit — Ha  cauaes  of  anaemia  of  the  cord  muat 
fint  be  removed.  This  must  be  done  by  a  tonic  and  stimu- 
Utiog  treatmcDtv 

The  patient  should  be  laid  on  his  back  with  his  bead  and 
legs  luied,  and  this  position  should  be  mainUiined  in  the  night 
and  for  a  considerable  portion  of  the  day. 

Special  stimulants  of  the  cord  itaelf  may  he  administered, 
I  the  mi»t  powerful  and  reliable  of  them  being  strychnine.  The 
I  enmtant  current  idiould  be  applied  daily  to  tba  rertebr&l  column, 
I  wpecially  in  the  form  of  the  aocending  stabile  current.  Warm 
I  applications  should  be  made  to  the  back,  such  as  hot  sand  bags, 
I  or  Chaptoao's  spinal  bags  filled  witb  hot  water. 
I        The  diet  should  be  generous  and  moderately  stimulating. 

^Hs.  An<emia  of  the  MeduiUi  Oblongata— Thrombosis  cmd 
^^ft  Etnboliam — Nearottc  Softening. 

§  oIO. — Aoa'caia  ti{  the  medulla  oblongata  is  generally  accom- 
patued  by  asfemia  of  the  brain  and  spinal  cord.  Some  of  the 
•ymptoms,  faonerer,  which  occur  in  general  amumia  are  probably 
eaufieJ  by  anasmia  of  the  medulla  oblongata. 

Thwrnbotis  and  fmbolimn  of  the  voskIs  supplying  the  me- 
duUa  are  not  very  rare,  and  the  aooymia  in  such  eases  is  so  great 
that,  uoleaa  the  circulation  be  quickly  restored,  the  port  soon 
undergoes  aofUning. 

JTiTombi  and  ernboU  generally  occur  in  the  vertebral  and 
basilar  arteries  (§§  353,  354).  TIiIh  subject  baa  received  much 
attention  in  recant  years,  and  in  consequence  caies  which  were 
at  one  time  classed  together  as  apoplectic  bulbar  pomlynis  ore 
now  known  to  have  been  produced  by  emboUsm  or  thrombosis 
of  the  arterie*  of  the  medulla  oblongata. 

$  511.  Symj^oVM. — The  symptoms  of  simple  anoL>mia  of  the 
medullo  do  not  rec|aire  to  be  separately  considered,  as  they  ore 
iMfged  in  the  symptoms  of  anosmia  of  the  cord. 


314 


VASCVLAB  DISEASES  OF  THB 


'•a 


The  sjmptoms  produced  by  obntmotion  of  tlie  arteries  differ 
accordiog  as  the  main  arteries  or  the  stnall  branches  are  aflMtetL 

The  following  general  symptoms  are  commoDly  obserred 
when  one  or  both  vcrtcbrul  arteries,  or  the  basilar  artery, 
obBtnicted  bj  thrombosis  or  cniI>o1isin.  A  more  or  less  conif 
bulbar  paralysis  occura  suddenly  or  in  a  Tery  »bort  time. 
without  losa  of  couHciousoess.  The  soft  palate  and  tongue  ar 
paralysed,  the  power  of  articulation  and  of  ddgluUtion  is  iott, 
and  there  is  partial  paralysis  of  tlie  muscles  supplied  by  tb«  in- 
ferior portion  of  the  facial  nerra  These  sjmptonns  are  80ne- 
timc!  accompanied  by  paralysis  of  the  ocular  and  maslieatorj 
muscles,  dulaesa  of  hearing,  and  noises  in  the  earSL  Respiratory. 
circulatory,  and  vocal  disorders  are  aUo  of  frequent  occurreo««. 


developed.      As   a  rule,  a  certain  degree  of   anaesthesia 


Paralysis  of  one  or  all  of  the  extremities  ia  simultaueoaslj 

develope 

present 

If  death  from  respiratory  paralysia  does  not  at  once  eosoe. 
the  disease  is  not  of  a  progressive  character,  and  at  fiiost  only 
a  slight  change  for  the  worse  takes  place  during  tlie  first  few 
days. 

In  some  cases  gradual  improvement  may  take  places  tlw 
paralysis  partially  diaappean,  tbe  muscles  of  the  extrcntitiee 
undergo  various  degrees  of  contracture,  and  the  tendon  refl«aB« 
are  ciaggerated.  but  life  may  he  preserved  for  a  comparatiTety 
long  period. 

§512.  Varietie: 

(1)  ObifnKtiim  i>/  tht  biuiiar  ttrtrry,  m  a  ral«,  pnduoss  biUtend  i 
IOBM,psnJyuB9fiillfuurcxtremitics,aDdofboUiBidesorth«f«c»-    B 
most  important  Ryni[itotii  is  tbtioeKsutioii  i<rtbe  faactiousoftba  vagasaod 
gloaao-pharyngeal  uuoloj,  atustog  Hvore  pospiiatwy  dwojsjers,  dy^iwa, 
erSBOals,  antl  ununtly  a  rapid  death  from  ssphyxia.    A  rapid  aod  i»iiip}et« 
obstraotjon  of  the  biuiUr  artery  goDoralI;r  produces  profound  oona  awl  npid 
death.    If  lifeUst  fur  ^  few  houracomplBteparaiyrisof  sllfoareiWemitTSi    ^ 
is  obMTTed.  ^H 

(2)  1/  (A«  ol»truction  «.rltn4  ojUj  h  a  ttnaU  f/ortian  of  On  btuilar,  Ot^H 
tbe  thromboain  be  m«rel/  attaobeJ  to  tbe  mils  of  the  resMl  and  onlj  cut 
tff  the  blood  bom  a  fev  tranchM,  the  aymptotaa  ar»  oftsn  less  thrvataabog. 
Individnal  cranial  nervM  nr«  paratysed,  aod  ihm  is  wimww  or  ponljiia 
of  tba  flxtremiti*)! ;  soTiut  nf  the  oeolar  musidM  mi^  bs  parslyssdl,  as  vkU 
aa  thoM  supplied  by  tbo  fadAl  and  trigeminal  oerres.    1(  bowevi 


8PUIAL  COBD  AKD  SIBOULU  OBLOKQATA. 


315 


cbnibftko  caofiaott  ia  Uw  poaterior  portioa  of  tbo  buihr  utorr  uul  Id 
(&•  TCrtshmJ  ■rtariM^  iMpintloo  U  uoC  arrcstMl. 

(3)  StMrnitaiuota  obutmction  of  boiK  verltbrat  arUrU*  producM  exa«U]r 
UivMBwcfllKlaMtbrombiMiaof  thobwUar  wUry.  Tbo  life  of  tho  palieat 
k  not  in  Mch  immndiaUi  dajigor  if  the  thrombosis  be  slowly  developed  so 
w  to  allow  time  for  collateral  circulation  to  be  eatablialied,  Jofflroy 
tttmhei  aome  importance  to  the  lockjaw  wbicfa  hfts  been  obnTvod  in  luob 

(4)  ChliX^atiiM  o/onc  tm^tral  arUry  [iro(1tl«M  iijiaptomB  which  aMitmi; 
to  aofue  extcat  tbo  bcmiplofio  fona.  The  Iceion  ia  mora  froquont  lu  tbo 
liA  mx\tTj,  from  which  tlw  anterior  spinal  artery  is  oft«ti  (rxduHivtfly  or  ia 
|n«t  part  givan  off    The  Luforior  cerabellar  orterj  ia  also  nbstructad. 

The  baouplegta  may  either  be  an  tba  auna  a]da  as  the  leaion  or  on  the 
enioaito  nda,  a  matter  that  depends  oo  Tsruble  ooDditioiia,  Hiich  aa  tbe 
wHmMoa  of  tbe  ofaatniotion,  the  point  of  origin  of  the  anterior  afiaol 
vtasy,  tbe  oomplotooon  of  tbo  rleouaaalion  of  tbe  anterior  pyramida,  and 
etbar  drcimutancee.  The  hyposloasal  and  Bpiiial  acc»BaoTy  nerves  nisy  b« 
pmdysad,  eaaoing  disordera  of  atiictiUtioi)  and  deglutition  and  aphonia, 
md  m  idditioa  there  may  be  parulyaia  oftlie  Inferior  brancbea  of  the  fatnti\, 
lad  paitial  paralyab  and  aoimtbnia  of  the  aoft  palate.  Thene  symptoms 
way  be  to  soma  extast  bilataml,  bnt  are  geoarsUy  mora  prononnced  oo  one 
iUeoflLcbody. 

Tba  anoceaaive  occtusioD  of  tbe  differect  arterial  territorisa  ma;  he 
fwgniawl  by  tbo  grouping  of  the  aymptoiua  and  the  order  in  which  they 
IbOdw  ooe  another. 

Hm  larger  the  Tsnel  obatracteil,  and  tbe  niore  complete  the  oodusjoo, 
tta  qoielter  doea  death  ensne.  If  thi.t  cinmlotioa  oaa  be  quieldy  tuAanA 
bgr  tbe  diaintegration  or  diaplaceinont  of  tbo  thrombaa  or  embolius  or  by 
HfBeiaet  coUatCTol  branches,  improrement  in  tbe  symptoma  aod  partial 
nooTWj  may  take  place. 

{6}  Ooofucum  t>J  tkt  tmioilt  arteriu  ^  tt«  nutfa^  dAmgaltt  can 
never  be  diagixwed  witb  certainty  from  the  aynptomiL  But  aa  these 
veeavts  are  terminal  tbnr  o1>lit<Tatioa  ia  aorely  ftjlowed  by  necroaie  of 
tbe  parta  affected,  and  it  oitly  dejieocU  mi  the  territury  of  such  artery 
irtiaCber  we  get  aymptoaa  or  not.  Obstruction  of  the  eualler  T«ssela 
nay  produce  partial  parmlyaisof  tbetoDgue^difficultieaofarticulaLfoaand 
•valbninDg,  uoilatenl  panlytaa  of  the  fiKial  and  abduceoa  &errt4,  respira- 
lay  dteMxlera,  and  perfaapa  even  fita  of  aathma. 

(0)  OSafinuYuni  qfihetuptriwotrd>eltararUry^nHnMK  paralyais  of  the 
third  narre  oo  the  aide  of  the  ooclodod  tcbooI  and  hemiplegia  of  the 
eppoeite  ride. 

§513.  Morbid  Anatomy. — Either  one  or  iMth  vertebral 
wtdrtM  may  bo  completely  obliterated,  an<l  the  thrombosis  may 
•xteod  from  them  into  the  b&silar  artery.    Tbe  b&sUar  artery 


322 


vahcdljir  diseases  op  mE 


with  fulmiDanb  symptoms.  The  patient  complains  of  violeai 
paias,  and  becomes  HutlJcnIy  paraplugtc,  but  without  loss  of 
coQSciotienesa.  The  diaeode'may  bo  preceded  by  premooitofy 
Byiiiptonu),  coasisting  either  of  llio»c  iadtcativc  of  spinal  coogct- 
tioD  or  of  the  symptoms  which  precede  acute  central  myelitiik 
nnd  these  miy  Inst  from  a  few  hours  or  several  ilnyn.  Bm 
even  ip  the  cases  io  which  the  ati'ection  is  preceded  by  pre- 
monitory Bymptoras,  the  onset  of  the  characteristic  BymptWBs 
is  always  sudden,  and  complete  paraplegia  develops  in  the 
course  of  a  lew  minutes,  or  at  most  ao  hour.  During  tb* 
development  of  the  parnlyKis  the  patient  oomplains  of  rioleel 
pain,  either  localined  or  extending  over  the  entire  spinal  cotumo, 
but  usually  disappearing  when  the  paralysis  has  become  cm* 
pictci.  When  tltu  cervical  rc:gioa  is  implicated,  the  paraplc^ 
extends  to  the  upper  extremities,  the  respiratory  muscles  an 
affected,  and  the  patient  breathes  laboriously  by  the  aid  of  tb> 
Jiaphragnt 

The  paralysed  muacles  are  flaocid,  and  more  or  less  completl 
ana^tliL-aia  of  ovt-Ty  form  of  cutaneous  Bcnaibiltty  having  tks 
same  distribution  as  the  motor  paralyou  is  prennt  Paralysl 
of  the  rectum  and  bladder  occurs ;  at  first  there  is  retentko  of 
urine  and  afterwards  varioas  degrees  of  iooontinenoe. 

Vaao-motor  disturbancee  ore'generaily  preeent.  Levier  foutd 
the  temperature  of  the  paralysed  extremitiea,  as  compared  with 
that  of  the  axilla,  increased  from  0*2"  to  2*0  C. 

The  reflex  actionn  vary  much  according  to  the  seat  of  the 
IcaioD.  When  tbo  grey  matter  ia  infiUrated  down  to  its  lowed 
point,  tbey  are  completely  abolished.  When  tlie  seat  of  the 
hatmorrhage  is  higher  up,  reflex  actionii  diioLppear  for  a  abort 
time,  owing  to  the  shock ;  but  they  may  afterwards  reappear  ia 
an  exnggerated  form.  In  most  cases,  however,  the  reflex  acliou 
disappear  after  a  time.  Priapism  is  mentioned  as  a  aytoptom 
in  a  few  cases.  The  paralysed  muscles  undergo  atrophy,  ihey 
lose  their  faradic  excitability,  and  manifest  tbo  reaction  of 
degeneration.  At  a  later  period,  when  secondary  change* 
occur  in  the  cord,  a  few  of  the  muscles  may  become  rigid  umI 
contracted.  The  symptoma  of  secondiuy  myelitis  may  b«  snper- 
addcd  and  give  rise  to  violent  pains,  twitching  movements  and 
jerkings  of  the  extremities,  and  the  formation  of  ouutracturea. 


SPINAL  CORD  AND  MEDULU.  OBLO^fOATA. 


S23 


Throughout  the  whole  couree  of  the  disease  BjrinptoinB  of 
motor  irritatiou  are  almost  entirely  nlweut  During  the  drat 
tovments  of  the  b^pmorrhage  Htight  muRcul&r  twitching  and 
paLftial  Bpsama  maj  occur,  but  tbe^e  plieDomcna  hood  give 
pUce  to  pamlfsta  Spaftmotlic  sj-mptoms  may  also  occur  at  a 
later  pcrioJ,  but  they  are  caatted  by  secondary  degeneratioo. 
TuigiiDg  and  other  panesthesiie  may  occasionally  be  felt  in  the 
parslyacd  partu,  biit^  oa  a  nil^  those  nyniptnina  arc  wholly 
abMut,  and  tbe  patients  do  not  feel  their  lioibe. 

Aft«r  a  few  days  or  weeks,  according  to  the  severity  of  tlic 
CAM-,  gaogrcQoua  bed-sores  appear  on  the  sacrum,  trochantera, 
and  other  places  exposed  to  pressure.  Paralysis  of  the 
!er  leads  to  aJkalegceaco  of  tho  arino,  cystitis,  pyelitis,  and 
Uwir  sequelw,  and  tbe  patient  dies  in  a  state  of  great  marasmuB. 

The  symptoms,  of  coarse,  varj  grc«tly  according  to  the 
■!■■,  extent,  and  sitnation  of  the  bn'mnrrlinge.  In  smalt 
lUBiaorrhages  the  symptomii  are  so  destitute  of  any  dis- 
ttDgaishiag  features  as  to  render  the  dliu^OHUi  a  n)att«r  of 
great  uncertainty.  When  the  biemorrhage  is  limited  to  the 
aaterior  comua.  the  xymptonut  produced  will  be  mainly  thoM 
of  local  paralysis ;  while  if  it  be  limited  to  the  posterior  corooa, 
itie  symptoms  will  W  eitrvmely  indefinita 

if  ibe  luvibar  ret/ian  of  tbe  cord  be  affected,  the  s/mptoma 
of  paralysis  and  anipsthesia  are  restricted  to  the  lower  extremi- 
bUdder,  and  rectum;  reilex  actioos  arc  absent,  and  rapid 
iby  of  the  muscles  and  bed-sores  occur  at  au  early  period 
of  the  diaeaae. 

U  tbe  dortal  r^^m  be  affected,  the  paralysis  extends  higher 
ap.  Tbe  expiratory  muscles  and  those  which  compress  the 
abdomen  are  paralysed,  but  re6ex  actions  may  be  retained  for 
4  lone  time,  and  atrophy  of  the  muscles  is  slow. 

If  Iba  {mvieal  tvffion  bo  implicated,  nil  the  four  extremities 
ara  afleeted,  a  portiou  of  the  inspiratory  muscles  ore  pnrnlyHed, 
oeulo-pupillary  symptoms  may  be  present,  and  tbe  implicatioo 
«f  the  reflex  prooeeaes  and  nutrition  depend  on  the  downward 
progHBW  of  the  ledoD.  If  the  ba-'morrbage  occur  alwve  the 
orifiD  of  the  phienic  nerre,  rapid  death  by  asphyxia  is  ineritable. 
lo  a  few  cases  the  haimonhage  has  been  found  limited  to  one 
hair  of  the 


Vbopi 


SS4 


TASCVLAR  DISBABBS  OP  TUB 


§  528.  Course,  Duratwn,  aTid  Terminatwn. — The  eottnt 
dcpendR  on  the  cause  of  the  diseaae  imd  the  exteui  and  locality 
of  the  bannorrhage.  In  Revere  coses  of  iliSusc  central  bleeding 
a  fatal  terminiitiou  occurs  soon  through  pemlysis  of  respiratioa, 
ot  death  results  from  acute  hed'flores,  py^min,  and  septicsemia 
If  the  hiefDorrbage  be  small  the  case  may  bo  rery  protncud, 
but  death  ultimately  reeulta  ^m  bed-sores,  cystitis,  ferv. 
maraimue,  and  other  complicatioDs. 

The  lesioQ  in  the  cord  sometimes  cicatmos,  and  partisl 
recovery  occurs  even  after  cystitis  and  bed-aore?  have  msde 
their  appearaooo ;  but  in  these  eases  some  muscles  or  group  ni 
muacles  usaalty  retn&in  paralysed  and  atrophied.  Complett 
recovery  is  only  possible  when  the  clot  is  small. 

The  duration  of  the  disease  varies  greatly.  R^d  cues 
terminate  in  a  few  minuteii,  houra,  or  days ;  while  in  less  MVSK 
ODC9,  weeks,  months,  or  even  years  may  ela^»se  before  death 
occurs. 


§  529.  Morhi'l  Anaiom'j. — The  bleeding  is  generally  liraitd 
to  the  grey  mihstance,  and  may  involve  the  cornun  or  the  eslire 
grey  subtitance,  and  may  extend  to  varions  distance*  tongiu* 
dinally.  Two  kinils  uf  extravasation  may  occur ;  tho  hamm* 
rhagic  or  apoplectic  clot,  and  the  ha^morrbagic  infiltraticsi  er 
softening. 

The  hamojrhagic  or  ajxtpleetic  dot  varies  in  size  from  tbst 
of  a  pea  to  that  of  a  hazel-nut,  and  its  longitudinal  is  geoeially 
longer  than  its  transverse  diameter.  The  clot  is  often  tecs 
through  the  pia  mater  as  a  bluish  nodalc,  vhite  the  pis  a 
sometimes  niptured,  no  that  blood  makes  its  way  into  ths 
subarachnoidal  space.  The  clot  is  surrouudcd  by  ragged  woUi 
formed  by  disintegrated  nerve  tissue.  The  ha-ioorrhage  may 
pass  for  a  considerable  distance  hetveen  the  bundles  of  white 
fibres,  and  a  large  portioa  of  the  grey  suhatanco  may  be  if 
Btroyed,  giving  rise  to  what  is  called  a  "  tubular  haemorrhage." 
The  portions  of  the  cord  most  usually  affected  are  the  cervical 
and  upper  dorsal  region!). 

The  olot  after  a  time  undergoes  a  series  of  further  cbajigw 
It  either  slowly  dries  up  to  a  cntmhiy,  caseous  mass  of  a  dark 
colour,  containing  crystals  of  hicmatoidin,  or  UDtlergoes  a  pro- 


CORD  AND  MRDrLLA  OBLONOATA.  '      32!i 

i\if  aofteoiog,  with  mbsequent  nbeorption,  bo  that  at  last  a 
mpsnle  of  oonnectire  tissue  U  left,  filled  only  with  a  seroua 
fluid.  Wh«o  the  extravasation  is  itmnll  it  may  W  alisorbod,  so 
H  to  leave  only  a  sraatl  cicatrix  of  ooonectiva  tissua 

flacondaiy  disnae  of  the  cord  is  rery  often  found  in  tlie 
Deigbbourliood  of  the  clot^  I'bia  generally  consists  of  floft«niDg, 
vbicb  ezteuds  to  a  rariablo  distance  both  upwards  and  down- 
Varda.  The  grey  matter  often  undei^es  luL'morrhaKic  softeniDg, 
and  is  Bometiaiea  ooorertcd  into  a  ttuftencd  mass  uf  a  rcddi^ 
black  or  chocolate  colour,  while  white  softening  may  be  observed 
JBtbe  Doighbourhood  of  the  clot.  Iq  old-staoding  cases  aeooodary 
:  and  deacendiag  sderoais  oocun. 
}amorrhagic  injUtrxition  or  softening  occurs  in  tlio  grey 
oiclusively.  It  ie  limited  to  one  or  more  of  the  grey 
bonu,  or  exteudit  over  the  whole  of  tho  grey  mutter,  but  rarely 
^pMada  to  the  wbita  subBtaooe.  It  may  extend  longitudinally 
ft  few  centimetres  only,  or  the  whulo  luugth  uf  the  cuid.  The 
gny  sabslanoe  is  changed  into  a  reddinh-brown  mass  dotted 
wilb  dark  red  pointa.  The  microscope  shows  elementi  like 
tboae  in  ibe  clot,  but  with  the  addition  of  granular  coipuaclei 
and  degenerative  changet  in  the  nene  fibres  and  ganglion  cella. 

Th«  usual  eridenoeeoTacutecttDtral  myelitiiimaybeobderved 
br  beyond  tlie  limits  of  the  hamtorrhagic  infUtraiion. 

§  £30.  DioffnoaU. — Tbe  diagnosis  is  chiefly  based  on  the 
■adden  and  very  rapid  invasion  of  paraplegia  without  much 
tnitatiou,  and  tic  immediate  severity  of  Lbc  ^ymptoma.  It  ia 
dtatioguiabed  from  cer^fral  apojAccy  by  the  retention  of  con- 
WMltlMia,  tlie  absence  of  all  eymptoms  of  paralysis  of  cer&bral 
MTvet,  the  paraplegic  form  aaaumed  by  tbe  paralyois,  and  by 
tbft  prH«ttce  of  poraJyits  of  the  sphinctcra 

In  meningeal  hamtorrhagc  there  are  active  syroptoou  of  irrita- 
tion, bypsHMtboaiA  and  pain,  violent  spasms,  while  paralyeiB  is 
1«»  prominent,  the  distorbancee  of  sensibility  are  slight,  and 
Mm  eoone  of  the  attack  is  Ta}Hd  and  comparatively  favourable. 

Aade  etntrul  myeiili&  ia  very  similar  in  ita  symptoms  to 
ipinal  apoplexy.  In  myelitis  tbe  paraplegia  reqnires  hours  or 
daji  lor  derelopmeot.  It  begins  with  Hyniptouift  of  irritation, 
.  pain  and  slight  spoam,  tbe  vertebral  column  i«  sensitive 


336  VASCUI.AB  DisBAua  or  va% 

to  proBsare,  fever  may  be  preseul,  and  aassthena  and  par- 
lestbens  are  prominent  symptoms,  while  purtisJ  panilynB  ajid 
weakDess  of  the  bladder  precedes  the  occurrence  of  leven 
paraplegia.  Tbe  accuiitling  process  of  central  rayelitis  nu; 
be  contrasted  with  the  stationary  nature  of  the  Bymptoms  io 
bfviuurrbitge. 

Polwmyditvi  anterior  actita  in  adulla  in  often  tike  liaunato- 
myelia.  It  may  be  diiitinguished  by  the  presence  of  fevertt 
tlic  commonccmcDt,  the  abeeocc  of  sensory  disturbaoces,  ud  ef 
palsy  of  the  bladder  and  bed-soree. 

The  i«(^(Bmio  parapletjla  caused  by  emboliBm  of  theaorto 
can  alone  be  mistaken  for  ha-morrhagc,  and  this  accident  may  be 
recognised  by  ab&eoce  of  the  fetuoral  pulse  and  otber  attei 
symptoms. 


Ddiiqi 


§  531.  Pivgnosis. — The  progooais  is  always  grave.  L«g* 
central  htcmorrhagcs  and  those  which  are  sealed  at  a  bigb  levd 
are  neceaaarily  fatal  The  prognosis  becomes  mora  hopeful  if  the 
first  few  days  and  weeks  pass  witliout  bringing  severe  oom|dt- 
cations,  but  complete  recovery  is  rarely  to  be  expected.  Small 
circumscribed  hteoiorrbages  are  less  daugeraus,  but  it  is  am 
that  the  diognoEis  of  such  casen  amouula  to  anytbiug  like 
cerlaiuty. 

§  532.  TreatTnent.  —  Prophylactic  treatment  should  be 
adopted,  such  m  removing  retained  or  suppressed  meDses,  oi 
alleviating  heart  disease  and  congeiition  of  the  cord.  When 
tho  fiymptoma  are  related  to  a  central  myelitis,  a  very  active 
antiphlogistic  trcatmcut  should  be  adopted.  Chapouui'a  ice- 
bag  should  be  applied  to  the  back,  but  after  tho  acute  mXa^ 
is  over  a  more  stimulating  treatment  may  be  adopted.  For 
tho  htemoi'rhago  itself  little  oaa  be  done  beyond  relicviog  tl» 
congestion  of  the  cord  by  tbe  employment  of  local  bleeding, 
b«e  application  of  ice,  and  mainteaaace  of  the  horiiontal 
position  upon  the  side  or  abdomen,  with  tbe  internal  a»e  of 
digitalis  or  ei^ot,  purgatives,  and  application  of  wannth  to  the 
extremities. 

Trophic  disturbances,  cystitis,  and  bed-aoros  mu«t  bo  sub- 
jected to  the  usual  treatment    If  tJie  first  weeks  pass  without 


SPINAL  CORD   AND   MEDULLA   OHLONQATA.  327 

■crioiH  resolte,  iodide  of  potassium  may  be  admtDLBtored  to 
^WOMte  abeoiptioD.  Warm  spring  and  brine  batliB,  oi  a 
■Dcdonte  hydropathic  treatment,  and  the  coustant  curreDt  may 
aD  be  occasioiuUly  of  use. 

1  ffjfperemnia  and  ffamwrrhage  of  the  Medulla  Oblongata. 

§  333.  Hypericniia  strictly  limited  to  the  medtilla  must  be 
oa  extronivly  raro  occurreuce,  and  in  the  majority  of  cases  it  is 
nothing  mora  than  ]tait  of  a  general  hypera^niia  of  the  brain  or 
ipiaal  cord. 

S  534.  I[<3Bmorrhaff6  of  the  medulla  is  more  closely  related 
to  the  raacalar  diseases  of  the  brain  thao  to  those  of  the  cord, 
and  the  froqacDcy  of  the  occurrcDce  of  bxmorrhagc  is  greater  Id 
the  cerebral  tban  in  tfae  spinal  end  of  the  medulla.  Rupture 
of  a  VBSwl  Li  on  the  whole  a  rare  occurrence  in  the  pons  and 
aodolla  oblongata.  Tbc  pathology  of  bR'morrhago  of  the 
medulla  is  the  same  generally  as  that  of  hiBraorrbuge  of  the 
rant  Disease  of  the  vessels,  iiuch  ns  miliary  aneurisms, 
alberocoa,  fetty  degeneration,  and  capillary  dilatation  resulting 
Aotn  processes  of  aoftcning,  is  the  most  important  con- 
ditioa  whicb  leads  to  the  production  of  hs^morrhage.  Cases 
of  atherooxa  and  aneurism  of  the  basilar  artery  are  often 
■ooompAnied  by  biemorrhage  from  tbe  smaller  branches  in  the 
medulla  and  pons.  Bright's  disease  is  a  very  tmportAOt  caaas 
of  luemorrbage  into  tbe  medulla.  Caries  of  the  cervical  ver^ 
lalitK,  purulent  basilar  meningitis,  and  tumours  in  or  around 
Um  medulla  predispose  to  beemorrbagce  by  impairing  the  nutri- 
tioo  of  the  walls  of  tfae  vessels 

Hirmorrbage  is  also  produced  traumatically  tbrougb  injurica 
Is  Ibo  skull  and  back  of  tbe  oeck.  Wcstpbal  protlucud  capillary 
iHBaMlTh&ge  in  the  medulla  of  the  guiDen-pigby  lightblowsof  a 
hMun^r  00  the  head.  Iq  cxteusive  cerebral  ksjuiorrhago,  whicb 
bcMks  tbroogb  into  the  ventricles,  tbe  fourth  ventricle  oftoo 
bcconot  filled  wtib  blood  through  tbe  aqueduct  of  Sylvius. 

if  535,  .SympfoTOA— Very  Htllo  is  known  of  the  symptoms  of 
•dive  bypeisoaia  in  tlie  medulla,  but  it  is  probable  that  some 
of  Uw  symptocns  of  general  cerebral  bypenomia  ar«  due  to 


VJISCULA.R  DISBASBS  OF  TUX 


coDgGstion  of  the  mcdulU.  Tbe«e  symptoms  are  dyspncea,  slow 
pulse,  vomiting,  geueral  coomUions,  anil  ocriaia  dcfoota  ti 
epeech.  Certain  initial  aytnptoms  of  acute  bulbar  diaeoae,  socb 
as  painB  io  ttie  head  and  back  of  the  neck,  sposma  iu  the  bet 
and  tongue,  and  fonnicatioo  in  tke  region  supplied  by  the  fiftk, 
are  probably  caused  byoongeatioQ  of  the  medulla  oblooKata. 

Hicmorrhafie  into  tbe  medulla,  oven  of  limited  exteot,  ia 
alwaja  exceedingly  dangerous.  It  commences  genOTrUly  witb 
the  most  alarming  symptoms,  and  not  un&equently  caoses 
instant  death.  In  these  cases  the  patients  fall  down  iritli 
a  cry  or  in  epileptiform  oonvulsiona,  and  die  instantaneoasij. 
Large  effusiona  of  blood  into  the  hemiBplieres  and  bml 
ganglia  Rometimea  reach  the  fourth  ventricle  ;  they  irriUCe  tail 
oppress  tbe  medulla,  quickly  producing  death,  preceded  hj 
vomiting,  convulsions,  como^  and  general  paralysii. 

Slight  kcemarrhag*  into  the  medulla  generally  produces 
symptoms  of  an  alarming  and  very  threatening  natura.  and 
these  are  more  grave  the  nearer  the  eHunion  is  to  the  respin- 
tory  centre,  for  when  the  latter  ia  affected  ioatant  dcatk 
ensues.  In  cases  which  survive  a  longertime  the  patients  irtter 
a  toud  cry,  or  aro  attacked  by  buEEing  in  the  ears,  dimneia, 
sudden  headache,  vomiting,  or  convulaive  npasm  of  the  botlr, 
followed  by  coma.  Epileptiform  convulsions  have  been  obscrred 
amongst  the  initial  iiymptamit  of  bivmorrhagc  into  Ibc  mcdolta 
and  pons. 

The  motor  paralysis  varies  greatly  in  extent,  sonustinus 
attacking  the  lover  extremities  only,  sometimefl  only  tbo  upper. 
and  at  other  times  causing  hemiplegia.  In  moat  cases  all  four 
extnimities  are  either  completely  or  partially  paralysed.  Some 
of  the  bulbar  nerves  aro  always  more  or  less  alfected.  The 
hypoglossal,  facial,  spinal  accessory,  and  trigeminus  are  amallf 
more  or  less  completely  poralywd,  and  eomotimos  tbo  uerres  ef 
tbe  orbit  also.  When  there  is  a  hemiplegia,  the  paralysis  oC 
tbe  extremities  occupies  the  aide  of  the  body  opposite  to  tba 
extravasation,  while  paralysis  of  tbe  bulbar  nerves  oocura  on  tbe 
same  side,  giving  ri«e  to  a  characteristic  htmipltgia  oftomona. 

Paralyse  o/aetuation  when  present  follows  the  name  rule 
BB  that  of  motion,  hut  is  not  usually  ao  welt  developed. 
When  coma  is  present,  it  is  impott^ble  to  asoert&in  i 


aPWJLL  CODD  AMD  UEDrLLA  ODLOKQATi. 


»2» 


irith  reipaot  lo  U>e  coDclitioo  of  neoaatioo.  "When  the  aflection 
iRQnilAteral,  tbesduory  diglurlMtaccs  are  also  crossed ;  butowing 
to  the  peoutiar  coun>e  of  Uie  sensor}'  fibres  id  tlie  medulla,  we 
caa  banlly  expect  a  sharply-tieliDetl  aneeethesia. 

Re»j>imtotnj  tliaturbmuxs  ftru  the  aiosl  important  and 
chatacteristtc  Rjmptoniii  of  lh«  nffection.  If  fatal  aspliyxia 
<loMi  not  ensue  at  once,  the  respiration  is  impaired,  becoming 
inc^lar,  stertoroua,  oflco  Uitcrmillent.  and  accompanitid  with 
p«ai  djspQcsa.  The  Chefoe-Stokes  roBpiratioa  is  Irequeotl/ 
obaerred;  the  breatliing  theu  becomes  more  and  more  ero- 
himued  till  ij«alh  fnira  auphyxia  rcmilta.  Alturatiuos  in  the 
action  of  tho  heart  are  g«Derally  less  prominent,  but  the  puhe 
iiORuUl/  frettoentk  irregular,  and  iatermitlcnt. 

Foio-motor  changes  have  not  been  often  described,  but  io 
the  peciod  immediately  Bucceediog  the  hemorrhage,  unilateral 
or  bilateral  rise  of  temperature  of  the  mkia  bafl  been  noticed, 
A  «oDnd«rable  rise  of  tompcraturo  occuts  duziug  tho  death 
igooT.  at  occurB  ia  other  forma  of  apoplexy. 

IkaturbanceH  of  eip««ch  and  deglutition  and  unilateral  or 
bilataral  paralym  of  tlio  soft  polatti  result  from  the  parti- 
cijiatioD  of  tJi«  bulbar  uurvea  in  the  paralyKis.  Deafhees 
■od  btuxing  of  the  earn  are  also  frequently  oUerved  from 
implication  of  the  auditory  nerves.  Frequently  recurriag  vomit- 
ing and  a  oontinuoua  troubleMime  hiccough  have  been  obscrrod 
M  •ymptoms.  I'otain  found  po^yu-n'a  present  in  one  case. 
Uadex  aad  Dcanon  found  albumen  in  the  urine  in  a  case  a'hure 
the  kidovys  proved  to  be  oormal  at  the  autopsy. 

in  caew  where  life  is  prolonged  the  electric  reactions  remain 
nonnal  lu  the  extremitiea,  but  there  may  be  Iohs  of  faradio 
eoatractility  and  the  reaction  of  degeneration  in  the  uiusdea 
Wppliad  by  the  pataljeed  cranial  motor  nervee. 


Jf  536.  Cour«.— Tho  diM&u  is  either  fatal  at  once  from 
pftralysia  of  Uio  r««piratory  centres,  or  dcftth  docs  not  result 
for  a  few  hwira  or  days,  but  there  is  Reneral  paralysia  and 
profound  noooaadoaBneM ;  or  life  ma;  be  maintained  for  a 
couidorable  time.  In  the  latter  case  the  patient  gradually 
rBOOvets  his  consciuuauesa,  aome  of  the  paralytic  and  other 
tjjafiaaa  dia^pear,  and  nothing  remains  but  hemiplegia  or 


sso 


VASCtlLAB  DISEASES  OF  THE 


partJAl  paraplegia,  and  more  or  lea  difficult}'  in  articulatic 
aod  •leglutillon.  Id  such  cas«8  coatimcUires  are  very  liable  lo 
ensue,  just  aa  occurs  when  ibe  pyramidal  tract  is  interrupted  io 
any  other  part  of  iu  course.  Very  little  is  known  of  the  symp- 
toms of  small  capilUry  W-morrhages  ia  tbe  meilulta,  but  tbey 
are  probably  Himilar  to  tbone  produced  by  cuboU  of  tbe  DUtrtent 
arteries  of  the  bulb. 


§  537.  Morbid  Anatomy. — Hypcraitnia  of  tlie  mcdall*  ia 
characterised  by  the  same  aaatomical  appearances  as  cerebnl 
liypuru-'uiia,  and  requires  uo  further  deacriptioo.  A  similar 
remark  applied  to  hutmorrhage  of  the  medulla.  A  clot  goes 
tbrou|;h  tbe  same  changes  id  tbe  medulla  as  io  the  bnis, 
ood  unless  it  is  rapidly  fital  it  ends  in  the  formation  of  s 
contracted  scar  or  of  B  small  cyst  Secondary  dogcneratiooKif 
tbe  pyramidal  tracts  are  generally  developed.  ExlravaaatiooB 
arc  usually  of  small  size,  except  vben  the  pons  is  nmn 
taneoualy  affected,  and  then  tbny  may  be  large ;  they 
roundigh,  resembling  an  olive  or  bean,  but  frequently  irregul 
Near  tbe  mediim  line  we  meet  with  small  triangular  spots i 
hiumorrhage,  with  the  apei  pointing  forward,  corresponding  to 
the  territory  of  a  median  bulbar  artery. 

§  5f)S.  Diagnosis. — It  is  probably  impossible  to  maJce  a 
special  diagnosis  of  byperaenua  of  the  medulla  obloDgata.  Lou 
of  coaticiousD^Hs,  epileptiform  conTulfiionx.  and  sudden  death 
are  siiDiciently  cbaracteristic  symptoms  of  severe  cases  of  btt- 
morrhage  into  tbe  subatunco  of  the  medulla.  In  cases  of  less 
severity  the  onset  may  be  attended  by  general  epileptiform  ooa- 
rulsioQs,  vomiting,  hiccough,  more  or  Ices  threatening  respiratory 
disorders,  dysphagia,  disorders  of  speech,  paralysis  of  the  tongue 
and  soft  palate,  of  tbe  inferior  branches  of  the  facial  and  of 
the  abducens  oeuli,  tbe  preeeace  of  albumen  and  sugar  in  tbe 
urine,  a  final  rise  of  temperature,  the  extetuioo  of  paralysis 
to  all  four  pxtromitios,  tho  unequal  degree  of  paralysis  in  the 
extromities  of  one  side  and  the  face  and  tongue  on  the  other 
side,  and  the  abolition  of  all  reflexes  in  the  regions  supjdied 
by  tbe  paralysed  bulbar  nerves.  It  may  be  concluded  that  the 
lesion  is  limited  to  the  anterior  half  of  tbe  floor  of  the  vent 


wfaan  Vtt  Bee  {WTalyus  of  the  kbducoDB,  fiicial,  and  trigQinious, 
•long  with  aural  disorders  and  sugar  aod  albumen  in  the 
ttiioe.  HKmorrhAge  iu  (he  poHterior  portioa  of  the  rbomboul 
ti&tu  produces  ponljsis  of  the  hypoglouus,  fiusial,  and  trige- 
mioiu,  &uJ  of  tbo  spinal  accesaor;  and  vagus,  accompanied  by 
gnve  respiraioiy  disorders  and  uHuaJly  by  paralyBed  extremities, 
asd  it  ii  a  aymptom  of  somo  importAoce  wlico  tbOBQ  latter 
tllemate  with  paralysis  of  the  toQgu&  Alternate  paralysis  of 
u  upper  and  lower  extremity  probably  iudicates  tbat  the  lesioa 
is  situated  in  tbe  centre  of  the  dccuBsation  of  the  pyramids. 


«> 


539.  PrOffnoaU. — The  prognosis  Is  very  uafavournble,  and 
B  the  tueDnorrliage  is  of  large  dimensions  the  lesion  is 
isTftriftbly  fatal  There  is  only  hope  lo  cases  of  very  limited 
hamonhage,  or  when  the  localisation  is  very  favourable,  espe- 
riatly  when  it  is  far  removed  from  tbe  respiratory  oeiitres.  The 
patient's  conditiuu  may  then  improve  gradually  smd  partial 
recovery  t&kc  place. 

%  ^^40.  Treaimenl. — The  rules  of  trtalment  are  the  same 
lor  byperasQua  and  hsemonbago  as  for  tbe  same  processes  in 
<)Ui«r  pftTta  of  tbe  brain.  YeoeaectioD,  combined  with  active 
•titDttlMits.  is  the  most  suitable  ireatmeut  in  i^cvcre  cases 
wbtn  respiration  is  threatened ;  the  latter  must  be  injected 
per  rectum,  as  the  patient  cannot  swallow. 

Iu  chronic  cases,  when  paralysis  ooatinues  and  when  speech 
umI  deglutition  are  impaired,  a  suiuble  application  of  etecuicity 
iiiDdtcaied. 


334  FUNCTIOXAL  AND  SBCOKDAKT  DISCASS8  OV 

divided  into  threo  classes,  according  as  tbe  symptoma  point  J 
the  upper,  middle,  or  lover  parta  of  the  cord. 

(1)  n^beti  the  Mrvteal  |)ortioQ  is  ftfiectod,  tho  |)aln  utd  seoaititeDc 
localised  iu  tho  oemcfti  vert«bne,  and  the  proraj&etit  ^mptoma  «•  ^ 
refoiTtnl  tu  tho  tj«(ul.  Theiw  syiQ[>tDm»  tiro  gitliliann,  dtwfitMKimat  <&■ 
turbaDoeii  of  the  specliU  Mnaaa,  pain  in  tha  oooiput,  and  paliw  in  tbs  im 
of  distribiiiioD  of  the  nerros  of  the  bnohul  plexus.  In  wUitioa  to  UmN) 
iiauMa,  vomiting,  |>aIi>iUtiMii,  n.ti<l  tiicrau^b,  And  imjiainnont  of  pomr 
ia  the  upper  extreuititic)  may  be  cuuiplntDod  of. 

(S)  If  tb«  dor§al  portiou  of  tlu  «ord  b«  •fitctod,  the  symptotus  an  local 
tenderness  of  tbe  donal  portion  of  the  vartcbral  columu,  intercoctAl  aeu- 
ml^,  K'^*^'*'h'ii^  uausoa,  djspepeio,  &ui  motor  aud  tteaaoiy  dutu^ 
aucoa  iu  the  laner  eitremitiea. 

(3)  Wbou  the  tmnbar  portion  of  th«  cord  i«affiict«d,  the  KjrmptonMl 
neiir&lgia  in  tbo  I«w9r  i-ztromitiM  nnd  pelvic  orgaos,  »p<wia  ov  p«rMif4 
tho  bliidder,  cold  fest,  and  woBkneas  of  tha  Iflgi. 

§  5*5.  Course,  Dtorat'ton,  nnd  Terminatiorui. — The  coane 
of  tlie  diseoae  is  usually  fluctuating,  aud  relapses  occur  witboBt 
apparoub  cauao.  Some  coses  run  a  comparatively  acute  coom, 
but  the  duration  geucraUy  extends  over  a  period  of  mootbe  w 
yean,  aad  aomu  patients  euS«r  from  occa&ioool  attocke  all  tbeir 
lives,  although  most  of  tbcui  ultimately  recover. 

^Nothing  is  known  with  regard  to  the  morbid  anatomy  of 
sptaal  irritatioD.  It  is  probably  a  fuoctional  disturbauce  of  the 
cord,  aooompanicd  by  altemating  coodiUons  of  bypera^raiaud 
anipmiA.  ^^^| 

§  ii46.  DiagruWM. — Spinal  irritalioD  is  very  difficult  to  dii- 
tinguish  from  liypencmia  of  the  cord.  In  severe  byponemii 
diHlinct  pamlysis  is  rarely  absent,  and  the  duration  of  Lb* 
disease  is  uot  as  long  as  that  of  spinal  irritatiou.  Hammood 
juiyn  that  utrychnine  injected  Kubcutaueously  does  good  in  epioal 
irritation,  and  harm  in  hypenemia  Spiual  irritation  resemhlea 
in  some  respects  spioal  meuiugititi,  but  in  the  hitter  there  are 
stiffnem  and  painful  tension  of  the  luusclee  of  the  back,  aad 
fever. 

The  6r8t  stage  of  meningeal  tumours  is  very  similar  to  spinal 
irritation,  but  in  the  fonner  only  deep  pressure  on  the  spinous 
processes  is  painful,  and  tberu  ia  no  circumscribed  hyperKttbena 
in  the  vertebral  region. 


TUB  SriXAI.  COBD  AKO  UBDULLA.  OltLONGATA. 


S35 


ItuiinpoenibleiaiJi&giKUticBte  nplual  irritiLiAontrom kjfiteria 
in  manj  cases,  aad  iodeed  the  two  affections  have  been  raided 
u  identical. 


§  547-  Prognosis. — Tbe  disease  is  always  cliroDic  and  may 
laat  for  raoatbit  or  yean,  but  the  prognoxis  is  gencmlly  favour- 
able, aod  tlfc  ia  nerer  id  danger,  altbougb  a  great  deal  of 
nffenog  is  produced. 

§  54S.  TrentTTifnt. — The  treatment  of  «pinal  irritation  offers 
di&cuUies  from  the  great  mental  irritability  and  changeable- 
iiM>  of  tbe  potioot 

Tbe  first  endeavour  must  bo  to  romovo  the  cause  of  tlie 
^— act  whea  tbis  in  ixjsHibte.  Tlie  next  endeavoitr  miiHt  be 
lo  impnive  the  general  nutrition,  and  to  direct  special  treat* 
ment  to  the  npinal  cord.  A  tonic  regimen  must  be  adopted, 
a  full  and  Htiuiulaling  diet,  as  well  as  nicKlerately  free  use  of 
wine  or  even  in  some  cases  brandy  or  whisky.  Active  and 
pHBiTo  ezeicise  in  the  open  nir  must  l>e  taken,  but  fatigue 
■bmld  be  nroided,  and  the  pattcut  ebould  frequently  reat  in 
ttw  recumbent  posture.  Tbe  air  of  mountains  and  forests  i» 
in«fal.  as  well  a&  a  moderate  hydropathic  Irratment. 

Tbe  moAt  useful  remedies  in  tUc  treatment  of  the  affocUon 
are  quinine,  iroa;  zinc,  and  atrycboiae.  The  aficendicg  stabile 
OMutAnt  current  passed  through  the  vertebral  columu,  including 
tbe  p«iaful  portions  between  the  poles,  may  be  of  service.  ICach 
fitting  should  be  short, and  the  strength  of  the  current  moderate. 
in*  negative  pole  acting  directly  on  tbe  painful  vertebm^  bos 
often  done  good.  Many  patients  of  this  class  are  benefited  by 
geoenl  Faradisation  and  central  g&k&nisalion. 

Coanter-irritants  applied  directly  over  the  painful  portion  of 
tbe  sjHoe  often  eflect  wonders.  Various  symptoms,  such  as 
neuimlgiform  paimi,  require  treatment  as  they  aiise. 


ou  rvxtrriONAL  weakness  of  tub  spinal  cord. 

NcurwtiKnia  Spinalis. 

§  &49.  Dejinition. — Neiiraathenia  spinalis  is  obeerred  in  per- 
aeus  wbo  aw  *nbjwt  to  tbe  general  Kymploms  grouped  under 


S86 


PUHCnOSAL  AKD  SBCOK&AaV  D1SSA8KS  OF 


the  popular  nama  of  "  norvouanesa,"  but  in  it  the  fanctioni 
the  cord  are  affected  io  a  special  degree 

§  550.  Etioloffy. — The  afibcUon  generally  occurs  in  neo 
patbic  families,  and  the  male  is  more  liable  to  be  attacked  tlua 
the  female  sex.  Youth  and  middle  age  suffer  moat  from  the 
disease,  and  it  ia  more  common  in  thv  upper  than  ia  the  lonei 
classes.  The  exciting  causes  are  exccA^iTe  mental  or  bodily 
ezeTtion,  the  depressing  emotions,  and  sexual  excess. 


4 


§  551.  Symptoms. — Patients  complain  chiefly  of  great  weak- 
ness of  the  lower  extremities,  accompanied  bjan  intense  feeliog 
of  fatigue  on  slight  exertion.  A  dull  feeling  of  weariness  is, 
iadoed,  often  felt  b;  the  patient  in  the  lower  extremities  in  ^ao 
morning  before  riHing.  After  prolonged  exertion  this  feeling 
may  be  accompnnied  by  occasioQal  tremors  of  tlie  l^s^  and  • 
remarkable  stiffness  and  pain  of  the  muscles  of  the  lower  exire* 
mitiea,  similar  to  that  produced  in  a  healthy  man  by  prnloogad 
marching.  Symptoms  of  rapid  exhuastion  and  fatigue  may  be 
observed  iu  the  arms  also,  but  never  reach  the  same  iotenan^y 
as  in  tbc  legs.  'V^H 

The  sensory  disturbances  consist  of  pain  in  the  back,  which  ts 
aggravated  by  the  movements  of  the  muscles.  The  pain  is  not 
intense,  and  rarica  greatly  in  its  time  of  occorrenoe  and  poattiea 
It  is  increased  or  brought  on  by  slight  exposure  to  cold,  and  by 
venereal  and  other  excesscji. 

A  diffused  Bonftation  of  burning  in  the  skin  of  the  baekii 
often  observed,  especially  between  the  shoulder-blades,  wtttcfa  »• 
usually  accompanied  by  sensitiveness  of  some  of  the  spisoiM 
processes,  as  in  spinal  irritation,  Nearal^form  pains  may  be 
present  in  the  extremities ;  they  are  never  of  long  duratioo, 
but  often  recur  after  unusual  exertion.  The  patient  also  coro- 
plains  of  uumbncfis  aud  formication,  e«pecially  in  the  Iowit 
extremities,  of  cold  hands  and  feet,  and  occasionally  there  is  a 
burning  feeling  in  the  feet 

The  sexual  functions  are  generally  more  or  less  iuterfered 
with,  there  is  dimiDished   power  of  erection  and    prematui 
ejaculation,  and  the  act  of  coition  is  followed  by  remari 
proatiatioQ  and  rcstlensneM  of  the  limbs. 


Tber«  may  be  a  littla  drlbblmg  of  urine,  but  the  faocUoiM 
or  tbe  blacltler  are  usually  normat.  The  paticDt  a  much 
tnrableii  with  sleeplesHiwtB,  aod  fe^Is  particuUrly  protilrate  iu 
tbe  morntDg,  he  C(Hn|)lains  of  a  sense  of  coniitriclion  of  the  head, 
is  lelf-conKioua  and  timid,  and  manifests  a  atrong  tundency  to 
■bed  tcan.  Vertigo  is  usually  ubseut,  and  the  special  seiiBM 
kod  higher  mental  faculties  remain  unoficctcd. 

Dyt^pBia,  along  with  coooti potion,  flatulence,  and  palpitaiioo, 
is  frequently  present  Tb«  patients  are  gonerally  Lypo- 
<faoodnacal«  and  Uvo  in  constant  dread  of  tabos  dorsalis,  or 
•ome  aahoBS  afiection  of  tbe  cord.  Tbe  general  nutrition  ia 
gwi«nUly  impaired,  the  patient  lo^oe  flesh,  acquires  a  sallow 
loolt,  mad  becomes  ansemic.  There  is  always  great  senaitiveueas 
to  cold  and  changes  of  weather. 

Tbe  objective  symptoms  are  almost  entirely  nogntivo.  The 
examination  rereala  do  trace  of  motor  diaturbADoes  or 
t  of  co-ordinaliuu.  The  sensory  diHturbaticea  are  e<}ually 
digbl.  TbofB  is  no  gre>at  seoiitiveneas  of  the  spioous  proousos, 
th*  toflez  funcuons  of  the  skin  and  t«udou8  are  noriual,  there  is 
BO  moicnlar  atrophy,  and  nocbaoge  in  tbe  eloctiical  reactions 
of  tbe  musclei. 

§  Ubi.  Ooune,  DureUion,  and  Terminaiion. — ^The  disease 
may  ucoudooally  begin  rapidly,  but,  as  a  rule,  it  develops 
gradually  and  increasee  in  sererity  for  weeks  or  months,  and 
tbeo  rvmains  more  or  less  stationary.  Slight  llucbuatioDS  in  the 
JnWwaJQr  of  tbo  symptoms  ore  common.  Under  proper  treat- 
BKOt  tbe  disease  bt-gitM  to  impfove,  but  moDths  <ir  years  may 
IMsa  before  complete  recovery  occurs,  and  rcLtpsce  arc  common. 
Intenmrreot  febrile  afifectioDs  often  appear  to  iaduenoe  the 
adcctioo  favourably.  In  some  caaes  the  patient  is  compelled  to 
rdinquish  bntbew  oa  account  of  the  offcctioD. 

553.  Morhiil  Pkyaiologtf.—The  simnltaDcons  occurrence  of 

Teuory  and  motor  disturbaoeea  of  tbe  legs,  and  tbe  affections  of 

Uw  bladder  and  sexual  organs,  show  that  tbe  diaeaae  tsof  ipin^ 

origin,  while  iu  fatoarable  eour»e,  and  the  absence  of  the  usual 

objective  symptoms  indicative  of  organic  diaea»e  of  the  cord. 

It  it  is  a  functional  affection.   jL^-srobafale  that  a , 


S3S 


FUNCTIONAL  AKD  SEUONDART  DISEASES  OP 


ccrtaia  amount  of  anaemta  of  the  corci  exists  oombioed  with  aa 
irritable  coDtlitioQ  of  tlie  norvoiu  tiMue  itoetf,  leading  lo  a  rt^dj 
discharge  of  nervous  force  and  subaecjiieat  eibauslioa.  It  umv 
also  be  assumed  that  repair  of  the  cxhaunlcd  tiaauei  doca 
take  place  promptl;  and  rapidly  aa  in  health. 

^  55k  Diitgnosie. — ^Thc  diagoosia  vrill  b«  based  on  the 
diaproportioQ  betveen  the  acuc«  subjective  complaints  of  Um 
patient  and  the  almost  negative  result  of  objective  examiDatioti. 
The  diagnosiB  becomes  dearer  when  in  addition  tboro  oxiitt 
general  nervous  weakneas  and  aleeplesaneas,  and  the  cause*  are 
present  which  induce  the  disease. 

This  affection  might  bo  mistaken  for  the  oarty  stage  d  \ 
dursaiis,  but  io  the  latter  the  presenco  of  the  taucinating 
and  other  disturbances  of  sensibility,  the  girdle  seasatioo,  aad 
eapeoially  the  ataxic  symptoms  ought  to  render  the  diagooda 
easy. 

Nervous  weakness  of  the  cord  may  be  dtstinguished  from 
adive  hypercemAa,  by  the  absence  in  the  fonuer  of  jpain,  cuta- 
neous byp«nefltheaia.  and  symptoms  of  motor  irritation.  It  may 
be  distinguished  from  passive  hypenemia  hy  the  •heaDce  of 
paretic  symptoms  and  by  the  feeling  of  hcaviuctui  in  the  legs. 

It  may  be  distinguished  from  incipient  TiiyelUia  by  the 
absonco  of  panuathesiu;  aud  &uii.-sthesiii,  of  puresis  ur  pandysis  ci 
the  limbs  and  of  pronounced  weakness  of  the  bladder. 

From  spinal  irritation  it  may  be  distinguished  by  the  &ot 
that  in  the  former  the  scosory  diaturba&eea,  as  donal  paioi, 
neuralgias,  and  sensitiveness  of  the  spines  of  tbe  vertebrae,  are  the 
most  prominent  symptoms,  while  fatigue  on  exertion  and  sexoal 
weakneu  are  the  main  symptoms  of  the  latter. 

§  555.  Ptw^nom— The  patient  goaorally  rccoven  after^ 
time,  when  the  cauees  of  tbe  uffectioti  are  removed  aud  a  suit' 
able  treatment  adopted.  Relapses  are,  however,  of  freqaent 
occurrence  when  the  patient  remains  exposed  to  tbe  ezciliii^ 
cau&es  of  tbe  disease. 

§  556.  Treatment. — Particular  attention  must  Bmt be  direct* 
to  remove  tbe  cictltng  causes  of  the  ^ectioa    Ormt  attend 


TBB  SPIKAI,  CORD  AND  UBDULLi.  OBLONOATA.  939 

■uut  bo  pud  to  tlia  regimen  aod  diet  of  the  patieot.  His 
work  dioald  be  light  aod  agreeable,  and  he  sbould  retire  to 
rest  at  ut  e«rly  hoar.  His  food  mtut  be  Qoumhing  and  easily 
digeaUbl*.  Alcoholic  b&vora£«8  may  be  allowed  in  moderatioa, 
ud  open-air  exefciM,  abort  of  fatigue,  should  be  ^Qjoioed. 
Sexual  excess  must  be  careAilly  avoided,  although  ooittoa  Dood 
»M  bo  eotireir  forbidden. 

With  rcganl  to  the  spocial  treatment,  a  moderate  hydropathic 
tnaUaeot  has  been  found  useful.  Chauge  of  air  to  a  raouataioous 
dtcttict  is  also  exccediogly  useful  in  promoting  recovery, 
SwitMrlaiMl  and  tbo  Tyrol  being  very  miitablo  places. 

Aa  aaoeoding  stabile  galvanic  current,  of  moderate  iutensity, 
ibould  be  applied  to  the  vertebral  columu.  Iron,  quinine,  and 
iniDe  are  tbe  most  lueful  internal  jemeiliea.  Chalybeate 
ore  uaeful  for  aoiemic  persona,  but  patients  who  are  scu- 
■tire  to  cold  should  at  firsl  be  suut  to  the  thermal  brine  baths. 
Sea  baths  ar«  useful  in  the  afler-treatmeat. 

Suoh  symptoms  as  sleeplessness,  pain,  spermatorrhoeia,  im- 
puteoce,  aud  digestive  disorders  mmt  be  treated  to  tbe 
ohib]  way. 

[IIL]  BKFLEX   AND  SECONDAKY   PASAPLEGIA. 

5&7.  It  has  long  been  knovn  that  paralysis  of  tbe  lower 
extremities  is  frequently  aa-wciated  with  geuito-unnary  diseases. 
Thaae  affections  were  at  one  time  grouped  together  under  the 
maattduriuartj paraiMjicE.  Brown*S^uard. however,  showed 
that  essentially  the  same  symptoms  might  be  set  up  by  irrita- 
the  dbeasea  of  the  intestiuc-fl,  and  other  organs,  and  on  the 
nppositioo  thai  the  purolylic  phenomena  were  caused  by  a 
reflex  HpiMn  of  tbe  spimd  veaacls  he  named  the  oficctioa  rtficx 
psroplc^ia.  Tbe  paraplegia  which  is  associated  with  discoset 
of  tlie  nhoary  organs  and  other  viscera  appeare  to  consist  of 
HTBnl  varietios.  Tbe  following  may  he  distinguished :  (1) 
Beooodary  myelitis,  caused  by  as  aacending  neuritis  of  the 
nervca  of  the  diaeoaed  organ ;  (3}  Functional  paralysis,  caused 
by  nine  roechaoism  not  yet  accurately  determined,  but  which 
'm  tbe  meaatirae  may  be  called  njUx  jxirapleifui ;  and  (3) 
Fanlyne,  ttused  by  direct  propagation  of  inSammatiou  from 


MO 


FUKCnONAL  ASD  SECONDARY   OISRASES  OF 


the  nerves  of  the  nrinarj  pasaagee  to  the  lombar  and  eacral 

plexuses  :— 

(1)  SeccmJary  ^g$liti4. — ^Tfae  dise&SBa  «bich  oatuJlj  cftUM  aM»DilM7 
njcliUa  are  gonorrbmc,  Btriotorft  of  the  unUiFa,  cluaoic  cyatitia,  ftmUtk 
ftbM«M,p79lci-nepbritiBaa«ociiitadwitbM]oalaa,Ukd  nepbrituL  Amhnk, 
■{niifil  piu-aly§it!  occiira  oiilf  in  chronic  affecUons  of  Um  urioary  [■■■jn 

The  sf  mptoms  are  usually  tboae  of  n  subacute  tnuivrorw  mjclitt^ 
situated  at  tbe  mi]>erior  part  of  Uie  lumbar  enlargemnit.  Tbej 
are,  briefly,  foraiicatiuu  a»i)  [lumbneia  in  tbe  lover  citreisitiMi,  girdle 
nenaatioD,  mud  IntcnuiiDsthiuiiacranalgceia.  Puspleginitisoon  crtabHabwit 
with  exCMs  of  tho  Kfl«i  actions,  but  theeo  baconie  diinininhMl  and  utb- 
mately  lo«b  w  tho  lumlNtr  oiiUrgeiuoQt  la  iavolred,  cysUtia  mai  bed-eoiM 
ttioii  foriji,  lUiii  HOOD  c&ua«  death.  lufluomatory  octiou  luay  at  ttctMs  ts* 
Wad  upwards  and  involve  tbe  upper  cxtremitiw  ia  tlw  pBrnlyaifc  It  lu* 
been  proved  experimentally  that  inflanunation  of  tbe  «ciatic  utxva  may 
cause  uyelitie  (TieMler),  aiiil  soreral  caaeo  are  rvcortlod  in  wbieb  i^iiiqr 
of  it  fajiB  been  Tolloived  by  mjeliti*  in  man.  A  cue  ia  reoovded  bf 
CuniU  iu  wliicb  tutnour  of  tlio  cauda  equina  produced  a  layetitia  of  ttm 
oenlral  grey  NiibHtitiiue  of  tlie  cord,  along  with  acleroaiB  of  the  [wiericr 
columue,  and  aimilar  cosca  bare  boaa  reoonled  by  Simon,  Laogc^  taA 
Leydeii  ;  a  cam  of  the  Idnd  baa  corn*  under  my  ova  obwrratlan. 
In  tho  cau  olrMdy  meatiouod,  ODder  tb*  etn  of  Dr.  Uorfuu 
a  aevere  iojury  to  the  aclatic  Derre  was  rolloved  hy  tli«  cympiloaM  «( 
subacute  ceutral  myehtte.  After  death  a  laicroaoopicai  erairiinrtlwi 
showed  perineuriLis  of  the  injured  sciatic  nerre,  centnl  myelitia,  nacfaiiig 
up  the  whole  length  of  the  curd,  aloug  with  gnj  degeuenttioB  ef  Um 
[Kwterior  columita  la  the  lumbar  aud  dorsal  rspotUv  but  limbdl 
to  the  coluiDue  of  QoU  io  tho  oerrical  rugiou,  the  porliou  wlucb  ad(i0tel 
tbe  posterior  commiMnure  beiug  heallhy  too  in  the  lumbar  legion. 

Iu  a  cose  related  by  Duiu^ml,  a  neuritis  of  the  saiatia  oam  «M 
followed  by  iiarajilegia,  and  at  a  hiter  period  by  par«lyaia  ef  oas  of 
the  iipycr  extremltiea.  The  paralvMid  inuaclea  became  alrojibicd  rnHk 
diiniiiutioa  of  tbcii  fkuudic  coutractility.  At  tbe  autopsy  llw  fftf 
tnatter  vu  found  diaeaaad,  while  tbe  white  aubataoee  was  una&neted. 
Charcot  doacribta  a  cn«  in  which  lesion  of  one  of  the  uerrea  of  the 
forearm  mu  tirst  followed  by  taflammabtioti  of  the  jiariiihenU  portioa  ef 
the  nerve,  atrophy  of  the  muaclee  of  the  band,  and  pooiphigoid  enptioim 
wliile  at  a  later  period  the  arm  of  tlia  <^po«ita  aide  was  affeetad  with 
atrophy  and  onaMttbeaia. 

(2)  Jlt/itj:  Parajilei/ia.—ht  this  foru  of  tbe  dtaeaae  tbe  paralyaie  new 
extends  to  the  upper  extreiuities,  while  tho  lower  extremitiss  an  only 
parutio,  and  uovm  oompletcly  iwittlyaed.  There  is  also  cotnplcte  absecM 
of  paius  m  the  luinu,  ^iriUu  pains,  dyatHthestn,  aQastbeau,  nnuoiihr 
temion,  and  coatraotiuve,  puralysia  of  tbe  bladder,  bcd-oorce,  aod 
other  troithic  distuibtsotai.     The  juralytio  ^ymptoDui  an  rariaUe  ia 


TUB  SPINAL  COBD  AND   UBUDU.A  OBLONQATA. 


341 


> 


llwir  iatcositj,  mad  nay  iiD|>r<>T«  ngtiilly  if  there  be  ad  Ameixliumit  of 
thf  feniiluTml  letiou  vbleh  is  the  cjuue  of  the  nSiKtioii. 

Brawa-S&jiurd  dbaarrtd  ihrni  Hjtttm  of  thft  hlltia  df  th«  kidnej  tu 
■lisiali  p*Qdneod  >pum  of  Hit  Toaads  of  the  spinil  oonl,  and  be  urgued 
that  the  panJjraia  which  ia  cMued  b/  diMOMs  of  tbe  urinary  vrguia  ie 
owiaftwri  bjr  aruwnia  of  tbe  spinal  card.  Obuvot,  on  the  oth«r  band, 
beliana  that  th*  p«h]ihei«l  irritation  [voduces  an  inhibitor;  effdeton  the 
ifMital  card.  lu  cbroaio  Briglit'i  disMae  tbe  &broid  chanfiea,  which  tbe 
iiaaal,  like  tbe  other  veeeela  of  the  bod;  undergo,  miut  oauie  atiromia 
aT  U»  aard,  whtob  ma;,  in  escepUooal  oan%  roaob  aucli  a  degree  m  to 
aaon  nata»  amount  of  iMmljrviB. 

(i)  Porifibend  pan];«ut  fr<tiu  eitonaion  of  DeiiritiH  from  the  nanrea  of 
tka  orinar;  orgaoa  b  rare.  Koasmaul  raporto  a  cam  in  nlucb  inflamma- 
Uaa  of  the  nrinai;  psHiagn  had  giran  riae  to  a  Dsuritis,  which  est«uiled 
In  the  Derm  of  Um  ncnl  aad  lumbar  pleioan.  Dnring  life,  the  [takient 
aaaijihuiied  <if  atwoting  iHina  alaug  the  couiw  of  ttie  aciatic  nerree,  while 
than  waa  paraaia  ot  the  lower  cxlroraitiea.  Paliio  atacBwaa  m%]r  mm 
tntammatiMi  of  the  aacrai  plexus  and  thiia  oeoanoD  pwaljaii  and  aona- 
«t  otw  or  both  the  lower  eitremities  ( Adanw). 


(TV.)   8ALTAT0BY   BPASU. 

^  55S.  Bamberger  first  described  in  18$9.  under  the  oamo  of 
aaltatorj-  apasm,  two  caMS  in  which,  as  sood  as  the  patients 
Kt  their  levt  OQ  the  floor,  the  lower  extremities  becatne  tbe 
•abject  of  such  strong  clonic  coiivuUions  tbnt  the  patients 
w«ra  tbrown  repeatedly  into  tbe  air.  Similar  cases  have  been 
rtpa/tt'ed  by  P.  Qutcauum,  and  A.  Frey  baa  recently  commnni- 
eit«d  *  cane  and  examined  the  nibject  in  detail. 

The  oamDioD  diaracteristic  of  all  the  published  casea  of 
lb«  atfoetioQ  ia  that  there  is  a  gnut  increase  of  redcx 
eicitmbility  io  certain  nerre  tracts,  w  that  on  the  sole  of  tbe 
foot  being  placed  ou  tlu>  flour  a  singular  spasm  occurs,  which 
baa  ibe  «tTeci  of  throwing  the  patient  repeatedly  into  the  air. 
Thoaa  spasmodic  contracttona  continue  as  long  sm  the  patient 
BMBtains  the  erect  posture,  aud  they  cauBO  ibc  patient  to  hop 
and  jump  on  the  floor,  and  render  him  quite  unable  to  stand 
•till  for  an  instant.  When  the  patient  sits  or  lies  down  the 
morem^nts  disappear,  but  can  bo  iimtantly  made  to  reappear 
by  tickliug,  or  preasing  on  the  eoles  of  the  feet 

In  saltatory  spoau)  the  reflex  mechanism  of  the  cord  is 
alano   affocted,  and  there    is   complete   absence   of  paralysis. 


344  FITMCTIONAL  AKD  8EC0XDART   DISEASSS  OF 

epliiDCtors.  Th«  paraplegia  usually  disappears  in  the  coone  of 
a  fow  hours,  and  gives  pl&oe  to  an  almost  complete  tntennisnon. 
Bcoompanicd  by  the  Appcuaace  of  a  critical  sweut.  Thi»  pn- 
asm  in  Topmtad,  iii  a  nioro  or  losd  regular  nuioner,  in  tbe 
quotidian,  terUan,  or  quartan  type,  and  the  affection  is  citlter 
«urad  or  favourably  intlueDoed  by  quinine. 

§  56+.  Aforbid  Phynioto<jy.—AXl  we  know  about  tbe  patbo- 
logj  of  this  affection  is  thai  it  is  in  all  probability  due  to  the 
malarial  poison  aiCtiug  ou  th«  spioal  cord,  but  of  its  mode  of 
action  we  Icdow  nothing. 

g  i>05'  DiafjnoaiiL — Tlio  iutormiltont  cliarocter  of  the  affec- 
tion readers  the  dif^nosts  eoHy,  and  the  treatment  is  tbe  same 
as  that  which  is  applicable  to  ail  forms  of  intermittent  fever. 

(Vn.)  TOXIO  SPINAL  FARALYfttS. 

§  566.  Opium,  belladonna, arsenic, pht^phorus,  lead,  mercury. 
carbonic  oxide,  sulphiiJe  of  carbon,  tobacco,  camphor,  ergot, 
alcohol,  ab-sintho,  muslirooms,  copaiba,  and  many  other  tozio 
ageutfl  induce  various  forms  of  motor  paralysis,  such  aa  para- 
plegia, paralysis  of  groups  of  muHcles,  or  of  single  extremities, 
and  general  paralynig. 

Permanent  paralysis  is  only  caused  as  a  nile  by  tbeaa  ageati 
when  the  organism  is  exposed  for  a  long  period  to  their 
iuHuence,  although  occaaioually  paralysis  may  result  fmm  a 
temporary  poisoDing. 

Absolutely  nothing  is  known  with  regard  to  the  nature  aul 
locality  of  the  lesion  caused  by  the  nu^ority  of  these  ageota. 
Laadouzy  has  recently  collected  all  the  raiioua  forms  of  pan- 
lysis  which  occur  iu  the  course  of  or  subsequent  to  infective  and 
other  acute  discasea,  but  ioaamoch  as  many  ef  these  are  not  of 
spioal  origin,  it  will  be  well  to  defer  their  ocvaaideratioii  at 
present.  This  subject  will  be  aobeequently  treated  in  greater 
detail. 

(VUL)  HYSTERICAL  PAKAPLBOIA. 

This  form  of  paralysis  will  be  described  at  greater  length 
hereafter,  and  is  mentioned  io  this  place  only  with  the  view 


346 


CHAPTEE    Vni. 


v.— TEAUMATIC  DISEASES.  TUMOURS,  AND  ABNOE- 
MALITIES  OF  THE  SPINAL  CORD  AND  MEDULU 
ODLONGATA. 


(LI  WOUNDS   OP  THB   SPINAL   CO&D  AHD   UEDVUJt, 
OBLDNQATA. 

Thb  ofTeclions  compmed  ia  ibis  section  &re  acute  trauaulk 
tesion  of  the  substance  of  the  cord  and  medulla  obloogxta 

§  5G7.  Etiology. — In  fractured  and  luxations  of  the  spinal 
column  the  iujur^-d  vertebra:  may  be  so  displaced  as  to  oote 
cotupruKSion  and  cruDtiiog  of  the  cord. 

Ounnbot  wounds  often  injure  the  spind  cord  eiiber  by  tfae 
entrance  of  the  bullet  Juto  the  spinal  canal  or  bj  fracture  of  Ui« 
vvrtcbriu.  Stabs  and  cuts  of  tbo  spinal  cord  arc  raro ;  but  abtfp 
ioBtrumonte  bavo  b>eeD  known  to  enter  tbe  cord,  the  point  of  tl» 
inatnimcnt  having  entered  the  canal  either  by  dirjding  tbe 
vertebral  arches  or  by  passinfc  through  the  intervertubnl 
spaces. 

Injuries  of  the  noedulia  oblongata  may  be  produced  by  a 
sharp  instrument  pieroinj;'  between  tbo  occiput  and  altas,  by 
ballets,  splinters  of  bone,  blows  on  the  back  of  the  ueck  without 
fracture,  and  oa  tlie  top  of  tbe  head  by  eoTttreeonp.  Fractures 
and  (1  islocations  of  tbe  BrHt  two  oervieal  vertebrae  are  also 
important  causes  of  wounds  of  tbo  medulbi  oblongata.  Dis> 
locaUon  of  the  first  vertebra,  or  rupture  of  tbe  odontoid 
ligament,  is  accompanied  by  a  backward  displacement  of  tbe 
odontoid  process,  wbicli  presses  against  the  anterior  sarfaoe 
tbo  meJulla,  and  causes  instaat  death. 


TRIUMITIC   mSEASBS   OP  THE  SPINAL  OOBD.  847 

§  568.  SympUyms. 

L  Womus  OP  TRK  SnxiL  Caaa. 

Tbe  »;mptoau  may  b«  subdivided  into  thoso  which  oro 

by  (a)  comparatively  slight  iojuriea  of  the  cord,  sucb  at) 

iple  incised  and  punctured  wounds;  and  (&}  tboae  which 

firom  tbe  more  serious  lesions,  each  as  compressioD,  cnish- 

Ig,  and  t«arit)g  of  tbe  cord. 

(a)  The  tiyraptoins  which  indicate  that  an  injury  by  cutting  or 
ftAbfato^  in  thu  Qiiighbourhood  of  the  spioo  has  pcDCtrated  the 
oonJ  wi[|  at  first  be  those  caused  by  losa  of  coaduction  to  and 
Krooi  tic  braia  in  the  portions  situated  below  tbe  sent-  of  the 
iojury.  At  the  moment  tbe  injury  is  reccircd  there  is  usually 
uotor  paralyaiii  of  various  extent  in  the  form  of  parapIegiA, 
btnU'panplegia,  or  gonemJ  piiralysia.  If  tbe  cord  he  com- 
plainly  divided,  there  is  complete  acjMthesia  of  the  paralyse 
part*;  bat  if  only  onc-balf  of  the  cord  be  divided,  the  sensory 
panJy>i«  hi  situated  oo  the  sido  opposite  to  the  injury  and  to 
tbe  motor  paralysis.  The  anesthesia  is  Botnetimos  partiaJ,  and 
if  the  leaioD  be  veiy  restricted,  hypem^sthciia  in  tbe  form  of  a 
^rdlo  is  present  If  the  injury  be  of  any  considerable  extent^ 
paralyns  of  the  bladder  nod  rectum  oociini,  and  there  is  also 
Taao-motor  paralysb  with  increased  teoipomturo  and  redness  of 
ifae  regiooa  affected  by  the  motor  paralysiH.  The  reflex  actJons 
■re  usually  abolished  at  &r»t  owinj;  to  the  shock;  but  if  tbe 
ItDoo  be  situated  in  tbe  dorsal  or  cervical  regions,  tbey  may 
aft«r  a  time  be  exaggerated. 

Oinlls  paios,  caused  by  irritation  of  the  posterior  roots  at  tbe 
mmt  of  iojury,  are  usually  present  After  a  time  tbe  symptomt) 
«f  Mcoodary  tmumntic  myelitis  complicate  those  caused  by  the 
primuy  leaiuD.  TUo  symptoms  of  irritfttion  now  appear,  such 
u  girdle  pains,  acliva  pains  in  tbo  paralysed  parts,  cutaneous 
bypeneathesia  of  rariable  extent,  attd  twitohings  and  spastna  of 
MMfle  muactos  and  groups  of  muscles. 

Wbeo  thu  ioflammotory  action  spreads  through  the  whole 
thtcknesa  of  the  cord,  the  paralysis  extends  in  tbe  traosTerae 
dircetioo,  m  that  oren  wben  the  wound  has  only  injured  a  imall 
pwtiM  of  the  treosrorse  diameter  of  tbe  cord,  complete  pu»> 
pisfu,  partpaoiwtbeaia,  and  paralysis  of  the  vaso-motor  paths, 


316 


TflAtmATIO  D13BA8I9  AND  ADKOBaULITies  OF 


Madder,  and  rectum  may  occur.  When  the  leaion  is  ntuated 
high  up,  disturbances  of  respiration  become  promineDt,  and 
various  nculo-piipillary  phenomeoa  and  raao-motor  disturbaoces 
of  tlie  head  nod  face  may  be  preseot.  At  a  later  period  bed- 
8or(»i,  cyytllis,  pya;mia,  and  eeptiaumia  Eupcrvcoe  with  alt  their 
deleterious  consequencea 

(b)  The  Bjinptoms  which  indicate  that  the  oord  ia  cnubed 
or  torn  in  severe  injimes  of  the  Hpine  arc  complete  parolrits 
and  aDsesthesiH  of  the  portion  of  the  body  below  the  seat  of 
injury.  The  roflex  uctious  arc  abolished,  there  are  retentioD  «l 
urine,  involuntaiy  evacuatioB3  with  cooatipation  and  metcoriiKn, 
paiofiil  erections,  and  eleracion  of  the  temperature  of  tb«  body 
below  the  lesion.  The  local  symptom*  of  injury  t«  the  apioe 
and  of  displacement  of  the  vertebr:t>  are  of  course  prcsenl. 
The  symptoms  of  acute  tr&umatio  tnyelitie  appear  \a  a  few 
days,  coQslfttiiig  of  bed-soroi  and  pysDmia,  with  their  usual  oon- 
aeqaenees. 

If  the  lumbar  region  be  crushed,  there  is  rapid  alropby  of  the 
muscles  of  the  legs,  with  loua  of  electrical  contractility,  and 
cystitis.  When  the  cervical  region  is  injured,  the  tetnperaton 
may  rise  to  an  eicesnive  height  (+3'— 44"  C)  (109°— Ml*  F.). 
In  Home  casea,  when  the  dor-wl  region  has  been  injured,  the 
temperature  has  been  abnormally  low  for  .some  days  befcwe 
death  (Nicder).  The  severer  cases  are  rapidly  fatal  by  paralyiis 
of  respiration,  while  death  i.t  caused  io  other  ca-^cs  by  acute 
bed-8ore8  and  pysemia.  In  partial  crushing  of  the  oord  tbo 
symptoms  run  a  milder  couibc. 

§  669.  Variaies. — The  «ymptom.s  vary  according  to  the  level 
at  which  the  leaion  is  seated. 

IT  tho  oord  be  injured  at  the  lord  of  the  first  or  aeoood  oenriok] 
vertebfa,  destb  usually  o<«ura  (it  atiee;  andwhsa  tba  Usioa  UaitostBd 
above  iho  origiu  of  the  plireitic  iicrvev,  renjiiratioii  is  o«klj  loaitituiwd 
by  the  forced  motion  of  tiui  auxiliwy  muiwlM  of  ini^lrttiou,  and  tb«  c*m 
tornimatoa  f«taUjr  in  a  brief  spooo  of  timn. 

rr  tUo  luaiou  bo  KiLiinLoil  ju  thu  corvidd  region  below  tba  ori^n  of  tb* 
l>lireuia  nvrvos,  tbe  orma  aro  partially  and  tbs  tegi  ooinpl«t«ly  pAralyiod, 
aDttitbesis  btiug  al»u  putial  io  th«  formor  and  ooinpl«t«  in  tb*  latter: 
iospintiou  is  porfomwd  by  th«  di&pUr^u,  expiralocy  acta  ara  laaUa, 
[uuoful  eractious  are  oftaa  praaeat,  and  life  may  be  pnlongod  Cor  aocna 
time. 


TBS  SPINAL  COUI)  ^-U  MlfDULLA  OBLOHOATA. 


349 


If  tbo  laaioD  be  Mtottwl  in  Um  dorsal  n£t(ni,  Iha  arms  reoiAiu  nn> 
tlfcttii,  the  miuelBs  of  the  trank  uid  lower  ertremitiea  ore  pftmI/*o<l 
fadow  lbs  Mat  of  tlte  laduii,  tlie  njilex  actiniis  euuti  beoutuc  exugijeratctl, 
|Mia(bl  crectioofl  we  rare,  tlte  bluUar  and  rectuat  may  after  a  time  becumo 
fMnljaed,  Kid  bed-florea  suiJerreua  with  their  usual  oiuiMiuenotui,  or  the 
MijnlttM  uaumea  *n  aaoeDding  ooiuw,  and  the  [intiuut  dien  from  MjibyxiK. 

If  tbe  leaiDD  ba  oituaiwl  inlbe  lumbar  n(iou,  the  aniu  andtUttgrBaUtr 
|iuvtiua  u(  Uie  trunk  OK  utiaRieuted,  tbelegi,bladder,and  rectum  iire  totally 
{lanljnml,  refiex  actioas  ol  all  kindii  arv  ftbviisbod,  tbara  an;  09  cndionai 
aiMl  th«  muadaa  of  th«  lownr  extreniititui  uudiirgo  rupid  atruphy,  with  tx- 
tiaotioo  of  their  elvotrioal  r«a«tion.  The  syrui^toau  AfinDg  from  loaioo  of 
tbo  caoda  aiuiiia  ara  immewhat  viniUar,  but  la  it  the  rcfloii  mpplied  by 
tba  luBtlur  plciu«  W  luiodectod. 

2.  Wofin*  or  tbk  Meovlu  OsLOKDATa. 

g  370.  If  tlio  injurj  to  cbe  medulla  bo  a  severe  acute  one, 

tbr  patieot  coUtipses  euj  if  struok  by  liglUQiag,  and  ilie^i  inatan* 

ibuioously.    Sumoiiraes  lie  giwa  uitcraace  to  a  piercing  cry 

foFD  falliogfOr  death  may  ba  accoinpatiietl  by  a  few  traaiulory 

imltioci^.      All   this   results  IVoin   middeD    paralysis  of  the 

■twpiratory  ceutre  and  cumplete  interruption  ol  all  the  cou- 

tlucting  pJittis  between  the  spinal  conl  and  tbe  brain. 

Wbeu  the  wound  is  leu  serere,  or  wheo  ibe  naedulta  is  only 
Jly  lacuruted,  the  affection  may  laRtforaomctimc.bnt  these 
too,  as  a  rnle,  terminate  suddenly.  It  is  probable  that 
lU  eomelimcs  surrivc  very  am&U  iojuriiis  to  tbe  medulla, 
Ik  tbu  IK  diOlcaU  to  prove.  Sudden  death  may  perhaps  some- 
timoe  occur  from  simple  concussion  of  Ibe  raeJulla  in  tbe  entire 
ftfa»eoce  of  any  Bcrious  IcKion. 

§  571.  Iforitid  Amtlomtf. 

Sifnple  inoised  or  panctu-red  ivounda  produce  injuries  of 
vanutia  ffizo  and  deptb.  Tbe  ed^'es  of  tbe  wouud  project  at 
first  beyond  tbe  pia  and  tbu  wound  is  cloaed  with  coagulated 
blood.  Id  a  few  days  tlie  edges  are  stilt  further  prouuded, 
while  the  neigbbouriog  parts  of  ibe  cord  are  wore  tx  Itm 
ifleoed,  and  the  mcrabr&uea  are  reddened  and  iuflaiiicti  and 
irsred  with  (ibro-puruleut  exudations.  In  aaimabi  at  least, 
Aod  probably  alau  in  man,  if  Ufe  be  presetred,  tbe  edges  of  iba 
wuuud  beal,  and  a  dcalrix  of  oonnecUvo  tissue  is  formed. 

Crwtftiiuj  pruduccs  sofleniog  and  liiaiutegration  of  the  curd, 


3aO 


TiUUMATIC   DISEASES  AKD  ABMOinULrriES  OK 


along  vitli  coDgeHtioo  and  hititiorrhage  into  the  membraii< 
The  crushed  spot  is  usually  flat  uutl  tlib,  and  the  u^dulUr; 
niihsiance  U  changed  into  a  dark  red  or  chocolate  coloured  iomi 
composed  of  blood  and  the  ddbrU  of  Derre-subetaoce.  The 
adjoining  porta  become  cougemtcii  aud  aub^ueotly  undergo 
iufhimiQutory  eoftouiag.  Tbe  micfxiacopo  fthows  gniuutar  cor- 
pusclen,  detritus  of  cnyeliiie.  decomposed  blood  corpuscW. 
piguicQt  atid  blood  crystals,  aud  r&maauta  of  gangttoa  cdk 
uloQg  with  iuflamoaalory  swelling  aad  disiotcgi-atioD  of  D«m 
hbree  aud  axis  cylinders.  Iq  a  few  weeks  the  cord  for  a  con- 
siderable distance,  both  above  and  below  the  injury,  uuderj[o« 
softening,  and  this  is  specially  apt  to  occur  in  the  lower  put  of 
the  cord.  AsceodiDg  and  descyudirig  seeoudary  degvneralion 
occur  when  life  is  prolonged,  and  in  several  OLses  fatal  within 
a  few  days  from  the  date  of  injury  I  have  found  decided  eri 
dcnces  of  a  central  myelitis  up  to  the  medulla  oblongata. 

If  tho  patient  live,  the  destroyed  nerve  tissue  becomei' 
abaurWd,  and  a  kind  of  cicatrix  is  formed,  which  may  eoclose 
cystic  cavities  coutuioing  clear  fluid.  Regoaeration  of  ncn'e 
substance  is  uot  known  to  occur  ia  man. 

Complete  ieveranee  o/  tfui  cord  occasionally  occurs,  ami  then 
the  pia  is  also  bom,  and  the  two  ends  of  the  cord  are  neparated 
by  a  considerable  space.  The  spinal  dura  mat«r  may  remaio 
uninjured.  Inilamm.itory  softening  occurs  as  after  cruebiog, 
uod  extends  more  or  le^s  upwards  and  duwawards. 

The  anatomical  chauges  found  iu  tho  medulla  when 
wounded,  lacerated,  or  crushed  resemble  the  acute  injuries 
the  spinal  cord. 


D 

] 


jbiog, 

"i 


§  57S.  Course,  Dut-ation,  and  Termination. — lo  siinple 
incised  wounds  of  the  cord  a  comparative  cure  may  be  effected, 
and  life  retained  for  many  years.  Fhysiologicul  experiment 
shows  that  auiiaaU  may  be  kept  alive  for  a  long  period  era 
after  complete  division  of  the  cord,  and  it  is  quit«  {voMible  that 
lesions  of  moderate  severity  may  undergo  repair.  As  a  rule, 
however,  the  secondary  myelitis  set  up  continues  to  iocroase, 
the  paralysis  becomes  more  complete,  bed-sores  with  all  their 
attendftui  evils  la^ktt  their  app«iirauce,  and  the  patient  dies 
after  protracted  suffering.      The  severe  forms  of  injury  to 


mS  SPINAl,  CORD  AND   MEDULLA  OBLONGATA. 


351 


spinftl  conl  &nt  alvajs  fatal.  Death  mny  takt:  place  a  few  houni 
or  dftjs  af^er  the  ii^uty  from  ahock  or  paralysis  of  reKpiration, 
bot  in  aome  cu««  life  may  l>e  protracted  for  maay  montlis. 

Acute  8CT«r«  lajUTy  lo  the  m«da11a  obloogat^  causes  iosianb 
doktb,  ADd  stigfat  iDJuries  are  exceediagly  daagoroua,  because 
tbc  iDHjunmatory  action  set  up  b;  them  gODcrultj*  t«&da  rapidly 
to  a  fetal  tertnioatioD. 

§  573.  Dioffnosis. — In  the  case  of  a  wonnd  of  tbo  pin  mater 
the  occurreDcc  of  raeDiogeal  bai^morrbago  might  give  rise  to  the 
kleft  of  injiLTj  of  tbe  cord.  lu  meningeal  btt-morrhage,  however, 
tb*  symptoms  of  irritation  are  very  proraiuoDt  at  tlie  outset, 
while  those  of  putalysis  are  less  severe  thaa  iu  injury  of  the 
cora. 

Hamatomydia  induces  a  certain  amount  of  crushing  of  tbe 
uord,  and  gives  rise  to  similar  ftymptoms,  but  in  it  there  is 
osoally  no  history  of  external  injury,  and  when  ttierc  is,  the 
diacnosia  between  the  two  affectjoua  iti  not  of  much  cousei)ucnco. 

Owea  of  severe  (Wneu«n<7ii  of  the  uord  may  usually  be 
rcoognised  by  tbe  absence  of  a  clear  domaicaUon  of  tbe 
aanstbeaia  aad  paIalyri^  and  by  tbe  absence  of  bed-sorce,  and 
oUutr  trophic  changes.  If  dislocations  of  the  vertebrK  are  found 
to  exist,  cmsblag  of  tbe  cord  is  more  probable. 

JS  57*.  Prognoaia. — la  all  the  severer  forms  of  injury  tbe 
pragnocis  ti  exceedingly  unfavourable,  but  in  cases  of  partial 
tajUTy  and  simple  incised  wounds  a  certain  amount  of  r«oovery 
may  take  place.  Sudden  injury  to  tbe  medulla  oblongata  is 
ahnost  uoironnly  futai. 

S  fiT5.  }Vwitm«nt. — Tbo  associated  traumatio  myelitis  must 
be  treated  according  to  the  principles  applicable  to  other  forms 
of  acute  inflammation  of  the  cord. 


(XL)  m/)W  COUPBESSION  UF  TUE  SPINAL  CORD    AND 
MBUtTLLA  OBLONGATA. 

§  576.  In  all  the  legions  comprised  under  this  section  au 
vxtenal   force  slowly  and  gradually  compresses  tbe  cord  or 


3.52 


TIUUHATIO  DI8KABB8  AJiD  ^DKOnX&LITIBS  OT 


medalla.  oblongata  in  a  limited  longitudinal  exMnt,  giving 
to  cbaracteristic  gruups  of  s^mpLonu. 

§  577.  EHofogy. — Any  circumtttaitce  which  gradually  □aixovs 
tbc  .ipinal  caual  and  leads  to  a  slowly  increasing  comprcfBiaB 
of  the  cord  may  become  a  cause  of  myelitis  by  compreanoa 
Such  compreasiou  may  be  caused  hy  niciiiugcsiU,  porimeuii^Ml, 
and  intramcditilury  tumouns  inliammatory  and  hKOiorrlu^c 
processes,  and  parasites.  Diseases  of  the  vertebra!  ooluaui, 
OHpcciuJly  caries  of  the  rertobro;,  couelitutc  the  most  inaporlant 
causes  of  comprcesion  of  the  cord,  and  may  produce  pre&ture  oa 
tbecord  in  several  ways.  The  wutiugaudaiokiDgof  tlicbodiM 
of  the  pcrtebnu  produco  kypboeia,  which  may  narrow  tfao  rer- 
tt-'bral  canal  to  sucb  an  extent  aa  to  compress  the  cord. 

In  oaries  of  tbe  vertebrsB,  however,  comprex^on  of  the  cord  vt 
generally  produced  by  the  extension  of  tbe  inBammatory  proeen 
iu  tbe  bone  to  tho  spinal  meiobraaea.  The  irritation  cauoed  by 
tbe  dis«aii(id  vertebnu  and  especially  by  accumulations  of  put 
produce  a  pacby meningitis,  bo  tbat  the  outer  layers  of  the  dura 
are  changed  iutu  a  thickened  mass  of  young  fibro-plaalic  tissue, 
which  either  surrounds  tbe  dura  like  a  ring  or  prwsea  it  taaa 
oue  aide.  TUu  nerve  roots  are  also  involved  in  tbe  morbid 
proceaa,  and  become  more  or  less  thickened,  awolleu,  and  in* 
flamed.  Tbe  cause  of  pressure  may  be  deposits  of  oueoua 
pus,  displaced  fragments  of  bone,  or  protruding  inteivertebfai 
cartilages. 

Carcinoma  of  tbu  vertebrae,  whether  primary  or  aeooDdaiy, 
causes  compression  of  tho  cord  when  it  grows  into  the  tct- 
tebral  canal.  The  form  of  compres^on  myelitis  known  ai 
paraplegia  dolorosa  with  most  acute  pains  is  then  developed. 

Amongst  other  diseases  of  tbe  rertebrte  which  oocaaonally 
cause  oomprestiioa  of  the  cord  may  be  mentioaed  exottoM^ 
syphilitic  now  formations,  dry  arthritis  of  tho  vort 
tbickening  of  tbe  odontoid  process  of  the  axis. 

External  tumours  of  all  kinds,  such  af)  cnrcinomata, 
mata,  aneunams,  and  ccbiuococci,  growing  ag^nst  the  Tcr 
bral  column  and  entering  the  vertebral  canal,  occasion  com- 
pression of  the  cord.  When  tbe  gradual  cuupreesioo  gives 
rise  to  traDSTerse  myelitis,  another  cbamctchsiic  group 


THE  9P1K1L  CORD  AKD  UBDULLA  OBLOlfOATA. 


1iS5 


aad  irritatiOD  of  the  inner  nde  of  tlia  tbigfa  baa  been  known 
to  prodoce  erections  of  the  penis. 

7%<  aentory  disturbatuea  ar«  not  usually  bo  well  marked 
M  tbe  motor,  aad  complete  ano-stbcaiA  of  llic  paralysed 
ptLTti  U  raro  in  vertebral  carieo.  Cancer  of  tbe  vertebral 
oolnnui,  growing  into  tliu  Hpinal  canul,  in,  bowevcr,  accompanied 
hf  pains  of  intense  severity  (Charcot).  These  paina  consist 
uf  a  Mvere  girdle  pain  and  pain  radiating  along  tbo  distribu- 
tion of  oerUin  nerves,  as  the  crural  and  sciatic  nerves  when 
tbo  Ituabar  vertebne  tire  aifected.  The  skin  to  wbicb  the 
AJIeeted  nerves  are  distributed  is  intensely  hypeni^sthetic.  so 
that  .tbe  slightest  touch  is  painful.  The  paios  arc  conatautly 
prateDt  but  are  liable  to  paroxysmal  exacerbations  of  inteose 
MTehtj,  which  are  difficult  to  all-iy  even  by  large  doaes 
of  narcotics.  Patches  of  aofpsthcsia  may  be  observed  in  the 
•kia  to  which  the  affected  nerves  are  distributed,  while  tbe  paia 
•tiU  ooDtinuea  unabated  (rnvrstfifulii  liolortyaa).  Tbe  »ymp- 
toina  of  ooniprcaaioa  of  the  cord  are  after  a  time  superadded  to 
tbsM  aensory  disturbances,  and  then  the  condition  has  be«a 
caiXnA  pirtipUgvi  doloro«i.  Ou  local  examination  of  the  ver- 
lebnl  column  an  excurvation  of  the  spine  may  be  observed, 
the  spinous  processes  iu  ibis  region  may  be  exceedingly 
to  pressure  or  percussion.  Itiaamucb  as  cancer  of  tbe 
nrtabral  cotnoia  is  always  secondary,  the  presence  of  a  can- 
cerous  tutnonr  in  some  other  part  of  the  body,  or  of  the  can- 
oeiDOS  cachexia,  greatly  aids  the  diugnoais. 

Trophic  dudurfxinoes  are  not  promineoi  in  compression 
myditia  When  the  lumbar  or  cervical  enlargement  is  affected, 
or  vben  secondary  infiammatiou  of  the  grey  substance  ostouds 
opwanla  or  downwards  to  these  parte,  the  nauscles  of  the  cor- 
raspoDitiDg  eztremitiea  undeigo  rapid  atrophy,  attended  by  loss 
«(  faniic  coatr&ctility  and  tbo  reaction  of  dcgcDcmtioo.  In 
•one  CMM  A  few  of  tbe  muscles  become  atrophied,  while  others 
ondcfgo  ooDtracture.  An  eruption  ef  herpes  sometimes  en- 
fioelei  one-half  of  Ibo  body  on  .a  level  with  the  lesion.  In 
saWB  eases,  and  in  the  terminal  period  of  ordinary  cases, 
bed^floras  and  cystitis  supervene,  with  their  usual  deleterious 
eooaeqnences. 

Tbe  sabeeqnent  wnHw  rrf  tkm  diaaase  is  not  uniform.    The. 


356 


TRACTHATIC  DISEASES  AND  ABHOIUULITIES  Vf 


less  serere  cases  contiaue  for  a  long  time  without  change,  bat 
aftenranls  improvement  majr  gradtully  take  ploccL  The  aiis*- 
thesia  first  diminiithea,  the  functiooA  trf  the  bladder  are  better 
regulated,  aiid  after  a  time  motor  power  gradually  retunia.  Is 
severe  cases  the  symptoms  grow  won«,  the  paraplegia  beconm 
complete,  the  bladder  and  rectum  are  paralysed,  cystitia,  bed- 
sorea,  and  pyaemia  aupervene,  aod  mod  cause  death. 


§  679.    V^aridiea. — ^Tbe  symptoms  diflfor  considerably 
ing  to  the  nitoation  of  the  lesion. 

(a)  CoMpreuion  of  the  Cenricd  Bt^iMt  of  tfc«  SpxnaX  C>rd,— Wfial 
K/ipcr  pnrf  of  ik*  cervical  n/fUM  is  KlTocted  the  diaeaM  oRea  befiaa  ij 
pun  in  tb«  occiput,  atilTiiMA  of  the  wholo  uock,  obliquity  of  th«  heW,  uii 
iaaliiUty  to  dcxI  or  to  rotat«  the  head.  Tlio  pRpralratn  oft«n  begins  in  tlw 
ui>p»r  extremities,  whil*  the  lower  we  wholly  or  compuratiTtly  aatlFtetti ; 
hut  at  a  later  period  the  axtrenutioa  become  paralywd,  tbo  re6«x  actms 
1>«iDg  exaggerated  id  all  the  extremities.  Paralytie  myona  or  sfMilie 
rajdriaaia  may  be  preoeut  on  oae  or  on  both  aidwi.  Other  symptoms  vfalelt 
have  bean  observed  are  repeated  vomitiag,  difficulty  of  snraUotring,  iBoca- 
eatit  hiccough,  rttturdatiijri  of  the  pulae,  which  may  heat  only  4^  to  SO  tlaie* 
In  tbo  minute,  fainting  fita  with  temporary  arrest  of  ths  heart's  aetiati, 
aud  oocksiciially  epileptic  attiicWa. 

If  tbe  ctrvtcal  mJargfintnl  be  affected,  the  ioitial  sytoptoma  t^  pain, 
aiiiosthiisia,  S|Hwra,  paralysis,  aud  atrophy  are  localised  in  the  Qi^per 
extremities,  aud  the  syiripLuiux  ap|wiir  iu  the  lower  eitrvmitias  at  a  talsr 
period.  Ooulu-pupilhtrf  s/mptvios,  disturbuioos  of  napintion,  and 
retarded  [lubKe  may  also  oc4:ur.  Reflex  action  ouy  be  abolhlMd  in  tlis 
upper  extremiUea. 

(fr)  Ci>myretiion  of  th«  Doraal  Rtgvm  of  iht  Cord. — The  dontt]  regwo  IS 
the  most  ftoiiueDt  seat  ol  oumpTesaioiL  The  symptoms  are  girdle  pains, 
iot«rooetal  neuralgia  at  difibroDt  levels  of  the  Irualc,  panplegia  np  to  th« 
oorrsapODdin^  level,  reflex  actiooa  in  the  lower  eztrtiaities  retained  or 
iucreased,  aud  the  uutritioa  of  the  muscles  and  their  clecthc*!  excitaUIi^ 
ijormaL 

(e)  Cov^prtisUm  of  lh«  tvmAar  Reyion  of  thi  Cord. — If  the  lumbar 
region  be  aifootcd,  the  paralysifl  is  contlaad  to  the  lower  eitremitieo, 
blddder,  acid  rsctum.  The  iuitial  symptonia  are  locahsed  in  ttie  lower 
eitnMuitice,  whom  reflex  ncttoiia  are  abolinhnlt  a»d  the  muscln  are  par 
maiieiitly  rvlaied  and  atrophied  and  exhibit  the  reaoliou  of  d^etMratksi. 
If  ouo  lateral  half  of  the  cord  be  compressed,  the  Gharaoteristic  syiaptom 
of  Brown  SS^uard's  uoiUtera)  lesiou  appear. 


THE  SPINAL  COKD  AND   UEDCLLA   OBLONGATA. 


357 


t.  Slow  Ooxraxsatox  or  tbi  IKiimiua  Obloxqatx. 

The  iDitJAl  aymptonu  are  caused  bj  irrit&lioD  aniJ  subsequeot 
lytnA  of  tbe  rootfl  of  the   nerves  of  the  medulla  and  pons. 

boM  of  iniLatioQ  first  show  tliemselves,  coDsiatmg  of  Deural- 
gifoTm  pains  in  the  region  of  the  trigeminutSw  either  on  one  or 
both  sides,  ani)  buzzing  id  the  ears.  The  motor  irritative  symp* 
toEos  consist  of  twitchiogs  of  tbe  facial  muscles,  transitory 
tfunpa  ID  the  tongue  and  lips,  and  occasioaully  clonic  or  tooic 
contractions  io  the  extremities.  When  the  medulla  oblongata 
in  teriously  compressed,  epileptlforat  conrulsions.  romitins;,  diz- 
BoesB,  and  hiccough  arc  produced.  The  socond  stage  is  ushered 
to  by  pandysis  of  the  seoaoty  and  motor  nerres.  There  may 
be  aniestheaia  in  tiie  region  of  the  trigeminus,  often  acoom- 
pftnied  by  intense  pain  and  neuroparalytic  ophthalmia.  There 
may  be  loss  of  taste,  or  deafness  on  one  or  on  both  sides,  and 
oa«  or  more  of  the  cranial  motor  nervt^i  may  be  panilysed,  while 
tbe  par«lyied  muscles  undergo  atrophy,  loee  their  fnradic  con- 
tractility, and  mauifvst  the  reaction  of  degeueration.  After  a 
tioie  a  true  bulbar  pxmlyxis  appears,  the  extremities  become 
pavalyKd,  and  disordere  of  respiration  supervene.  The  symp- 
tMU  b^n  aometiroes  so  suddenly  aa  to  simulate  embolus  or 
tliTDmbonH.  These  acute  symptoms  are  caused  by  a  rapidly 
dftTelopine  bulbar  myelitis,  or  by  a'dema.  thrombosis,  or  hB:mor- 
rhage.  The  optic  nurvcs  arc  not  affected  unless  the  tumour 
b*  of  laigD  sise,  and  probably  then  only  when  it  ts  accomptuiied 
by  ^iudoo  into  the  ventricles  of  the  brain. 


§  iSO.   CouT«f,  Dur^ion,  aiui  Terminaiicn.— -The  course 

tba  disease  depends  on  the  naturo  of  the  primary  lesion. 

and  intra- medullary  tumours,  ax  well  aa  carcinoma 

!0(bar  BuJigoant  tumours  of  tbe  vartebne,  are  always  TolaL 

.  most  cases  of  rertebral  caries,  on  tbe  other  hand,  the  course 

compeiatively  favourable.      Many  cases,  however,  progress 

slowly  with  remisnons  and  exacerbations  to  a  fatal  t«nniDation. 

Id  other  caset  the  recovery  is  incomplete,  partial  paralysis, 

oooUactureK,  muscular  atrophy,  and  ansegthesia  remain,  and 

rebpaee  we  freijuent. 

§  &81.  Morbid  Anatoimy. — The  meninj^ea  are  often  hyper- 


SoS 


Tni.UUATIC  DISEASES  AXD  ABS0R3IAL1TIES  OF 


lemic,  opaque,  and  adbcrent  to  tbe  neigbbotiriag  parU,  oc 
covered  with  deposits  of  various  ttiickness.  Tbe  nerve  nou 
mikj  he  c\ose\y  united  vritb  tbe  tumour  or  exudation.  At  fint 
tbey  are  swolteu  aud  hypenemic,  and  theii  Ghna  are  io  a 
state  of  fatty  ilcgcncratiou.  At  a  later  period  the  roots  an 
atrophied,  pale  grey,  degeDerated,  and  nearly  reduced  to  COB- 
oective  tissue. 

Tbe  aub&tance  of  tbe  spinal  cord  is  rendered  more  or  lesi  flat 
and  tbiu  at  tbe  point  compressed,  and  it  may  bo  reduced  to  tke 
size  of  a  small  quill.  The  compression  is  sometimes  greater 
anteriorty,  somolimcA  greater  posteriorly,  at  other  times  from 
one  or  other  side,  eo  tbnt  tbe  cord  assumes  a.  di8tort«d  and 
irregular  appearance  The  compressed  spot  variea  in  length, 
and  is  usuntly  softened,  although  it  may  bo  sclerosed  in  long- 
standing caaeB.  In  chronic  cases  the  usual  ascending  and 
descending  changes  occur  above  and  below  the  level  of  th^H 
lesion.  ^1 

A  micFOJit-oplcal  examination  of  tho  spinal  oord  reveals  the 
appearances  which  usually  characterise  a  chronic  inteisttliiJ 
myelitis.  In  addition  to  the  characteristic  phenomena  of 
ascending  and  descendiag  sclerons,  a  myelitis  of  the  oeDtral 
grey  Kubstance  may  often  be  discovered  for  a  considerable  dis- 
tance abovo  and  below  the  seat  of  lesion.  In  favonrable  cues 
restor&tion  and  almost  complete  recovery  may  take  place,  anil 
ooDsequeptly  the  nerve  elements  must  be  to  some  extent  restored 
at  ttiu  point  of  comprestdon.  Charcot  and  M  ichaod  examined  ft 
case,  fatal  from  other  causes,  in  which  recovery  from  compresston 
myelitis  had  occurred.  Tho  transverse  section  of  tbe  oord 
at  tho  scat  of  compression  was  much  smaller  than  the  other 
portions  of  the  cord,  and  looked  grey  and  degenerated. 
Microscopical  examination  showed  that  there  vras  an  exeeaof 
connective  tissue  at  tbe  seat  of  compression,  through  which  a 
considerable  number  of  normal  though  slender  nerve  fibres 
passed.  The  grey  substance  was  much  reduced  in  size,  bot 
some  henlthy  ganglion  cells  were  observed  in  it.  It  is  probaUe 
that  the  axis  c)'liuiler8  of  all  the  fibres  were  not  destroyed,  and 
that  they  bad  assumed  a  new  medullary  sheath  on  the  pressure 
being  removed. 

The  medulla  oblongata  may  be  Battened,  either  on 


THE  6PIXJLL  COmi  AND  MEDULLA  OBLONGATA. 


359 


both  sides,  turned  on  its  axis,  and  distorted  in  various  ways. 
Xba  tiiSDe  aS  the  laedulla  is  antemic  and  aofleoed,  while  cxtza- 
TanUooa  of  blood  arc  ofteo  observed.  The  roots  of  the  craoial 
B«rT«8  may  b«  oampresaed  aud  flattened,  aud  the  ocrvct  tbcn 
nodergo  degeoeratlTe  atropby.  The  pyramidal  tracts  of  the 
htetml  columns  and  tho  coIqidds  of  TUrck  may  uodergo 
deMeDding  dcgcncratioa  throughout  the  eatire  leuj^h  of  th« 
■pioal  cord. 

y  £82:  jyiagnons. — The  initial  symptoms  caused  by  com- 
pnMJOQ  of  the  roots  of  the  nerves  are  of  importaace  in  the 
diagnosis  of  the  afleotioo,  and  in  ordinniy  cases  confirmatioQ  of 
Uut  fUaguosis  will  be  obtained  from  tbe  external  appearances 
praisDted  by  tbe  primnry  disease.  In  Pott's  currature  the 
gradual  formation  of  angular  kyphosis,  and  tbe  history  of  the 
oaae  generally,  aitbrd  indications  of  the  nature  of  the  affection 
which  are  unmistakable. 

Id  carcinoma  of  tho  vcrtebnu  the  girdle  scnsutiou  and  other 
Moantric  pains  are  of  the  most  agonising  severity;  ihey  occur 
in  Bociiimal  paroxysms,  and  great  hypera>«thc«iii  usiiaily  exists 
in  tbo  painful  region.  If  primary  cancer  can  be  fonod  in 
uotber  organ,  or  there  be  a  gcnoral  cachexia,  the  diagnosis  will 
be  loH  di£Scu]t. 

The  recognition  of  the  rarer  causes  of  compression  of  tbe  cord, 
■neh  aa  exostoses,  syphilitic  new  formations,  and  aneurisms,  is 
nadc  from  tbe  general  symptoms  of  the  respective  diseases. 

Slow  compression  of  the  medulla  oblongata  may  be  suspected 
when  symptoms  of  irritation  in  the  rejrions  of  distribution  of 
■Ckme  of  the  bulbar  nerves  are  followed  by  those  of  sensory  or 
BoboT  paralysis,  and  when  electrical  examloalion  shows  that 
the  motor  paralysis  is  of  peripheral  origin.  The  diagnosis  is 
s^t  further  confirmed  when  the  patient  suffers  from  giddiness, 
violent  beadacbe,  severe  vomiting,  epileptoid  convulsions,  and 
vben  twitching  and  subsequent  paralysis  and  coDtxactures  occur 
in  tb«  cxtxemities,  more  especially  when  tho  distribution  of  these 
in  the  latter  is  uuHymmetrical.  Oases  of  compression  of  the  an- 
terior pyramids  of  the  medulla  may  closely  resemble  spastic 
qaval  paialyaia.  The  points  of  distinction  between  tho  two 
■ffiwty'nf  an  that  tbe  paralysis  begins  suddenly  In  compression, 


360  TRACTHATIC   niSUBEB  AND  JLUNOHUALITIKS  OF 

tbo  upper  OKtromities  Are  usuftll;  affected  before  the  tow«r, 
and  bulbar  para.1;sts  sooner  or  later  superveuee ;  while  in  spastic 
paralynis  the  coinmencemeDt  of  the  paralysis  is  slow  ani] 
gradual,  the  lower  extremities  arc  usually  affected  before  the 
upper,  and  bulbar  symptoms  probably  never  appear  in  primaiy 
lateral  scleroais. 

§  £83.  Prognosi*. — In  most  casen  of  slow  comprewdoQ 
cord  the  prognosis  is  uufavourable.  Cases  due  to  the  presnr* 
of  syphilitic  formationa,  peri-meningeal  exudations,  and  verte- 
bral  canes  often  recover.  In  young,  well-nourixhed  persoDi, 
who  are  not  scrofulous,  recovery  with  slight  deformity  of  Uie 
rortebral  column  gcncially  takes  place.  In  many  coses,  bow- 
ever,  recovery  is  imperfect,  and  a  certain  amount  of  paralysia  of 
the  loner  extremities  with  contractures  remaina. 

The  prognosis  of  slow  compression  of  the  medulla  obloo; 
is  always  uufavourable. 

§  SHi.  Treatmtnt. — Id  severe  caaea  the  treatment  most 
altogether  palliative,  and  directed  to  tbo  relief  of  paiu 
other  diacomforta. 

The  moat  promising  cases  for  treatraeDt  an  those  of  Pott 
disease.  In  them  rest  in  boil  for  months  is  Deceasary,  in 
to  maintain  the  spine  in  a  condition  of  repose.  Various  kinds 
of  iipparatua  have  been  used  for  the  support  and  protectioa 
of  the  spina  The  boHt  appnratus  consists  of  the  plaster  of 
Paris  bandage,  introduced  by  Dr.  Sayre,  but  I  must  refer  the 
reader  to  surgical  works  for  a  full  deacriptioa  of  the  metbod 
of  application. 

The  internal  treatment  should  be  that  adapted  to  serofulc 
patients  generally,  consisting  of  fresh  air,  cod-liver  oil, 
iron,  and  quinina     The  hot  iron  has  been  recommended 
Charcot  and  otherti  to  be  applied  every  two  weeks  on  each  side 
of  the  curvature. 

In  slow  compression  of  the  medulla  oblongata,  treatment : 
of  very  little  avail,  unless  the  case  bo  one  of  caries,  or  sypliititic 
tumour. 


TBB  SriKAL  COKD  AND   HBDDUA  OBLONGATA. 


361 


(CIl.)  irEMIPLBGlA  KT  HBUtPARAPLEOlA   SPIKAUS. 

Unii^tral  Lenon  of  the  Spinal  Cord. 

^  SSS.  IkJtnUion. — Tbe  s/inptouu  wbicL  are  grouped  to 
gether  under  the  nnme  of  unilateral  npinal  paraljrsis  are  mainl/ 
cbttncterisad  hy  uuilater&l  motor  paralysis  and  tiypenestliMia 
OD  tbe  aida  of  the  Wioa,  ansstbAsia  on  the  opposite  side;  and 
IogaI  syraptoms  caused  by  implicattoD  of  the  nwta  of  the  nerres 
oa  a  level  with  tbo  primary  IckIod. 


§  586.  Etiology. — The  Bjmploins  depend  not  upoo  the  nature 
of  tbd  leaion,  but  upon  its  localisation  in  one  lateral  half  of  itie 
CplDjU  oord,  BO  that  it  is  unoeceeisary  to  give  a  detailed  account 
ufall  the  caiwee  of  the  affection.  Tbe  pcnelratioa  of  the  ver- 
tebral caDftl  hj  pointed  instruments  constitutes  tbe  most  frc- 
qqe&t  cause.  Compression  of  tbe  cord  from  meningeal  tumours, 
fiMctam  or  dislocation  of  the  vertebra-,  meningeal  birmorrbage, 
tDtra>medullary  tumours,  bs^morrhage  into  tbe  subxtaoco  of  tbo 
cord,  and  circumECribcd  sclerosis  may  also  give  rise  to  the 
<ymptomi  of  unilaleral  spioal  paralysU. 

§  5H7-  Hym-ptiOTM. — The  symptoms  of  unilateral  spinal 
paralysis  may  be  developed  iusidiously  and  gradually,  or  t^uite 
•tMidenly,  tbo  mode  of  invasion  depending  of  coureo  on  the 
nature  of  the  lesion.  The  most  prominent  feature  of  the 
affection  ia  a  motor  paraly-slR,  which  is  uniiatemi,  and  vhicb 
maj  ooly  involve  one  leg  (hemiparaplegia),  or,  if  tbe  lesion 
b«  aittmted  high  up,  may  aUu  implicate  the  arm  of  the  same 
aide  (apiual  hemiplegia).  The  muscles  on  tbe  paralysed  side 
asaolly  aodergo  early  and  rapid  atrophy,  and  their  faradic 
etatabilitr  ia  dimiaisfaed.  The  aido  opposite  to  the  seat  of  tbe 
laaion  la  either  free  from  paralysis  or  is  only  affected  to  a  slight 
degree. 

Efid«ao«  <]/[  vcuo-tnoior-paralyaia  arc  generally  found  on  the 
tiiie  of  the  letioo,  especially  if  tbe  affection  has  been  rapidly 
dareloped.  Tbe  temperature  of  tbe  paralysed  limbe  is  usually 
raised  to  the  cictent  in  18°  F.  or  more,  nltltougb  it  may  be  tower 
than  natomJ  when  tbe  disease  boa  existed  for  some  time. 


3»;2 


TRAUMATIC  DIBKASRS  1X0  ABN0BUAUTLE3  OF 


AfusciUar  wnsibUUy  and  imtacidar  $enae  are  osually  dinu- 
Dishecl  un  tbe  affected  side,  but  all  torms  of  cutaoeoiu  MosibUi^, 
instead  of  being  dimioished,  are  grxmtly  increased.  Impresaioiu 
of  toucb,  temperature,  and  pain  are  felt  with  great  acutonesB,  aad 
there  is  an  iacreasod  power  of  localiaiDg  tactile  seDsattoos.  At 
tiroes,  however,  the  hyperajsthesia  is  Hnaited  to  a  few  only  of  tbe 
forms  of  cittaneoiu  seu&ibility.  The  hypericathetic  region  of  skia 
is  usnally  bounded  fay  an  anfestbetic  zone,  which  corrMpondi  with 
the  height  aud  loogitudinal  extent  of  tbe  lesion  in  the  tpinal 
cord ;  and  a  narrow  bypora-sthetic  zone  which  extends  to  tba 
opposite  side  may  sometimes  be  detected  abore  the  anicitbetie 
bolt  The  state  of  reflex  actioa  on  tbe  paralysed  side  varios. 
It  lias  beeD  found  iticreaited  by  Paoluzzi  and  Rlegel,  tod 
diminished  by  Brown -St^quard,  Bozire,  and  others.  Not  many 
obitervations  have  hitherto  been  made  with  respect  to  the  ftatt 
of  tbe  reflex  irritability  of  the  teudoDS,  but  Erb  found  U  in- 
creased  in  one  ca.se. 

There  either  are  no  motor  disturbances,  or  they  are  only  of 
slight  degree  ou  the  side  opposite  tbe  lesiuD.  and  both  tbe 
muscular  sense  and  tbe  electromuscular  scnsibilitjare  retaiDed. 
There  is  more  or  less  complete  ausjstbeua  of  the  skin.  Some 
forms  of  sensibility  may  at  times  be  involved  to  a  greater 
extent  than  othere.  Tbe  aoieathesia  extends  to  tbe  median 
line  of  the  body,  and  it  is  ofteu  bounded  above  by  a  aligfaUy 
bypenoathetio  region,  corresponding  to  a  mmilar  zone  on  tb* 
opposite  side.  There  are  no  vaao-motor  disturbaocea  od  tbi» 
side,  and  reflex  action  is  usually  normal,  although  it  hoi  ooea- 
sionally  been  found  increaaed  (Brown-Sdquard).  Tbe  patieot 
sometimes  complains  of  a  painful  feeling  of  constriction  ua  a 
level  with  the  le«ion,  along  with  various  painful  sensations,  soeh 
OS  burning,  darting,  and  boring  pains,  which  may  at  times  bt 
more  prominent  on  the  aaipstbetic,  at  other  times  on  ibe  byper- 
Ksthetic  and  paralysed  side,  and  occasionally  oocors  on  botb 
sides.  Acute  tmumatic  cases  are  usually  associated  at  fint 
with  retention  or  incontinence  of  urine,  but  afler  a  time  otdy 
a  certain  amount  of  weakness  of  the  sphincters  of  the  bladder  and 
rectum  remains.  Tbe  sexual  funclJoiis  are  at  times  uooiFected, 
and  at  other  times  more  or  less  weakened. 

Acute  bed-soru  may  appear  on  the  aaicatbetio,  and 


THE  SPINAL   CORD  ASO  BfEDDI.LA   OBLONQATA.  9Qi 

nation  of  the  knec'-jolnt  on  the  pamlysed  side,  white  wcll- 
markod  ataxia  may  be  obflerved  on  tho  cotum  of  motor  power 
in  the  paralyied  teg  (Joffroy  and  Sotmoa). 

§  5S8.  Varietia  of  Oniiateral  ParalyaU. 

Tbe  nrmptoms  differ  ooDsiderahly,  acconliog  to  the  level  at 
which  the  lesion  a  situnt^d  ia  the  cord. 

(1)  la  ft  ouUtend  lenou  of  the  lumtfar  tnt-trytJHcnt  of  the  cord  as 
■  wiMii  Ml  EODe  nuj  be  fbuad  on  th«  poraly wd  Bide,  correipODdiag  bo  tbe 
tnm  of  (JistributiffD  of  oafior  non  of  Lltu  luuiW  uervea,  in  kdditioo  to  tbe 
other  cfatfactetiBtio  aDilatertl  sjrinptoiDm.  Thla  area  is  uot  alwaya  \a  the 
form  «f  *  b«ltt  and  maj  b*  ntuatod  nnuid  tbe  abdomcu,  in  tbe  ngioo  of  tbe 
groin,  or  m-er  tbe  anterior  eurfooe  of  tbe  thigb,  *a  tbat  fivm  an  iia{)(irf«ct 
aawninabon  ooe  mi^  be  led  to  bellATO  Umt  tbe  aDiMtba«ia  waa  diffuaod 
onr  the  lower  extremiliea. 

(fi)  UuiUt«i«l  Imumm  of  tba  dartal  pitrtion  of  tb*  oord  giT«  riw  to  tbe 
moet  cbaiacteristic  eTTopboiiui  of  tbe  diaoaeo,  u  ftlroady  dncribed. 

(3)  In  onilaUml  toeiooa  of  tba  MrmiMl  ponion  of  tho  eord  tbe  grouping 
wi  tba  Bymptonw  Tariee  graatljr,  according  to  tbe  lerel  at  which  tho  lenon  ia 
:  and  ita  longittidiDal  ezUat  It  is  maniiiBat  that  tbe  dietribution 
FUm  ■uobor  and  aeDaorT-  duturbsticea  will  difibricoording  aa  the  upper  or 
law  rwpU  of  tbe  brubial  ploina  are  involved  in  tbe  Imaob,  and  aocordiog 
••  tbe  eflio-apiiuJ  ngioo  ia  or  is  Dot  inipticatMl. 

In  tbe  toww  attramltie*  ami  trunk  the  motor  and  sensory  dUturltanoea 
■n  ths  nniB  as  when  the  donal  portioa  ia  implicated.  In  the  upper  ex- 
iNBilUaa  OB  Uw  aide  of  tbe  ladon  a  oeitaia  nambor  or  all  of  tbe  miuolae 
■(•  paralynd,  ther»iab3rpenBabluaia  of  certain  parte  of  the  eldn  min^ad 
vttb  aiigalbeeia  of  otber  regioDS  or  tet  certain  varietiea  of  aoMKUon. 
On  tba  aide  oppoaite  to  the  leaioo  there  la  no  iioraljrHiB,  bat  tbora  ia  more 
cr  !••  eomplrta  aonatbeeia  avtce  tbe  whole  skia  below  the  hHiou,  or  orer 
•fecial  leralariML 

Tba  Deck  aud  bead  m  the  nde  of  tbe  lenoo  maaifeet  aawathaela  and 
hjyafwIbeBi*  of  certain  araaa  of  the  aldn  and  paraljsia  oC  the  nao-motor 
aad  oeaIo>(ni|»llHt7  flfarei^  giving  riae  to  itusreaeed  tentporature  of  that 
■id*  of  tJxa  bead  and  body,  hJi^oed  eenmbUit/,  oarrowtng  of  the  palpa- 
hnl  OMiue,  aod  ooutiactioo  of  the  pupil.  On  the  aide  oppoaito  the  leaiaa 
thcca  i»  oaoally  aaanthnaiB  of  tbe  neck,  along  with  a  narrow  looe  of  bjper- 
,  and  a  oonnal  condition  of  the  fac«  aiitl  e^e. 


JS  589.  Morbid  I'kt/siotogy. — It  ie  almost  nocdlcea  to  mention 
lfa»t  anilAterU  aectioa  will  divide  the  columns  of  Tilrck,  tho 
anterior  root-zones,  the  pyramidal  tracts  and  direct  cerehellAr 
fibres  of  the  lateral  columos,  the  posterior  root-zones  aad  the 


S64 


TRAUMATIC   DI8BASRS  AND  ADSORMALinES  OP 


Fia.  16i. 


1!  t    1  1 


7^ 


oolumns  of  Goll,  and  tho  anterior  and  posterior  horns  of  grey 
matter;  and  when  the  lettioQ  is  of  conaideifthle  loDgitu>]inil 
extent  a  considerable  number  of  the  anterior  and  poeterior 
nerve  roots  may  be  destroyed. 

Divmion  of  the  pyramidal  tracts  in  the  anterior  and  Utenl 
columns  will  sever  the  muscles  below  the  point  of  the  letioa 
from  tlie  cortex  of  the  brain,  bence  there  will  be  coinplet«  Um 
nf  voluntary  power  below  and  on  the  same  tide  aa  the  lenon. 
Wlien  the  leaioa  \n  permanent  the  pyramidal  tnurts  i)ndei|0 
Becoudary  descending  dej[eneration,  and.  after  u  lime,  tocreaatd 

muMHilar  tension  and  ooatiao- 

turee  are  superadded  to  the 

motor  paralysis.      Recent  io- 

vestigations    have    appareotiy 

^  proved    that    th«    raso-tnotor 

^^  tracts  also  run  io  the  lateral 

~  ~\}  columnB,  thus  division  of  these 

would  produce  vaso-motor  dis' 

\  turbaooee  on  the  side  of  tbt 

^  -^  lesion. 

Dtvisioo  of  the  anterior  root- 
zone  and  direct  cerebellar  tract 
ia  not  known  to  give  rise  to  any 
eymptoms,  probably  because 
the  rCHult  of  injury  to  these 
parts  ia  msftked  by  the  preseaoe 
of  motor  paralysis.  Similu 
remarks  apply  to  injury  of  the 
colunanftof  Goll  and  ^e  pos- 
terior root-zones,  but  it  is  in- 
teresting to  find  that  Jofin^ 
and  Solmon  observed  the  occur- 
reuoa  of  well-marked  ataxy  on 
the  return  of  motor  power  tB 
theparalysed  extremity,caused 
doubtless  by  the  injury  of  the 
poiiterior  root-zooe  of  that  sida 
Division  of  the  grey  matter 


Tio.  IRS  (After  Erl>l.  Diagram  of  tkt 
Cnnrtt  of  Ihf  priitcipal  Cmititctiiip 
Pnth,  vMi,,  th*  OartL—l  utd  I', 
Tba  uoiiir  Kiid  vMo-molor  tncU, 
PM*iiisLliroii|iti  thatateiiarroot  |vx 
Bad  MiaaiuioK  on  th?  *miiv  m-lt  of 
tb«  onrd;  2  md  t.  TVmU  nhjcli 
ouiiiliu't  the  uiiiscutBr  Knsibilily. 
»Uo  puniiig  thrnii^b  the  niil«rior 
rcMiU,  knd  rpnuuiiing  im  the  uung 
»iiJoHi(  lhe<ir<rl ;  ;i  »inl  .T.  Tha  Uncto 
wUcli  ctiuduct  iK'UBury  iiui'rcs*iuiu 
r>f  tnuflh,  t«iii[>«nitur«,  pun,  ind 
tbklinu.  Tb«w  antar  thn  cord 
tbrPUBn  the  tHwCCTinr  moU,  kod 
omu  to  the  otDDr  «!<!•,  uni  [iiirinin 
tbair  cuurae  up-wkiil*  on  ilMt  liile. 
Scotinn  of  Ibe  ti^'bt  hfttf  i>f  thn 
C<u4  (a)  miut  intermpt  O'luiluclbn 
tbrnaiili  tbH  mntor,  Tun-mntnr,  ud 
cauwulo-aeiiMUT  lract«  (1  kad  3)  on 
tht  riRtit  Ri]«,  und  thv  ciitMi«oiu 
Mentorf  tneU  on  the  Mt  rida  (S*). 


of  the  one  half  of  the. 


THI  SPINAL  OOUD  AND   KEDULLA   OBLONOATA. 

pmduoes  aiueaUieua  of  one  balf  of  the  body  below  tlie  level  of 
the  leMon  on  the  opposite  side,  ahowing  that  the  sensory 
fibres  cnm  over  to  the  opposite  side  soon  after  their  entrance 
into  the  cord.  The  fibiee  conducting  impreaaions  of  touch, 
lempeiBture,  paio,  aod  ttckliog  dccuiuato  with  those  of  ihu 
other  nde  verj  near  their  point  of  entrance  into  the  spinal 
oonl,  and  run  to  the  brain  iu  the  opposite  eide  of  the  ooriJ. 
ThoM  ooncemod  in  the  phenomena  of  miiaciilar  senso  ftre 
tupposed  to  enter  the  cord  with  the  anterior  roots,  and,  like  the 
motix  tracts,  run  through  the  cord  ou  their  own  sido  of  the 
body. 


BrowQ-S^uard  states  that 
^ho  conducting  tracts  of  the 
^^Bnoas  forms  of  cutAneona 
Aetisibility  cross  at  difTcrent 
iMtghtJ^  IhoBO  concerned  in 
tbfl  leoaatioD  of  temperature 
Cfloadng  Mcnewlmt  earlier  tlian 
tfce  i«atv  He  also  thinbi  that 
tlM7  are  Keparated  from  one 
•BOtfacaria  their  further  coune, 
tmch  lying  in  certain  definite 
■cgmeotd  of  the  cord,  and  tliat 
the  leDsitire  tract«  of  the 
lower  extremiticti  lie  behind 
tboao  of  the  upper  in  the 
oarrical  portion  of  the  cord. 
The  ocDtripetal  fibres  oon- 
CMiMd  in  reQez  action  have  a 
OMaed  coune  vithin  the  cord 
(Miewfaer). 

Il  is  evident,  therefore,  that 
MCtioo  of  one  half  of  the  spinal 
eofd  niiiit  cause  anwsthesia  of 
tb»  oppoaite  side  for  sensations 
of  touch,  pab,  temperature, 
mad  tickling,  and  Ion  of  the 
moacalar  eense,  and  motor 
[ytu  on  the  same  side. 


FtO    183. 


Fi<i  lilS  (Altw  Brk).  iSofiran  rf  tA* 
tilaoM-us  tfwatamt  in  MniiratBwt 
taio*  aj  Mc  wnf  nartMn  cf  M« 

JtiittU  tord  im  Atldl  •Uc— Tb< 
iuoMl  ibAdlH  (aJAgaUM  motor 
Mi<rvM(>-iiK>tar  MraljMi ;  the  *ntt> 
oJ  •badliif  It.  dj  aigiufiM  cntamoiu 
■itnUiMU  \  III*  doUad  ilMdliig  (a,  <) 
IwBaalM  tviNtaaitiaia  ol  lb*  iUb. 


3G6 


TIUtrUATIC  DI3EABES  AHD  ABHORUALITIES  OP 


The  phenomena  which  result  from  sectioD  of  one  half  of  tbe 
spinal  cord  are  well  illustmted  by  Fig.  1S3. 

AoAtoiiusU  have  dMCribed  4  middle  and  «  sup«rior  ciOMiug  oTi 
Hbra,  both  of  which  tra  ■upponed  to  Uk«  i>Im:«  in  the  taeduUk 
Tbe  (wtwry  <lKtu4«ti«n  of  the  pyruuids  described  b;  Uo^meit  cocuifta  of 
fibres  wbicb  issue  from  tli«  nuclei  of  the  ouneate  sod  slender  fasciculi- 
Tbasa  fibres  pursue  an  arcuate  courae  around  Uw  central  grtt^eolumn,  sod 
becnme  mixed  with  the  croasiog  Qbrea  af  the  lateral  cchinin.  Flecfasift 
however,  aworta  that  th«se  fibres  out%-e  round  the  ohrarr  bod;  of  tb« 
nme  aide  aiul  enter  into  ita  aubitance.  The  luost  recent  researches  with 
regard  to  tlio  twuxury  crwuuug  have  bo«ri  imdertalteo  by  Mil.  Dthort 
nnd  Oonibault.  Th«ir  obserratiouM  irere  made  LnacMeof  amfotraffaic 
lateral  scleroaia,  in  wbicli  the  motor  fibre?  of  the  anterior  pyramids  < 


Fio.  l»i. 


-m 


•  Vli^lH  CAfler  Debove  sad  OumbaulB).  Sfaum  of  (At  Anlmer  PpmrnU  (P)  sT 
Ml  MelitU*  OUonsiKa,  «ii  a  Itrd  vUh  tht  mvidli  fan  ef  tKe  crommg  of  Urn 
Stutter  fara.-Vii,  S«M«rr  fibrei  j  FSA,  PmUum  and  rxtervai  MseMT 
flMiettHls  which  dnes  sot  peaatrate  Inu  the  nibttsaos  ot  ibe  pjramidt  B, 
Oraonng  of  iho  tDoaotj  libra ;  O,  Nudeus  of  tbc  pjiamid ;  Z,  Stratum  wn^ 

medulla  had  iindergoue  degeneration.  The  sensory  Qbra  bsoooM  aib- 
divided  iiito  amaU  faauiuuli,  wbiich  pcuvtrate  into  the  poaterlor  and 
eitenial  ixtrtion  of  the  anturior  pyramids.  The  libna  Uwo  com  up- 
wards and  bcooiito  iuoeparahl  j  mixed  with  the  motor  fibres.  A  little  higbar 
up  some  of  these  fibres  become  mixed  with  the  fibm  of  the  atratem 
toualo.  The«o  fibres  are  vk-ry  well  seen  in  some  of  my  se«Uons  of  the 
luedolli  ublungata  from  a  niaa  mantha  liiunan  etnbryo,  but  I  bare  always 
r«(;urdi)d  them  a«  b«iug  derived  bvm  the  eztenal  pottioa  of  UMnisar 
division  of  ihe  inferior  peiluucle  of  the  oerabellam,  and  I  am  bf 
means  satisfied  that  their  functions  are  sensory. 

The  retatious  of  refiex  action  to  unilateral  section  of  the  oord  are  ] 
yet  well  ascertained,  and  th«  coaditioo  af^pean  to  vary  in  ditfa 
animals.     Aocordlu({  to  the  eiperimeuta  of  Woroachiloff,  it  wonkl  appMr" 
tliat  tbd  fibrsa  which  check  or  cotitrol  raSax  aotlott  la  k  lower 


THK  SFISAL  CORD   AND  MEOUIXA  OBLONOATJl. 


367 


ttcMiiM  princtiMllj  in  Iho  uiao  half  of  the  conl,  while  tbo«o 
fjtil  fortti  nUet  Bction  run  cliivfljr  iu  lh«  (>p()otutfl  half.     Wb«u 

)  Utkia  «xt«n<U  lotigitndinxll;,  no  m  to  destroy  MToral  of  th«  poatmior 
rent  fibres  befgrv  tbotr  orouiag,  tben  will  b«  an  wiBjatbotic  jaae  on  lbs 
panljMd  «idfl  lying  abora  th«  h]rp*nmth*ttc  ngion,  aud  oireKpondiDg  in 
width  to  the  Qombar  ot  fibres  destroyod  by  ttio  loslon.  Impllcatifin  of 
lb>  flilio-aptaal  region  e«iM«  Ttso-matar  diBtarbaooM  in  the  fac«  and 
■Me  of  Hm  biMd,  paimlytio  ayoila,  uid  naiTowiug  of  tli«  palpebral  liuure  oa 
Um  sida  of  the  lesioa. 

The  narrow  bjperasUieti«  aoDe  ootnetimM  observed  above  t-tia  aiuw 
tfaetic  belt  ia  exfjained  by  Brown-Stftiiuml  on  the  ground  that  the  dn- 
Oiwfing  fibrea  of  the  poeterior  roots  fall  within  thit  range  of  the  ledon. 
Ma  hM*,  bowerer,  reoaotly  obtained  a  curiotu  result  by  making  a  aertion 
I  half  of  the  pouH  in  anintala  immediately  in  front  uf  the  nuddlo 

lonole  of  the  aerebellum,  followed  after  a  timft  by  aectjon  uf  the  other 
hair.  A(W  MclioB  of  the  &rat  half  of  the  poiw,  tbero  in  hypcranttiewft  of 
ooe  half  of  the  body,  on  the  aide  of  the  leHimt,  aud  ausntheHia  of  the 
vppeait*  half,  the  Musory  ditfturboncee  being  »p«cially  w«U  miu-lctid  in  the 
Iwmr  •xtiamitiM.  lo  an  animal  which  had  undergone  hemiseotion  of  the 
fi|^  M»  «f  tb»  pMiB,  and  wbioh  waa  coowquoatly  hyp«rMth«Ue  oo  tba 
li^ili^bnaiMctionoftbe  left,  aide  of  the  pone  produced  a  ravetBal  of 
IbtMMorypbeaoueDa,  eo  that  the  left  half  of  the  body  bo«*i»e  hypftr- 
■atbeCio  and  the  right  anicstbetic.  Thia  curioua  reault  abowa  that  tbo 
pbenooaeB*  of  aentoiy  ooaduction  are  by  no  meana  so  definite  or  h  well 
•Kcrtaitied  aa  thoae  of  motor  conduction. 

The  eiUtenoe  of  tntooeoua  bypenoetliMia  oo  the  Ms  of  the  leoioo  >■ 
naoalty  explained  on  tbe  euppositiOD  that  it  is  a  phenomenon  of  IrritatloD 
eauMd  by  lb«  aMoudary  inflammatiom  surrounding  the  lesion  ;  but  after 
lbs  nsulB  oUaiuod  by  BruwD-3tfquard  it  will  probably  Iw  better  to  Kuapeod 
Mr  jodgnsnt  with  regard  to  it  in  the  meantime.  It  does  not,  bovorer, 
■f|MU  to  me  that  much  light  is  thrown  apoo  tbo  point  by  poetulstiog 
Bks  Brown-S^oard,  the  existeoos  in  the  cerebro-epinal  axis  of  speoial 
ooitrei  pmaeaaeJ  of  Inhibitory  aud  dyuamogenic  fnuctioua 


§  690.  Course.  Duratunx,  and  Ternnination. — Tbe  course  of 
tliv  qrmptoQU  depeudi  cbtefly  upon  tbe  nature  of  the  lentoa 
which  bu  caused  the  offectioa  and  varies  greatly  in  different 
CMoa.  Tl»  Itoion  aa  a  rule  exU-sds  both  lougitudinaliy  and 
txmanenely,  and  only  remains  stationary  in  rare  casoa  When 
tbe  leaioo  eitendu  tnuuventely.  paraplegia  and  the  other  nyrap- 
UMos  of  traosrene  myelitis  result  As  tbe  iufliunmition  sub- 
ud«etbe  ■jiuptoms  of  the  unilateral  lesion  may  recur,  and  may 
th«a  coiktiouc  unchanged  for  many  yean.  Complete  recovery 
hH  oec&MHUtlly  been  observed  \a  traumatic  unilateral  tesiona,  and 


870 


TBJiinitATic  DISEASES  AND  ABsoiurAr.mes  or 


paretic  parta  ma/  b«  iDcreaaed  or  depieewd.  Imprarement  begiiM  Id  « 
teif  dA>t).  Tlie  piiliuut  ia  ^ble  to  stautd  and  irallc,  tA  Ant  alotrlf « totMj. 
and  vitb  lT«ui>r ;  tbe  paiua  dia&ppeu-,  uirl  nconrj  ii  oompWto  Id  k  1 

(5)  iSf(*«  Sj/tn/itonu  nx  JtrH,  Jalltnittd  frf  Protnctmi  IOt*a»  tjf 
|war/  (/wiolwi ,'  Bcovery  in  ipuvf  tfWM.— The  pftticot  wmpUiiM  of 
vealoiMs  soon  after  tho  acddwit,  which  gnulaallj:  iDorewM  aiitil  tbT* 
■itnmitiea  aro  pwalyMd.  Ue  also  coinptaitui  of  paiui  which  an  boom 
times  more  or  leu  dilFiufx).  but  are  often  Rituatad  iu  the  bactc  of  the  Ded; 
Igina.  or  H<ms  th«  vertebral  coluuia.  Various  |)«rw3thmi»  ars  ootn- 
plaiiied  of,  but  aQieatbeaia  is  not  usually  w»U  marked,  R«t«atiaci  ti 
uriDQtii^Enetiines  occurs.  Thcrenwybe  romitingand  Incii  nf  rniin  JLiusrirsi 
at  Unt,  and  vatieuts  oftea  mauifeet  a  lilgh  degraa  of  mantal  iiritabilt^ 
for  a  long  time.  The  extremities  are  oiMd  aod  lirid,  and  the  pcrtcbnl 
culiimii  m  tender  oti  (>ren»iire  aud  uCteu  eioeasi?eljr  aeiLiitivci  1>nidail 
improvftrocut  cow  occurs,  but  the  patient  oomplatna  nf  great  wealeueas ; 
theraitwy  l>e!>li|thtatn>(ihjoraoinsof  tie  musclea,  nn<l  oi>ni|ilctc  ncmtrj 
mAyni>t  take  place  for  several  years,  and  the  patient  may  r«maiR  imtaUe 
and  seniiitire  louj;  after  all  the  |iaralytic  nym[>tomit  hare  diM4>pe«r«rf. 

(4)  Very  SUgM  Sumptomt  at  tl*«  beyinnitty,  &u(  trfkr  a  Umgtr  artlmUt 
time  a  SemJ-t  I*roymMi!t  SpinU  Diaeaat  <ievtlopt;  cA<  Aemft  it  DetbffilL 
Tbeoe  casea  are  iMoalljr  cauMHi  by  a  rwlway  coUieioo,  and  the  oyaploiM 
are  g«ueniUy  inaigai&o&ut  immodiatcly  after  tbe  iiijaq-.  Tb*  patisal 
faas  a  wosatJon  of  hitviug  b«en  «everely  shaken,  auflets  from  momeoUfy 
weaknMS  and  slight  confuaiou  of  mind,  but  soon  reeoven,  picka  kimnlf 
u|>.  and  walkn  about.  On  tbe  nest  day,  or  several  days,  wtaks*  w  eno 
months  lator,  iiioru  tlireut«tiiii){  ayii]|il<iiiH  wet  in.  Pain  appean  intbt 
back  and  limb^  aud  gnulually  increaaea  in  intensity;  the  jiatieut  fetb 
feeble,  sufTers  from  meiit^d  depresaiou  and  »luvplcssuesB,  wiUi  a  atioDg 
leiiilancy  to  emotional  weakneac,  and  cannot  attend  to  Ilia  booineM 
He  also  often  complains  «f  noUes  in  the  ears,  and  tJiera  may  beaUgU 
dsafhsaa,  aciil  on  atLumpting  to  raid,  tlio  letters  become  coufowd.  Tbe 
flubaequeiit  oouRH)  of  the  diseivsc  Tiiric;  gmatly  in  iiiJiridual  caiea,  bat  the 
following  are  the  most  osiud  plitiiiomeua  observed  :  The  gait  it  uneerUto, 
stnuldling,  atilf,  and  drawing,  indications  of  disturbed  oo-arditutioa  an 
preaeut,  aud  the  lags  become  progreasively  feebler.  Them  it  atiSbsaa  of 
tbe  back  and  of  tJie  ganoral  attitude.  The  back  is  iMtinfiil  wfaea  mmred, 
and  some  nf  the  spinous  procoasea  ore  teudnr  on  piasauiw.  Oirdl* 
eeusatioQs,  {lantutliiMiiw  of  all  aorta,  uniontbaun  in  var^iog  digma  aad 
in  diflvniiit  HittintiDuu,  or  bypemathema^  may  be  p««asat.  WeakoMa 
of  the  bladder  and  diminution  of  aeiual  power  are  geaeniUy  preaent,  Tbe 
eipreaaion  of  the  cnuntotiaiic*  ia  changed,  the  oomplexion  becomes  paU 
aud  aallow,  and  the  general  nutrition  impaired.  Marked  aUo|iby  ooconi 
ID  individual  muscles  and  groups  of  musclea,  and  It  may  at  tiawe  ba  at- 
teuaively  diatributod.  DiHturliances  of wroulatioa  maalGaat  tbamselva*  b 
the  form  of  eokl  extr«muifiii  aii>l  bluish  oompleiioo.    Tbe  fatlant  ia  tm- 


THE  SPINAL  COBD  AND   UEDUIJ.A   ODLOXOATA.  S71 

Ubk  «oiI  tioad.  auffim  from  a  froiing  of  conatrlclioii  ot  the  head,  sleep- 
k^BH^  vtakDoM  «t  tmtaarj  and  tut«Uig«Doa,  impaired  power  of  vorlt, 
•od  tB  bet  hi«  wh«l«  elunctar  hiu  uodargonv  oh&uge. 

Tlw  tipapbjau  point  to  a  mMiiujpMnjralitii,  anociaitml  nrith  more  or 
Im*  eiaia«iil«nblo  disturlMocM  of  the  aetwbral  faucUorts.    Tb«  aubavqiWDt 

t  ooonv  at  the  affecCloa  vorlu.  Poriods  of  App&reut  improvcmeot  wid  com* 
psnUve  boilth  alternate  vrith  tfaoM  of  dowaward  ptogresa,  but  on  tli« 
vbal*  «  Ctroorable  termiDaLion  ia  wlilom  witnemted.     C&sea,  faomnr, 

I  memr  in  wtuoli  Um  dJuaie  e«MM  to  ft^gnn,  and  In  wfaicfa  ocosidenbU 
iwy— TwDcut  majr  take  place. 

$  J9&  J/i/r&itZ  Anatomy. — la  cases  which  liave  termtuat^d 
I  UuUy  at  an  early  poriod  scoall  extraraaatioos  of  blood  have  bncn 

found  in  the  cord  aad  iu  membmoes,  but  it  is  probablo  that 
I  tbew  an  of  secondary  importaaco  to  the  molecular  disturbance 

of  the  whole  substance  of  tbe  cord  produced  by  tbo  shock.  It 
\i*  probable  that  chronic  meoingiUs  aud  myelitis  may  develop 
loai  of  oooaiseion,  and  then  the  usual  Appearftncce  which  dis- 
,  linguliih  these  alTectioDft  will  be  found  after  death. 

^  At>9.  Oioffnosia. — Oaaes  of  concussion  in  nhicb  severe  symp- 
MH  doTirlop  immodiatoly  after  the  injury  may  be  mitttakeu 
'  erailuDg  or  conludioo  of  the  cord,  hetnatomyolia,  or  bfcma- 
\\B.    The  course  of  coucumiod,  LoweTer,  is  much  more 
lid  and  (arounble.    It  may  bo  inferred,  when  a  severe  para- 
[pl^p&  cxxoea  to  a  favourable  ending  in  n  few  days  or  weeks 
ritbcnit  bed-«orea  or  other  grave  sy  mptoma,  that  tbe  case  la  one 
\ot  concucnoo. 

Tbr  miltAl  symptonu  are  more  severe  in  concassion  than  in 
bviDaturrhacliit,  and  in  the  latter  affection  the  preponderant 
Bymptoau  are  those  of  pain  and  Bpa.<im,  and  the  paralysis  is 
It,  wbile  in  the  former  the  opposite  condition!)  obtain. 
Oasea  of  concussion,  in  which  the  syuptoms  are  slight  at  first 
gndanily  increase  in  seventy,  arc  not  essentially  different 
myelitiii  and  meningo- myelitis  with  a  slow  beginning,  and 
;ac»ia  must  dupcnd  in  great  measure  on  the  connection 
affsctxtiD  with  an  injury. 
ChisfaiuK  of  the  cord  and  concussion  are  frequently  combined, 
tkat  it  ia  almost  imponible  to  diiitinguish  between  thosymp- 
wbich  aie  due  to  the  uue  and  th<Me  due  to  tbe  other, 


372 


TIUOMATtC  DISEASES  AKD  ABNOEMALITIKS  OK 


and  tbe  cliagDosis  can  oaly  1)0  made  after  die  duappeftr 
the  sjinptomii  of  concus«ioD. 

§  600.  Prognosis. — In  the  severest  form  of  concuasioo  known 
as  shock  the  prognosis  is  always  grave,  but  the  slighter  coaea  o( 
the  kind  generally  recover  Compared  with  theseveriLy  of  the 
symptoms  the  progDosis  ia  good,  and  indeed  tbe  severe  i&iti&l 
symptoms  seem  to  be  the  very  cases  to  warrant  a  favourable 
prognosis  as  compared  with  those  the  development,  of  wfaicfa  tt 
slow. 

Evea  in  cases  where  symptoms  of  meningitis  or  myelitij 
appear,  tbe  prognosiH  is  not  absolutely  bad,  hut  wheu.  after  one 
or  two  years  of  rational  treatment,  no  further  progress  is  madcv 
recovery  is  hardtj'  to  be  expected. 

§  601.  Treatment. — The  treatment  must  vary  according 
the  form  assumed  by  tbe  afTection. 

In  cases  with  severe  initial  symptoms  the  treatment  mast 
be  first  directed  against  the  shock.  The  patient  must  be  placed 
in  the  recumbent  posture,  and  warmth  applied  to  the  body,  and 
full  doses  of  some  sUmulaut,  such  as  wine,  coffee,  tea,  hot 
spirit  and  water,  or  drugs  like  aromatic  ^irit  of  ammoiii* 
etbor,  muak,  and  <ampbor,  muat  he  at  once  admimstered. 

Symptoms  of  reaction  must  be  treated  by  absolute  rest 
in  a  suitable  position.  If  the  patieut  cannot  bear  lying  oo  his 
face  or  side.  Erichsen  recommends  bim  to  Uc  on  bis  back  on  a 
couch  tilted  at  its  foot,  Tbe  usual  remedies  for  myelitis  mvst 
now  be  employed. 


I  (T.)  TITMOURS  or  THE  SPINAL  CORD  AND  UEDCLI-A 

OUIX^NUATA. 

§  602.  Tumours  are  rarely  found  in  the  substance  of  the 
spinal  cord,  hut  are  more  frc<|uent  in  the  medulla  oblongata. 

§  COS.  Vurielia  of  Tumoitre  /ound  ift  M«  S^nol  C«ri 
and  Mtdulla  ObloTigcUa. — Tbe  following  are  the  otora  usoal 
tumours  found  in  the  substance  of  the  cord  and  in  the  medulli 
oblongata : — 

1.  Otiomata.~Tbe  tumiKir  ia  geu«rally  of  a  roundsd  or  more  «f  Is* 


THE  SPINAL  CORD  XKD  MSDOU-A  OBLONGATA.  373 

dkftpe,  bat  kl  other  tiuMs  it  cuy  extAcid  Um  wboI«  Ungth  c(  tb« 
afbui  card,  m  iu  »  owe  recorded  bj  inj*elC 

5.  Myxo-Gliamala. — TliJsform  of  tumour  isonljavnriotjof  Qlioatk. 

3.  Giia-Saroamata,  Myra-S(trwMata,  iSurcomata,  and  CardnomtUa  are 
ooljr  iu*lj  foand  in  the  (.ubsUnee  of  the  cord  and  tho  medulla  oblougato. 

4.  J^iiramata  haro  boen  olnervod  in  tho  medulla  oblongata,  oitber 
pwrisg  btna  the  ii]M!iidytDa  or  hi  the  moduUajy  substanco. 

6.  Satiloff  Ttt&tnU. — This  u  trnt  ot  tha  moet  frvquent  tumouni  of  the 
•|iisal  eord.  It  may  aiipUFat  *ny  poriod  af  life,  but  is  relatively  mora 
firaquciit  la  joMi  Uud  in  old  oga  Tb«  flirourit«  sitw  of  solitary  tubercles 
or*  Uie  orrtcol  and  lumbar  «alaTg9iaonta,  espeoiaUjr  the  latter.  They 
QUjr  hm  lituatod  aithcr  in  the  grey  or  nkibe  aubatance,  atid  vary  in  »ize 
ftoD  that  »f  a  hemp-ieed  to  a  hazel-nut.  Solitaiy  tubercle  may  attain 
W  lb*  aist  of  a  walnut  iu  the  medulla  obloDgala. 

(k.  Otmnats  or  S]/pAHomaiit.^Tham  tumouni  are  on  tha  wholf  rarely 
kwid  io  th*  cord  aod  uedulk  vblougstiL 

7.  The  tyHie  dilatattooa,  which  have  been  calM  hyilromyultu  or 
llfTUigntayelia,  may  be  reckoned  anODgst  the  tumoun  of  the  •pinol  cord 
•ban  they  oomprsM  the  nerroua  aubetanc* ;  they  are  "ftiiu  <uuu>c>atoil 
■ith  HsW  |^«irthSt  mob M  glioaiata,nyxo-gIkmKta,aiidiiiyxo-*aiOQmBta. 

§  804  Etudogjf. — ^Tbo  causes  of  tumours  of  the  itpinal  cord 
and  modulU  oblongata  are  very  obscure,  but  it  ia  probable 
tiut  iDJuriM,  Bucli  as  blowii  or  jan  of  the  spinal  ooluRin,  may 
act  w  exciti&g  oauses. 

§  605.  St/mptcma, 

( 1 )  Syrt^Unna  of  Tumou-rs  of  the  Spinal  Cord. — The  aymp* 
locna  eaased  by  the  growth  of  a  tumour  wUbiD  tbe  sitbstanoe 
of  tbe  cord  are  very  variable,  but  are  generally  the  same  as 
iboM  of  comprtaaitin  ■myditis.  They  are  paraplegia,  aiuea- 
tbeata,  iacrcaaed  reflex  action,  paralysin  of  tbe  blwldcr  and 
rectaiD.  moBCular  atropby.  and  bed-sores.  Tbe  development  of 
permtogi*  may  bo  preceded  by  sliootiug  poioa  in  the  Hmba, 
girdle  pains,  and  various  para^tbeinte.  Indcflnitc  initial  symp- 
lOfU  nuy  persist  for  a  long  time,  and  then  paralysis  develop 
•oddenly,  o<ca«ioned  by  au  acute  attack  of  transverse  myelitta 
or  baimorrhage  ioto  tbo  substance  or  neigbboarhood  of  Um 
tonwar.  Tbe  dovelopmcat  of  paralysis  proceeds  at  other  cimea 
nan  tlowly.  One  limb,  probably  an  upper  extremity,  beoomea 
fint  a£re(:tt--d,  tfao  other  extremities  becoming  gradually  impli- 
CKtcd  until  tbe  paraplegia  ia  complete. 


37t 


TJUUilATIC  DISK&SSS  AMD  ABA'OBIUMTIES  OF 


Id  slowt/'^owing  and  daatc  turaours  the  nerve  Hlires 
tobe  thrust  aside  without  being  raptured,  and  cxtcnaiTecliaagM 
may  sometimes  bo  found  after  death  lii  the  cord  while  only 
very  slight  and  indefinite  aymptomfl  existed  during  life.  In  a 
few  cases  tbo  syuiptoma  ant  cauaed  by  a  difTaaed  aMeodiaj; 
niycUlifi,  while  ia  occaaiooal  inntonoM  tlio  dtsappeu-aDce  of  the 
reflex  excitability  and  the  occurrence  of  extensive  muscolar 
atrophy  iudicato  tlmt  tba  grey  aohetance  has  been  dcatroyid 
by  a  secondary  dewendiog  myelitis  or  by  ft  dMcending  exleo- 
sion  of  the  new  grovrth. 

Various  other  symptoms  may  oppoor  id  the  oonree  of  the 
difloase,  aceor-liog  to  the  situation  of  the  tumour  and  the  dire«- 
tioo  in  which  it  is  growing.  The  chief  groups  of  symptoow 
which  may  bo  thus  caused  are  progressive  muscular  atropbj 
ataxia,  and  spastic  paralysia 

(2)  Symptwns  of  Tumours  of  the  hf&Iulta  ObUyt^ftttiL- 
Tumours  in  tho  substance  of  the  meilulla  obtoagata 
remain  tat«ut  for  a  long  time,  and  may  either  cause  no 
rocoKuisable  symptoms  during  Iif«.  or  not  until  a  few  liounoi 
days  before  death,  which  results  from  asphyxia. 

The  most  prominent  of  the  initial  symptoms  are  paroiyamal 
attacks  of  headache,  situated  in  the  occiput  or  nucha,  dizntien. 
violent  vomiting,  tinnitus  aurium,  hiccough,  and  oocaBiooally 
epileptoid  attacks.  These  symptoms  persist  and  grow  woiw, 
while  others  arc  soon  suporoddcd  to  them,  the  latter  bcin;: 
caused  by  compression  of  some  of  the  fibres  of  the  bolbai 
nerves  as  they  pass  through  the  medulla,  or  by  d«Btructi«n«f 
portions  of  tho  bulbar  nuclei.  The  most  usual  s/mptoms 
cansed  by  compression  of  the  fibres  of  tho  norre  roots  aw 
distortion  of  the  face,  unilateral  and  bilateral  paralysis  of  the 
tongue,  internal  squint,  ditmrders  of  articulation,  voealiaatui), 
aud  deglutition,  a  nasal  tone  of  voice,  and  disordore  of  ctrea- 
latioQ  and  respiration.  There  may  also  be  more  or  loss  ax* 
tensive  paralysis  of  tho  extremities,  consisting  of  unilateral 
or  bilatt^rul  pareaitt,  with  or  without  contractures.  Hemiplfgist 
altenmling  with  paralyms  of  the  facial,  abducens,  or  bypo- 
glossal  nerves,  forms  a  characteristic  symptom.  Reflex  acUoii 
is  often  increased  in  the  extremities. 

Disorders    of   motor   co-ordination    have   sometinuM 


THE  SPINAL  CORD  ASD   HEDULLA  OULONUATA. 


375 


obaerred,  which  may  resemble  those  of  locomotor  ataxia,  but 
tDora  commonly-  ft  cere1}«llar  reel  (§  86),  probably  caueetl  by 
ioterfereitce  with  the  peihiRcloN  of  the  cercWtltinn. 

The  aeiuory  are  not  so  well  marked  as  the  motor  dtslurbance^ 
Hioy  geoenlly  consint  of  paio,  and  panvtitbesiie  in  the  uiicha, 
back,  and  extremities,  and  an.«!Ctliesia  may  occa-Monalty  1)e  pre- 
sent in  Ihe  tniult  and  extreiaitiea.  Wbwu  the  tumour  or  the 
tnflammaluzy  action  which  aurroundit  it  extends  itito  the  pons, 
thcfe  may  be  paralysis  of  the  masticatory  muscles,  bypera^s- 
t^Kia.  neuralgic  pains,  and  subsequeuily  anieatheaia  of  one  or 
hottt  ttdcfi  of  the  face,  while  one  or  ttotb  eyes  may  suffiar  from 
Deoroparalytic  ophthalmia.  Deafaesn  on  one  or  both  sides  may 
be  met  with,  and  double  optic  neuritiit,  anibiyopin  ur  aitmurosiH 
•re  aimoat  constant  accorapaDimenta  of  the  pretieQco  of  tumour 
within  the  cranial  canty. 

Glrcotiiria  and  polyurin  inay  be  progcnt,  nnd  the  tompcmture 
of  the  body  is  generally  pereietentty  depressed. 

Pitychical  dixturbeocea,  such  as  loss  of  iotelllgence  and 
■Bsmofy,  have  occaeionally  been  obser\'cd  at  an  early  period,  and 
•TO  almost  eoaatoatly  procant  towards  the  termination  of  tbe 
Jiaeeae.  Tbeae  aymptoma  are  probably  cau<;od  by  the  hydru- 
oipbalDs  interutis  which  almost  altvays  accompanies  tumours  of 
tbe  medalla.  Tbe  elTusion  into  the  ventricles  may  be,  to  some 
eiteal,  caused  by  the  pressure  of  tbe  tumour  on  the  veins, 
especially  the  ven»  galeui  ;  hut  probably  depends  rather  upon 
tbe  hindrance  offered  by  tlie  tumour  to  the  return  oftheoerehro- 
i|^fial  Buid  into  tbe  sub-arachnoid  space. 

As  tbe  disease  adrancca,  the  headache  and  paralytic  symp- 
toou  grow  womc,  the  vumiting  and  hiccough  may  Ixxonie 
iiififaiiiit.  epileptic  attacks  occur  more  frequently,  coma  super* 
venee,  aod  tbe  patient  dies  from  asphyxia. 

g  GOS.  Loudimtion  of  the  Tumour  in  tht  Cord  and  MedulUx 

Oblongata. 

I.  7Viiuhfn</f4«^'M/<70ft^— TtiAleTAlatwhichthsMTdUttSbeted 

I  (vcMffwll/  li«  mule  out  lij  tbe  beigbt  to  which  the  pandjmis  ezteada. 

\ai  \tj  Uu  tfonditioo  of  the  rarioui  cutaneous  an<l  d««p  nflaxea.    Tb» 

exteoL  to  whidi  tlw  ^ny  aaheiunee  ia  diaeawd,  either  hj  tho  iaTMJan  of 

tte  taomw  or  by  aMoodarj  myelitis,  can  be  aacactaiiiod  by  tbo  imueular 

■tni^  and  other  trt^ibio  afRtctioni  wociated  with  the  psnljmis ;  while 


376 


TBAUUATIC  DLSGASBB  ASD  ABSOHlLU.niES  OP 


uiii>li(»tion   of   tbo  pMUriot  or  Ut«r»l  columoa  lUftjr  be  ravpeotiTri? 
rocr>gniMid  \jj  tlu  pmonu  of  &Uiiii  or  aputio  panlyaU. 

3.  7\imQi(n  of  tit  MtdvUa  OhHotv^ia. — (a)  Tatooun  io  tbe  amtmnir 
p_^am\di  of  tb9  iii«duUa  prodaoe  uiiLlatenl  or  UkterU  fmrnlyMla  uf  t^ 
muselw  of  tho  «xtrMaitiM  and  to uuk,  Moompamed  bj  ooatneturw  utA 
inoTVMed  tondon  nfluos.  Pnniljrsis  of  ths  bkdder  U  aoowtiiDn  npar* 
ftdded,  bub  Miiiaibilitv  ronuun*  auimpftinKl.  In  tb«  Ut«r  «UfM  of  tk« 
disMM  tba  sjtDptatns  of  bulbstr  paraljntU  ars  mi|ient<JtlML 

(b)  TumourH  >!>□  tho  /^po^  of  i^e  faurtA  tttlritU  may  caiiae  rouitin^ 
hiccoDgh,  gljcoauria  aud  polyuria,  ^ow  pulse,  and  rcspiratoi^  dbofden. 
Th«  nymptotiw  which  jndjoato  pHralysis  of  cranial  twrvm  mxy  be  pnMot, 
but  piinttvnU  of  Uie  exLrecattifls  it  itrtaeiit  at  all  la  a  late  sjniptom.  Sen- 
sory didordi^ra  are  r&r«,  but  aoms  degroA  of  ataxia  or  vMliog  maj  be  praaeat. 

(c)  Tiiiuoiin  of  tho  natiform  body  may  giTU  riiM  to  Mtonorf  diaoidtn  in 
the  «xtreiDiti«ii,  tiailnt«ral  ansosthesiit  in  tba  faca,  aiiiitarj  troublaa,  and 
ataxic  wn1k,but  ourkoawlodgeof  the  ■ytnptoum  oaused  bjr  tliMO tumoon 
■■  not  KiiHiuiontly  accurato. 

(ti)  Tumours  of  tho  /ormaiio  retiaUarie  and  o/trartr  boJiea  can*  ma 
Hyiiiptoiim  bj  which  thvir  prsMvce  can  ba  rMogDiwd,  sinpi  thoao  eooi- 
moti  to  intntcratiiAl  gnintha.  When,  bonever,  tb«M  tanwan  incnan 
Ui  Kuoh  u  nizu  that  tliuy  coinpreng  the  bulbar  imelci,  tha  £braa  of  tha  bultsr 
nerval  iu  tbrir  iMonagc  thraugh  tli«  modalia,  or  the  anterior  p^rstnid^  tha 
grou[nug  of  t\m  ayioptamB  any  b«  aiioh  u  to  render  it  poaatble  ta  Dufca 
lui  accurate  diagnonis  of  the  iMalisatiou  of  tho  lonioo.  Th«  folloiriiig  c»m, 
fir  tho  iiotea  of  whloh  I  am  iodabted  V>  Mr.  HnHgmn,  who  was  than  om 
<jif  the  Hoiua  Pbynicians  of  tfa«  Royal  laSmtaiy,  well  ciamplifiaa  Uh 
l^otipttig  of  tho  Hyiuptoiiw  which  may  take  placa  from  a  tiunour  omb* 
meucing  in  the  /ormationticutaru: — 

VVilliuin  B— .  set.  eight  yearn,  vaa  admitted  Fabniary  17,  ISSCt,  ibta 
(bo  Royal  Infirmary,  under  tb«  care  of  Dr.  Rosa.  Ht  is  a  wcU-iHwriabad 
boy  fir  his  yeani,  and  his  mental  faoultiea  do  not  appear  to  be  in  apy 
way  impairvd.  IU  oomplaina  of  headadie,  and  tbe  ooc^iital  re^oo  if 
aetimtivo  to  touch.  Both  eyeballs  ars  inverted,  tJie  external  recti  moaeka 
being  completely  pAralyad  Th«  right  pupil  DM««urta  &  and  tbe  Uft  i 
mm,,  but  Ixith  cixitract  readily  tn  light.  Th^re  is  slight  facial  paralya 
oil  tho  right  aide  «xteuding  to  the  oynlid  of  the  aamo  sido,  which  cannot 
be  clonod.  The  eoft  palate  is  looeo  and  pendaloua,  and  tho  avuhi  oaou|de« 
the  middle  line,  until  a  reflex  coutractioa  of  the  palatal  moaclea  ia  eieitad 
wbea  it  aasuinee  a  curred  form,  tho  |)oiiit  beinu  directed  to  the  right 
nnid  tho  convexity  tn  tho  left.  There  an  no  eonsory  diaardera  of  tbe  bM  or 
buily,  no  IcHh  of  taxU),  deafness,  panlyais  of  the  tongue,  or  reoosnlaaUe 
pandyKia  of  the  extntDaities.  The  veQox  contractility  of  the  tight  bdal 
muaclen  in  diminiithed,  hut  they  still  contract  to  a  faradic  medium  ottmol 
The  galvanic  contractility  is  also  somewhat  diminished,  but  there  an  »o 
qualitatiro  chscigea  When  the  cliild  stiu>da  hi»  head  ia  inclined  to 
the  left,  but  it  is  dlffioolt  Iu  Imow  wbatbar  thia  attitude  ia  due  u 


E 


TUB  SPIHIL  COKD   AND   BtSDDLLA  OBLONGATA.  377 


paffwu  of  tbt  right  AUn)D>c]«tda-RiiuttiMd  miude,  ur  to  a  voluntarjr 
elEnt  to  wmot  the  t»3m  iuuigea  causod  hj  thn  double  iutrnikl  squiitt. 
Wban  Im  walks  his  gait  ia  ataggtriag,  and  he  matiirDnUi  a  coitataiit 
temfaiwy  to  fiiU  towarda  th*  rigbi  aids,  jet  there  ia  no  paraljrdB  of  th« 
right  lower  exireinity.  The  oanrwal  ^mda  at  th«  auglea  of  the  jawa 
aai  alaog  the  atarno-uiHtiiid  mnaclaa  on  both  aktos  an  alightly  culargvd. 
Tha  hBMTt  and  louj^  are  healthy.  The  uriite  is  acid,  n.a.  1036,  contains  no 
•IbuaMRi  or  mtg/tr,  and  ia  iMniul  in  quantity.  Tiie  r«ll<«a  of  Uw  anl«. 
and  th*  cnuusteric,  abdondml,  eptgaatrio,  gluteal,  and  ioteno^ular 
art  [KMisal. 

Xaroh  XS.  Whta  tba  pattent  i^nda  ho  »«1ii  Trcta  aide  to  nd«,  and 
a  gratar  teodoDoy  to  fall  to  tho  left  than  the  right,  ami  tlia 
patiBar-latidoB  ndai  ia  nort  marked  in  tho  loft  than  right  log.  There  ia 
•laodacidMl  ]«nniB  of  both  the  }oirer  aud  ui^pcr  citrcmity  on  tho  left 
aide.    Opht)udrao«co|)ic  ouniitiation  reveabt  douhle  nptic  neuritis. 

April  it.  Tho  Uft  half  of  tho  body  is  diotinctly  poralywd,  vrilh  mn*- 
cnlar  rigidity,  tba  right  ami  ia  feebte,  and  the  luitient  cainiot  atand. 
The  tarn  IB  nov  aynunetrical.  and  thoni  is  decided  lo»  of  ezpneatDii, 
wbila  both  «ya«  roinain  open  duiiug  rieep,  and  the  imtient  cannot  close 
tbMn.  The  pownr  of  aitKuUttoo  ia  interfered  inth,  and  the  food  baa 
Id  he  placed  far  back  on  the  domim  of  the  toogne  in  order  to  Mcure 
deglmitloo.  The  tnaaticatory  utiaolee  ar»  feeble,  the  jaw  hangs  loose, 
tfc*  UHmth  is  half  upeu,  and  wJiva  dribbles  constantly  from  the  mouth. 
n«  aiiople  n»ov«iiMute  of  the  toogoo  can  stiH  be  roadily  eiTected. 

Tb*  mental  brtiltlea  am  Iwooming  bluntwl.  Imt  so  far  aa  can  be  judged 
th*  eeiieea  of  tiwte  and  hearing  are  uiiimpairod,  while  ereo  the  mcmo  of 
b  fairly  good.  Seiisihihty  to  pain  and  touch  aro  impaired  on  both 
of  tii«  f*ce  and  in  IIm  Ijiiibe. 

Hay  11.  ifiuce  last  report  the  paralytic  phenomena  hHra  beoonu 
(ndoally  won*.  The  left  ana  aud  kg  are  now  coiuptot«]y  paraiyeed, 
nUb  the  right  Umha  are  Tery  faaUa.  There  ia  double  faciid  panJyds, 
—■Mwtory  paraly«ia  with  oontnwtaro  of  the  muaelea  eo  that  the  jaws 
a«B  held  close  together,  and  incrraaing  difficulty  of  articulaUon  and 
da^nlttion.  The  right  conjunctiva  has  been  for  aome  titaa  red,  and 
€»>«ad  by  tenacious  secretion,  and  the  cornea  is  now  beeoming  cloudy. 
Hm  pttUe&t  ban  bad  ftR  attack  of  Mv«r«  vomiting  about  two  weeks  ego, 
bat  it  baa  not  ncutrad. 

May  sa  !M»oe  last  r«poK  the  aymptoua  have  beoAtno  gradually  worse. 
AU  the  Uu)m  are  paraljMd,  the  right  cornea  is  ulooratcd,  while  the  left 
OMJoiMitlT*  Is  injected  and  GcTer«d  by  teuaciouB  seorHion.  Inability  to 
•wallaw  waa  ■onifaated  thia  monuog,  and  he  died  in  the  afWooon  ftora 
jfTCit  of  rwpintioa. 

4t  (JU  amiopiy  no  changoa  worth  noting  are  obserrod  in  the  nerroua 
eyalea  with  the  eioeptioo  of  the  medulla  oblongata  and  pons.  On  the 
foorth  vrntrida  being  eipoaed,  a  taoiour  is  obaerved  to  project  from  ita 
mrUm  M  ■  level  with  the  atrin  medullana.    It  ie  about  the  km  of  ■ 


m 


378 


TRA.UMATIC   DISEASES  AXD  ABKORMALtTIES  OF 


pigeoii'a  egg,  and  tlio  grMtor  portion  of  tl  Iim  ta  tbo  right  of  tli«  mtiiim 
n^ifa^,  wliilo  it  projaobi  rorwanlii  into  tho  BabsUnoa  of  tbe  t™^")**  aai 
poii*.  Twa  tumours,  eiich  tiiunit  tlui  Hixa  of  a  haml-iiat  and  ooca{PfiDg 
Hjiuntdtriditl  positions  on  tacb  ddo  of  tbo  nuddUi  lia»,  are  ohmmi  in 
the  ujifHir  [liirt  of  the  vetitricla  innuedintsly  uitder  tho  vain  of  Viatoanc 
A  Tow  soattond  luili&ry  tulierclos  are  found  in  tha  aptoM  of  tba  luagL 
Tb»  tumouni  in  the  pous  were  tubercular. 

Dr.  L«ocb,  who  IdtMlly  trauftTerred  this  case  to  my  care,  told  ma  that 
the  BjrmptoiQB  bej^Q  by  uiteriial  aqaiut  of  Ibo  right  e;e,  aud  ■Hfgailm 
g&it,  witb  a  tutideucj  to  fall  to  the  rijcbb  »ida^  tbceo  ajmptMiMi  b«iii( 
followed  liy  right  fnutal  paralysis.  The  symptoms  wore  ao  defiaita  in  thk 
uuK  that  an  occuntto  dii^nosis  could  raadiJy  (m  nada.  Tbt  biaiaahi, 
p-aduitl  iiiTasiuQ  of  the  aymptoms,  and  thopwiMoca  of  doable  optic  aaivilii. 
ahowcd  that  tho  case  woa  one  of  iutracnuiial  tumour,  wbile  tha  amUvl 
glands  ill  the  neck,  aud  other  oiicuEiutaDoeB,  indicated  ita  proUAIa 
tubeKular  uature.  The  sacoeoBiou  d  the  ranous  groupe  of  \nSm 
symptonm  vere  an  deflnita  that  there  oould  be  do  pontbility  of  tmttakiii| 
the  loc^tutliuu  of  the  uaiu  focua  of  diseaae.  Tbe  earl;  p«nlr«a  of  tbe 
external  ractun  of  thn  right  aide  allowed  Uxat  the  [irimary  fiwua  bcgao  ea 
a  kvel  vrith  tha  sijLtb  uorvo,  and  to  tho  right  of  tbe  median  n^lw^ 
SupLXMa,  theu,  that  the  tamour  began  to  gnxr  in  tbe  fonnaUo  relicul 
oil  the  right  aide  (Fig.  185,  ar)  oo  « lervl  with  tbe  aixth  none  (kn), 


Fia-185. 

L      I.       >Vf 


■/-^ 


'ar 


71' 


^ 


\ 


^. 


•ft... 


X 


Fi4.  l&S.  Tntntwtrtt  Stttim  of  Uu  Pont  on  a  ttnt  teOA  lAc  FoiiUt  ^  Ortatm  ^  Or 
Sixth  and  Sert^A  Jfirru.     (See  Fig.  1»,  p.  ».) 


TKK  SPI.VAL  OOBD  AND  MEinDLLA  OBLONGATA.  379 

that  K  gnm  eqatU;  [n  All  direetJora.  It  wottld  finit  produca  [wralTtos  of  tbe 
•ifbt  «xt«rDal  tcotiu,  nad  aa  it  grow  fonnnls  it  would  pntm  on  tim  Irtina- 
Tm»  fihm  of  tbfl  ppns  uid  prwluce  r«eliD(^  with  a  tcndenej^  to  fall  tu 
tbt  rig^t,  or  tb«  ajmptoiiis  whicb  wi>ul<l  have  been  ciui»edb]'ditt«Mi>f  tht; 
niddle  pedunde  of  tbe  oonbeUum.  Aa  the  tumour  enlurgod  to  tbs  right 
11  vmild  yttta  on  the  fibres  of  tha  sevcutb  ucrro  (Rrii),  and  ntuse 
pandjMK  or  the  right  raitMin  of  the  hxia,  having  tho  cfaftrocUn  of  a 
|«ripbcT»l  peralr»ia.  A»  it  gnw  tonranli!  the  left  it  vouM  ynmt  cm  tho 
left  «iith,  aud  thsu  on  thu  Ixft  iwvoiitli  iiurvo,  cauBing  enoGeaairttlf  in- 
wjuiut  '^  Die  k-fl  tyc  and  left  faoiol  penph«rnl  pnxalysia.  As  it 
>  atill  further  fimmrds  it  would  compnem  tha  fibres  nf  tbe  pyramidal 
Inet.  first  on  th«  right  aide,  cauaiiig  croased  poialjBis  of  the  left  ci- 
tnmitiea,  and  then  oa  the  left  tract  {Fi^.  ISb,  F,  p),  oaiuing  paralysis 
of  tbe  «2tre]iufiMi  on  Ibe  riitht  side. 

Agsiu  aatlu)  tuaKHiT  exteDdoddoffnwardH  it  would  oomprwa  tbe  niutb, 
Bth,  twelfth,  and  pvobably  oloa  tbe  eloveDth  nervea,  tod  M  give  rise  tu  the 
ipureljr  l>ull)araymptoiiiH|ir«ineiil,micb  as  th«  vomitlDg,  aiid  disorders 
faf  aitieulattoa  and  deglutition.  Aa  it  eilondMl  upwards  it  would  compreas 
tbe  motor  and  to  eoiu«  ext«nt  tbe  wmtrary  divuione  of  tbe  fifth  tierrcsi 
ito(  ibe  nuattoator;  paralyMx,  the  facial  sensory  diitlurbaTicM, and  the 
"ptnlytio  opbtbaloiia.  Not  only  was  an  aocurata  localiMtioo  of  tbe 
I  capable  of  tniitgmade  in  this  case,  but  we  were  even  able  bo  auticipale 
I  a  larice  cstenb  the  later  symptonu  which  Buporvencd.  When  ]iaral}«ia 
of  Lbe  left  rrcliis  oocorrw),  w  wore  able  to  forotvll  that  it  would  eoon  be 
fullowcd  fay  periiihcral  paralyme  of  tbo  left  side  of  tho  tux.  It  wy  olao 
pMiAle  to  anticipate  that  left  hemtple^  would  euper^'ODe,  «bich 
weald  end  in  ganeral  ]»ralyaU  If  the  iiatieiib  aun-ived  long  euougbt 
■ltd  thU  the  upward  and  downward  extensions  of  tbo  tumour  would  give 
riaa  to  taotar  and  auumy  diiturbMioea  in  tho  r«eion  of  tlw  fifth  oa  tha  Cdte 
hand,  and  dilBeuItka  of  articulation  and  de|{lutition  ou  tbe  other. 

§  607.  Courst,  Vuraiion,  and  Terminatioiia.—The  course 
of  iDtrnmedulIary  tumour  U  usuaJ);  very  protract«d,  and  tbe 
pfttienl  may  lire  for  many  montlia  after  complete  paraplegia 
i»  Mtablislied.  iDtramedullary  tumours  arc,  with  the  exception 
of  gummata,  uniformly  fatal.  Death  may  bu  caused  by  cystitis, 
Iwl-aorM,  and  their  coa»c(|uonoe«,  arrest  of  retipiratiou  wlieo  the 
myelitU  takes  au  ascemling  course,  or  intercurrent  dixeosa 

Ttie  course  of  tumours  of  the  medulla  oblongaln  ii^  probably 
uniformly  &tAl.  The  dii«asc  may,  however,  extend  over  a 
ptriod  of  years,  with  considemblo  variattOBs  io  tbe  intensity  of 
the  Bymptom.1,  but,  &&  a  rule,  it  proceeila  uninterruptedly  to  a 
fatal  tcnninntioo. 


S80 


TRAUMATIC  DISBASBS  OF  THE  SPINAL  COHD. 


§  608.  DiagTioaia. — It  ib  not  always  poesible  to  make  a  decided 
diagnosis;  but  ihe  presence  of  a  tiimour  may  be  suspected 
wlieu  the  inleusity  of  tbe  pmalytic  symptoms  fluctuate,  or 
wtieu  Hymploms  of  ceatral  myelitU  oi  bicmatoniyelia  superrene 
upon  tliuae  of  a  loag-coDtinued  and  iosidious  spinaJ  affection. 
Evidence  of  scrofula,  tuberculosis,  or  syphilis  may  greatly  aid 
the  dingnosis.  The  initial  symptoms  of  irritation  aro  K<^ci^ly 
of  lens  iutcusity  in  iotramedullary  thao  meningeal  titmour,  and 
tbe  former  is  more  apt  to  give  riae  lo  aa  ndcundiug  myelitis 
tbau  tbe  latter. 

Tumour  of  tbe  meduUa  oblotigaia  may  be  recojrniaed  with 
some  certainty  when  the  general  eymptoms  of  an  intracranial 
growth  are  accompanied  by  Bigas  of  local  irritation  or  paralysis 
of  some  of  tlie  bulbar  ncnres,  and  when  in  addition  there  are  ob- 
stinate vomiting,  hiccough,  gtyoosiiria,  or  polyuria.  When  ataxia 
or  reoliug  is  a  promiaent  symptom  of  tumour  of  the  medulla 
obluugata,  or  nheu  tumours  of  tbe  cerebellum  implicate  tl» 
medulla  secondarily,  it  may  be  imposable  to  distiogabb 
tumours  in  tbe  two  regions.  If.  however,  the  patient  hat  been 
under  observation  from  an  early  period  of  the  dieean,  (be 
mode  of  iovasion  and  succettsion  of  the  Kymptoms  generalljr 
enables  tbe  diagnosis  lo  be  accurately  road& 

In  profjrtssive  bulbar  paralysis  tbe  regular  symptoms  of 
tumour  of  the  medulla  oblongata,  such  aa  headache,  vomiting,      , 
hiccough,  disordeni  of  hearing,  glycosuria,  amblyopia,  epileptt^^l 
form  convulsions,  and  double  optic  neuritis,  are  never  pieeent.  ^^ 

It  may  be  impoiutiblu  to  diBtingiiinh  tumoiim  in  the  auhstance 
of  the  medulla  from  those  which  grow  in  the  membranea  or 
surrounding  bones,  but  signs  of  irrit&tioQ  and  paralysis  in  tlie 
region  of  distribution  of  tbo  cranial  nerves  are  probably  teg 
prominent  in  the  former  than  in  tbe  latter. 


§  609.  Prognosis. — Escept  in  tbe  ca*e  of  syphilitic  gumr 
the  prognosia  is  absolutely  unfavouta.bla 


§  610.  Tr«at7iwni. — It  is  only  when  syphilis  oxista  that  treat- ^ 
meut  is  of  any  avail,  when  large  doses  of  iodide  of  potassiui 
should  be  promptlyadministered.    In  other  cases  the  treatment 
should  be  the  same  as  that  of  acute  and  chronic  myelitis. 


PI3E<kSB3  OP  THE  UCMBRAKBS  OP  TEIE  SPIKAL  CORD 
AKU    MKDL'LLA  OBLONGATA. 

<l.)TA9CrLAR  DISEASBS   OF   THE   UEUBKAKE8. 


1.  Hyperamia  of  the  SptTial  Membixines. 

§  611.  Hypenemia  of  tb«  spio&l  mcmbraucs  caDoot  be  eepa- 
rmtcxi  Troiu  bjrperseoiia  of  tbe  spiaol  cord,  and  has  already  be«u 
Buffici«Qtljr  contiidered. 

2.  Hasmatorrha^is — Mtningfal  ApopUxy. 

§  612.  Hematorrbachia  implies  aoy  effuuoD  of  blood  in, 
about,  or  between  tbe  Bpinal  naeDingee. 

§  613.  Etiology. — The  disease  is  more  fFB(]iient]y  observed 
in  DWD  tliaD  women,  but  very  little  is  Icdowd  witb  respect  Co 
the  predispodog  causes  of  tbe  affection. 

Tbe  moat  usual  cxcitiDg  causes  arc  iojuricii  of  tbe  spinal 
oolomo,  such  as  fracturea  and  contusions.  Cariea  of  the 
Tortebna  has  In  Bome  cases  led  to  injuries  of  the  vessels  of 
tb«  cord  and  to  hnmorrbagc  from  tbera.  Kxcesaivc  bodily 
ezertioo,  tho  riolent  spasms  uf  epilepsy,  eclampsia,  and  tetaaus, 
tbe  wddm  tuppreesioD  of  accuatomed  discharjiiies,  aod  all  the 
etriMiDStaoecfl  which  induce  npiiuU  hypcncinia  ma;  act  as  exciting 
eauMS  of  meningeal  apoplexy. 

lleningGal  hsemorrfaage  may  occur  in  ooorbutus,  purpura 
biKDorrbagica,  amallpaz,  and  typhoid  fever  and  other  acuto 
infectious  diaeoMa.  Aneurisms  have  been  frequently  known  to 
rapture  into  the  vertebral  canal,  and  blood  effused  into  tbe 
bmin  or  cerebral  membranes  may  someUniea  pass  down  into 
(Jh  apiaal  ninnl. 


su 


DISEASES  OF  THB  UEBCBRANES  OK  THE 


caused  by  a  permmient  lesioo,  such  as  the  growth  of  a  tumour,^ 
improverQent  nod  complete  recovery  tdaj  take  place.  Whof^f 
the  biEinorrhage  is  cunaiU^rable,  or  when  it  ia  situated  to  tti« 
cervicnl  regiw,  or  if  the  symptoms  of  myelitis  Kupervene,  liie 
progaouta  becomes  uafavourable.  Wbeo,  on  the  other  buid, 
the  hicmorrhage  is  umalt,  tbe  reactios  moderate,  and  the  patieol 
young,  tbe  progooais  la  favourable. 

§  619,  r»*«a(m«nt— When  the  syraptoms  of  mcDiaj 
kcetQcrrbage  have  occurred,  absolute  rest  ia  the  borizottt 
posture,  with  tbe  patient  lying  on  his  side  or  face,  shoold 
be  maintained.  The  primary  object  is  to  prevent  the  bleeding 
from  extetidiug,  the  n)u<it  usual  rtaniE^dy  buiog  application  of  ioe 
to  the  vertebral  column,  and  ergot  may  be  given  iuteraally 
wb«a  eymptoois  of  inllnnimatory  reaction  set  in.  Leydeii  n:'Dom- 
mends  mercurial  inunction  and  repeated  small  dotes  of  calomel 
When  tbe  period  of  reaction  has  pas-ted,  absorption  may  be 
promoted  hy  the  external  and  internal  use  of  iodine,  and  the 
galvanic  currunt. 

(IL)    INFLAMMATIOK   OF   THE   SPINAL    DURA    MATKR. 

Packyviettingilis  Spinalis.    Peri-meixingitU. 

§  620.  Fachymoningiti!)  may  bo  subdivided  into  two  Toriettei: 
(t)  Bxternal  pachymeningitis,  when  the  morbid  products  an 
deposited  in  the  loose  cellular  ti&auo  between  the  duranuter 
and  vertebrae;    and  (S)  Internal  pachymeningitia,  when 
inner  surface  of  the  dura  mater  is  attacked. 

(L)  PACHTHBViKanim  SPlSAUa  ExnutA.    Pxu-r iCHVMEXiMDms. 

External  pachymeningitis  cousists  of  inSammation  of  the 
outer  layera  of  the  dura  mater  and  the  cellular  tissue 
rounding  it. 

§621.  Eiiohgrj. — Various  diseases  in  and  about  the 
bral  column,  such  as  vortebral  cariea  and  bed-flores,  cooBtitvl 
the  most  frequent  cauaea  of  the  affectioa 

§  622.  Syi/tjpfom*.— Pain  in  the  back,  which  T&riea  ia  ita  sMt 
and  extent  according  to  the  locality  of  the  lemon,  is  one  of 


SPtSAL  COBD  <IMD  M&I1ULLA  OBLONGATA. 

th«  most  constant  aatl  importftot  symptoms  of  the  afTectlno. 
Rigidity  oribe  Imck,  which  renders  it  diffictilt  and  painful  for 
th«  patieot  to  sit  up,  spasm  of  various  groupii  of  muscles,  f>cc«D- 
tric  puna  in  the  form  of  a  girdle  or  Hhootiog  into  llie  extremi- 
ties, formicAtioQ  and  slight  liyperatstheitia  of  the  skia,  arc  the 
wtal  symptoms  complained  of. 

After  a  time  symptoms  of  corapresBion  of  the  cord  are  gradu- 
illjr  superadded  Both  sensory  and  motor  paralysis  may  occur 
tli>wly  or  suddenly,  and  muwuUr  tension,  increawd  reflex  action, 
wpacially  iocresjied  t«ndon  reflex,  paralysis  of  the  sphincters,  and 
bed-sores  appear  after  a  time.  These  symptoms  are  caused 
partly  by  local  eompreiinon  of  tho  cord  and  partly  by  mretitis 
aod  Mcondarr  degencrattuos. 

The  symptoms  may  develop  in  an  acute  or  chronic  form.  To 
the  acute  purulent  forms  tho  prominent  symptoms  are  caused 
by  irritatioD,  a-htl«  in  the  cliromo  fibrinou!i  form  tlie  symptoms 
of  oompressiun  and  paralysis  of  the  cord  predominata 

§  6S3.  CburaSL— When  pacbymeniogitis  eztcma  sccompanies 
caries  of  the  rertebnc  the  disease  is  frequently  arrested  and  the 
parftlytic  symptoms  disappear.  In  llio  severer  coses  its  course 
may  Tary.  but  is  iinualty  protrnctecl,  and  only  sfter  the  lapse  of 
BtDj  weeks  is  there  a  termination  in  rt^oovery  or  death 

§  6S4.  M(frbid  Anat<nnif. — The  essential  nature  of  the 
■ITectiun  consists  of  aa  iaflammation  of  the  outer  layers  of  the 
don  mater  and  surrounding  cellular  tissue,  with  cxudstion  of  a 
pomlent,  plastic,  or  tuberculous  nature.  The  exudation  has 
been  found  as  much  u  half  an  inch  in  thickness.  The  inner 
surfoee  of  the  dura  is  nUo  ifaickened  and  opaque,  and  frequently 
eovered  with  a  thin  iihrintias  deposit.  The  pta  mater  and 
aru^Doid  do  not  often  participate  in  the  affection,  but  tbey 
hare  at  timee  beon  found  adherent  to  the  dura,  opaque,  and 
mftltmted  with  pus.  The  morbid  changes  are  usually  limited 
to  a  small  portion  of  tho  cord,  even  when  they  eitend  over  the 
greater  part  of  tbt>  dura  mater. 

The  coni  itaelf  is  more  or  less  compressed,  flattened,  amemlc. 
aod  often  Bi>flcned.  Red  soflening  and  hypenrmia  are  found 
in  tbe  neighbourhood  of  the  compressed  portion,  and  in  chrooic 
K 


380 


DISEASES  OF  THK  MEUBRANES  OF   THE 


caaea  ascending  and  descending  aecoudary  degeaemtioiu 
oburred,  Tbe  nerve  roots  wliicb  pass  out  at  tbe  teat  or  tbf 
pacbyrnCDingitiR  are  oumpr«Med  aud  atrophied,  or  iuftuned  ml 
•on.  Tbe  prtmnry  lesion  which  hu  produced  the  pacbymeHfr 
gitis  will  of  coiiriie  he  found  on  post-mortem  eitaminauoo. 

§  GiS.  DUiffnosiiL — The  diagnosis  is  diieBj  founded  catb 
slowl^'-iucreasing  Hymptoms  of  meningeal  irritation  aud  of  eon* 
prenion  of  tbe  cord.  Valuable  aid  to  diagnosis  may  beobaiMi 
by  the  discovery  of  absoess  or  tbe  other  morbid  chai^ 
the  vortebinl  column. 

§  6S6.   The   Proffntms  depends  upon  the   natnre 
primary  lesion  which  boa  caused  tbe  pachymeningitia. 

^  627.  T^rtalnvtnt — The  first  aim  of  treatment  is  to  i 
the  efTecta  of  the  original  lesion.     The  use  of  brine faath^ij 
of  potaaaium  and  iodide  of  iron.  fricLioos  with  mi 
tnenti  and  Yarious  other  remedies  hare  been  emi 
Charcot  recommends  the  oae  of  the  cautery  for  ofamiBaltl 

m)  Vkewnt^Bianina  Itrmau,  (HTrwRvormc*  ■* 
{  8S8.  HeAnitUfn. — Internal  pachymeoingitls  ii  aa  ii 
matioe  chiefly  of  the  inner  surfiue  of  tbe  duta 
depontion  of  morbid  prodocts  beiwccD   the   dura 
arachnoid.    Tbcrc  are  two  (ona»  of  tbe  diaeeae: 
meningitis  interna  bypertropbica,  aoKa»&ng  of 
tbe  dnra  mater;  and  (S)  pacbymentDgitis  interna  1 
or  bKoutMiM  of  the  sfrinal  dan  mater,  t«»«rinM 
lion  of  locDefiuve  pewido-membranotta  layvn, 
blood  is  effasad. 

§  «S9l  Aiolopy.— Tbe  eatue«  nsaaUy  MnigMfl  totel 
tropbte  fonn  are  expoasre  to  eold  awi  damp,  and 
oraleohaL 

Thi  hmannhfir  fnnn  nftm  infHa^Miiln] 
otnbcal  doia  oiatoc,  asd  is  pcodooed  by  the  ai 

4*«i  aandatod  with  dcBMMia  paralytks  a^ 
vdm.    H  affNan  ■iwiKwiji  to  nealt  f^«H 
■hI  L^dn  has  described  a  n^-^i^yic  fo,^ 


SPINAL  CORD  AND  UEDlTLtA  OBLOlfGATA. 


887 


g  630.  Nym|j(<»iLi— The  hifpertrophic  form  asually  occurs 
tbo  cervical  region,  aod  baa  been  described  hy  Cbarcot 
aoder  the  uame  of  iKuhijin^ingite  cennctiU  hjptHrophique. 
Daring  the  fint  stnge  of  the  disease,  which  lasts  two  or  thxee 
BBootba,  the  symptoms  of  sensory  irritAllon  predomiDate.  The 
Bost  iisual  of  these  symptom;)  are  aeuralgiform  pains  io  the 
wck  aad  bead,  which  ext«ud  to  the-  shoulders  ami  anus,  uDd 
paioful  &easation  ia  the  upper  part  of  the  chest,  as  if  the 
Atieot  weru  bound  by  a  tight  cord.  The  musctefl  of  the  nock 
ki«  in  a  state  of  spasmodic  rigidity,  the  patient  often  complaiius 
>f  formication  and  Dumbueas  of  the  upper  extrcmilics;  aud 
Mtooeoas  trophic  disturbaucos,  such  aa  vesicular  and  herpfttie 
vuptioDS,  may  make  their  appearance  on  the  upper  extremities. 
The  trantitioo  to  the  second  stJ^^e  is  clmracteriaed  by  the 
ndoiU  dovelopmcDt  of  paralysis  and  miucukr  atrophy.  At 
nt  there  is  simply  pareeifl  of  the  extremities,  which  after  a 
Ba  becomes  developed  into  a  more  or  less  oompleti^  paralyns, 
ttbflaccidity  of  the  affected  muscles.  In  tbeupperextremitie« 
le  panlysis  often  predominates  in  the  muscles  supplied  by  the 
iIdv  aad  median  nerves,  vrbile  those  supplied  by  the  musculo* 
pin]  nerve  are  comparatively  spared.  The  consequence  of 
his  mode  of  distribution  of  tbe  paralyHis  is  that  tbe  hand  is 
.Uune<l  in  the  position  of  exaggerated  extension,  the 
jges  are  Scxed  on  the  metacarpal  bones  and  upon  one 
BO  that  the  fingers  are  held  like  claws,  and  the  thumb 


Pia.160. 


'  (liMWt).     AttituiM  i^tht  Hand  in  PrntMrmmUfiUt  CtnieoK* 


988 


DISFJLSRS  OP  THE  MEMBItASES   OP  TOE 


is  extendet^  (Fig.  186).  This  porition  of  the  hand  is  not.  bow- 
ever,  80  much  a  sign  of  the  disease  as  it  is  of  its  locality. 
Wben  thiK  deformity  is  preseot,  the  lesion  is  Bituat«)  in 
tLe  lower  half  of  the  cervical  eolargemeot  of  the  cord,  ami 
the  distortioQ  indicates  that  the  roots  of  the  ulnar  and  mt- 
diaa  nerves  stand  at  a  lower  level  in  the  cord  thaa  those  of 
the  masctilo-.Hpiral  ncrra  When  the  diseoM  is  situated  in  the 
upper  cervical  region  and  implicAtee  the  upper  portion  of  the 
cervical  onlar^mcnt,  the  rcGuttiog  deformity  differs  greatly  fron 
that  just  described.  The  distortioa  of  the  hand  present  QDder 
those  circiimstauces  is  shown  in  (Fig.  187),  tAkeo  from  a 
photograph  of  a  remarkable  case  aoder  the  care  of  Dr.  Letcb. 
The  arm  is  held  close  to  the  side,  the  forearm  ia  extended  wa 
the  arm  and  strongly  pronntcd,  the  hand  is  Dcxed  oa  the 
forearm,  the  Bngera  are  in  a  line  with  or  only  slightly  exlenilf'il 
on  the  melacarpnl  hones,  and  the  phalanges  are  extcaded  upon 
one  another,  whilo  the  thumb  is  flexed  into  the  palm  {Fig.  187j. 

Fio.  167. 


Fro.  W.  AHilaJtof  1A«  Band  in  PaeliyiHi„,ny,i.t  Vtrritatit  Bjmtrtnpkitt, 
Iht  lenon  u  titaaltd  <m  u  (trtl  trUh  (A«  itpji^T  fliil_fi\flhf  ririfiiiil  iMriiiwiii 


All  the  muscles  of  the  forearm  and  hand  were  oo  douht  mora 
or  leas  paralysed  in  this  case,  but  it  will  be  seen  that  the 
muscles  supplied  by  the  musculo- spiral  nc-rvc  were  on  Uht 
whale  more  affected  than  tboee  supplied  by  the  ulnar  and 
median  nerves. 

The  paralysis  is  accompanied  by  marked  atrophy  and  loss  tf 
the  faradic  ctintractility  of  the  affected  nuscleit.    After  a  tirae 


SPDfAI.  OOBI>  AKD   MEDULLA  OBLONQJLTA. 


389 


muscular  tensioD  aiid  contraotureH  appenr  in  the  paralysed 
mnadei,  sad  circuniHcribed  areas  of  »na>itbc«ia  may  bo  ob< 
MTved  in  tlie  ftkm  of  the  upper  extremlltea  At  a  later  period 
tb«  lower  extremitieH  become  paralysed,  and  contracturee  n-itb 
JDCiMM  of  tbe  t«ndiuou8  reileies  appear  after  a  time  in  the 
iDBsdes.  Bimilar  to  that  which  occurs  iu  primary  lateral  scUroxitf. 
The  mavdes  of  the  lower  extremities  do  Dot  undergo  atrophy 
like  those  of  the  upper  extremities,  or  at  least  not  uutil  a  late 
ficruKl  of  the  dis&aso.  la  iwTcrecascs  complete  parapk-gia,  with 
Btarkcd  aoiestheeta,  paralysis  of  tbe  bladiler,  aud  bod-Boree 
ante,  [eadiog  to  a  fatid  termiuatiuo. 

The  ■ymptoQis  arc  at  first  due  to  compression  of  the  cord  by 
I  dun  matei  ooQtnctiag  around  it  and  to  transverse  myelitis 
lli«  spot  compreasad,  and  at  a  later  period  to  descending 
dagmentioD  of  the  pyramidal  tracts.  This  form  of  tbo  disease 
bM  a  resemblance  ta  progressive  muscular  atrupLy,  amyotrophic 
latanU  acterosis.  and  other  dtseases  attended  hy  atrophy.  The 
mwt  important  poiiita  of  distinction  are  tho  sUtge  of  pains,  the 
parttal  aosstbeeta,  and  the  paraplegia  without  atrophy. 

In  heamoirriiagie  paehymeningUis  interna  Uie  symptoms  are 
very  obacure,  and  uiiualty  complicated  with  those  of  oo-erisiing 
eanbnl  disease.  They  point  to  a  slow  meningitis,  and  consist 
ef  puns  in  tbe  loins  and  back,  tearing  pains  in  the  extremiiios^ 
ttiflfbea  of  tbe  vertebral  column,  increasing  muscular  weakness 
which  may  gradually  develop  into  complete  pemplegia.  contrao- 
Uunea,  various  degrees  of  cutaneous  hypeni:sthc!iiiL  and  ana-s- 
tb«Bia,  and  weakness  of  the  bladder.  If  a  patient  with  these 
vymptoms  be  at  the  same  time  suffering  from  cerebral  para- 
lyvia  and  chronic  alcoholism,  hoimorrUagic  pachymeningitis  may 
b«suipect«d 
Tbe  diagiiusia  ia  not  readily  made  in  thiti  form  of  tbe  affecltou. 


g  G31.  Morbid  Anabmy. — In  tbe  hypertrophic  /oi-m  the 
Amm  mater  ia  much  thickened  and  consists  of  a  large  number  of 
aoBOWtrie  layers  of  cicatricial  nonnectivo  tissue.  Tbo  pia  mater 
and  arachnoid  are  also  thickened  and  adherent  to  the  dura 
mater.  The  thickened  membrane  may  compress  the  cord  on  one 
■kle.  uT  from  behind  forwards,  but  u&uaJIy  embraces  it  like  a 
ling.     The  oompteased  portbn  of  the  coed  is  pale  and  soft,  and 


SdO  DISEASES  OP  THE  UEirBRAKES  OF  THE 

generally  preeenta  all  tlie  oharacteristics  of  traDiTeree  mjvlitir 
The  Derve  roots  on  a  level  with  the  lesioo  are  comprestied,  md 
the  muscles  supplied  hy  the  nerves  issuing  from  them  ftraioa 
cooditioD  of  degcueratiTB  atrophy. 

Fio.  188. 


SV* 


iJ^.^ 


w:^ 


i-^e^^ 


Flo.  188  lynin  Cbarait  mdiI  JoHroj'l.  Timafertt  .SKfim  efOU  Middl*  aflM  O 
^itaii  EntargfrnnU,  fifjm  a  nur  o/lti/pertrmJiir.  Cmieat  iPacKf»eni»fnttt.-—^ 
BrptrtnpluMl  duM  tunttr;  B,  Il<i«M  of  ui«  iMTTM  traTMvtag  tb«  iU^mm 
mflnbrktiM;  C,  Flk  inati>r  kiilwrmt  InUisdDtsiiMUr;  1),  Lwinii  at  < 
mjclitu;  K,  Cyitic  fornutiiui  in  the  yny  mibabuicA 

la  the  hcBmorrkagio  form  a  portiou  of  tbo  dura  mater ' 
wvered  by  a  soft,  rusty-browo  exudation  composed  of 
and  connective  tissue,  and  studded  with  numerous  htemorrliagif 
flxtravasatiooa.  The  exudation  cantains  numerous  blood -crystab. 
pigmaut,  detritus  of  decomposed  blood,  and  is  only  aligbtlji 
adherent  to  tbo  dura  mat<r  ot  arachnoid,  so  that  it  is  readi]} 
stripped  off. 

§  632.  Treatment. ^The   treatmeot  la  the  same  as 
meningitis  in  general. 

Id  tbe  ehrouie  form  counter  irritation,  preparations  of  itxline. 
galvanism,  and  the  use  of  baths  or  the  cold  water  treatmeot 
deserve  a  trial 

(in.)  mpu^MMATroNS  oy  the  pia  mater  and  spinal 

ARACHXOID. 

Leptomenitufilia  SpinalU — PervmydiiU  and  Jracfcittfia 
§  633.  Spinal  leptomeningitis  presents  many  varieties, 
for  practical  purposes  it  is  ttufficicnt  to  subdivide  the 
into  the  acut«  aaii  cbrooic  forms. 


SPIKAL  COBD  XHD  URUVU.M.  OBLONGATA,  391 

(L)  LiPTOHBRiVfitna  Stisalib  Actta. 

ti«  acute  rariety  b^os  suUdenl;  with  violoDt  scneory  dis- 
iDCGo,  attended  by  marked  fever. 

634.  Etiology. — Tho  prodisposing  eaiues  of  the  afTection 
a  scrofulous  or  tubercular  coaatitutioa,   inauSicieot   food. 

dwelUogs,  and  sexual  and  otber  ejcccfisea.  Tbe  diseaae 
by  preference  cKildren,  young  poraons,  mad  tho  mnle  8CX. 
be  mwit  important  of  the  ercuing  causes  tire  exposure  to 
wounds  and  injuries  of  tbe  vertebral  column,  and  ezteit- 
of  infin-mmatioR  from  ncigbbouring  structnrea.  Tubercular 
baaal  meniagitis  is  usually  accompaoiod  by  a  spinal  alfeclion 
of  tbe  Mme  oature.  Spinal  meniugitis  may  occur  along  witb 
or  during  coavalesccnc«  from  pneumonia,  acute  articuUr  rliea- 
nm,  ftod  otUer  febrile  and  infectious  diseases.  Epidemic 
-apioa)  tneuingitis  will  be  HubsequeDUy  ileiicribed. 

635.  Stfmptoms. — Acute  spinal  meningitiB   is  generally 
licated  by  a  simultaneous  atfocclon  of  the  cerebral  pia 
V  BO  that  it  is  not  always  easy  to  separate  tho  purely 
.1  from  the  cerebral  symptoms. 
e  disease  begins  suddenly,  but  the  outbreak  of  the  cha- 

tic  phenomena  may  be  preceded  by  premonitory  eymp' 

such  as  general  heavinesii  and  dcpressioa.  aligUt  chilliQess. 

ic  disturlMUioeav  tranflilory  pains  in  the  bead  and  back, 

esa,  and  sleeplessness, 
e  clMUacteristic  symptoms  of  the  dis«aae  ore  usbored  in 
by  a  ri^or  followed  by  pyroxiu  of  irregular  type,  and  if  the  pia 
mater  of  the  brain  be  affected,  vomiting  and  severe  cerebral 
rmiptoma  are  also  present  The  patient  now  complains  of  an 
mteofie,  deep-eeated,  boring  pain  in  the  loins,  back,  or  nape  of 
tbe  neck,  corresponding  to  the  tocaliaatton  of  the  lesion.  The  pain 
i>  iDcreased  by  movoments  of  the  vertebral  column  and  by  prc»- 
nre  on  tbe  spinous  proceatea  The  pain  is  subject  to  remissions, 
CqIIowmI  by  exacerbations  of  great  seventy>  and  radiates  from 
tbe  vertebral  column  rouud  tbe  trunk,  shooting  in  all  directions 
ibrongb  die  extremities. 
The  moscles  of  tbe  vertebral  column  are  in  a  state  of  spas- 


0  pUDJtt] 

the  mBH 


Sd2  DISUiiGS  OF  TQC   UCMBKAHES  Or  THB 

mcHJic  rigidity.  Wtieu  the  iuQammatory  prooeM  U  limited,  tbe 
rigidity  may  be  limited  to  oerLain  portions  of  the  vorlebnJ 
coluinD  corwMpooding  to  the  aitualion  of  the  lesioD,  but  the 
spasm  may  extend  over  the  whole  l«ngtb  of  the  xpioe,  so  u  to 
reKetnble  a  teUxnic  seizure 

Tlie  iDUHcles  of  the  extremities  are  also  Kubjcct  to  paiofol 
tuuxiou  and  Hpa»in.     The  limbs  are  then  rigiil  ami  immoi 
or  the  subjects  of  painfal  twitchings. 

Cutaueoua  aud  muscular  hyperie-'ilheaia  ia  often  pre 
tLe  extremities  and  triiuk  in  places  correspondiog  to  the 
of  distribution  of  the  uerres  wlioso  postcnor  roots  aro  IqitoItci) 
iu  tlie  iiiQumuiutiou.    ReSex  activity  is  at  first  incrdaaed  ami 
subfltqucu tly  diminisbuJ. 

FuDcliooal  di&turbaoces  of  the  bl&ddcr  and  r«ctuta  app«ar  at 
att  early  period  of  the  disease,  probably  owing  to  a  spasm  of  the 
sphincters.  When  the  ocrvicnl  part  of  the  cord  is  involved  in 
thu  inflammatiou  the  musclea  of  respiration  beoimie  rigid  and 
painful,  producing  dithciilty  of  breathing,  which  may  increaae 
to  such  nn  extent  as  to  caiiso  asphyxia. 

When  the  cerebral  pla  mater  is  implicated  the  patient  may 
suffer  from  vertigo,  violent  beadodie,  delirium,  UQCDnacioasou^ 
and  coma.  These  may  occur  at  an  early  or  late  period  of  th« 
disease,  and  usually  iudicate  a  fatal  tvtmiaatiou. 

As  the  disease  progresses  symptoms  of  sensory  and  raolor 
pftralysls  supervene,  although  those  indicative  of  irritation  may 
for  a  time  be  variously  combiQcd  with  them.  CutaiMOUt 
sensibility  becomes  diminished  and  complete  an^ntheaia  may  W 
edtiibliahod,  wliilc  the  extremities  maaifcst  various  degrees  at 
motor  weakness  up  to  complete  paralysis.  When  the  lesioa  is 
situated  high  up.  pamlyais  of  the  respiratory  mochouism  may 
lead  to  a  fatal  terminatiou,  and  the  Choyno<Stoke3  respiration 
has  been  repeatedly  observed  towards  the  fatal  terminutioa 
The  pupils  may  be  contracted,  dilated,  and  uuvfiuat.  In  Sstal 
Cases  deep  coma  supervenes,  accompanied  by  a  rapid  elevation 
of  temperature 

At  other  times  deceitful  signs  of  temporary  improvement 
appear,  but  paralysis  and  bed-soies  supervene,  and  death  follows 
after  long  suffering.  Sometimes,  however,  there  is  real  improve- 
ment, aud  filight  cases  may  speedily  recover,  but  in  most  instasca 


aPlKAL  CORD  AKD  MEDULLA   OBLONOA.TA.  393 

coQValcaccDCc  is  slow  uaJ  the  sjmptoms  of  scnsoij  aod  motor 
imtAtioQ  only  disappear  after  a  loog  period. 

locurkblQ  defects  are  ofteo  left  behind,  such  as  ana^hefltn 
of  vatiabte  degreo  aod  exMct,  and  paralysis  of  iodividuul 
iDttScl««,  groups  of  muaclcfl,  or  of  entire  extremities.  The 
iDUiicolar  paralysis  may  be  fls*ocifttcd  with  atrophy  aod  con- 
tractures. The  eymptoms  which  indicate  sclerosis  of  aiDgIc 
oolumna  of  the  cord,  such  as  ataxia  and  apastio  paralysia,  may 
Bocoetimes  become  permaaoutly  established. 

If  the  inflammattoD  ezteud  to  the  medulla  oblongata  or  to  the 
base  of  the  crauium,  the  characteriftUc  flymptom8,vomitiug,  head- 
»die,  delirium,  aod  paralysis  of  the  ocular  muscles,  cuperveoa 

§  G36.  Oourse,  DmyUion,  and  Termination. — Id  oerebro- 
qnoal  mooiugilis  death  occurs  early,  occaaioualty  within  a  few 
hours,  hat  more  usually  it  ia  postponed  for  a  few  days.  In  less 
viuleut  cues  the  duration  may  be  two  or  three  weeks,  and  the 
■arerity  of  the  symptoms  fluctuates  greatly. 

Id  other  caaea  the  acute  B^mptums  siibtiide  and  the  disease 
ianiBea  a  chronic  form  which  is  usually  auiocialed  with  mye- 
lilia.  Cystitia  and  bed-sores  supervene,  and  the  patient  dies 
from  cxhaustioo. 

lu  mild  cases  the  threatening  symptotiui  may  disappear 
rapidly  aad  tlic  pationt  apvcJily  recover.  But  convalescence  ia 
as  a  rule  protracted  even  when  the  patient  ultimately  makes 
ft  complete  recovery,  tut  iu  a  large  number  of  coses  a  certain 
Bmoaot  of  patolyais  aod  tnaBtbena  remains. 

J}  637.  Morbid  Anatomy. — The  morbid  changes  found  in 
acute  spinal  meningitis  may  be  subdivided  into  three  groups, 
aecordbg  to  the  period  of  the  disease  : — (1)  A  stage  of  hyper- 
a>mia  and  commencing  exudation;  (1)  a  stage  of  serous,  purulent, 
or  tibriiKjus  exudation  ;  (3)  a  sta^jo  in  which  chronic  changes  are 
eacabliahed. 

(1)  In  the  first  stage  the  pia  mater  is  congested,  of  a  nwy 
or  a  dark  red  tint,  and  dotted  with  hsemorrhagic  cxtrava^tiona 
The  ttasue  ia  swollen,  infiltrated  with  serum,  and  the  cerebro- 
spinal fluid  ia  slightly  turbid.  The  amchuuid  is  uIbo  cougeated, 
■mi  tbe  hyperemia  extends  to  the  cord  and  to  the  dura  mater. 


$94 


DISEASES  OF  THE  HE3tBBA»ES  OF  THE 


(8)  lo  the  seooDtl  stage  th«  spiual  fluid  becomes  more 
mora  turbid,  and  fibriDOuti  floktss  aod  platca  are  found  in 
Bub&racbnoid  tissue  or  adtiering  to  the  surface  of  the  dura  mkX 
The  pia  tnater  becomes  more  aud  more  opaque,  and  the 
arachnoid  tissues  are  transformed  iuto  a  gelatinous  mass. 
exudation  becomes  more  and   more  purulent,  and  at  last  th« 
whole  pia  mater  and  subarachnoid  tissues  arc  iatiltratcd  wiih 
puB.    The  Bpinal  tluid  assumes  a  serO'punileDt  appearsace  aod 
contains  numerous  flakes  of  flbrine. 

Small  miliar; nodules  maybe  foitud  iasome  CBnea  distributed 
along  the  cauni«  of  the  vessela  of  the  pia  mater,  comitituuag 
tubercular  spinal  meniogitis. 

The  distribution  of  the  exudation  varies  greatly,  II  usu 
covers  the  grealur  part  or  (he  whole  of  t^e  oord,  but  the  potterior 
surface  ia  afiected  in  a  greater  extent  than  the  aoterior,  and 
the  changes  are  sometimes  limited  to  a  small  portion  of  the 
cord.  Tlio  exudation  not  unfrcquenllj  extends  from  the  spinal 
canal  into  the  braio,  and  the  arachnoid  ia  always  involved  to 
the  inflammatory  acliou.  It  is  thickeued,  op&4uc,  hiilltmted 
with  serum  or  pus,  and  often  abounds  with  grey  miliary  tul 
while  the  sub^acbuoid  ti^ue  U  Kimilarly  afiected. 

The  dura  mater  ia  often  hypcra-mic,  opaque,  aod  ooverad'' 
thin    fibro-purulfnt  exudation.     The   ncrvo   roots  are 
always  involved,  they  are  enveloped  in  thick  masses  of  exuda- 
tion, and  are  often  swollon  and  softened.   The  cord  itself  is  pale 
and  (edematous,  or  congested,  and.  is  \uuaUj  aofkoued  either  ^^ 
limited  spots  or  diCTusely.  ^H 

(3)  In  the  tbinl  stage  chronic  changes  aupervene  aod  b«oni^^ 
pennanent,  the  most  common  of  these  being  opacity  aod 
thickening  of  the  spioal  membranes,  adheatonB,  accamulatiooi 
of  fluid  in  the  arachnoidal  Kpace  (hydrorrhachis),  and  sderocis 
and  atrophy,  either  difl'uaed  through  the  oord  or  affectiog 
isolated  portions  or  systems.  lu  casus  where  abeorptioa  bM 
takcu  place,  thure  is,  of  couno,  no  third  stage. 


§  638.  Morbid  Phy»iolog\/.^-'t\io  poios  in  the  back,  ecoeo- 
trio  pains  in  the  extremities,  bypcncathesia,  and  muscuhu  rigidity 
and  twitchings  arc  caused  by  irritation  of  the  posterior  anJ 
anterior  roots  of  the  nervea.    Tbo  sensory  and  motor  paialt 


K 


^ 


SPIHAL  CORD  AND  XEn(Jt.L&  OBLOKOiXi.  395 

hicti  cfaaracteffues  the  second  stago  of  tho  disease  is  caused 
tbo  coiupreasioD  of  tbo  aervoua  tisoea  oocukwiAd  by  the 
exudation,  Implicatioo  of  the  anterior  roots  and  anterior  grey 
bomi  explains  tbo  miutculur  atrupby  wbicb  ia  sometimes 
obntred,  while  afl'ectioD  of  the  posterior  grey  hocQa  in  tbe 
lumbar  rcgiou  accounts  for  t3)e  paralysis  of  the  bladder  aod 
r«ctum. cystitis,  aod  bcd-sorc«  wbicb  are  sometimes  present,  while 
eztCDBUM  of  tbe  morbid  proccesto  tho  upper  part  of  tho  cervical 
region  cauaoB  the  disturhaaces  of  respiratioQ  wbicb  occur. 


§  639.  Diaf/no»ii. — ^The  geaeral  evidoDcea  of  the  diftcaw 
are  ferer,  paiD  and  rigidity  of  the  back,  stiffness  of  tbe  ueck, 
maacuUr  spurns,  cutaneous  hyperesthesia  and  paresthesia, 
paiDfl  in  and  paralysis  of  the  limbs,  retention  of  urine,  cousti- 
patioD,  and  dyspocsa. 

When  the  membranes  of  the  brain  are  implicated,  the  cerebral 
symptoms  will  of  courae  coustitule  tiie  most  ptvmiueul  feature 
of  tbo  duease. 

It  is  not  always  ponlble  to  distmgulsh  acute  spiaal  meningitis 
from  acute  myelitis^  inasmuch  as  the  two  aiTeclioni  arc  often 
combined.  Sliffaess  in  the  back  and  neck,  eccentric  paina  in 
tiie  limUi.  and  hypcm-sthcaiai  are  characteristic  of  aoule  Bpioal 
ncaii^itiji;  while  sensory  and  motor  paralysis  predominate  in 
myetitia 

In  Utanua  cerebral  symptoms  are  always  absent,  there  in 
no  hypenestheaia  of  the  akin,  and  reflex  excitability  is  very 
fTMtly  exaggerated.  The  pretenco  of  tho  risus  sardonicus  and 
Um  aarly  occuttcqco  and  severity  of  the  tetanic  spatm  in 
tstanus  render  tbe  diagnosis  between  it  and  spioaJ  meningitis 
as  a  rule  easy. 

Tbo  diagnosis  of  the  tubercular  form  of  the  disease  must  rest 
chiefly  ou  geneml  considemlious,  such  as  the  evidence  of  scrofula 
or  tuberculoais  of  other  orgoju.  It  is  probably  nlwajrs  associate<l 
with  tubercular  basilar  meningitis;  so  that  the  presence  of  the 
osrebral  symptoms  characteristic  of  that  afTection  may  be  of 
nae  in  clearing  up  the  dugnosis  of  tbe  sfnnal  disease. 

§  640,  Proynogia. — Tbe  prognosis  raries  greatly  in  different 
Hypemcate  and  tubeKular  meningitis  and  that  caused 


898 


DISBASBS  OF  THE  UEHBBANES  OF  THE 


when  tlie  patient  is  lying  on  bis  back,  and  then  it  ia  prol 
that  the  cord  \s  liable  to  become  pawrirely  congeflted. 

liypera'tttUesia  is  a  rretiueiilsjmploin,  but  aiupstheeia  is 
There  in  usuallj  only  elight  blunting  of  the  cutaneous 
bilitv,  limited  to  tbe  feet  aod  lower  part  of  tlie  legs. 

In  iievere  cases  the  muscleji  maj  undergo  atrophy  with  lOMt 
electric  excitability.    ADB:;8tbe)3ia  Is  developed,  tbo  re6ex  acUoi 
are  abolishe^l,  bed-sores  and  cystitis  appear,  and   the  patieat 
dies  from  pysemia  and  maraamua 

g  6M,  Couree,  Duratitm,  aTid ResuUa. — Thediseaaeisalvajs 
elow.  and  extends  over  a  period  of  months  or  years.  Some  oun 
recorer,  but  the  riitum  to  liunlth  is  slow,  and  often  intcimpled 
by  nlapecs.  The  sensory  disturbaocea  are  tbe  Srst  U>  diaappeai, 
tbe  motor  persisting  longer.  In  many  eases  recovery  is  only 
partial,  and  paralysiii  of  some  muscles  or  extremities,  with  or 
without  atrophy,  circumscribed  aiitesthesio,  weakness  of  th« 
bladder,  and  other  symptoms  remain  permanently.  In  the  gran 
majority  of  cases  chronic  m«uingitifl  endu  after  a  time  fatally, 
The  symptoma  which  precede  and  cauw  death  are  usunlljr  para- 
plegia, paralysis  of  the  bladder,  cystitis,  bed-sores,  aod  marasntoi. 
In  ottier  cases  the  morbid  process  extends  to  the  cervtcal  region, 
giving  rise  to  difficulty  of  breathing.  At  other  times  death  i* 
brought  abuut  by  an  acute  attack  of  purulent  meningitis  super- 
vening on  the  chronic  form.  Death  may  also  be  caosed  by 
many  other  complications  and  acddents. 

§  (Ho.  Morbid  Aiu^omy. — Tbe  pia  mater  and  aiadmotd  in 
chronic  spinal  leptomeningitis  are  congested,  thickened,  opaiiue, 
often  pigmented,  and  clo!)u)y  adliercnt  to  the  dura  raater  on  tlie 
one  side  and  the  cord  on  the  other.  Tbe  spinal  fluid  n  oaually 
in  cxcow;  it  is  gL-uerally  turbid,  tinged  with  blood,  or  mixed 
with  an  nbnndant  fibrinous  exudation.  Numerous  thin  aad 
small  calcareous  plates  may  be  obeerved  on  tbe  anwhaoi^, 
especially  in  tbe  lumbar  region.  Tbo  cord  is  usually  implicated 
in  tbe  morbid  changes.  Transverse  myelitis,  or  cortical,  sya 
malic,  or  disseminated  sclerosis  may  b«  observed. 

§  646.  j&iajj'nosisL^The  diagnosis  of  chronic  spinal  lept 


sphtai.  cobd  asd  medulu  oblokqxta.  3s9 

nke&ingitis  preKotd  no  difficulty  when  the  disease  is  fulljr 
d«T«lopeO  and  aacomplicated,  but  ts  difficult  during  tUo  first 
olncare  cyoipCocos  of  tbe  aSectioo,  and  nhoo  it  is  complicated 
with  chronic  myelitis. 

Pain  and  stiffness  in  the  back,  eccentric  pains  in  the  extre- 
cniticfl,  girdle  painfl,  and  othvr  symptoma  caused  by  irritation 
of  the  roota  ot  tlie  nerves,  a  slight  degree  of  paralysis  with 
flaotaatioDB  in  its  inteosity,  especially  when  the  last  varies 
MWOidbg  as  the  patient  is  in  the  prone  or  erect  posture,  hyper- 
tttbwia  or  a  atij^bt  d^ree  of  aniesthesiu,  nomiiU  or  ahwnt 
teedoe  r^Dexcs,  and  painful  inuacutar  jcrlciogs  point  etroogly 
to  spin&t  meningitis. 

When  severe  puralyais  and  anustheina  arc  present,  the  pains 
slight,  and  the  tendinous  reflexes  exaggerated,  the  presence  of 
myelitis  may  be  inferred. 

Spiual  tneniugitts  may  be  readily  distingtiished  from  loco- 
motor ataxy,  but  it  must  be  remembered  ihat  the  two  diseases 
are  often  combioed. 

§  6-47.  PrO'jnotU. — ^Tbe  prognosis  is  always  ^rave,  althoagfa 
many  apparently  hopeless  cases  have  boon  knovn  to  recover ; 
■a  a  role,  some  permoneDt  damage  to  the  cord  is  geuetaliy  left 
behind. 

{j  G4d.  Trfatment. — Tlie  acute  form  should  always  be  sub- 
jected lo  energetic  treatment,  with  the  view  of  avoiding  (he 
eitabltahment  of  the  chronic  variety.  Active  onliphlogistic 
treatment  does  uo  good  in  the  chronic  form  uf  the  disease. 

Oounter-irritation  along  the  vertebral  column  is  one  of  our 
hest  means  of  treatment  Repeated  large  blisters  to  the  back 
are  the  most  effectual  of  this  class,  although  the  milder  counter- 
irritants  may  ba  luffident  in  some  cases. 

Iodide  of  potoMium  in  moderate  doacs  Is  the  only  reliable 
internal  medicine.  Uercury  should  not  he  administered  unlec» 
the  presence  of  syphilin  be  suspected.  Ergot  and  belladonna 
w  of  no  Qse.  The  patient  should  be  kept  warm,  and  warm 
baths  of  all  sorts  are  efficacioua 


400  DtSEASES  OV  THE  MKHDILAKGR  OP  THE 

irV.)  TUMOUltS  OF  THE  SFINAL  UEUUKANE. 

§  6fd.  Tbe  tuatoun  wbicb  are  fuund  within  the  spinal  cat 
usually  develop  from  the  spinal  mcmbraQea.  The  nujorii^of 
them  spring  from  the  dura  mater,  but  some  originate  Irom  tbe 
MTMlilloid  and  pia  mater,  and  remain  limited  to  these  mem- 
btftDUL  Morbid  growihH  may  also  arise  from  tbe  ncighbourinj^ 
structures  and  extend  towarda  the  canal  &o  aa  to  involve 
menibraneH  secondarily. 

§  650.  Etiol(Kji/.-~T\ie  causes  of  meitiiigeal  tumours  art 
obscure.  Many  cases  bave  been  obierved  where  tbe  first  ayinp- 
toms  oocur  afUtr  a  fall  or  blow  on  the  back  or  spine  ;  in  m&Bjr 
cases  the  commencement  of  the  diseaxe  dates  from  childhood. 
Disease  of  ibe  vertebne,  tbe  tubercular  and  scrofulous  diatbesis, 
sypbilia,  and  prul)ably  an  inherited  teodencgr  to  the  formation 
of  carcinomatous  and  other  growths  are  the  main  predisposiag 
cuuHes.  ^^^_ 

§  651.  StfinpUyim. — ^Thc  aj-mptoms  may  be  divided  mUt  tws 
groups — (1)  those  caused  by  local  irritation  and  compression  of 
tbe  iierve-roote  and  nieinbraues  fiitst  involved  io  the  tumour; 
and  (S)  thoeo  caused  by  irritation  and  comprcmion  of  tbe  cord 
itself,  and  by  consecutive  myelitis. 

The  symptoms  of  tbe  first  group  may  precede  those  of  the 
second  by  many  year%  They  are  very  variable,  as  might  b« 
expected,  vbcn  it  is  considered  tlat  tbcy  must  largely  depend 
upon  the  locality  of  the  tumour,  aud  tbe  direction  and  rata  of 
its  growth. 

Violent  Paina  of  a  lancinating,  tearing,  and  boring  ebaiacter 
are  complained  of,  nnd  those  may  remAln  confined  to  a  single 
point,  or  attack  a  nerve  trunk.  They  either  surround  tbe 
trunk  like  a  girdle  at  various  levels,  or  invade  tbe  upper  at 
lower  extremitieii  of  one  or  both  aidefi.  They  may  also  eiteod 
gradually  or  suddenly  into  neighbouring  nerve  districta.  ThfJ 
are  oflen  increased  by  movement  of  tbe  spinal  column,  mod, 
like  all  neuralgic  pains,  are  made  worse  by  sudden  changes  d 
weather. 

ParceMthMus,  such  a«  tingling,  formication.  numbiiOM,  eitW 


SPMAL  CORD   AN1>  MICDULLA   OBLOMOATA. 


401 


is  the  form  of  a  f^irdle  or  liimt«d  to  c«rtain  ref^oas  of  tbe 
•ttreiniticit,  uro  observed. 

TwitcAings  and  Spcimis  of  iodividual  roasclcH  may  appear 
when  the  motor  roots  are  firat  sulijecteil  to  tlie  presauro  of  tbu 
tacooui. 

TbeM  symptoms  ar«  almost  always  accompanied  by  local 
puD,  and  stifiben  of  the  spioe  in  Lbe  neighbonrbood  of  tbe 
umnar. 

Symptaroa  of  both  sensory  and  motor  paralysis  appear  aooner 
or  later,  but  tbtse  ore  at  firat  limited  to  tbe  regioo  of  distribu- 
iioo  of  tbe  nerves  which  tak«  origin  fmm  tliu  part  of  the  cord 
■fleeted.  Theeo  sjmptoms  coasist  of  circumscribed  anipathesia, 
H^»ti  uaociaied  with  pain  {anaatiuaia  dolorosa),  and  local 
^■Mui  or  paralysis  of  the  oomepODding  muscular  groups, 
followed  by  atrophy  aud  tbe  reaction  of  degeDcratioD. 

If  the  cervical  portion  be  the  scat  of  the  affection,  an  upper 
tixtreniity  may  Grxt  be  eciz^  by  pams,  pancsthtj^iiu,  partial 
punUyaifi,  and  atrophy  before  the  symptotus  of  comprOBsion  of 
tbe  cord  appear.  When  the  dorsal  region  is  tbe  seat  of  the 
imnoar,  tita  iUuess  is  introduced  by  iiitorcotital  neuralgias  and 
bcrpea  BOater  Nuuralgioa  and  trophic  cUangeH  iu  the  diBtrict 
of  tb**  lacnbar  or  aieral  plexuses  iudicate  tliat  the  lumbar  region 
is  invotred. 

After  a  period  of  weeks,  months,  or  years,  acoording  to  the 
rate  of  growth  of  the  tumour,  the  symptoms  due  to  compiestiiou 
aod  myelitis  appear  either  gradually  or  suddenly.  When  para- 
plegia occun  suddenly,  or  in  a  period  of  a  few  hours,  it  is 
gtnermlly  caused  by  seoondary  myelitis.  If  tbe  paraplegia 
malt  from  tbe  compression  caused  by  the  slow  growth  of  tbe 
toiDOur.  one  lateral  half  of  the  cord  may  be  subjected  to  pres- 
•ore,  or  tbe  compreeeioo  may  occur  on  the  anterior  or  posterior 
■urfiioe  of  the  oord.  Uotor  phenomeiia  predominate  whcD  the 
■Marior  turfaee  is  chiefly  affected,  and  tenaory  j^eDomena  wbeu 
tbe  postarior  is  princiiwUiy  inrolrod.  When  the  cord  is  oom- 
plitely  compniBod.  or  transrerM  myelitis  occurs,  the  whole  of 
iha  body  bebw  the  seat  of  the  tumour  becomes  more  or  leu 
eompletely  aotustbetic  and  pamlyeed,  and  the  bladder  and 
nettun  are  panlyaed,  white  cystitis  and  bed-sores  with  their 
eaueqavDOes  superveoe. 

AA 


402 


DISUSSB  OF  THE  UCHBUintS  OF  THC 


Symptoms  of  motor  irritatioD  often  ftccompuny  tboep  ol 
paralysU.  These  ustsaJly  coueiat  of  muacular  twitchiug  nnd 
tranateot  spaAtns,  and  after  a  time  secoadarj  degeDeralion 
occurs,  cauaiDg  contracture  of  the  extremities.  _^^M 

The  reBex  octious,  both  supcificiai  and  deep,  are  u^<m 
iDcreased,  but  when  tbo  grey  subataace  becomoB  seoondanly 
diaeaeed.  or  when  the  tumour  Is  situated  io  the  lumbar  regioD, 
the  reflexes  are  abotiahcd. 

Muscular  atrophy  may  at  Hrst  be  limited  to  the  area  of  di»- 
thbutioD  of  the  nerves,  the  anterior  roots  of  which  are  compressed 
by  the  tumour;  but  after  a  time  all  the  paral^Kd  mind«s 
undergo  rapid  atrophy,  and  their  faradic  contractility  Jiasp- 
peara.  Death  is  geuerally  caused  by  cystitis  and  bed-«ores, 
but  when  the  tuoiour  is  utuated  high  up  ileatb  may  be  caned 
by  arrest  of  reiipiratioa  Death  not  uufrequeoUy  results  froio 
an  ioteivurrent  attack  of  pneumonia,  or  spinal  meningitis. 

§  652.  Courm,  DKrafmn,  and  TermiTMticn. — ^Tlie  fintt stage 
of  the  disease  is  very  insidious  and  may  extend  over  many  yean- 
When  once  paiaplegia  makes  its  appearance  the  progren  ii 
usually  more  rapid  ;  but  even  then  years  may  pass  before  death 
occurs.  The  symptoios  fluctuate  greatly  in  severity,  and  ibe 
entire  duration  of  tbe  aH'ection  varies  from  eight  muuths  to  iunr 
or  five  years;  although  cases  are  known  which  bare  extended 
over  a  period  of  fifteen  ycais.  The  iliaeaao  generally  enls 
fatally,  but  in  the  case  of  aypbilomata,  scrofulous  tumottn,  sad 
inflammatory  ouw  formations,  complctu  or  partial  recovery  may 
take  place. 

§  G53.  Diagnosis. — During  the  iirst  stage  of  the  disease  it 
ma^r  be  inferred  that  there  is  a  circumscribed  lesion  of  the  cocd, 
but  it  is  not  possible  to  make  an  accurate  diagnosis  of  tamooc 
When  symptoms  of  a  slowly-developtDg  oompreasion  of  the  ooid 
are  present,  and  when  these  have  been  preceded  by  symptoms 
of  irritation  or  compressioo  of  the  nerve  roots,  a  tumour  may  h> 
suspected. 

The  diagnosis  of  the  luUV're  of  the  tumour  miint  be  made  hy 
a  careful  cxamiualiou  uf  all  the  circumsiances  of  the  casa. 

When  Pott's  disease  or  marked  acrofulA  exists,  a  peri-meoin* 


SFIVJlL  COBD   AKD  AIKIOULLA  OBLOKOATA. 


403 


gitic  exiKlation  m&j  be  iDferred ;  kud  when  there  is  primary 
awoet  of  Ibc  vertebra?  or  of  some  ottier  port,  a  carciaomatous 
tamotir  may  bo  cocndcrcd  probable;  wbile  if  tbero  be  otb«r 
«vit)«Qees  of  sypbilis  a  gummBtoua  tumour  is  to  be  expected. 
EchtnocoocnB  may  be  tnlerreO  to  be  prestmt  wben  ttie  paruite 
has  beeo  fmitul  io  otiier  organs,  and  neuroma  if  neuromata  are 
fbniid  OD  the  peripheral  ni-rvea, 

§654.  Morbid  Anatomy. 

Fihrtnna  aitd  jUtro-mrc&ma  are  usually  staall,  oval  tumours, 
3  to  5  cm.  long  and  2  tu  4  cm.  thick.  Tbey  spring  frnm  the 
dnim  or  pia  toater,  and  may  be  situated  cither  vilhia  or  without 
tha  mc  of  tbe  dura.  Tboy  con^iac  of  coonective  tissue,  with 
mora  or  less  abuadaat  spindle  or  roauil  celliL 

Sarcoma  oocure  in  ever/  possible  form,  as  liard  and  soft, 
6>)nMu  or  cellular,  and  often  as  a  cystoearcoma.  It  generally 
originatee  from  tbe  inner  membranes,  and  is  usually  of  an 
elosffaled  form,  and  frequently  lobular. 

iti/teowui  almost  exclujitvely  origioatee  from  ibe  aracbooid  or 
pia  mater.  It  is  a  soft,  juicy,  lobulated  tumour  of  moderate 
■4X8,  and  pale  colour. 

Paammomn  appean  in  tbe  form  of  a  small  roundish  or  oral- 
kbapctl  smooth  ur  lobeJ  tumour,  am]  generally  originates  in  tbe 
aoft  membraoea  It  is  really  a  sarcomatous  tumour  with 
gFanalar  coocretiooa  of  lime  imbedded  iu  it«  substance. 

Liftoma  has  repeatedly  been  found  in  the  vertebral  canal, 
ntay  originate  either  lu  tbe  fatty  tissue  out«ido  the  dura 
or  from  tbe  tuft  mfrmbmnes. 

Snchondnnna,  of  the  sixe  of  a  haxel-out.  and  firmly  adherent 
la  tlie  dura  mater  and  cuunected  vertebne.  baa  been  found  by 
Virchow. 

Oaltoma.  in  tbe  form  of  so-callect  cartilagiooua  disca.  is  very 
oonuoon  io  the  aracbnuid,  and  diffuse  oiUtilicatioD  of  the  dum 
■mtcT  aUo  occurs,  but  ueitber  of  these  can  be  regarded  as 
pruprr  tuBioure. 

JtiUtipte  FibrouM  UdaTwma  has  been  found  in  the  spinal 
taual  by  Virchow  and  Santler. 

Xruromala  have  been  found  on  tbe  ne 


404  DISEASES  or  TBK  UEMUKANES  OK  THE 

the  cuuda  equina.    Tliey  are  generally  false  oeuroinata,  anJsrv 
either  multiple,  or  occur  siDgly. 

Carciitoma  spriQgs  ver^r  rarely  from  the  epioal  ineiiibnM« 
These  luraours  are  almost  alwnyg  developed  secontUlilj  iiy 
exUnatoD  from  tho  vortcbrffi  or  Qoigfabouriog  parta,  or  hj 
tnetastasU  from  other  organs. 

Miliary  tnherclea  are  iouad  in  the  soft  membnuies,  aud 
closely  aJlied  to  tbeae  are  tumoura  vriiich  originate  from  inflam- 
matory, hn>morrtiagic,  and  otber  processes  in  the  spinal  men- 
branes  or  the  neighbouring  parts,  such  as  peri-pocbymeniDgitic 
cxudatiou!!,  circumscribud  masses  of  a  purulent  or  caMOUS 
nature,  scrofulous  exudations  between  the  dura  and  reitebral 
colunm,  and  hfeinatoma,  ^H 

Syphilomata  uauoJly  consist  of  gummata  of  the  dura  or  |H 
mator. 

Paratitic  gr&uih^  are  rarely  met  with  in  tbe  vertebral  c&uaL 
Cysti<«r«us  c«lluli>sa;  has  been  found  by  W«stplial,  aud  c<biito- 
C0CCU8  has  been  occaBiooally  observtd. 

§  G55.  Prognosis. — The  prognnsis  is  always  rery  serious. and 
the  more  quickly  the  nymptoms  have  developed  the  worse  itia. 
The  preeeoce  of  carcinoma  wnrrantsi  the  worst  prognosis.  lu 
the  inflammatory,  syphilitic,  scrofulous,  and  hwoiorrbagic  fbnni 
the  prognosis  is  more  favourable.  If  paraplegia  be  oompletc 
tbe  proguusis  is  bopelefia. 

§  656.  Treatment— The  internal  remedies  from  which  mw 
is  to  be  expected  arc  iodide  of  potassium  and  mercury. 

The  paiuful  and  other  distressing  phenomena  must  be  relieved 
by  etiitublc  remedies. 

(V.)  DEFoRMrrres  of  thb  spinal  meubbangs. 
tj  Qo7.  Spina  Bijida  consists  of  an  abnormal  accumalatioB 
of  Uuid  within  the  cavity  of  the  dura  mater  in  connection  with  a 
greater  or  lesser  deformity  of  the  vertebral  eolomn.  tt  preMBti 
itself  as  a  sac-likt^  dilatation  and  pouching  of  a  moK  or  b« 
drcumscribed  portion  of  the  cavity  of  the  dura  mater,  which  m 
generally  associated  with  deficiency  or  absence  of  one  or  more 
vertobral  arches.    The  sac  protrudes  tike  a  hernia  through  ths 


SPIKAL  OOKO  AKD   MEDULLA   OBLONQATA. 


405 


doft,  BDcl  raises  the  slcia  in  the  form  of  a  taraour  of  vguinbte 
lixe.  The  seat  of  the  tumour  i»  general);  in  the  sacral  and 
lombar  regions,  anJ  more  rarely  in  the  (torsoJ  or  oervioal  por- 
Uoos  oT  the  cord.  It  is  almost  alwayg  nituated  in  tlie  middle 
Itni  and  eeldom  deviates  to  either  side.  As  a  rule  there  is  only 
one  tumour,  but  several  are  uccasiooally  present  They  vary 
to  aixe  from  a  hazel-nut  to  tliiit  of  a  child's  head,  and  are 
ttwialty  round  or  elliptical  in  form,  hut  at  times  may  eitend 
orei  a  large  portion  of  the  spinal  column.  The  tumour  is 
eiliier  wesile  or  pedunculated,  and  sometimes  subdiTided  into 
two  or  lobulated. 

The  ekin  over  the  tumour  may  be  normal,  or  elretched 
thin,  red.  and  ulc«ntted,  and  at  times  an  urabilicated  depression 
may  be  seen  at  soma  point  on  the  surface  of  the  tumour,  caused 
hy  the  insertion  of  the  end  of  the  cord  in  the  interior  of  the  saa 

The  dura  mat«r  is  cither  tbtclcoRed  or  thin  and  stretched, 
aad  usually  lies  immediately  bunealU  ibe  skin.  The  arachnoid 
luaaUy  «ncloeea  the  fluid,  and  ifhydromyeliaexiBt,thep!a  mater 
takea  part  in  the  formation  of  the  sac.  The  aeck  of  the  sac  is 
mir*  or  less  narrow,  and  communicateH  with  the  spiual  canal. 
Oocauonally  it  may  be  clo«ed  by  adhesion!*,  so  that  the  extertial 
«ac  fonns  a  cystic  tumour. 

The  condition  of  tbe  apinul  cord  varies  in  different  coacs. 
As  a  rule  the  cord  is  normal  and  takes  no  port  tn  the  deformity 
cioept  that  its  lower  extremity  may  be  adherent  to  the  sac. 
Th«cord  may  be  lengthened,  and  rendered  thin  and  Bat  by  its 
•stremity  being  drawn  out  of  the  vertobral  canal  In  these 
CMM  the  nerve  roots  return  alongtbe  walls  of  the  sac  or  through 
the  fluid.  When  a  bydrorroehis  interna  exists  along  with  the 
Apioa  bifida,  the  lower  portion  of  the  cord  is  more  or  lees  de- 
raoyed,  atrophied,  and  the  cavity  of  the  sac  communicates 
llir««(ly  with  the  dilated  and  open  central  canal  of  the  cord. 

Tli«  oonteuts  of  the  aac  cousisl  generally  of  a  light  colourless 
dear  lluid,  identical  with  the  normal  oerehro-ftpinal  fluid, 
'ftttd  ita  quantity  may  amount  to  from  Sox.  to  2)b.  or  more. 


[^  8&S.  Symptom*. — The  raoHt  marked  symptom  at  birth 
Tonntti  of  a  tumour  over  the  vertebral  column,  usually  seated 
in  the  sacral  or  lumbar  region,  and  oocadonally  at  a  higher 


406 


mg^SSI^ 


TUi:   ItEUDKANBS  OF  TUB 


point  of  the  spinal  column.  When  the  tamour  is  large  the : 
ma;  hurst  during  birth,  and  the  child  then  generally  dies  from 
asphyxia  a  few  faoun)  or  at  most  a  day  or  two  aAer  birtb.  The 
tumour  may  rcmuiQ  stationary  ur  increase  in  size  In  rare  i 
it  may  develop  for  the  first  time  aflcr  birth. 

The  tumour  is  tense,  elastic,  flucluatiog,  and  when  the  a 
is  thin  and  stretched  it  may  appear  transtncout.  At  tim«s 
skiu  may  be  ulcerated,  so  that  the  wall  of  the  sac  is  coiutittited 
by  the  distended  flpinal  membranes.  The  aac  can  be  emptiixl 
by  stow  and  gradual  pressure  exc«pt  in  thofte  caa«s  ia  which 
communicaliou  of  tho  apiual  caaal  has  been  cut  off  by  cloture 
of  the  sac ;  and  if  there  be  eoiocidcDt  bydrocephalug,  preenm 
on  the  tumour  cauaea  swelling  and  protniRioa  of  the  footanellBs. 
The  awelliug  also  increases  on  assuming  the  erect  poature,  and 
(luring coughing  and  sneezing.  The  tumour  iseometimes  seoai- 
tive  on  prcn^nrc.  It  may  remain  statiooaiy  and  give  rise  to  no 
other  symptoms,  and  the  patient  may  arrive  at  maturity  without 
developing  any  serioii-t  symptoms.  As  a  rule,  however,  it  in- 
creases in  i^iz«  and  produces  pressure  on  the  lower  pait  of  the 
cord  and  the  cauda  equina,  su  that  the  children  affected  booo 
suffer  from  paraplegia,  incontinence  of  urine  and  feces,  and  bed- 
sores,  and  the  case  soon  terminates  fatally.  When  there  is 
coexistent  hydrorrachia  interna,  paraplegia  and  poralyva  of 
the  sphincters  are  present  from  the  beginning,  and  death 
speetlily  reHiilta. 

Rupture  of  the  sac  may  be  caused  in  varioiis  ways,  and  \s 
followed  hy  purulent  inflammation  which  usually  extends  fion 
the  sac  into  the  spinal  canal,  and  a  purulent  spinal  mcQingici* 
reaults,  which  terminates  fatally  in  a  few  daya  When  the  per- 
foration is  very  minute  and  the  fluid  flows  out  very  slowly,  tbe 
ease  has  been  known  to  terminate  favourably  and  to  load  to 
the  cure  of  the  disease.  When  the  opening  is  large  and  the 
fluid  is  rapidly  evacuated,  death  may  follow  very  quicklj 
ceded  by  general  convulsions. 


§  659.  Diafftums. — The  diagnosis  is  as  a  mle  exceedinji^y 
easy,  and  presents  no  difficulty  except  when  the  tamour  ia  small 
aad  when  the  orificu  of  communication  is  small  or  entkel} 
doaed.    The  chaiscteriatic  signs  of  the  disMse  mi^  b«  gat 


SPIHAL   CORD  AND   UEDULLA   OBLONOATl.  407 

from  llie  iiymptoins  alrcoHy  ileacribed.  The  sacral  tumour, 
remltiDg  from  die  ilisplacement  of  tlio  abdominal  and  pelvic 
Titoets,  can  as  a  rule  be  readily  distioguUbed  from  the  tumour 
uf  spioa  bifida,  and  the  tnaironnattons  and  defects  which  oot 
rarely  coexist  with  spina  bifida,  such  as  hydrocepbaluH,  deformi- 
ties  of  the  tower  extreroilicH,  anoniatiex  of  the  genital  apparatus, 
inrernon  of  the  bladder,  with  coogenital  fissure  of  the  abdominal 
walb,  can  be  readilj  recognised. 

§  660.  Prof^notio. — ^Thc  prognosis  is  as  a  rule  reij  uofarour- 
ablo.  Tbc  majority  of  tbe  children  dio  either  from  accidental 
opeoiog  of  the  sac,  progtMhive  growth  of  the  tumour,  or  in 
CMuequeuce  of  opcrationa  undertaken  to  cflTect  a  radical  cure. 
The  tar^  tbe  tumour  and  tbe  higher  ita  situation  tbe  more 
oufavourablo  is  the  prognosis.  Tbo  prognosis  is  also  bad  when 
Um)  orifice  of  communication  ta  large,  when  hydromyetia  and 
bfdiocephalus  arc  associated  with  it,  and  when  the  constitution 
of  the  child  is  feeble. 

§  661.  Uarhul  Physiology. — ^The  origin  of  spina  bifida  ta 
ttill  iloubtful.  Some  regard  it  as  being  due  to  dropsy  of  the 
cabfttachnoidal  space,  or  an  a  primary  dropsy  of  tfao  central 
eaoal.  with  diuippenrancc  of  tbo  cord  and  secondary  wideoing 
and  distention  of  tbe  spinal  roembrauee.  If  these  changes  taJce 
plaoB  before  the  Tertebral  arcben  are  clotted,  a  cleft  of  tbe  rer- 
uAnl  column  may  be  itntucetl.  Others  think  that  the  cleft  of 
tbc  vertobml  column  is  the  primary  part  of  tbc  process  and  tbe 
bydrorracbta  is  dereloped  at  a  subsequent  period. 

§  662.  Treatment — Tbe  surgical  operations  which  have  been 
Attended  with  tbe  beat  results  arc  methodical  compression  of 
Um  tumour,  simple  and  repeated  puncture  of  the  sac,  and 
puncture  with  subsequent  injection  of  iodine. 

SimpU  puiuiure  may  be  performed  repeatedly,  and  it  is 
bw6  efTcctixl  by  means  of  ibc  hypodermic  syringe.  The  sac 
■boold  oot  be  completely  emptied,  and  preastire  should  be  after- 
wards lightly  applied.  For  the  details  of  tbe  treatment  of  spina 
bifida  surgical  works  most  be  consulted. 


410      ANJLTOHICAI.  A8D  PHTSIOLOOICAL  IKTRODDCTIOH. 

form  partitions  between  divUioQs  of  the  eocephalon. 
partitions  are  respectively  named  the/aLr  c^rtifri,  tentorium 
eerthdli,  and  fttlu  cerdtelli. 

Tho  cranial  dtira  mator  is  mainly  oompcxed  of  two  layen  of 
6broufi  tissue,  winch  sopante  from  oacli  other  along  certain 
lines,  so  a»  to  form  tubular  paaaagea,  canied  »inu»c6 ;  tbM* 
transmit  tbu  venous  blood  returmng  from  tbe  brain. 

The  sintiBi^s  usually  pass  from  before  backwariJs,  and  sercitl 
joio  opposite  the  internal  occipit&l  protuberance  at  a  spot  which 
is  called  the  toivulay  if^vpkUi,  The  blood  ig  drained  frooa 
tbe  tonnUar  by  the  laUsral  sinu»e»,  which  termioata  io  the 
intemal  jugular  veioR.  The  minute  etructure  of  the  membranes 
of  the  brain  is  tbe  same  as  already  described  in  the  cmae  of  tlM 
apinal  membranea. 

§  C04.  77j«  Artichnoid. — The  arachnoid  \a  a  delicate  and 
transparent  membrane,  and  between  it  and  the  dura  mater  is  a 
space,  containing  a  small  quantity  of  limpid  seniin,  which 
lubricates  the  smooth  oppotied  surfaces  of  the  two  mcmbraiiM. 
This  spsice  is  regarded  as  equivalent  to  the  cavity  of  a  teroos 
membrane,  and  is  named  the  anichnoid  cavity  or  eub^rid 
apace.  The  arachnoid  and  pia  are  separated  by  a  distinct  space 
called  tbe  saJj-aracKnoid  sjKice.  Tbe  space  contains  a  Hmpiil 
cerebro  spinal  Suid,  varying'  in  quantity  from  two  drachma  to 
two  ounces. 

Pacchionian  JJodit«. — Clusters  of  granular  bodies  are 
observed  oa  each  side  of  the  longitudinal  sious  imbodded  to 
the  <Uira  mater,  named  Pacchionian  bodies.  Those  bodies  spring 
from  tbe  arachnoid  membrane,  and  sometimes  attain  a  relatively 
large  size. 

§  065,  Pia  Mfii«r. — The  pta  mater  cloaely  invests  the  whole 
outer  surface  of  the  brain,  and  dipe  in  tbe  fissures  between  the 
convolutions,  difloring  in  this  respect  from  tho  arachnoid,  which 
poEBCs  from  the  summit  of  one  convolution  to  that  of  another. 
A  wide  prolongation  of  this  membrane  posses  into  the  iut«iior 
of  the  cerebrum,  named  the  vdurn  inUrpoi'ttum.  The  pa 
mater  is  prolonged 'along  the  roots  of  the  cranial  and  ipiul 
nerves  and  filum  torminale.    It  ia  the  vascular  in«mbrue  of 


ANATOMTCAL  AXD  PBTSIOLOOICAL  INTRODDCTIOH.       411 

the  brmio,  ftod  tb«  arteries  wbich  pass  from  it  into  tbe 
mtutaoce  or  the  latter  are  invested  by  it  witb  a  loose 
fanncV-iib&pod  shcMh,  wbi«h  opens  iato  tb«  sub-arAcbnoid 
^lace.  and  contAins  cerebro-spioal  flaid  (Key  and  Betsius).  Tbe 
veDtriclcs  of  the  braio  arc  also  supposed  to  b«  ia  free  conuuu- 
oicstioQ  with  the  sub-aracbnoiil  Bpaca 

THE  BRAIN  OR  KXCBPUALON. 

The  port  of  the  ceatral  nervous  axis,  wbich  is  contained 

ritfaio  tlie  cavity  of  the  ukul),  is  termed  thehrninoTenerpfmlon. 

Tbe  htuiB  is  conveniently  divided  into  (1),  the  medulla  ob- 

longatei  (2),  the  pooa  variotii;  (3),  the  cerebellum;  and  (4),  tbe 

osralrrutn. 

§  (J66.  7%e  MeduUa  Obloi\g<Ua. — ^Tbe  medulla  oblongata  is 
the  expanded  upper  end  of  the  spinal  cord,  and  has  already 
been  described. 

§  0G7.  Tlie  Pons  Variolii. — The  pons  rests  on  the  dorsum 
•die  of  the  Hpheiioid  bone,  and  is  marked  on  iu  inferior  aspect  by 
a  taedian  longitudinal  groove,  in  which  the  basilar  artery  lies;  its 
posterior  surface  receives  the  pyramidal  tractH  and  the  upward 
oontioDation  of  tbe  anterior  root-zones,  and  the  grey  matter  of 
tbe  cord;  its  anterior  surface  givea  orij^o  to  the  two  crura. 
oeiebri  ;  each  lateral  surface  is  in  relation  tn  a  beniispbere  of 
Um  cerebeltuuij  the  superior  surface  fonus  iu  part,  the  upper 
portion  of  the  flour  of  the  fourth  ventricle,  while  the  corpora 
quadrigemina  rest  upon  its  anterior  hal£ 

iSKnMfuTf  tf  ifu  Pcmt. — Tlw  |)Oiw  ooohmU  of  gray  ftod  wbiu  taiAUst. 
Tlw  pvater  portioD  uf  tbe  gray  matter  of  tbe  poos  U  an  upv&rd  continua- 
tioe  of  the  grey  nutter  ef  tbe  spuul  cord  sud  ueduUA  oblcngata,  which 
baa  bnea  ahtady  deacribed.  la  addiUoo  to  the  grey  maUor  on  tbe  floor 
flf  thafeiuth  veotriele,  there  is  soonsiderable  qiuatit;  iiit4<rp(>Mil  l>etwa«n 
Um  tnoBvefM  fibres  of  the  pons.  Tbe  tnutsverM  flbrea  derived  from  esoh 
laUnl  lobe  of  tbe  cenbeUum  sppear  to  tenaiaate  in  tbe  interposed  grey 
natter  of  ibe  oiipoaite  belf  of  die  pona. 

Tit  wkit*  mailff  of  the  pone  cooasta  of  longitudinal  uid  tTanavane 
Slsea.  The  ImiicitudiDsl  fibtea  an  the  upwnrd  coutiauatiane  of  tbs 
anterior  |ijTsiniHii  of  tbe  nednlls,  the  anUnor  roAt-ienea  of  tbe  oofd, 
pmb4bly  aUo  fibroa  anccDdiog  from  tbo  oliruy  body.  Tbe  loogi- 
f"*^"*!!!  are  alao  reinfoiced  by  fibroe  aristDg  is  tbe  pons  itael£ 


412       ANATOMICAL  AND  PHVSIOLOOICA!,  tNTHODUCTIOSI. 


Th«  tnuisvarae  fibren  ^  from  oao  hemispben  of  the  eenMlam  to  1 
of  tlia  opposite  (dde,  although  the  fibiM  are  iirobablj  interrupUd  in  tbt 
pons  by  rotrnpoBeil  gmy  rcAtter.  Theiw  libiM,  tlxirefore,  eonalitutA  tbe 
cominiMural  or  oonnccttiig  Bmiigeineot,  hy  xaeaoB  of  irhicli  t^  two 
btDdaphcrMof  thacerabellum  boeoBW  aoKtomlotll;  oodUquoiu  wUhom 
■Dobh«r. 

THE  ciVSBELLVSL 

§  66sS.— Tho  ceroboUum  occupies  the  inferior  occipital 
It  corsists  of  two  lateral  beioiapherofl  joined  together  by 
raodian  portion  called  the  vermiform  jyrowM.  On  the  suporior 
surface  of  the  ccrebollum  this  is  a.  mere  elevation,  but  un  iu 
inferior  surface  it  forms  a  weU-inarked  projection,  ofttued  the 
inferior  vermiform  process.  This  process  lies  at  the  hottwn 
of  a  deep  fossa  {vallecula),  which  is  proloaged  to  the  posterior 
border  of  the  cerebelluoi,  atitl  forma  there  a  deep  notch,  iu 
which  the  falx  cerehetii  is  lo<lged. 

Tfie  Peduncles. — The  cerebellum  is  connected  below  with  tbe 
medulla  obloagntB  b/  the  two  rettiform  bodies  which  farm  its 
tfl/irritfr  pedunclea  The  crossed  connection  of  the  6bm  iTfthe 
inferior  peduncles  of  tbe  cerebellum  with  the  olivary  bodies 
hu  already  been  described.  The  cerebellum  is  coDDCctod  with 
the  corpora  quadrlgeraiua  and  crura  cerebri  by  two  supericr 
peduncles.  Tho  ^cater  portion  of  tho  fibres  of  tbo  superior 
peduncles  decussate  in  tbe  upper  end  of  tbe  pons  and  in  the 
tcgmcata,  the  fibres  of  one  side  beoonung  connecter!  with  th" 
red  nucleus  of  tho  tcgme-Qtum  of  the  opposite  side.  The  iraw- 
vorse  6bro8  of  the  pons  form  the  middlt  peduncles  of  the 
cerebellum. 

Folia. — ^The  surfaoo  of  the  cerebeUum  consists  of  numeroos 
laminre  or /oiia,  which  are  separated  by  figures  or  sulci  of  diflfo- 
ront  depths. 

Fitstireit. — llis  tjrtut  lumzontnl  finsxire  begins  behind  th« 
middle  peduncles,  passes  horizontally  bnckwards  round  dit 
circumference  of  tbe  cerobelluni,  dividing  its  leotcwial  aod 
occipital  surfaces.  From  thtx  primary  fissure  numerom  otben 
proceed,  and  some  that  are  constant  in  their  position  and  deeper 
than  tbe  rest  liave  been  described  as  sopamting  the  cerebeUam 
into  lob«s. 

XoW. — ^Tho  tentorial  surface  is  subdivided  into  two  smallef_ 


AKATOXICAL  AND  PBYSIOLOOICAL  INTRODUCTION.       413 

lobes,  QameU  anierior  miperior  aail  jioaierior  etiperior.  Od 
Un  oodpitd  Butiaccr  each  bcuiBpbcni  ig  subilmded  from  beliind 
forwards  into  the  posterior  inferior  lobe,  the  ol^nder  lobtt 
the  biventnU  lobe,  aad  the  Jioceulu».  Immediately  iotcnuU 
to  the  biventraj  lobe  is  the  am^fgdakt  or  tonsil,  which  forms  the 
Uteral  boii  dcIbfj  of  the  anterior  part  of  the  vallecula.  The  infe- 
rior vermil'orin  proce«3  is  Hubilivided  iiito  a  poaterior  part  or 
pgrTomt<I,  an  eleratiDDoruvuZaBituated  between  the  two  tonsils, 
od  an  outtiriur  pointed  process  or  iwdule.  Stretching  between 
!ie  two docculi,  and  attached  midway  to  the  sides  of  the  nodule, 
is  a  thin,  white,  8«tiu-lunar>«Laped  plate  of  nervous  nutlter,  called 
the  ■posttrioT  medutUiri/  velum,  whilst  the  layerof  grey  matter 
(Xretchiog  between  the  umla  and  touHil  on  each  aide  is  called 
the /umjwed  Uind. 

f  ABB.  liUtmal  Struettm.  — Th«  wreboUom  cooaiats  of  both  grty  and 
wfait«  matter.  Tho  gny  matter  fomis  tha  eitvrior  or  oorlez,  while  the 
wkita  forma  th«  iutcrioc  of  tho  orgu.  A  rcrticol  seotioD  through  the 
eMvb^um  prewuts  an  arboreaoiiit  appeanuoe  Imowa  by  the  qudo  of 
■rivr  titm.  JuJepeudaut  luaoMa  of  gnj  li»tt«r  an  fuuud  iu  th«  inttinor 
if  Ihs  eanbetlutu.  If  the  heuiispbvrs  bs  cut  throa{li  to  tbo  outer  side  of 
Uh  audUn  lobe^  a  Diwlaus  of  grej  tuattor  ia  obaarrad  aimilu-  in  Ita  UTMgo< 
■MBt  to  tbo  olivar/  body,  and  uainMl  tba  eoryui  daUatun*.     It  «uoloiiw 

Pio.  100. 


9m.  100  (From  Ttunn)      Tkr  Orfiintal  Sur/tiet  n/  At  CertMlut 


ViII*«iU; 


k  rynunid;  r.  ITruU:  d.  NoifnU:  f.  #.  Marsin  of  Untorial  •urfaoe:  /  /,' 
U««bI  ImvIjoiiIaJ  fiMurr-  0,  p.  PMlFiior  Iflfnlur  loWi  A,  A,  Slmdu  lotm; 
k,  k,  Bitt«lral  loUa ;  I,  ToiNil ;  m,  Floocnliw ;  »,  PowtMiw  iB*diiUM7  nlom; 
D,  Cat  aarfM*  traa  vbub  tba  hll  lowU  liu  beoi  dotactud. 


414      AHATOMICAL  AND  PHTSiOLOOlCAL  IKTRODUCnOK. 


vhitv  fibre!)  whSoti  lenve  the  intenor  of  Uw  eofpua  at  its  ionsr  uid  iMRt 
aidw.  Stilliij][  bu  (l«Krib«d  two  graj  maino*  sitiaatod  id  Uw  soUrior 
end  of  tbn  inforior  venuirurm  proo«n  whiob  ho  nanMd  m^  ttiu/ti. 

Tbo  vA»(c  mof^tr  is  for  tbe  mosi  [>u't  MaUnuous  vith  tiio  fibrva  of  Um 
peduiicU'H  uf  tliv  ccnttwiluni.  Tbe  filinnof  tin  infmor  pedanclM  fut 
upwarda  to  join  the  grcf  aiatWr  of  the  eupcrioT  mutiux  o(  tbo  oinbaOvia, 
espedall;  in  the  nwiiaii  lobe.  Tb«y  u*  abw  ooaDaotad  with  the  oorpw 
dantatuta  and  roof  naolti.  ThoM  of  Um  aapohor  p«duocl«a  doKand  Im 
tbe  corpora  quadrigeuiliiti  and  reach  the  gray  c»rtical  matter,  mon  m^ 
ciuJljr  thftt  of  tbe  iufvrior  aurfaoo  of  tbe  Mnbollum,  aud  thejr  »n  also  oao> 
uvcteil  with  the  corpus  d«otatum.  Tko  flbrea  of  tlM  middla  pedosdM 
torminutc  cbioOjr  m  the  c«rtex  of  tfa«  lateral  lobes.  The  oarob^Jom  alM 
ooiitaitiH  fibre*  which  couuect  diOereiit  p&rta  of  Ita  gn^  nattar  with  nw 
a&othor,  a&tati/bra  propria.  StiUiog  d«Mril}««  a  oivdiiui  fatei<vlm,  tb* 
Gbm  cif  which  cuiiiitjct  tho  Bnijwrior  aud  infenur  runiiifunu  proo^HB. 
Other  fibro«  cn>a8  tb^  tatdian  plane  to  uoita  Bfraruetrioal  rogiofM  of  tka 
latetiU  lobea.  Mej^uert  doHcriliea  a  cerebellar  origin  of  tbo  andiUxj  and 
fifth  tioTvea. 

Jfinvte  Stntclfin.—Tht  groy  tnatter  of  the  cortex  la  divided  tala  aa 
avfenuii  ^y  or  e*itliUar  Ujvr,  and  an  tHf^nao'  nut-colowvd  layer  of  about 
eijtial  tbiukiieas.  Tho  <j.taniai  taytrr  consists  of  a  delicate  malriz  oontain- 
iiig  ae\U  aud  fibree.  Most  of  the  flbrea  have  a  direction  at  right  acglea 
to  bUe  flurfuco,  the  mAJnrit;  of  tbciu  bt'ing  tbe  inoceaaaa  of  PuridnJ^a 
cells,  to  b«  imme'.liatel;  described.  Of  tbe  cella  Mma  are  email,  aul 
appear  to  bcluiig  to  tbe  coimeotive-Uiiiiue  tuatrii,  while  others  an  laipr, 
and  |irol>ubly  cnuneoted  with  the  pTocesnea  of  Purlciiijfr'a  ealla.  Tba 
inner  pari  <)f  tbe  eiteriitd  lujrer  (juutaius  fibrea  which  ran  parallel  vitb 
tbe  ^iHrliu-'U. 

Tht  inner  or  ffraniUa  lagtr  oonitists  of  graiialo-Uka  oorpuadaa,  wbkli 
lie  iu  ilorjHn  ip^tiiM  iii  a  geULiiiuiu  tnatrii,  cotitaiuiug  a  pleius  (vf  tat 
nerve  Itbros.  Sotue  arc  round,  while  others  are  angular  and  poMees  a 
protoplaamic  cDi'elope  with  procauuiu,  which  are  mppoeed  to  be  DOonaetMl 
with  tbe  plexua  of  Hue  aorfe  fibres  amongst  whiuh  the^r  lie, 

f A«  mU«  oJ  l'\irlnnji  lie  in  a  single  lajer,  bvtw«wii  tho  outer  Itod  tBMT 
layers  of  tho  cortex.  Mont  of  them  are  Raslc-thaped  boidiea,  ooatalniiy  a 
•phorical  niideua  and  nu<!!«oliia.  Tho  loug  aztn  of  tbe  eeil  i«  geatc^ 
directed  at  right  angles  to  the  eurfaoe.  From  tbo  external  surface  of  the 
cells  two  pTocMaea  are  given  off*;  thaiw  paaM  out  towaids  the  •uiface  and 
divide  repeatedly  in  thoir  counw.  Tho  fiucr  aabdivisions  oF  tfaaaa  p>o- 
onnnrn  hsvo  been  itatd  to  curve  hack  towards  the  granule  layer,  wbere, 
•coordiug  to  Boll,  thuy  form  a  network  of  oitreme  itiiiiutenem,  bv-m  which 
it  ia  believed  that  n^rvo  fibrve  arim.  From  the  inner  end  of  the  eatl 
another  fibre  ia  glvcu  offi  it  ia  u&bnutched,  passes  into  tbe  graoole  layer, 
and  is  auppoeiNl  to  be  uoutlDuous  with  the  axis  cyllndar  of  a  nerre  Sbn. 

The  mt^uUary  eentn  coiitusts  uf  nerve  filirea  armnged  io  pamllel  or 
[aterlaciug  hundlea.     Tbe/  form  ihu  central  »t«m  of  tiu  CuIul,  whauv 


XNATOMICAI.  AND  PHY8IOI.0O1CAI  INTBODrCTIOK.      415 


Uk;  mlute  Uib>  tbe  cortex.  Tbey  diuppcaj  ia  tho  gnsuln  Ujrer,  And 
«f«  Mnuouly  balitwd  bo  b«  continuous  with  tho  iauer  proc«e»es  of 
Purkii^f a  ocUh. 

TllE    CKRHBRUM. 

§  670.  The  Mrrhram  constiUites  tbe  largest  division  of  tbe 
eDcepbalotj.  anil  lies  abuve  ttie  level  ot  tbe  Ivatorium.  It  coa- 
■tsts  of  ft  narrow  conatrict«(l  portion — the  crura — of  certain 
iMual  gnnglia — the  corpora  quadrigemina,  optici  tbalami,  and 
cwrpura  fttriatA — audofan  upper  expauded  portiou — tbe  cere- 
bral becuBpbercs. 

§  671.  EjoUri<fr  of  the  Cwwfrrttm. — Tbe  cerebrum  is  ovoid  io 
•faape  and  pteaeuta  superiorly,  aateriorty,  and  posteriorly  a  deep 
fweftan  tongilwiiTwl  Jmure,  which  subdivides  it  into  two 
iMmiaptieres.  Tbo  two  bomispbores  ore  cooQeeted  across  tho 
metliao  plane  by  the  wrpus  etitlomim.  The  outer  surface  of 
Mch  bemiaphcre  is  convex,  and  ndaptod  in  Bbnpo  to  tho  con- 
cavity of  the  inner  table  of  the  cranial  bouos.  Its  iuuor  sur- 
iaee  is  flat,  and  !■  Kepantted  from  tbe  oppoait«  hHrniBphere  by 
tbe  /uLt  certfrri.  The  under  surface,  where  it  rests  on  the  tento- 
riunt,  ia  cuncavH,  and  ia  separated  by  that  membrane  from  tbe 
cerebellum  and  pons.  From  the  front  of  the  pons  two  strong 
vhtte  haods,  tbe  crura  caxlrri  or  oerebrtd  j^eduncUt.  pass  for- 
wards and  upwards  to  enter  ibo  basal  g&uglia  of  their  respective 
huumpbcriMi.  The  ojiiu}  tracts  wind  round  eocb  crus,  and  con- 
verge in  front  to  form  the  optic  oommiasurc  from  which  the  two 
optic  uerves  ariae.  Tbe  crura  cerebri,  optic  tracts,  and  oplie 
ooaaraiMure  enclose  a  lozeagc-sb&ped  space  which  includes  from 
behind  forwards  the  posttrwr  perforated  fpace,  the  corpora 
aibitantia,taid  tho  (u6er  cin«reum,  from  which  the  infnndi- 
btUum  projecu  to  join  the  piluitarjf  Uody.  Immediately  in 
front  of  the  optic  commiRsure  is  a  grey  layer,  the  lamvaa 
esn«rv<i  or  Inuiinn  icrminnlis  of  the  third  ventricle;  and  between 
tba  optic  curuiniiuiuie  and  tbo  inner  end  of  each  Sylvian  6--ti«iire 
**  *  K^  ^V^  perforated  by  small  arteries,  the  anUrlor  per- 
forated »pace. 

The  peripheral  part  of  each  heniispbere  consists  of  grey 
matter,  aad  exbibits  a  characteristic  folded  appearance,  known 
as  tbe  cunv^itul'wnt  or  ijtfri  of  the  cerebrum.  The  oonrolatioos 
scparateU  from  each  other  hy  jiesM^ree  or  tvlci,  some  of 


416       ASITOMICAL  AND  PlIYSIOUWICAL  fNTttODCCTIOK. 


which  ar«  considered  to  subdivide  tbe  hemispheres  into  Ha, 
whilst  othera  separate  the  convolutions  of  each  lobe  from  «adi 

other. 

Pio.  IBl. 


Fto.  191  [From  HenW*  AnMooiie).    Btm  cf  ikt  Brmn.—'P.  Ptma:  1V\  Oftk 
UuUamxu;  I^pp,  fatUnor ptrfmnMi tpact ;  3a,  I^iutcfMiil. 


TIjo,  OUacUiry  Imlb. 

JjtX,  Luuiu*  dncrab     To,Tiaber  ctQ«r«(u&. 

Ccl*.  KpCK  of  the  corpiu  MkUiMUtil. 

Pec,  rnlunclM  of  th*  oorpw  AlUMDin, 
Cbo,  rommiHonofUiaoonnucMUaaiuu. 
Sps  Aataior  paifgntvd  apM*. 


Cc,  Corpcn  kllMuBUa. 
Of,  Qynw  runuoOiM 
T,  T«gnwnUiu. 

8r,  SntMuitU  ntlcaWki 


TIm  Bciua  UtUn  iodiMto  Uw  oomqioBdiiiK  cnkU  korvM :  L  OKMlniy 
Bim:  I>  OirMtnrbnlb;  11,  Optic  d'vt*  ;  1 1 '.  Optio  tnet ;  •,  gjlvua  flMVtt 
**.  thB  point  u[  ihfl  irmporiMpbaDOJilftl  tulw  ilnvo  tiadito  •fcimilM«oollKslLr« 
thla  loba  wiib  tLt  portvrior  oaoralntion  uf  tbn  laUad  of  Rail 


A^fATOHICAL  AXD  PUT8I0L0G1CAL  ISTBODDCTION.       41? 

§  <j72.  Lobea  of  tJte  Cerebrum. — TBoy  ore  five  in  number, 
oatned  re«pectiirely  frontal,  parietal,  occipital,  temporo- 
tpfirnoidal,  sDd  c^ntnd.  The  divisions  between  these  lobea 
■re  maxkciJ  partly  by  certain  conHpicuoiis  fiusures,  and  partly  by 
■riificikl  lines. 


§  S73.  The  Primartf  Fmutm. — ^Tbo  Stflvian  Jisgti.iis  ia  the 
fint  to  appear  in  the  development  of  the  hemisphere.  It  passes 
obliquely  along  the  outer  surface  of  the  bemisphcTe  from  before 
backwards,  and  upwards.  In  man  it  divides  into  two  rami — 
tbfl  posterior  or  borizontat  {Ifitj.  192,  S'),  aud  the  ascending  or 
utarior  {Fig.  192,8").  The  portion  included  between  these 
two  braoches  receives  the  uarae  of  the  opereulvtm,  and  form« 
ibe  roof  of  the  oentral  lobe  or  Island  of  Reil.  Below  the  fiKsure 
of  Sylvius  lies  the  temporo- sphenoidal  lobe,  and  above  and 
in  froot  of  it  the  parietal  and  frontal  lobea.  The  frontal  is 
Mfiarated  from  the  parietal  lobe  by  the  ftsnure  of  RoUindo 
{/iff.  192,  c)  or  Centrtd  Sulcus.  It  extends  from  the  longitu- 
dinal fiasure  obliquely,  downward^  and  forwards,  along  the  outer 
■urfiue  of  the  hemisphere  towards  the  SylviH4i  [i.>«ure.  The 
parieto-oecipit'tl  jiasurc  commences  at  the  longitudinal  fissure, 
about  two  inches  from  the  posterior  end  of  the  hemisphere.  It 
paan  down  the  inner  surface  of  the  hemisphere,  and  also  traoa- 
Tnady  outwards  fur  a  abort  distance  on  the  outer  surface,  and 
■epaiKtea  tfae  parietal  and  occipital  lobes  from  each  other. 

$67L  Seamd/trif  Fi-ivtirea  <^ndConvo^u^i<ma.—Theten^porO' 
tpt^eHoidiU  lobe  prcBCQts  on  the  outer  surface  of  the  bcmtspberes 
three  parallel  coovolutionB,  named  the  BUperior  {Fig.  192,  Tl), 
middU  {Fig.  1!>2,  T2),  and  inferior  temporosphenoidal  {Fig. 
ISSyTA)  conwlutioTM. — ^The  fissure  which  separates  the  superior 
tad  middle  ol  these  convoluttoos  is  called  the  paralUl^Mwre. 

The  occipital  tabe  alio  consists  of  three  parallel  oonvolutions, 
ume<l  ntperior  {Fig.  102,  01),  middle  {Fig.  192,  02),  and 
inferior  (Fig.  1 1*2,  03)  occipital  convoUUioiia. 

Tb«  frontal  lobe  CMiiists  of  three  convolutioos  arranged  in 

'  laralleL  tiers  Crum  above  downwards,  and  named  superior  (Fig, 

IM,  Flj,  miJdU  {Fig.  192.  F2}.  aud  inferior  {Fig.  192,  F3) 

froKtaX  oonvolvilonB.    These  are  protouged  aoteiiorly  to  the 

BB 


418      ANXTOUICAL  AND  PHYSIOLOGICAL  IK7R0DUCTI0K. 

orbital  aiirface  of  the  froDtal  lobe,  and  terminate  poetMiorly  m 
tbe  convolution  wbtch  forms  the  anterior  boundary  of  lh« 
fissure  of  Rolando,  named  the  ascending  frorUai  convolutwa 
{Fig.  192.  A). 

Tbe  sccoodiu-y  fiHsures  wliicH  scpomte  the  Buperior,  middle, 
and  iDferior  frontal  convolutions  from  one  another  are  Uw 
miperO'fronial  {Fig.  192,  /I),  and  the  infero'/rorUai  (Fig. 

Fio.  IMl 


ft 


-na, 


ft 


IP 


v- 


N 


-fi 


V 


.M 


»f 


^^ 


rs 


Ti_ 


ti 


T' 


N, 


Thii.  I9t  iKtiWer).  LattJ-al  Fiflf  ef  tht  BvtaaH  B'^m.-V.  Vrontai  labi. 
Pftriotft)  tub".  O,  llcdpitsl  [ahe.  T,  IVmpnrD-aiihpDniilKl  itibm.  &  Via 
at  HylviuB,  H'  Huriionul,  S'  Aicotiillnc  rsniiu  of  lh«  Mm*,  c,  Bnam 
tmlin,  or  fiMUcv  of  R«liui<ln.  A,  Anterior  t-eatrhl  or  ••MndiBg  (MUtal  •oa- 
vnlnlifln.  B.  Puateriiir  ctiiitr*!  or  uoruiliuj^-  iMkrieUl  OODTolntMn.  F,  Sfi*. 
Fa  Mlddli,  mni  ¥,  Inferinr  frosUil  contnlutiooL  /,  tJuprHar  •Bd  /,  Udaiv 
(todU)  iuIcih:  /•  Kuleo) pm-cciitr&Iu.  V,  SDp«rioT pkrirtel  «t pat/lm-Btlitui 
lubiilo;  P,  Inferior  pftrietal  li)l>nlc.  vli.  P,  Gjrainpr»-iiiuyiakU*,  P,  OfrH 
MiiralariB.  ip,  Sukue  iDtra-puietalis.  cm,  TemnBUwii  ol  u«  aftUcMo-niMniJ 
Ornvn.  0,  l%>t,  O,  Hvcimi,  Q,  Third  oodpitd  ooanlntMM.  m,  Piirtito- 
oeoliiltol  fiwnira.  o,  SuIoih  ooeiratalu  trutmnu ;  9,  SuJent  MSliMlUii  tafW 
ludiDftU*  tuferior.  T,  Pint.  T,  SMcnd,  T,  TUra  taaipenM(bnoiild  cai*«- 
In^ou.    t,  Fint,  r,  Sfcoixl  t«n)por«-fpbtiwt>U  Bmihib  ^^^^ 


420       ANATOMICAL  AND  rB?RtOIAGrCAL  tKTBODtrmOIV. 


The  orhital  tnvrfaee  or  orbital  lobule  presents  two  fissure*— ^ 
the  ot/anttyry  aulcM,  nbicli  nins  parallel  witli  tlio  loDgiiadinnl 
fissure  and  lodges  the  oiractorjr  bulb,  and  the  orhitul  mdaa 
{Fig.  105, /5),  whicli  Ilea  io  tbe  centre  of  the  lol>uIeand  ii  oftcD 
triradiate,  Tbe  iftraiglU  conrolutioD  {Fig.  1^3^  Fl)  lies  between 
the  loiigitudionl  fiitsurc  and  the  olfactory  sulcus,  aod  is  coq- 
tinuous  at  its  anterior  extremity  with  the  superior  frontal 
coDTolutioD.  lltTee  convolulions  are  Bometimee  deacribed  aa 
lyiag  around  the  orbital  sulcus,  oauicd,  according  to  llieil 
po«ilioii8,  the  inUmai,  the  anterior,  and  the  povUrwr  i>t\ 
courolutioDS. 

Tbe  parietal  lobe  prosontB  several  ooDTolntions.  The 
■Ulterior  is  the  ascending  parietal  convolution  [Fig,  193* 
which  liea  immediately  behind  tbe  fissure  of  Rolando,  and  is 
bounded  posteriorly  by  a  «uleu«  termed  the  inlrO'jiarittal 
suUms  {Fig.  192.  ip).  The  poetero-ftarittal  eonKotviion  or 
superior  pari^tl  lobule  {Fig.  192,  Pi)  Bprings  from  tlie  upper 
end  of  the  back  of  the  nsccnding  parietal  convolution,  and  fomu 
tbe  boundary  of  the  luugituclinal  figure,  extending  as  far  back 
as  tie  parieto-occtpiial  fi*«uro.  Tbe  s^tpra-mitrginal  convo- 
lution {Fig.  192,  P2)  spruigs  from  tbe  lower  end  of  the  ascend- 
ing parietal  convolution  at  ilspoEtterior  ajipect,  and  arches  round 
tbe  posterior  extremity  of  the  Sylvian  fissure.  Tbe  angvlar 
gyrus  {Fig.\Q2,Pi,')  is  cootinuous  with  the  stipra-marginal  cod* 
volution,  and  bends  round  the  poaterlor  extremity  of  the  paralld 
fissure.  Tbe  supra-murginal  convolution  and  angulargyius  ha»e 
together  been  described  as  the  inferior  parieUil  lobule  (Kcker),! 
or  the  convohdions  of  the  parietal  eminence  (Turner).  Tbejr^ 
occupy  tlie  iioUow  iu  the  parietal  bone  wbiob  correspuudA  wjj 
the  parietal  eminence. 

The  occipital  is  connected  with  the  parietal  lobe  by 
annectant  or  bridging  gyri.  The  mptrior  anneetanl  gyrut ' 
passes  botween  the  poatero-parietat  and  the  superior  occipital 
convolutions,  whilut  the  second  annectant  gyrus  connects  the 
middle  occipital  with  the  angular  gyrua  Two  anoectant  gjri 
alBO  pojBs  from  the  inferior  occipital  convolution  to  the  lower 
convolulions  of  the  tern poru- sphenoidal  lube. 

The  central  loba,  or  Island  o/Reil,  lies  deeply  witbio  tht 
fissure  of  Sylvius,  being  invisible  except  when  tbe  lips  of  the 


ANATOSaCJU.  AND  PHTSIOLOOICAL  INTRODUCTION.       421 

fififitire  are  sep&rated.  It  consisU  of  abont  mx  short,  Btraight 
convolutions  (gyri  opcrti),  wbich  radiate  outwards  from  the 
anterior  perforated  space.  The  anterior  codtoIuUoq  U  coq- 
tinuoui  with  llie  adjacent  posterior  orbital  convolution,  whila 
tfa«  posterior  coovolution  joins  the  temporo- sphenoidal  lobe. 
Externally,  the  island  of  Reil  ia  separated  by  a  deep  sulcus 
from  tlie  coatiguouH  convolutions  of  the  operculum,  and  it 
ooTcrv  the  lenticidar  nitcUus  of  the  corpus  striatum. 

The  small  coavolutionx  which  lie  behind  the  paricto-occipilal 
Ibmire  form  the  internal  convolutiona  of  the  occipital  lobe, 
named  the  intcmai  occipUal  lobuU,  or  ctincus  (Fig.  1 94,  Oz). 
Those  which  Ue  immediutoly  in  front  of  tho  intornal  port  of 
Um  paiieto -occipital  lobulo  and  between  it  and  the  curved 
extreinity  of  tbo  calloso- marginal  fissure  are  called 


Fio.  IW. 


A  e  B 


Ft 


1^ 


J 


j^ 


^ 


'JD 


Ortwi  cdta^lBMCiiiaUa.  r ',  U«dtu  uptct  of  t)te  nm  (nmtd  eoBTohitlaik 
K  Tminal  partion  of  Uie  mIcim  cmlntUa.  or  fi«urt  of  Bohn^o.  AjABtarior; 
B|  PMiMwv  oMtnl  cottrolMim.  Pi*,  Phfouimiu.  U«,  Cumm.  ro,  P*ri*lo- 
■mrtrhal  flMMnt  a.  Sulci  oocipitslM  UniMTcmu.  oo,  CfttoariH  fiaiim. 
«^.  Onpcriov :  oe*,  [nlwlar  nmraa  ul  llw  umc.  P,  Ojrm  dotMnkna  Ts 
Cma  oo«Mt«-t«(n|xnali*  UUnIi*  (lolmlu  (uwforinU).  T*,  Onw  oodeiio- 
"  I  Mdialb  (MniliM  Uninulk). 


422      AKATOMICAL  AND   fBTSIOLOOIC&L  nfTBODCCTIOK. 

ihe  j)?^^^^-?!^!!^  or  quadnlcUeral  MmU  (Fig~  194>,  Pi-).  The 
paracentral  tobuU  lies  immodiatel;  in  front  of  the  pnecuneas 
It  coDSiKtH  of  the  upper  extremities  of  the  ascending  frooUl 
and  parietal  convolutions,  viewed  from  the  inleroal  surface  of 
the  bemiiiphere.    It  is  cutomarjrto  name  the  convuluUon  Kkicli 


Cc) 


*     Coi 


Fia  Ids. 


SH 


C^ 


FU- 


Sl 


-W' 


J 


Ccl- 


Cs 


/ 


Lei 


:^ 


Rp 


no.  195  (  From  Heulr**  Aoktomie ).     InUnai  Vltw  of  tMt  Btrnivkm  ^ 
(Ac  Caihratn. 

Cd',  Kniw  of  tlie  < 


Ftp,  PMlerior  tr»niTcn«  ftMor*. 
Vq,  FoiurUt  vpntriole. 

P.  Piiim. 

Cc*,  CurjiorA  caudlcuit!*. 

Te,  Tubftt  nn»r»UKk. 

H.  rilmlmry  IxkIj". 

II',  Oriiic  trncL 

II,  Ojitii^  HKTO. 

Let,  Tiuaink  oiofna. 

CuA.  Anterior  i.'oiiiiuuMim  ut  ihe  Iblnl 

««itridc 
Oba,  ConvMura  of  Iha  corpiu  «■!■ 

lanun. 
Col',  lUMlnim. 


Cd%  Cotptti  MllMnn. 

Col*.  SplminDof  Uwi 

81,  HeMwn  laoadiint. 

Com,  SlvdUo  oMDtniMotv  of  t^  i^iri 

vobtriele. 
SM,  SbIou  Uawci 
Cop,  FmUiIw  QomnUmn  «(  th>  lUri 

ytdiMd*. 
On.  Pfncal  gUnd. 
Ln.  CMponqudi, 
A.  AiMMdnol  of  S^lvJM. 
FU,  Anterior  tnaivMM  (hmr. 
Tm^  Anttficc  BeduUaiT  ntan 
Obl,Otc«MkB. 


ANATOMICAL  AND   FHTSIOLCKIICAL  IKTBODUCTIOH.       4S3 


extenda  fonrarda  from  the  p&rieto-oocipital  figsiir«  along  the 
margin  of  tbfl  loDgitudinnl  fissure  to  ibo  anterior  extreraitj 
of  tfae  heQiifiphen!,  aoJ  which  then  tuma  back  to  the  anterior 
perfonUed  space,  the  marffiiuU  convolution. 

Tho  ititerntU  U  not  divided  iuto  lobea  like  the  external 
Mir^e.  but  the  oonrolutioas  may  be  studied  in  conneotion 
with  the  corpus  callosura  aad  with  certain  fissures  situated  in 
ihiK  nirface. 

The  paTvcio-occipiial  iwsure  {Fig.  194,  Po)  is  continnous  with 
the  fissure  uf  the  same  name  on  tbe  exterruii  Hnrfacc.  Jt  ex- 
teoda  downwards  and  forwards,  and  blends  with  the  calcajiue 
fittore.  The  calcarlnc  JimvLTc  {Pig-  ISf  oc)  comEQcuecs  at  tho 
posterior  extremity  of  the  hemisphere,  u»aalt;  in  a  bifurcated 
UftDDer,  aod  exteoda  forward*  to  tcrmioato  beneath  tlio  pos* 
lorior  extremity  of  the  corpas  callosum.  It  nwrka  the  position 
oCtbeco^r  amor  Aip;K>cam;m« -minor  in  the  posterior  comu 
the  lateral  ventricle.  Tbe  caUoto-vwurginai  jimur*  {Fig. 
cm)  commooces  beneath  the  anterior  extremity  of  the 
loa  callueum,   and    posses   forwards,    upwards,   backwards, 

lod  tho  corpus  callosum,  terminating  behind  tbe  superior 
lity  of  the  ascending  parietal  convolution, 
[Tbe    convolutiou    which    immediately   bounds   the   corpus 

llomm  is  termed  the  j/yrua  frmteatuH  {f^.  19+,  Of).  It 
b^ni  at  the  anterior  perfomted  space,  turns  round  the  an- 
mior  end  of  the  corpus  callosum,  extends  pcLraliel  to  its  upper 
mfiMW,  and  then  tunu  round  \la  posterior  end.  It  is  uepa- 
rated  from  tbe  corpus  callosum  by  tbe  caUomd  Jtsmure,  and 
from  the  marginal  convolution  by  the  callosu-marginnl  fissure. 
The  posterior  end  of  the  gyrus  fomtcatua  curves  downwards 
aod  then  forwards  under  the  name  of  j^j/rtu  uTtclncUus,  or 
ffjrnts  hippocampi  {Fig.  194,  H),  to  the  tip  of  tlie  inner  sur- 
Cioe  of  the  tcmporo-spbenoidal  lobe.  The  uncinate  gyrus  coda 
anteriorly  in  a  crook-like  extremity,  or  crochet,  named  tbe 
«nciu  i/yri  fomiaxH,  or  auhiculuvi  oomu  amincmia  {Fig. 
194.  U).  Tho  gyrus  is  separated  anteriorly  by  a  narrow-curved 
fiaun,  called  hippocampal  or  dtntaU  JiMiirt,  from  a  white 
b*Dd  named  tbe  toiiia  hippoeampL  This  band  posscssca  a 
fVw-curved  border,  round  which  tbe  pia  mater  enters  the 
lateral  rentricle  through  tbe  great  tnuuverae  fiasure  of  the 


424      XKATOMICAL  AND  PBTSIOLOGIOAL  INTRODUCTIOK. 

cerebrum.  The  grey  matter  of  the  gyms  liippocaropi 
nates  at  tbe  bottom  of  tbe  bippocampal  fissttre  in  a  welMoflotd 
(leDtated  bonier  named  tbe  fascia  deniaia.  Tlie  bippocain|nl 
fissun:  marks  tbe  position  of  an  eminence  in  tlie  di 
corou  of  the  ventncle  called  the  hippocampus  mayor. 
Riinniuc;  atoug  tbe  internal  aspect  of  tbe  occapital  i 
puro-Hpbcuuidul  lobes  is  a  fissure  termed  the  wMa-ieral,  wbicb 
marks  the  position  of  tbe  collateral  emioeoce  in  the  lateral  ren- 
tricto.  It  separates  two  coDvolutioDu  from  each  other  wluc^ 
connect  the  occipital  and  temporo-Hphenoidal  lobes  vith  ead 
other,  and  are  therefore  named  the  MCiTnfo-tomporoI  con.v9- 
lutiom  {Fi{j-  l^i,  T4,  76).  The  upper  of  these  is  termed  the 
gyrus  occipilo-tempo-mlis  m«dialie,  or  iirigitai  loi/uU  pLo), 
white  the  lower  is  named  the  gyrus  oceipito-temporaU* 
lateralis,  or  lobiilus  fusif&miis  (T4), 

}  GTS.  RELATIONS  OF  THE  C0HV0LCTI0N8  TO  THE  SKITLL 

The  relations  of  tbe  primary  fiRRurea  and  convolutiona  of  the 
brain  with  relation  to  the  skull  have  been  inrcatigated  fay 
Broca,  F(!r^,  Turner,  and  others.  The  following  is  an  al 
of  Turner's  conclusioDS  : — 


IhJinUe  Laiidnarht  on  tit*  fiar/ace  of  the  Stull. — ^Tbe  folIoiriDg  i 
tnna  and  m&rkiDga  trt  eudljr  tMOjpUMd  ivn  tbe  ■balL      Tba  etilaiDd 
oocdpita]  iirotijt)eni[ice  (F^.  196,  a),  th«  parietal  (P)  and  frontal  (F)  m^ 
nonces,  &ad  tKo  ftst«mAl  unguliLr  proceM  df  tht  ftentol  bone  (A\ 
coronal  {c)  atid  lAmMoidnl  (T),  wjiiiudoiu  (i),  iKiuuDotKKsplwiKMd 
and  parieto-iphetinid  Hiilurcx  {pi),  and  the  curved  Hue  of  the 
lidite  (0- 

Primtrif  Ar«u  of  the  Himil. — The  coronal  mitun(i!)ri>niuihB(>Qst«ri(ir 
boundary  of  the /wH/ii/ofM.  A  vortical  Ime  (^^y.  196,2)  diawa  franttlic 
aqiisiDouB  euturo  («)  upwards  through  tbe  parietal  em>a«oe«  (P)  Ia  Uw 
BOgiital  BUture  lica  almcMt  parallel  to  the  oorooal  suture,  and  mbditide* 
tho  parietal  regioa  into  on  anltro-parittai  (f^.  198,  SAP  -|-  lAP) 
aiidapottav-parietalarta  {Fif.  100,  SPP  +  IPP}-  The  ecCTjritol njM* 
lieH  between  the  lambdoidal  sutura  {I)  and  the  occipital  {notubvfaooe  if), 
with  tht  Bij[>erior  curved  line  estendiug  from  it  (Fig.  190,  »). 

5(?twuftiri/  Artat  of  the  .WuH.— Tbew  four  primary  dirisioaa  of  tiw  iknil 
may  he  subdivided  into  secondary  ar«a«.  Tbe  Uicnporal  ndge  {Fig.  196,0 
starting  fVom  the  external  frootal  procois  curros  baokwarda  acnas  tb* 
frontd  (A),  aiitero- parietal,  and  poet-parietal  areas  to  ths  iiitoraal  ansla  o( 
the  occi|)iUlhone,  and  subdividee  each  of  tbeaa  regiona  into  au  uppsr  ■nd 


ANATOMICAL  ANB  PHrSIOLOGlCAL   rKTRODUCTION.       425 


a  Iow«r  an*.  The  upper  frontal  are*,  wbicb  iDcliidea  all  the  frauUl  refpooa 
■bare  the  tamponl  riJgc,  u  agtiiii  divitlvi:!  t>y  a  Iiii«  dranrn  vorticall; 
spiiArd*  and  badivanU  from  aboro  tbo  orbit  throtigli  tlio  rrontal  ominmico 
tai  Iba  oofooal  cutura  [Fif.  190,  o).  Tbia  lim  divide*  the  upper  frtrntal 
ana  into  a /itr>«n>-/rontai  (8F)  aiul  s  mid-/irwn4at«r<i<i(UI'}. 

Twu  other  areas  remain  to  be  deacribed.  Tbea*  are  concealed  bj  tha 
teaponl  tnuacle,  aod  are  limited  auperiorlj  hy  the  M)iuuiiMo-parieta], 
Ido-parietal,  aud  frooto-splieDoidul  siiiuns.  The  lines  of  tba  Kuturaa 
all/  divi^  thia  ana  into  a  tq*iamot^tnnpor<*l  (^)  and  aJi-tpitmaiiiai 
(A3). 

Tb»  following  tb«n  are  tbo  Mcondarj  arena  of  tb«  wicull:  Sapmot 
FnMai  (SF),  JtiJdtt  FroiUal  (MF),  M/frior  Frontal  (IF),  Cf^ier 
AiUm^Paruiat  (SAP),  Loavr  AnUro-I'anttal  (lAP),  Upper  Pf>iten>. 
farttial  (3PP),  /oim-  I\Mtfro-rarui4U  (IPP),  Ocetpiuil  (0),  Sqtumon- 
nmfoni  (8c)),  and  AU'Spitnoidal  (AS). 

Fia.  196. 


SAP 


\ 


?fP 


IA» 


.MJ 


ir 


\" 


ts^ 


rto.  liS  (F«rT«r1.  j:«bTnl  rinr  of  (fa  ffUMan  5IW<,~A.  Ttw  eittnulancahr 
pmMAUlhp^MtalboiM:.  r.TVfaonlaleiiuBwiaB.  P.  Tlw  [«H«tol  w^DMog. 
iV  'n*  ompiul  |in4alMmMM^  «,  Th*  owMial  Rienn>.  ^  Iji*  lambdotdal 
wtforc.  (.Tb«l)|iiaiiiotu«MitN.  (.TktUntiwnl  ridte.  /i.  Tb«  (runlo-aftheiMU 
■tin  I.  pa.  The  p>rial4HvbnMiil  nttiM.  m,  Tba  •quMigM-tpbanoid  ■nton. 
^^  llta  Mriri<Hmartaid  mtnr*.  1.  FroaUl  )ii.«.  S  P'tfutallinn.  SF.  MP, 
IT  TW  anp*!*!-.  wAi-,  aad  iiif(Ti>froDt&]  luUliiitioni  of  Ui«  fronlal  araa. 
^■Vl*.  Tbe  ni|>e[D-Mtno-p*rielal  arva.  lAf,  Th(  iiifero-«aUro-pari»taI  arM. 
.■*l*l'.  TU«  ™p«ro-iw«t««w[«rUUl  wwm.  IPI*.  'ITw  infoto-jiMUro-paKrtal  ana. 
V.  Tbm  oedpttal  um.  Sq,  Tba  (qnuiuMa-tMDpont  arva.   AS,  The  aS-apaeaoid 


428      ANATOMICAL  AND   PUVStOLOOICAt   IHTRODCCnOK. 


The  ali-tpkfwidiU  otm  {Fig.  197,  AS)  oMiUiiw  Uto  Iowa 
eitrecaitjr  otthe  tecaporo-Bpheiioidallobe. 

Th«  c<7Unl  Ml,  or  lalaiid  of  R«il,  do«s  notcoDM  to  Um  Marine,  bd 
lie*  At»p  ill  tlia  Guun  of  SjrlrioH,  atid  UcaiiCG«led  bj  the  oouvoluUou 
wbich  Turm  tho  mArgiQ  of  th&t  fi«aun  uUricrl;.  It  Uh  oppodte  Ik 
upiwr  part  of  the  gre&t  wiug  of  the  t^tieooid  and  ito  tin*  of  KiUosWiaii 
with  tho  anterior  iuferior  angle  oEtb4  parietal  utd  tbc  aquaswusfutif 
ilia  t<;in|>orsl. 

Tha  cAnrnliitioQ*  8LtuAt«d  on  tho  iDt«rDa1  upoct  of  Ih*  bemuplMn  m 
Itltogathcr  out  of  relattoii  to  bba  surface  of  the  ikuU. 

Tbo  d&op-seatfrd  |ko§itioii  and  dinotion  ot  the  hippooami>kl  repoa  m 
suporQcially  indicated  1)y  tlie  coitrolutioiia  of  the  tenipoiXKsptieiioidal  1o)m% 
coiitAined  chi«tly  in  the  ioferior  postaro- parietal,  Bqaamoao-tempon^pni 
ali-spboaoida)  araaa. 


studied    1 


8677.  IKrERNAL  PAET3  OF  THE  CEREBRUM. 

The  ajiatoniy  of  the  cerebrum  is  moat  coDveoicatly 
by  su<x:e«aive  horizoDtal  sections. 

Centrum  OvaU. — X  horizoDtal  scctioo  made  half  ao  isctt 
above  tho  corpus  callosum  displap  the  white  matter  of  mA 
bemispbere  surrounded  on  all  sidea  by  the  grey  matter  of  tb* 
convoiutions.  Tho  white  central  naass  in  each  hemisphere  wu 
named  by  Vicq.  d'Azyr  the  cfftitrum  ovaU  mvMia.  A  aeetm 
made  at  tlic  level  of  the  corpus  callosum  shows  that  tho  white 
substance  of  that  part  ia  coDtinuous  with  the  ceotrol  white  sub- 
stance of  each  hemiRphere.  The  large  white  medullary  lOMi 
ttiiis  displnyfid  is  named  the  ceTitrum  ovale  maju*. 

The  CorjiUJt  CaXlosum  connects  the  ceotres  of  the  tvo 
bemiaphures,  and  it  approacbea  nearer  their  anterior  titan 
their  pa^terior  extremities.  It  terminate)!  behind  in  a  free 
rounded  end — the  spleniwni.  whilst  in  front  it  forms  a  knee- 
shaped  bend,  and  passes  downwards  and  backwards  as  hr  u 
the  lamina  cinerea.  It  is  thicker  behind  than  in  front,  IbB 
middle  part  being  the  thinueat  It  consists  of  bundles  of  nem 
fibres,  almost  the  whole  of  which  pass  tmnsrerscly  between  tiM 
two  hemiepheres.  The  fibres  may  be  traced  into  the  whits 
cores  and  grey  matter  of  the  convolutions,  and  appareatlj 
connect  corresponding  convolutions  in  the  opposite  hemispliiRa. 
A  few  fibreH  run  longitudinally  on  the  surface  of  the  oorpos 
callosum,  named  the  strlce  UmffitwUnaUs  ot  nerves  of  JUntcwi 

Topography  of  tJt«  CefUrum.  OvaU. — A  systematic  d(bd«- 


AVATOmCkL  AND   PHTSIOI/KIICAL   INTRODUCTION.       420 

eUcuni  of  the  varioiia  parts  of  the  centrum  ovale  has  been 
itevtsed  hj  Fitros.  HU  system  consists  ia  miLkiDg  verticaJ 
■ectioDB  of  the  brain  at  ilefioite  points,  and  Darning  the  vurioiLi 
fATts  of  the  medullary  gub.stance  exposed  In  each  section.  A 
vertical  xectioQ  of  the  hemisphere  at  right  angles  to  its  loogi- 
todina]  axis  in  the  pr^-frontal  region  gires  the  pnr-ffxmtat 
tKtion  (Fi^.  198).     The  next  section  ia  made  two  ceDtimitres 

FlO.  IQB. 
/-  " 


>.  IIH  lAttm  ntraa).  Pr(t-Jn»Uil  lit<tian.-1,  1  3L  Ttrst,  Mcond.  aiiil  UiIH 
fnwlwl  OMivolatJoiiB.  4,  Utbtlal  convotnUoo*.  R,  Ccnvolotinm  on  tba  inWiikl 
a^Mt  of  llw  boDUl  kite.    0,  Fi«-(ronUl  (udeull  ot  tb*  oentraui  uvalc. 

Vm.  180. 


«_ 


KAIlvPtbw).   jW«ri««r*./nni<aI5M«aN.-].S,8;  ll^nt,MC9iid,UHltliird 
hrf  oMT^ntieBL     t,  AoKnor  sxtmidtjr  of  »■  Janlar  Io(m.     a,  Poaitfior 

Jill      ttyi  UMOrttittt  cmvohtUoiM.    6,  Superiur imlnaciilo^nNital  twdcalu*. 

r.  UMdkpc^a>c*ili>-fr<«MllM<>c«Ia«.  8,  l»f prior  poctunmlofninial  ImcIchIiu. 

t,  OrWlal  u**i^"*-    to,  CaipwatUoatuo.    II.  CkucUtosiicUiu.    U,  Inunikl 

■-     u,  LaotionlM  ntnlni. 


430       ANATOMICAL  AKD  PHTSIOIXWICAL  INTBODUCTTON. 

iu  front  of  the  fissure  of  Rolaodo  and  pusses  through  the  "btmt 
of  the  three  front&l  convolutions,  and  is  Dimed  the  pedwfmlit' 
frtmtal  section  (^V/y.  190).  The  medullary  BubsLaocc  in  tin 
saciioQ  is  fiubilivided  into  r  mperurr,  miflttU,  and  inferior 
pedii/nffulo-fTont(U/a9Ciealu»,  ooireBpondiDg  with  the  respeettva 
frontal  convolutiona  The  next  nectioo  is  made  through  the 
asceudmg  frontal  coovolution,  parallel  with  the  Assure  d 
Rolando,  and  ia  named  the  frontal  eectton.  It  also  pit— 
through  a  small  portion  oftbe  sphenoidal  lobe.  The  mcdulhiy 
eubatance  of  this  section  is  aUo  subdivided  into  «up«ru>r,  midSt, 
and  inferior  /rt/iUal  fascictdi  {Fiy.  200).     The  fourth  lectiM 

fjq.  zoa 


Fid.  aoo  (After  P!tna).  Fnmtel  SMttOL—l.  AKmdla;  ffonUt  ooanfeiAi*- 
3.  Iiumlu  lobole.  3.  Spli'^Qf^i'd*!  lobe.  4.  0,  6.  Snpwior,  middiB,  ■nd  iaMrn 
IninlEj  (uciniliu.  7.  Splirnoidsl  (aainculna.  8,  Cwpoa  citQnMUB.  fi^CwW* 
nnolcui.  10,  Uptie  tb&lBinui.  11,  liit«niMl  c^koI*.  U;  LiBlienlav  bmIik 
13,  Extenutl  o*|mU.    14.  Clauittum. 

is  carried  through  the  asceDdiog  parietal  oooTolution,  and  is 
named  the  parieUd  gtctioju  Jt  is  subdinded-  into  auprrior, 
midlife,  and  inferior  paruUd  faaciadi  {Fig.  201).  The  oexi 
is  tlie  pedunctdo-parietal  aedion,  made  b;  diridiog  the  html- 
epherc  three  centimetres  behind  tbc  fissnre  of  Rolando,  and 
cutting  the  Buperior  and  iDferior  parietal  lobulee.     It  if  sab- 


492       AKATOMlCAl  AND  PHTSIOtOOlClL  nJTRODOCnOK. 

divided   ioto  auperwr  and   inferior  poduoculo-parietal 
gpiunaidal  fatcicuH  {Fig.  202). 

The  last  is  the  oceijntal  section  {Fig.  SOS)  in   wbieb 
tepATnte  fasciculi  are  diKtingiiinhed. 

Fi...  2i>3. 


Fig.  203  (Aftw  TitrM).  Oteipilal  StaiiM.—\.  Oolpitbl  (mbvoIiiUmw.    2, ' 
buoiouli  iif  Uic  oontruo)  attXv. 

Lateral  VontricUa. — ^Tho  Interal  ventricle  is  divided  ioto  k 
cenlml  i^rpace  or  body,  and  three  curved  protongationsoreomuo. 
The  wnterior  cot^iu  extends  forwards  and  outwards  into  tite 
frontal  lobe,  the  poid^rior  curves  backwards,  outwards,  aod  in- 
wardfl  into  tlie  occipital  lobe,  &ad  the  deactndi'ng  eomu  comi 
backwards,  outwards,  downwards,  iunrards,  and  inwards,  beliiwi 
and  below  the  optic  thalamug  into  the  temporo^pbenoidal  lobe. 

Oa  tlie  6oor  of  the  ceniral  space  taa.y  be  seen  from  before 
backwards  tbe  cavAait  nucleus,  and  to  its  inner  and  posterior 
part  a  amall  portioD  of  the  optic  tfuUamua,  whilst  bvtwcen  tbc 
two  ia  a  curved  flat  band,  the  tcenia  semiciTcvUaria,  Th< 
akoroid  plexus  rcata  on  tli«  upper  ituiface  of  tbe  optic  tbalaniitf. 
and  innniediatcly  iotemal  to  it  is  the  free  edge  o/  ihg  fornix 

The  anterior  end  of  tbe  caudate  nucleus  projects  isto  tbe 
anterior  coriiu,  while  tbe  posterior  corau  baa  on  clevatioo  o&  its 
floor,  named  tbo  hippocanipua  minor,  and  the  eminentia  wl- 
UitffratU  lies  between  the  posterior  and  desceodiog  comoa.  Tbe 
hippoeampiu  mnj<^r  extends  along  tbe  floor  of  the  doMending 
eornu,  and  tvrminatcs  below  in  a  codutar  end,  the  pes  hippo- 
campi. Along  ita  inner  edge  la  a  narrow  white  band  proloogod 
from  the  posterior  pillar  of  the  fornix,  iiamed  tbe  tamiti  hippO' 
campi.    If  tbe  tSQuiu  be  drawn  aside  tbe  bippucampal 


JLSATOUICIL   AND  PaTSIQIXWICAL   INTItODUCTION.       433 


I  ANA 

Innpoeed,  at  the  bottom  of  which  the  grey  matter  of  the  gyrus 
bippnaunpi  CDAy  be  seen  to  form  a  serrated  border,  named  the 
fascia  dantaia.  The  choroitl  pIcxttH  entcni  tho  descending 
eoruu  tbrougU  tbe  great  traasrerse  fissures  of  tho  brain  betwdOQ 
Uw  tteaia  hippocampi  and  optic  thalamus.  The  lateral  ven- 
tricle U  hood  b;  cjliodrical  cpithcliom,  which  rests  od  a  layer 
of  oeoroglia,  and  ia  ia  manj  parts  ciliated.  This  lining  is  con- 
tinaoQs  with  tlut  of  tho  third  ventricle  through  the  foramen  of 
MoniD,  the  lining  of  tbe  latter  being  cuQtiuuouawilli  tliatofthe 
Gmrtb  ventricle  through  tho  aqueduct  of  Sylviu&  A  little  fluid 
ti  contained  in  tho  cerebral  ventricles, 
Sqituvi  Lueuium. — If  the  oorpus  callosuin  bo  divided  trans- 
KMneljr  about  itit  middle,  and  the  two  halves  reflected  forwards 
^^pl  backwards  respectively,  the  fornix  and  $e]tlum  liuidum 
are  «xpoaed.  Thia  septum  extends  vertically  between  tlie  corpus 
caUomim  above  and  the  fornix  below.  It  consists  of  two  layers 
of  grey  matter,  having  an  interval  between  tbuin  cuiitaiuiDg 
Bnid,  and  covered  by  uo  epttbcliuted  membrane.  This  space 
ti  iJtutfifUk  veniricU, 

Tbe  fomim  is  an  arch-shaped  band  of  nerve-  fibres  which  «x- 
tAoiis  in  the  aatero-poaterior  direction,  its  anttjrior  cud  form- 
atg  the  anterior  2>i/^r#.  its  posturior  the  posterior  pilian. 
mad  its  budi^  the  summit  of  tbo  arch.  It  consists  of  lateral 
halves,  but  at  tbo  summit  of  the  arch  the  two  are  joiaed 
together  to  foim  the  body.  Tho  anterior  pilhirs  are  separate 
£rom  one  another;  they  descead  in  front  of  tho  third  veutricle 
to  tho  base  of  the  cerebrum,  where  they  form  tho  e^r^wra 
atbieantui,  and  then  enter  the  suUttance  of  the  optic  thalamus. 
The  posterior  pillars  are  alao  sepatato  ;  each  curves  downwards 
and  outwards  into  the  descending  oornu  of  tbo  vontricio,  und 
Conni  the  free  bonier  of  the  hippocampus  major,  which  is 
Domiol  tbe  f<mi'a  hiypooampu 

Till)  iWum  interponihim  is  a  fold  of  pia  mater  which  passes 
into  the  interior  of  tbe  bemispberes  through  tbe  great,  trau»> 
v«ne  Ssnirs.  It  is  triangular  in  shupe,  tbe  base  is  in  a  lino 
w^itb  tbe  posterior  end  of  the  corpus  callosum,  the  lateral  mar- 
gins are  fringed  by  the  choroid  plexuses,  and  the  apex,  where 
the  choroid  plexnses  blend  with  each  other  through  tbe  foramen 
of  Monro,  lies  behind  tbe  anterior  pillars  of  the  fornix. 
00 


134      ANATOMlCJkL.  AND  PBTSIOLOOICAL  INT&ODUCTIOX. 


Tb«  choroid  plexttMS  consist  of  highly  vaacalar  folds  ot 
membrane,  and  the  epithelium  of  the  venlricles  is  contiuoed 
over  their  surtace.  These  plexuses  conUin  the  small  dtoroidal 
arterieB,  and  supply  the  oorpom  striata,  ihe  opUci  thalami,  and 
corpora  quadrigeroiDa,  the  blood  from  these  bodies  being  re- 
turned b;  tiio  vciiie  of  Galen,  If  the  relum  ioterpoaitum  be 
raised  Troin  before  backwards,  the  optic  thalami,  thinl  rett- 
Iricle,  pineal  gland,  and  corpora  quatlrigcmiua  are  exposed. 
{Fig.  204). 

Tbe  third  ventricle  is  a  cavity  situated  is  the  mesttl  pi 
between  the  optici  thalami ;  its  roof  is  formed  by  tfa«  relii 
interpositum  ood  tbe  body  of  the  fornix,  its  floor  by  tbe  pos- 
terior perforated  space  (jions  Tarini),  the  corpora  olbicaotia, 
the  tuber  cincrcuni,  inruudibulum,  and  optic  eommissare ;  its 
antorior  boundary  by  tbe  anterior  eommismire  and  laniiw 
cinerea ;  its  poflterinr  bonndary  hy  the  corpora  quadrigemiM 
and  poflterior  commissura  Tlie  cavity  of  tbe  venlride  is  smsD, 
and  it  is  crossed  at  its  miiidle  by  tbe  midMe  or  eo/t  oommw- 
mbre,  which  coDHist^s  of  grey  matter  and  connects  tbe  ttro  imier 
tctrfaces  of  the  optici  thalami  togetber.  If  the  anterior  pillars  of 
the  fornix  be  Bepanited,  the  aTiUrior  while  oommissure  may  be 
seen  entering  the  lenticular  nueUk  The  white  fibres  of  the 
posterior  commissure  paas  across  between  the  two  ot 
thalami  in  front  of  the  corpora  fiuadrigeniina. 

BASA.L    GAXGLIA. 

§  678,  The  ganglia  of  the  base  of  the  cerebrum  are  the 
oorpoiib  striata,  the  optici  thalami,  the  corpora  geniculata,  the 
COipora  <xundrigcminn,  and  the  locus  aiger. 

(l)  The  oorpoiu  etriatum.  is  situated  in  front  and  to  the 
outer  side  of  the  optic  tbalaiui,  and  cou&ists  of  two  masses  ol 
grey  matter,  separated  from  each  other  by  bands  of  meduUated 
fibres,  which  paas  from  below  upwards  through  its  substantt 
The  upper  mam  projects  into  tho  lateral  Tcntriclc,  ood  ia  called 
tbe  iutnrTeotricular  portion  or  caudaU  nuc/^t4A 

1%  coHdai*  nMoletu  consists  of  a  clcb-shaped  portioo  (Ui-aetod 
and  a  alcador  tail-like  extremity  directed  baclrmrds,  the  two 
fonning  ^moat  a  comi)li>t«  rins,  wbich  cndrelfls  tbe  optle  '*'*t*«— ■»  i 
itit«reiJ  caiMule,  \ik«  a.  loop  or  auroiogltf.    Tba  hoij  gf  tl 


436       ANATOJIICAL  ASD  PHTSIOLOOICAL  INTRODDCTIOX. 

t«nDU)at«a  in  an  «iilai:ged  extremity  almoBt  einctl;  nppoaiU  tbo  point 
whore  it  atarteil  in  tb«  Mit«ri««-  bom.  Tbe  head  of  tho  oaadal«  miia» 
it  oontinsons  with  tbe  IniUculAr  nualeun  and  with  tho  grey  tnattsr  of  tte 
Ulterior  perTorateil  ifpue.  The  oitrcmity  of  tho  aardiiglB,  on  ths  oUxr 
hBix),  JH  c(>iiiM!ututl  with  a  ilvixmit  of  j^ey  niattor  forming  the  anUnor 
wall  of  the  uiferior  horn  of  the  rcutricle,  oanied  the  anyyiiaU.  TW 
ttenin  semlcircalsria  acoompoDiee  the  concsTe  border  of  the  surcio^s,  sod 
runs  furnards  aJong  tha  roof  of  tho  inferior  horu  of  the  Teutricle  to  iti 
anterior  eotl,  and  there  t«rmiDatea  in  tbe  amygdala  (Daltoo).  In  afertital 
tranawTM  B«utiou  of  the  hratu  tlin>u([h  the  optic  thalamua  the  •ii[<erv)r 
portion  of  Che  aureiitgla  ii  vlNihle  abor*  tha  lenticular  duoI«iw  and  interual 
capsule,  vchilv  tho  iufmor  [lortion  appean  ai  an  isolated  maae  of  f/ttj 
matter  below  tbo  levvl  of  the  lenticutar  nucleiix  and  near  tbe  outer  ptft 
of  the  inferior  horn  of  Lbe  Tenbricla. 

Fia.  S09. 


0 


h^. 


Via.  203  (After  Ualtuu).  LongUintmalaMd  i'tttttal  Stetiam  of  Ut  Sigiu  Urmi^Ji^ 
Awiiitif  tKt  Caritg  Iff  Um  Imterat  Pcntnole  •■•»W  At  IWrntal*  Xuelau.  ~  C,  IM 
efthacandatenueltiM.  8,  SnroBgle.  V,  VcMttele.  AtAnyplakL  l,Pm*- 
iMctplul  UMtira.    2,  Celcuio*  fimtre. 

The  lower  extra- to iitrieulBr  portion,  or  leiiiieuiaf  nudeut,  El  aetwiwl 
from  the  intra-ventricuhir  part  by  a  Uyor  of  white  nibittancc  named  Hit 
inttrnai  atptuie,  whilo  it  ia  separated  from  tbe  Island  of  R«il  by  a  layct  ft 
whitti  substance  Daraod  tbo  external  eapnh,  and  a  grey  lamina  tonned  Ol' 
davttrwn.  The  lenticular  nuoleua,  aa  its  name  iraptiaa,  is  of  tbe  fimi  ef 
A  ln-«ODrei  leim  on  horiiontal  eectioii)  but  on  a  rertical  aeoikm  Ifantib 
iU  miiidlo  it  apiieare  triaiigukr,  the  apex  b«iug  dirwted  iuwarda.  Tae 
white  biuida  which  run  pnTallol  to  the  out^r  etirfAce  of  tlia  uuckua  or  the 
external  aiptiule  divide  it  into  three  mwe  named  from  within  outwinlf 
Uio  &rA,  wcond,  and  third  diTuuou  of  tbe  loatioular  i)u«l«iiia> 


ANATOMICAL   A^[>  PUYSIOLOOICAI.  INTnOPUCTlON.       437 


(2]  The  optic  thalavivs  i«  of  fto  oval  sbapo  and  restd  oa  the 
eras  cerebri  of  the  aame  side.  It  is  bounded  cxusroally  by  ilie 
ooqiUB  striatum  and  tfeoia  setnicircularis.  The  upper  surface 
IB  Ene  Bud  ia  purtly  soea  in  the  Jutvral  watricle,  aud  i«  partly 
COTBretl  by  the  foroix.  the  former  being  called  the  ajUerior 
te6#raf0  and  the  latter  the  posterior  tiUt&rcU  or  piUvinar. 

Fid.  306. 


( 


C«l' 


Ytt 


— s 


■~^' 


■Cp 


/      '^ 


\ 


-.Co»' 


V 


Cm 


.>' 


An 


Pm.  3M  (Tntm  Heale'a  Aoklotnid).  Vtrtital  ."trtiom  trf  Uk  £rai»  imatdMUtg 
MiiMj  tit  Atilenor  f>>mmi»*«rt  «f  tkt  Tiint  I'tjtlnetf.— Uvl*  Car|iii*«illopiiiD ; 
ViL  Tlia  Cfth  vmUids ;  I^,  r«iiiitia  of  Iha  MiAam  IneUiun  iVt,  CauiUU 
aawai    1)',    laiern«)  capmilo;  tU,  Tiralk  MiQlrimUrte :   Kl.   LcuLlcnlar 


t  Op.  iUUnui  capai]» ;  Cos,  Anterinr  oMMBtmn  ot  UM  tUcd  Nn> 
;  Co*',  AjtMriv  eamniHBn  m  it  wiixU  back  hracatlh  th*  lenUcnlar 
■«cl*a«  to  imitk  U>t  CMiroluHiw  «(  tbo  cortex  -,  Am,  Hi^Kdidliig  b^rn^if  th« 
UtMBi  rtitfUli  t  Sn,  SahitMiti*  Ntk.  kllM.  i  II',  Ui>tk  UuX;  Te,  Tntxr 


433       AKATOVICAL  AUD  PHrSIOLOQICAI.   IKTBODUCTION. 


The  posterior  surfiaco  is  also  free  and  projects  into  the  desoetui- 
ing  corou  of  the  lateral  ventricle.  The  inner  surfaces  of  tii# 
two  tbalami  form  the  lateral  walU  of  tho  third  veuTxide,  and 
are  coQnected  together  by  a  trftosvoise  portion  which  forms  the 
middle  or  soft  eommiagnre  of  the  third  veotride.  The  inow 
surface  is  lined  by  grey  matter  which,  according  to  ]ll.eyneit,ii 
distinct  from  that  of  the  interior  of  the  thalamus,  and  is  pro 
bally  the  upward  coutjauataou  of  the  central  grey  substance  of 
the  spinal  cord. 

The  internal  capsule  consists  of  a  thick  band  of  meduUated 
fibres,  which  separates  the  lenticular  nucleus  on  ihe  ooe  bud 
from  the  caudate  nucleus  and  optic  thalamus  on  the  other.  On 
horizontal  section  the  luternal  capsule  is  seen  to  cotuist  of  an 
atittsrior  and  posterior  divisino,  which  form  an  obtuse  aogln 
with  one  another,  the  latter  being  called  the  kn^  of  tin 
tfotomal  capiule.  The  anterior  division  lies  between  llie 
anterior  and  intoroat  margin  of  the  lenticular  nucleus  and  Urn 
head  of  the  caudate  nucleus,  and  the  po«tcrior  division  between 
the  posterior  and  internal  margin  of  the  lenticular  nucleus  axtd 
the  optic  thalamus ;  while  the  knee  of  the  capsule  is  directed 
inwards  towards  the  tliird  ventricle,  and  forms  by  ita  projectioD 
a.  partial  separation  between  the  caudate  ouelcns  and  optiv 
thulaiuus. 

The  external  capatde  consists,  as  already  mentioned,  of  a 
thin  band  of  while  sub&lauce  which  hounds  the  leoticulsi 
nucleuK  externally  and  lies  between  it  and  the  clauiilram. 

(3)  The  corpora  geniciil<Ua  consist  of  two  small  oblong  ind 
flattened  eminences  connected  with  the  posterior  extremity  of 
the  optic  tract,  named  respectivety  corpus  genieulatum  ez* 
temwrn  and  internum. 

(4)  The  locus  niger  is  a  dark  mass  of  grey  matter  wbicb 
lies  between  the  crust  and  tegmentum  in  the  crus  cerebri.  It 
occupies  nearly  the  whole  diameter  of  the  cma  and  exteml* 
from  the  anterior  edge  of  the  pons  to  the  corpora  aJbicantia. 

The  pineal  body  or  gland  is  a  reddish  body,  enveloped  hj 
the  velum  interposilum,  and  situated  upon  the  ajitcnor  clerr 
lions  of  the  corpora  quadrigemina. 

Tho  ptduncUt  of  tJta  pinial  body,  by  nuaoa  of  wUcdi  it  is  oonaeotad  < 
the  rwt  of  ibQ  Mrebrum,  pu«  fbrvards,  eoeon  the  innar  side  of  each  i 


AHATOinCU.  AHD  PU  fSIOLOUICAL  INTBODVCIIOH.      439 

Uulama^  to  join,  aloDj  with  Um  faenis  MtuioircuUna,  Uie  ftatwior  pillar 
«f  tlw  foniz  of  ita  ovd  aide. 

(5)  The  torpara  ^imdngfrmiim  or  o^(«  Zofe«  are  situiOed 
bdund  and  becweeu  the  oplici  tbalami,  and  reHt  upon  the 
poitarior  Burface  of  the  crura  cerebri  Those  bodieg  are  divided 
into  four  emiQ«ncea  by  a  longitudinal  and  traosvene  figure,  the 
aoieriur  pair  being  nani«d  itatea,  aud  the  poslerior  tesiea.  From 
each  t«sti8  a  white  cord,  the  auperioT  peduncle  of  the  eere- 
btUwn,  passes  backwards  to  the  cerebellum,  while  the  vaim 
of  Vieumetu,  or  anterior  maiulltiri^  ixltim,  atretcbes  betweaQ 
the  pair  of  cerebellar  peduuclea 

The  aqueduct  of  Sylvius  is  a  narrow  canal  which  paaeei 
beaea^  ibe  corpora  quadrigemina.  and  connects  the  third  with 
the  fourth  reatiicle.  [t  ia  lined  hy  a  ciliated  cylindrical  epi- 
thelium. 

DisntmunoN  or  the  arteries  of  tue  bkaw. 

$  ^9.  The  arteries  of  the  brain  are  derived  from  two  great 
trunks — the  vertebral  and  internal  carotid  arterieft.  The  branches 
of  tlie  vertebralH  and  of  the  basilar  trunk  formed  by  their  union 
supply  ihe  posterior  and  lesser  portion  of  the  brain,  while  ilie 
t«miioal  branches  of  tlie  internal  carotid  arteries  nupply  the 
anterior  and  greater  part  of  the  brain.  The  branches  distrU 
bnt«d  to  the  brain  from  the  vertebral  arteries  may  be  called 
the  posterior  or  Tertebral,  aud  those  derived  from  the  internal 
ouxitida  the  anterior  or  carotid  arterial  nyatem. 

7%e  poaterioT  cerdtral  arUrtee  aru  the  terminal  brancheti  of 
tbtt  basilar  trunk.  Each  artery  vriuds  round  the  cms  cerebri  to 
svftdi  the  occipiul  lobe,  and  gives  off  a  number  of  twigs— (Ae 
potUrior  median  group  (Fig.  SIX,  S) — which  pierce  tho  pos- 
terior perforated  space,  and  supply  the  internal  surface  of  the 
optic  thalamus,  and  the  walla  of  the  third  vcalncle. 

I  A9makm.—A  oboniil  tntaah  ia  gina  off  to  the  ralum  iDtatporitom, 
I  woall  twifa  paaa  tuto  tlia  aabatanea  of  tlia  «na  aorobri  aa  tba  vaual 
wind*  roand  it.  A  numW  of  sbulU  hnDcboa,  the  potUrv-lalrral  grvvp 
C>1^Sll,4),«Dtcr  tils  baiaoftlM  brain  Iwfaiod  tba  portarivr  bordor  of  the 
cm  MNlwi,  and  |>aaa  into  tba  optk  tluUouis  aad  oocpors  quadrlgKuiitL 

Tba  tortieat  frninah«t  are  tbrve  ia  iiumber ;  tba  fint,  or  anterior  tem- 
fonH  aiUry,  Mac  diathbttt«(L  tu  th«  aut«hor  part  of  tUe  auoaste  Kjma 


ANATOMICAL  AND  PHTSIOLOatCAL   IHTRODrCTION.       441 

The  anterior  cej-ebntl  ai-Ury  {Fig.  211,  C  A)  runs  forvards 
_  tlie  longimdioftl  fissure,  and,  turning  round  tho  corpus 
callomm,  ut  distributed  to  the  anterior  part  of  the  cerebrum. 
He  arteries  of  the  two  sides  are  united  at  their  oommeDcoment 
bjr  a  short  uaoaverse  branch,  the  atderior  aynvmv.nicating 
artery. 

Fio.  »& 

^cB 


7- 


Fi 


U 


Gf 


r  r»- 


ft 


.v;'  cc 


m 


o 


fM.  3M(AfmEdceruult>nnl}.    tnmrSv/ace^BifklSmkplMt. 

Ditmannox  or  vvumtM. 

IW  nclMX  bmuiiM  bjr  tb*  Una  I )  npnaent  tli*  UrritoriMaver  wkiohlha 

bcmocka  of  Uic  Antuiiok  CuiXBBAi.  Autkbi  an  dblribalcd. 

1    U  tlia  Uiritory  of  UM/XmaraitdjIirio-iDr  JVirnlof  Jr<rrr> 
Ul.  „  „  IntmtU  and  Ptnttrnae     „  „ 

wfeiA  tilt  IraieaM  af  tba  PoainuoR  C'eriikiijil  Airttnv  m*  diMritniMcL 
n    !■  tbt  tanilocT  of  lb*  FcMtriur  Tttaptrrvl  Artery. 
in.  ,(  Omv*1«' -ilHcrT^ 

BmiuluM. — Tho  anieriermedittnffr4mp{l'iff.ill,'i)  am  given  off  IVom 
Um  aatorior  oonuminicatiiig  and  th«  oommenccmrat  of  tbo  luitvrior  oen- 
faal  artcviM ;  tbe;  xipplj  the  uit«rir<r  part  of  the  head  of  th«  caudat« 
ttodiifc  Tbs  eorfMof  Iff&iiohra  ATS  four  in  uumbcr — tho  fint  being  div- 
Mboted  to  the  two  intamal  orbital  canvolutiooa ;  the  aeoonil  to  the  ante- 
rior  ■xtmoitjr  of  iba  DoaiKiiul  eouVoIuiiou,  and  to  the  mpMior  and  ootcrior 
patthimi  of  tba  middle  frootal  oouToIutiotw  on  tba  outer  auiface  ;  th« 


+42       AXATOMJOAL  AHD  PHTSIOLOOICiL  IJ.THODUCTIOS. 

third  to  the  inner  surface  of  the  hemb'pbcre  u  far  u  the  estieniitj  cf  tU 
callaM>>nur^u&l  Gwtiire  ;  uid  the  fourtJi  to  the  qiudntv  lobule,  the  iMt 
auppljiog  a  hnnch  to  the  ooipus  cjUlomm. 

The  midtlU  cerebral  or  Sylman  artery  (Figa.  210,  211,  S] 
niHR  in  the  fissure  of  Sjlvius,  and  in  the  largest  and  mou 
important  branch  of  tbe  internal  carotid  artery.  It  gives  Bmoll 
brandies — tJm  anterthlatentl  group  {Fig.  211,3) — which  [Mtroe 
tbe  anterior  peribrated  space,  and  supplj'  the  corpus  striatam 
and  anterior  part  of  tbe  opdc  thalamus. 

Pio.  209. 


v; 


f2       !. 


! 


v.* 


/\; 


"X. 


/ 


n 


\B 


m 


I'l 


p.^- 


IV 


(r 


'/ 


Oft 


r^ 


^^^■1 


V 


Pio.  S09  (Aftas  Eokw  bod  Ducct».    Oulcr  SHrybec  ^t)^  Ltji  BaiOitlkn 

iHHTMtir'naH  or  rsHKia. 

Hu  ngicrn  bonodH  bj  tho  Ui>«  ( )  r<q>rcawt«  tke  t«rrit4tT  Of^  «1m 

bnuioiioe  of  th*  AxtbUqk  Cwudiul  Abfuit  av*  dutribtttod 


The  Ulterior  i«done  bonn<t«d  br  tbe  lin*  |- 


-)  N|ir«Mnt  the  UBit«fiM 


urvT  which  Imktiohei  of  tlia  MiuuLi  Ckxcmal  AJinsT  we  i 

I.  U  tbe  roKion  of  the  lUtfmat  atut  fnfiritt  Ptvmtal  ArUry- 
II.  t,  „        jinifriorj'aritiat  Jrtrrf, 

UL  „  .,        J^Urior  Faritlal  Artery. 

IV.  „  „         rart(to-$ph(itoidal  jlrftrf. 

Tbe  porterior  end  IdImIof  n^tan  twnndtd   br  tbe  line   t— «•— ..- 
lepriMfile   tbe  tcnUofj  o«0  uluob  IvMicbDa  of  tbe  PosnaioK 
Anmr  «•  diitribnlod. 


AKATOHICiL  AND  PBYSIOtOaiCAJ,  INTKODUCnOM       4+3 

Brmmkm, — A  cfaoroi4  bnuich  ui  gireu  off  either  lijr  the  middle  ocnbral 
or  iaUnul  MMtId  uteriw,  whicb  modH  round  the  cnu  oerebri  to  reacb 
Um  oboroid  pluiu  of  Um  Uberal  reutrick.  Tbo  main  trunk  diiidosinto 
rMirbnoGfaes.    The  Snt, or  infiirior  Ih>nta1  bmnofa  (A^.  sin,  l),i4UcBit«l 

Fio.  2ia 


/, 


Ti> 


S,  SflviMt  <«  tiiMI&  oofvbml  Htcnr;  P,  INxfoneing  bnuicIiM;  1.  lalttitr 
trem^ti  bfMteh ;  S,  AaMmBng  fraMiJ  bMudi :  S,  Atotadiug  jkAiiatal  bMuicb : 
4  Md  A,  PiwtoUi  inhtnoliM  ud  sphuinldRl  bnaoliM :  A,  AMmdlns  (todmI 
oonvvhiliMi:  B.  AaomJIa;^  iNuirt*!  oonToIatloo:  T„  Tt,  T%,  Fint,  wccuuL 
•adtkad  fronUl  cnovoltibMia ;  V,,  P„  I'„  Virwt,  ■eooodi  mm  Uutd  pwwUl 
mtTolntiDiHi :  T,.  T,.  T.,  Elrrt,  meciui,  uid  thitd  t«nipoio«)lMBOMiil  con- 
ivlMiDU  i  OU  Ctodpital  kU. 

to  lU  diMtribatiuu  to  tbe  outer  port  <^  the  orbital  aurfkoa  and  the  u^ueat 
iaSniot  or  tltird  frout&l  ootirolutiou.  'l'h«  B«c>}ud,  oor  attending  fnmtcU 
WimIi  (Fi^.  Slu,  i).  npiJiai  the  posterior  part  ot  the  middle  CronUl  and 
Ik*  «luif  pAit  of  Um  ueeadiDg  frontal  conrolutiooa.  The  third,  or 
—mnfflfyj'nrrrrnf  arf^ry  (Fig  210, 3),  paaaea  into  the  fimmof  RoUndo,  utd 
•■(pliM  tbe  T«Bt  ftf  tbe  tsconding  ft«i)t«l  and  the  aaccndiog  parietal  cod> 
wIbBop*  m  well  as  th«  anterior  part  of  tbe  su|)eri<tr  paiieldl  lobule.  Tbe 
bartb  and  fifth,  or  paritia-tpKenoidal  and  wphauiidal  branobea  {Fig.  SIO^ 
4  aod  b},  aoppl/  the  lobrior  pariotal  lobule  aotl  the  aaperior  temporo* 
^baooidal  ooAv«liitiona. 

Tkt  podcrior  tommxvni<xUiT\Q  ariery  is  a  long  aud  slender 
vaoel  wbicb  conoecU  tbe  ioterual  carotid  with  the  posteiior 
cerebrml  arteriitt. 


4*t      ANATOMICAL  AND  PHYSIOLOGICAL  UO-RODCCTIOS. 

The  ovrdi  of  IFiHtg  is  formed  by  the  union  of  the  anUmr 
and  poslcrior  arterial  cerebral  syRtenu  by  mcoDB  of  the  posUrior 
comraunicating  arteries.  Tho  free  ADastotnosiii  which  ja  ihtif 
formed  enuhlc»  the  circulation  of  blood  iu  the  brain  to  be 
on  when  oQo  of  the  main  trauks  is  obatxuctcU. 


FiaSll. 


/ 


CA 


CP 


;S1I    (Afln- Cbucat).   Diatrannf tin DiHrilMtian of  tin  TtaidM  aH  ^\  . 

■ddUk  C<r'-r("unt.  -   CA,  AaterinT  corolirhl  artory.     B,  S,  SjrlnMl  itftwriifc    Tt^ 
V«rf  hnl  nrtenM.     It,  BmiIu-.      OP,  CP.  PmUnAr  CM«tw«l  MtailM,     \,\ 
3,3.  4.  t.  tin>up*  «(  DutriUve  krtoriML     The  Hna  ■■•-  Umiu  tiw  fu^wc 
vuouliir  »rc». 


The  fullowiog  parts  of  the  enccphalon  are  situated  wit 
thiH  vanailar  urea ;  the  optic  commissure,  Umins  ctoereat 
fundibuliim  and  tuber  cinereum,  corpora  albic^ntia,  pottetiot 
pcrforatuil  spot  with  part  of  the  crura  cerebri,  and  the  origin  of 
the  third  pair  of  norvca, 

Cart\csJL  Sijstern  of  A  rteria. — The  arterion  which  aapplr  the  oortlB  rf 
the  bnin  r&mify  in  th«  fix  iant«r  tmi  are  dlBtnbut«d  to  tb«  grer  tuHer 
of  the  ooorolutioiia  nadsubjacoDt  white  toatlvr.    Tba  tortainBl 


AXA.TOMICAL  AXD   PHYSIOLOQICAT.   HfTaOOUCTIOK.       *io 

tioaa  of  tlM  SjIvUu  utMj  xiuy  b«  taken  u  tho  type  of  the  dUtribatloa  oF 
tba  oorlical  sjrst«n  of  orUnet.  The  maiu  itrt«iy  diviJon  into  the  fiva 
Moondary  tmnekM  which  have  ahvady  be«u  described,  and  each  »f  thoM 
agiin  aubdiridBa  into  two  or  tfcrca  tertiary  bnmohea.  Each  tertiary  braiMi'a 
(fif,  Hi,  A)  of  tba  main  atUry  aubdividea  tuto  primary  {Fiff.  SIS,  B), 
and  aocoudary  twigs  (f\g.  213,  C,  C),  and  thoM  form  in  the  [lia  mator  a 
■aacular  ramificattoo  froin  wbich  tho  uulntitro  arteriaa  of  the  hraiu  are 
ifcriTed.  Puret  annrta  that  tha  tertiary  brHoohea  of  the  tnaia  artery 
aomatimH  anastotnoae  with  Niailar  branebaa  of  the  HMghbouiiog  raacular 
Urritoriaa,  but  the  |irintary  autl  seeuuJary  twiga  of  thee*  brauchea  do  not 
•aiBtanoaa  aownget  (heotaetrca. 

Pio.  213. 


l'\ 


f/ 


V/j 


% 


ffla.  US  (After  DarMl.-A,  TarlUnr  braoch  of  (h«  mals  ktUt/.  B,  PittnatT 
Iwiga.  C,  C  SeooaiiMT  twig*.  2,  2.  Corlioal  arMriM.  3,  K»»wo«k  o(  corneal 
Mtcriaa  la  tha  Mnbral  tiMuta. 

Xutrititt  Aritriet  of  iks  Brain. 

Tha  cutritirs  arteriea  an  flcnred,  Dot  ooly  from  the  axtnoiitice  of  tba 
fvinaacy  and  aeooodarj  twigs,  but  a  large  number  ia«n«  from  tbn  anion  uf 
thaae  taij^  M  wall  aa  from  thaaideeof  the  tertiary  hrattchnof  the  mam 
■rtary  (/V  ''''<  h  ^^  "^^  nutntiva  artaries  are  of 'two  kioda— («i)  (A* 
lamff  mr  mtUulUry.  and  (b)  the  t^orl  or  cortietU  arten'a. 

(a)  Tba  at»dull(uy  aruriti  pass  into  the  anbatanoe  of  the  oeatnioa 
onda  for  a  tlintanoe  of  three  or  four  oeDtltnetren.  Tboy  do  uot  coouuu* 
Bwat«  with  Mch  other  is  their  oouiaa  except  by  Ana  MpiUaries,  and  ooo- 
■aqnanttj  conatitate  ao  many  atDal]  iodepoadont  raaoutar  Icrritoriea.  Tha 
IwiilbaWnm  «f  th«as<roaaeii  appntaoh  tba  upwanl  continiiatioD  of  the  gai^ 


+46       ASATOjnCAI.   AND   pnTaiOLOGICAl   tSTBODUCTIOS. 

lionic  ijateta  or  tmmIs,  but  Ibe  tiro  apAaim  do  Dot  appetr  to  i 
wHb  one  uiother.  In  k  section  of  n  euiTolution,  tweivs  or  flllMB  mAil- 
larj  arteriea  aimj  «)>peu' ;  three  or  fonr  of  these  |Maa  into  the  fres  taxbea 
of  the  oonvolutioa  {Pc^.  SI3,  1),  ftndiiurmDaTertioftl  course ;  thow  wfajcli 
«ut«r  tli«  niJen  of  tEio  oonrolntion  ponnu  an  obliqtu  coone  tfanatll  iK 
nbile  tbuao  wbiali  pan  luto  Ui«  t)ottom  of  tb*  fimin  igaia  baooDU  wtliad 

FiQ.  SIS. 


L.T=^^^^- 


TiQ.-JlStAfUrDnnt).-!,  I,  MednllBrr  Brterica.    I'.  GwrnpttmeivOmm 
\a  th«S«V»katwcftritwoii«ighbauril>Cc«nTa1iiti«iW.    1',  ArtttiMof  tli*^^ 
of  unuM  flbrta.    2,  3,  2,  Art^rin  of  the  gnf  milHiUiiMAf  tlw  onctai.    ilA' 
terie  medwd  MtuOnry  network  aitiiuvd  imiler  tb«  pU  nuiw.    fit,  A  ^Hlkr 
tmMWJ  M^la(7iiFti*orl(i>itu»tvdl  in  tbe  loiilille la^ra of  tli«oavt«X>    t,  Ba— 
wbU  larger  nctvorlc  in  tba  intcnuhl  laj'sn  kitjcniung  Uw  whit*  foCaMMk. 
rf,  CaiilllAry  i)ctw»r1(  of  tbo  whib!  auhKUniK. 


{^^  The  ^orticai  »utritif«  orivrM  aHm  from  Uio  TMonlar  oetwcckcf 
th*  pU  matar  iu  the  .vame  wny  u  tha  long  Mrttiia,  but  tbe  rormT  at* 
thinner  tluD  tbg  Utter  ud  pumu;  a  sborttr  ooorw.  Soom  o(  Umm 
TOBUli  pam  through  th«  whol«  thiokaen  of  th9  gny  sabrtAOoe^  and  ^re 
•aui]J  capiUftries  to  th«  owttruBi  onle,  vhil»  oUien  kwtninfebe  ia  Um  w^ 
stance  of  the  oort«L  The  vuinilar  network  In  ths  oonTOlutiiMis  poMtate 
the  following  obaraotecuttoa : — la  the  first  byer.  abovt  oee-half  milb- 
BWtn  in  tlu«kn«i%  the  neabea  of  tb*  oatwork  an  larse  {Fig.  813,  a) :  ia , 


Um  Moood,  cafrespoiulng  to  two  layen  of  ganglionic  oelb,  «  rery  cl<w« 
•ad  fliw  TMcuUr  networlc  is  romiMl  {Fig.  S13,  6} ;  in  the  tbin),  oorr*- 
■ponding  to  thoinlBnul  layaranf  thocortui,  a  lai;gBr  ftnd  eottnar  vawuUr 
octvoric  niftts  (Fig,  3 13,  i) ;  and  in  tbo  fonrtb  lajror,  or  nwdoUvx  mb- 
■Une*,  ft  atill  bigger  sod  ooanw  vwoalv  network  ia  obsonrvi). 

Thi  C^\trat  or  OangUottic  S^/aUn  »/  Arttriti, 
ThcM  ut«ri«8  cotwist  of  small  branebos  ntuch  ore  giren  off  fmni  the 
tranin  of  Uw  chief  cerebral  ressela;  they  pierce  tiio  bane  of  tba  bniu 
pKpiadlsalari/  to  reub  tba  substanoe  oF  the  hiuwl  gwigliB.  Tbrnw 
Mtariaa  fttin  six  maia  groapa,  which  may  bo  ausMl  tho  Mit«rior  and 
poatcrinr  toediau  [/1r^.  311,  I  acd  S),  tba  right  and  lofl  anlMv-Iatoral 
{Fiff.  Si  1, 3, 3).  and  the  rigbt  aod  left  po&tafo-lat«ral  (Ay.  21 1, 4. 4)  groapa. 
An  imagiuaiy  Um  paanng  round  tbe  circlo  of  Willis,  s.t  ■  distanoe  of  two 
MUtitaetna  oxleraal  to  it,  woaltl  oom|ilittelj  BurrooDd  all  tbaao  roaacb, 
and  tb«  araa  ao  ltiiut«d  ma;  tbcrefore  be  called  tbe  gangUonic  naoolar 
an*  (CbafDOt).  All  Ibaaa  nasciU  ara  terminal  crteritt.  Some  of  Uwaa 
T— iliOTO<  aaAcieut  importaace^  owing  to  their  Uability  to  rapture,  aa  to 
dMarr*  apacial  deaoriptioD.  Tfas  naaeb  derired  fr^ini  tli«  middle  oarebral 
■rtor^ — tht  aataro-lataral  groap— afl«r  piercitig  the  anterior  paifcnted 

Fid.  214. 


Pw.  SIKPkmk  Dimtt.  TVaiunrMAoHMie/tfaOmAraliintini^pAfrM,  aloMtrai. 

Mind  Ot  Oftie  Ommimn. 

AMtam  or  m  Coaprs  fttBUnw.  —  CK  CHunu :    B,  fledian   of  tbg 

nptk  tatk  \  L,  L«ntic«Ur  nvdcw ;  /,  luUriiJ  <*rauU  ;  C,  Cft«d«W  nocWiM  ; 

m.  Matmnai  <Hfaa]« ;  T,  Claaainaii :  JI,  [>1juuI  r.i  KuU  ;  r,  K,  Seetloi  oT  tta 

VAaocua  Aaua.-!,  AntcHor  cenbral  MUr^j  II,  Middle  onttal 
miUfWf ',  Vn.  PoetarVir  otrtbtal  artmy.— 1|  InUnuil  oMntld  uUry :  H.  ajrlvbui 
mtUTj;  \  AaMttOT  Otnbrat  mUtj  ;  4,  t.  [:(t«nial  WrrlM  of  Ul  00n>iM 
■Malaa  (WtlaikMltUw  aftMj) ;  \  h,  loteraU  iLit«riM  d  thAoai^iW  ■biatom 
llantiettlaranMiMi.    Tba  opto^UUie  arterj  U  doi  wptwenlad  la  thi  figort. 


450       ANATOMICAL  AKD   PBYSIOLOOICAL   ISTRODtfCnOK. 


No  tucis-cyltnder  process  has  beeo  obsenred  Bprin^^Dg  from 
cells  of  the  caudate  ducIciu. 

The  lentlettlar  nttcleu^  in  contiouoas  below  with  the  amdatT 
□aci«us,  aud  with  the  grey  loatter  of  the  anterior  perfoimtel 
space.       The  two   inncrmoift  zones  cootain    Dnmeroaa  lai^ 
branching  oenre  cells  with  jellow  pigment.    The  oclli  art 
amallor  ui  the  outer  division  of  the  nucleua 

The  cla-uetrum  ii  mnde  up  of  fusiform  tnO  bipokr 
somewhat  reeembUng  the  cells  of  the  vesicular  column  of  Clarice 
on  the  one  hnnij,  aad  those  of  the  6fth  layer  of  the  cortex 
the  other. 

Tlje  amyifduloid  nueUitB  is  a  Email,  round  mass  of  grey  matter, 
connected  with  the  inferior  part  of  the  claustrum.  It  lien  in 
front  of  the  aolerior  eJEtremity  of  the  descending  horn  of  the 
lateral  ventricle,  and  is  corapoBed.  of  fuaiform  cells  similar  to 
those  of  the  clauHtnira. 

(c)  The  Grey  Matter  of  the  Cori«r.— When  a  couvolutioo  it 
divided  vertically  the  grey  matter  is  seen  to  be  ooofiaed  to 
the  surface  and  to  enclone  a  white  core.  The  cortical  sabstaikce 
consists  of  cells  and  tihros  embedded  in  a  matrix  similar  i 
netiroglia  of  the  spioaJ  cord. 

The  cdle  are  of  various  forms,  the  moot  usual  forms 
spherical,  stellate,  pyramidal,  and  fuaifonn.  The  Jibrta 
into  the  grey  cortex  from  the  white  centre  of  each  oouvolutioa, 
their  course  being  vertical  to  the  free  surface  of  the  oonvolutioa. 
They  are  arranged  in  bundles  as  they  paw  through  the  gre^ 
substance,  and  this  gives  to  the  nerve  cells  a  columnar  arrange' 
metit.  The  radiatiug  fibres  are  wanting  in  the  sulci  between 
the  convolutions,  but  the  internal  la^er  of  the  grey  substance 
of  the  corteic  geueraliy  contains  fibres  which  pursue  au  arciform 
course  and  connect  adjacent  convolutions.  Fibres  pan  in  all 
directions  through  the  grey  substance  connecting  its  seTersl 
layers,  and  forming  a  dense  network,  like  that  of  Gerlach  b 
the  spinal  cord. 

Layers  of  the  Cbr^cr.— The  cortex  of  the  cerebram  is  dtridad 
into  several  layers,  eacli  of  which  poa^esses  a  delinite  histological 
character.  The  most  commonly  distributed  form  of  structure 
is  what  Muyncrt  has  called  the  "five  laminated  type"  The 
external  layer  consiata  of  neuroglia  and  a  layer  of  dc 


8JIT03UCAL  LHD  PUTSIOLOUICAL  INTRODCCTION.      4-51 


■bet,  aioag  with  a  few 

d    small    oerve    cells 

An  destitute  of    pro- 

Tbe  DBxb  layer  is  com- 

Dr   aoiftU    aogiilar    or 

Ul    oerve    oella    with 

Bb  pToceasea.        The 

^IPeoDtaina  large  aod 

K^nmidal    c«tU    with 

p>g  processes,  arranged 

icir   poiaWd    exlrerai- 

irards    the    tarfmea   of 

RvotutioDH,    and    sepa- 

nto  groups  by  buDdI«s 

kdia^g  Sbres.    Id  tbe 

tBt  portion  of  thi»  laj'cr 

uaidal  celU  are  larger 

the  retDaining  portions, 

hu  ihereforo  bees  de- 

as  a  separate  lajer  hj 

kbari  Clarke.    In  the 

if  the  occipital  lobe  the 

eelU  of  tbv  third  la^-ur 

Bioidal   ill   form,   with 

luee     taroed    iDwardv 

the    medullar)'   »ub- 

but  their   L(a«al  pro- 

atcrally  bo 

adjacent  cells, 

of  them  appear  to  be 

inwards   to  conoect 

with  the  Bhres  of  the 

Rubatancc.     la  the 

portion  of  the  frontal 

lu  the  diapositioQ  of 

iaeotnewhat  uniilar, 

Dct  basal  process  has 

been     observed, 

towards  thv 


Ftn.  SIR 


rrrj 


Fia.  215  (Aftec  Nt«)-*nt!.  yVwunarntf 

StKtitm  of  a  fMrnXB  0/  Me  Thiri  <W 

Irat  ComroiiUion  nf  Mam.  jr«>i<M 
100  tftfiouttr*.— 1,  Layiir  of  Ui«  Kst- 
Urad  •owll  ooiiical  ooiyotolc* ;  i. 
Layer  ol  oIom-mI,  mutll  pTTaaud*! 
OorptuclM;  3.  l.ipr  n(  Utv«  |>yr*- 
mldkl  cortical  corpiudt*  ((orauttkiB 
of  tfas  Mtira  AmmonU)  j  4.  LMtfoE 
mmU,  ctuta  art,  iinviilar«bapM  acr* 
tkvl  corpoMlM  <niutiU*-lll»  fomu- 
tMDl ;  S,  Iavm  of  tatUnna  roftmtl 
wrpoKlM  (eUMral  («nii*taaB) ;  m, 
tlw  tBednlluT  lamina 


452       ANATOMICAL   AND   PHTSIOLOQICAL  INTRODCCTlOy. 

medullary  aubaUmcc  of  tho  oonrolutioD,  and  wbicb  aftei 
becomes  coutiDUoas  with  one  of  the  fibres  of  the  oentna 
ovale. 

In  the  cGDtml  ooDrotuUoos  of  the  bnun  BoU  and  He»^ 
jewski  have  disooverod  cella  which  are  two  or  throe  tuoee  tU 
«ze  of  the  pyramidal  cells  of  the  other  regions  of  the  corta, 
and   they   have   ooDse^iuCDtly  named    tbem   giaiU-c^     h  i 

PtG.  216. 


i7_ 


Fio.  S16,    Pymmidi^  Oiant-CJl,  —  it,  VodviMi   b,  a,  a,  Brutchid  ftoommi 
r,  Uchnnehad  biml  fwaatM.  ^ 

addition  to  the  branched  protopUgmic pfooooaoa  {Fig.  £10,0,1 
which  coDoect  neighbouring  cetls  with  one  another,  tbeae ' 
possess  a  dtstioct  axis-cylinder  process  (Fig.  216,  c)  The  latur 
is  always  uabraoclied,  and  after  becomiog  surrounded  by  ■ 
medullniy  sheath  it  forms  the  axi«  cylinder  of  a  Donre  fibre  of 
the  centrum  ovale.  Qtant-cells  have  been  observed  io  the  paa^ 
central  lobule  and  id  a  portion  of  the  postero-perietal,  aa  wall  as 
\n  the  ascending  frontal  and  parietal  coovoUitioos.  and  posterior 
extremities  of  the  three  frontal  fQ'ri.    These  celln  are 


ANATOMICAL  AMD   rHTSIOLOQlCAL   INTRODDCTION.       453 


ia  groupa,  and  comspoad  in  pcuition  to  Ihe  motor  centres  uf 
physiologiate.  The  giant-cells  vary  greatly  in  size,  the  Largest 
bctog  found,  M  wc  hare  already  seen,  in  the  puraceotral  lobule, 
wbich  may  be  regarded  as  tlie  upper  extjr«mity  of  the  ascending 
froDtal  and  parietal  coufolutioos.  Large  pyramidal  cells  are 
also  fouod  in  the  upper  part  of  tbe  ascending  froot&l  cootoIu- 
tioos.  but  Dr.  Bcvau  Lewis  lias  found  tbat  they  diminish  in  size 
frem  the  upper  extremity  until  at  the  lower  extremity  they 
an  bat  faalf  the  size.  The  pyramidal  cella  of  the  posterior 
extremities  of  the  frontal  convolutloas  are  on  the  whole  smaller 
than  those  of  the  ascending  frontal,  and  the  cells  also  diminish 
from  above  downvarda,  those  in  Broca's  convolution  being  the 
•nallest 

The  fourth  layer  consists  of  elosely-flot  angular  corpuscles 
with  fine  processes,  placed  irregalarly  and  not  diatinctt;  sepa- 
nUd  into  groups. 

The  fifth  Uyor  consists  of  mcdium-sizod,  fusiform,  and 
bipolar  cella  The  long  diameters  of  these  cells  run  parallel 
|g  Ihe  Inyent  of  the  cortex,  and  are  asgociated  with  the  syst^in 
of  fibres  nlitoh  connects  different  convolutions  of  the  same 
hemisphere  with  one  another. 

(2)  The  whiU  matter  of  the  cerebrum  cooaiste  of  (a)  trans- 
verve  or  comtiiLBsural  fibres;  (b)  longitudinal  or  collateral  fibres; 
aod  (£)  ascending  or  peduncular  fibres. 

(a)  The  truntvene  or  eommisttirai  jU>r&a  consist  of  the 
ioUowing : — 

(i.)  Tbs  friMfww  /Vw  of  tke  ow/nu  cotforvm  pau  traiisvorMrl;  from 
•XM  lids  to  tha  oUwr,  sod  connect  cormpoadiug  oonralutioos  in  th» 
ktmuplumn.  Thwa  fibrw  lis  oti  a  p1au4  suiwrior  to  tlicao  of  tbs  ooroua 
njiala,  and  cooMciiuntly  the  two  sjitsma  ot  fibrua  icterUoe  on  their  my 

te  tlw  MfiVolutioiM. 

<iL)  Tbs  jifirw  (^  (A«  anterior  otmnUaHra  wind  badcvarda  through  the 
taDtfeokr  oocIm  to  rMoh  tlw  omivolutioiw  around  tlM  Sjlviao  fissurs. 
(IJL)  Tbp.^fcf«</rt«jioitgi<)r  com nttwiire  run  through  tba  optic  thtlami. 

(&}  The  longitudineii  or  coUeUeral  system  of  fibres  are  the 
foOowiog : — 

(i.)  JretnCa/tnc  or  Jt&rm  propria,  nhioh  ar»  aituatod  immedlatdjr 
baoHUli  tbs  toner  ■orfaoe  of  tho  cort«x,  and  connect  together  tba  grey 
tDSttor  at  adjeoent  oonvohitionii. 


45*      ANATOMICAL  ASD  PBTStOLOOICAL  ISTKODUCTIOS. 

(ti.)  Filrrts  oj  Vu  gyro*  /omieattu  tAkn  a  loogihidinftl  coune  tna*- 
dictol;  abovo  th«  corpus  oallomim  oad  form  Um  whit*  matter  ai  Utt 
conTolutickn.  Id  front  they  beod  round  Ibe  corjms  oalloatiDi,  aod  becaai 
VDuuected  nith  tho  anterior  |)«ffor&t«d  apooe.  Behiod  they  tarn  nmA 
tbe  back  of  the  same  1>od7,  tad  txn  udd  to  pan  fbnranU  to  reach  tbt 
aulerior  i>erforat«d  <pac«,  m  thU  tbow  Sfatna  «OB[)latoly  aiuroutid  te 
ooTpiu  calloAuui.  O^ta  firom  those  Bhn»  pua  upvanb  aod  badmiA 
to  reitch  Mio  sucnmiU  of  thooecondary  convolutiMM  d«rir»d  from  the  | 
fon])ca.tus  near  the  loDgitudinal  Assure. 

(iii.)  LcngitHdinal  Mptai  fibre*  lie  on  the  inner  «iirfiw«  of  Uia  i 
lucidum  and  extend  ioto  the  ^rm  fDmicutuit, 

{\7.)  The /<tJtfu)ulu4  unatnaf iM  posMB  aoroas  the  bottom  of  tho  Sjlrin 
fiiuum,  and  ouDnccts  tho  ooiiTolatJana  of  tho  frontal  aod  tUDporo- 
Hphenoidal  lobas. 

(t.)  Tho  longit\tdiital  inferior  faieictilus  oonncctfl  Un  oooTolationa  of 
tho  occipital  with  thoae  of  the  temporal  lobe. 

(ti.)  The  totujituilinat  Jihrtt  of  tht  corpud  ocUIofuia  (luntM  0/  LamBim) 
coDQect  the  anterior  and  poBt«rior  onda  of  tha  calkoal  ooavolataDiL 

(c)  The  AseendiTig  or  Peduiundar  Fibre*, — The  fibres  wbidi 
connect  tlie  contra!  grey  tube  with  tbe  eDC«pbalon  bare  already 
beuii  traced  as  far  as  tbe  crura,  llie  upward  coaciouatioo  ol 
tbe  fibres  of  the  anterior  root-Eones  of  tbe  cord  terminate  io 
tlie  optic  tbalamua  The  poiterior  longitudinal  fasciculus  Uei 
in  front  of  the  nucleus  of  origin  of  the  third  nerre,  and  wben 
the  aqueduct  of  Sjrivius  opens  into  tbo  third  rentricle.  the 
fibres  of  tbo  foeciculua  bend  outwards  in  ibe  poel<:riur  comniii- 
tiure  of  tho  third  ventricle  to  reach  tbe  inner  wall  of  tbe  optic 
thalamuit,  where  they  appear  to  terminata  Ueynert  deschbM 
these  fibres  oa  passing  dovrawarda  and  outwards  to  form  pan  of 
tbe  fillol  of  the  eras  cerebri,  but  examination  of  the  cnw  ia  tbe 
embiyo  does  not  bear  out  this  statement,  llie  fibrea  of  i.ht 
posterior  longitudinal  fasciculus  are  meduliated  at  an  eaHv 
period  of  embryonic  life,  but  in  a  niao  months  embryo  tu) 
medullated  fibree  having  tbe  course  described  by  Meyaetteaa 
be  seen  in  the  crua  cerebri.  The  fibres  of  tbe  pOBterior  com- 
missure, on  tbe  other  band,  are  the  first  fibres  of  the  oerebnm 
t«  assume  a  medulla  (Flechsig],  The  upward  oontinaatioe  of 
the  external  portion  of  tlie  anterior  root-zone  of  tbe  cord  lies 
in  the  cms  cerebri  to  tbe  outside  of  tbe  tbiid  Derve  and  posM- 
rior  loDgitiidinal  fasciculus,  and  the  fibres  of  tbui  area  are  con- 
tinued upwards  into  tbe  optic  thalamus,  wbn^  tbey  form  1 


AJIATOUICAL  AlfD   PHTSIOLOCICIL   UtTRODUCnON.       435 

•CnitQOi  of  fibres  which  sepAratos  tho  grey  matter  whiob  lioea 
the  third  ventricle  from  the  rest  i>f  the  optic  tbalamua.  A 
portion  of  the  upward  ooattaaatioo  of  the  external  part  of  the 
Ulterior  root-zone  of  the  cord  benda  backwards  in  the  pons  to 
reach  the  corpora  quadrigemiiia. 


M' 


Si 


Ct. 


U 


I 


Wifjfj 


t 


f/' 


yi« 


3f*«8i.     ^''1       K'    Clj 


flMVM  a/  U«  J«rm4uv  Jiinw  </  lAf  JtifrU  CmUni  PtduixU.  -«,  Urwt  lomti- 
tadbwl  fianm;  1,  Ld% ;  ud  2,  Bkht  btrKtanbara  -,  Lq.  lAnhia  qwidrU 
fMslMi  Ca.  iWftl  Glwd:  C<cl',  CfrpoB  okUonua  i  Tbo,  IVUuum:  Si, 
Wrtrtii  «nnle  ol  Um  tkuunu ;  Ca,  Canduc  iiuel«u ;  Nl.  l^nUoitlu 
■ocfaoi ;  TboL  Tabcr  tiUMctorium  ;  CI*.  Cbtiutntgi  \  So.  Limu  r.igvr  ;  Nl<. 
Il*4  BoelMa  «l  lb«  twBtBtum :  F(H  aoil  Fqi ,  SupotMr  Mid  bdtriyr  tnn«v«n« 
Btm of  tb* poM I  Ir,  OpUo  ln<t 

Tbe  corpora  tjuailrigeniiDa  are  connoctcd  with  the  optic 
thalami  \>y  nervous  tracts,  named  bracKia.  The  cerebellum  ia 
wtUMCted  with  tbe  corpora  quadrigeroina  by  tbe  superior 
padoDclai.  A  targe  number  of  the  fibres  of  tbe  superior 
peduQctn  of  tbe  cerebellum  decussate  in  the  tegmentum,  so 
that  the  6bres  of  the  one  ndc  croM  to  become  connected  with 
the  red  nudeua  of  the  opposite  side.    Some  of  these  fibres 


456      JLSATOMICAL  AND  PHT8I0W0ICAL  LNTBODUCTIOK. 

probably  terminate  in  thia  nacleos,  vbilo  others  appear  In 
pursue  an  UDioteiruptdd  coarse  to  the  brain.  The  coarse  of  Uk 
6bre8  of  the  Buperior  peJuncIes  of  the  cerobeUum  is  oot  i«II 
ascertained  beyond  the  red  nucleus     Some  aDatomtftU  Uiiil 
that  these  fibres  terminate  in  the  optic  tbalamuH.  while  otkn 
believe  that  they  pan  uoiDtemiptcdly  as  a  thin  stratum  <i 
fibres  between  the  optic  thalamas  and  the  iatemal  cape&k, 
and  through  the  corona  radiata  to  reach  the  grey  matter  of  ik 
central  coovolutions. 


Fio.  218. 


m 


Sp. 


OoiT 


In 


C» 


m 


-114/ 


FlS.  SIS  (From  U«nle'*  Anatotoio).  Bori»nlat  Stetion  «/  U«  tttwtimAtn  ^  Ik 
Orain,  etoM  lo  it*  Infiriar  liurjact.—\ii\,  L^imiw  qiudti|«ftlaftt  Al  AqMM 
of  S)rlrit»-  Ntg.  B«d  nudeim  ^t  tltc  tegmiouniB ;  Rdf,  and  Baf,  DaanBl* 
•ikI  iMviuuaK  root*  «f  Um  foroix ;  C»,  Opilc  omnDiamre,  wea  thfoai^  m 
-AiMir  af  tlu  tEird  ventriale;  V.t,  CkucUts  nuolMiiof  UieoorpoB  attiaMtt;  M, 
Tb*  IratJoDlu  ]iuel*>iu:  *,  IrivUinn  tntwoD  tba  t«o  dimM  of  tha  eonV 
atri«tiM&  1  8p>,  Ajittrior  p«not*t«(l ■{■•c«i  1b.  1«Ihu1  «(  lUl ;  Om',  Awnftr 
Mmmiimn I  fin,  Sabstutl*  nlgr*!  B'.  TMoivftw  Metiea«f  tin  riiwii .  Xt, 
OptJotTMU:  O^,  ExbMUkl  gwuanuU  bodf. 


4SS       AS4T0MICAL  AK1>  PHYSIOLOGICAL  IXTBODUCnOII. 

thau  tlio  anterior  pyramid,  b«ncc  tho  fibres  of  the  latter  nmd 
have  been  reinrorced  in  tbeir  ascent  through  the  pou. 
The  crust  or  the  poduode  is  quadrihitenl  in  form,  bat  ia  «- 
cending  to  the  bemUpberefl  it  hMomei  flattened  from  abon 
downwards,  and  from  within  outwards,  and  tho  fibres  apnti 
out  liko  a  fan,  the  edges  of  which  arc  directed  fonrudi  ui 

Fic.  SSO. 


£H 


US'- 


■r 


M 


Via.  iV)  (From  DachikK  BorUonbtt  aeitim  of  Iht  Brain  oj  a  CkSd  *imj 
of  asK,  the  right  ridtMiiSr  Ota  mmrxliat  lowrlertt  Otan  lh<  Ifft  kal/.—F, 
T^.  Tsmporo-Bpbanisidiu,  uul  O,  Oodpital  I«I»m;  C^.  0]MreultuB ;  /»,' 
Kril ;  CU,  Ciinalnim  ;  /'".  Third  fntatttl  ooqtvIiiIIco  ;  TK.  Oplh)  Hi  ill— 
JfC,  C*iiuatc  nndsua  1  ffC,  TtH  of  G>tiilat«  nuL-lnia:  T  V.  T  i  iiliimlii  iinil»g" 
I,  tl.  It!,  Fmt,  BMioiid,  kud  third  tlirisi-Mi*  of  tbe  IcntkuW  oneU^ ;  U 
Axurnhl  cApsuU:  IK.  FoBUrior  diviiiim.  IK  .  AnUrior  diriidaii,  %aA  JC,  Eaw 
of  the  inUrnnl  ckpanilc ;  ah,  pA.  Anterior  and  iwatafior  hons  raq>cellrvt(>'  >k' 
Ifttctnl  rrntridiM  ;  per,  Ki>«o<i(  lb* corpiu  a*U(i«iim i  4p,  8|>leBi<u;  ■•(,HiU> 
oonuntHaie ;  /,  Fornix;  it,  Se|;>tiUQ  Inadom ;  •,  Cvntn  AwnMnh 


ASATOmCAL  l,^-D  PHYSIOLOGICAL  INTBODDCTION.       459 

btdcwanU  The  fan  fonned  hy  these  fibres  ia  bent  into  the 
Axm  of  aa  incomplete  bollow  coDe,  haviog  its  concave  surface 
directed  downwanlB  and  outwards,  and  its  coavex  upffarda  and 
mwarda.  A»  tbe  fibres  ascend  tbey  paNi  at  first  between  the 
optic  thaUmus  and  lenticular  oucleus,  but  bigher  up  Uie;  puiflud 
their  coune  beneath  nud  to  the  outside  of  tbe  thalamua  and 
caudate  nucleus,  and  over  the  lenticular  nucleus.  On  Uori^ODtal 
KccioD  of  tbe  hemisphere,  cltwe  U>  the  infurior  surface  of  tbe  braio, 
the  cnista  ia  seen  to  be  of  an  irregularly  quadrilateral  form. 
with  iu  long  axis  directecl  from  before  backwardB  and  from 
within  outward*  (Fig.  218,  B').  At  a  higher  level  the  crust,  or 
what  maj  now  be  regarded  aa  tbe  internal  capsule,  is  of  the 
■ame  general  form  as  in  the  procoding  section,  but  its  long  axis 
ia  Bomewhat  lengthened  in  proportion  to  its  sbort  axis  (Fig. 
S19,  B').  Still  higher  up  the  ioternal  capsule  has  spread  out 
from  before  bnckwatds,  white  the  anterior  half  forms  an  obtuse 
angle  with  tbe  posterior.  The  angle  whore  the  halves  meet  is 
called  tbe  htet  (Fiy.  tS.0,  K),  while  ttie  diviHious  tliemseliTL-a 
an  called  the  antarior  {Fig.  220,  IK')  and  poaterior  KgmenU 
{Fig.  220.  IK)  of  the  internal  capsule. 

Curona  Hadiala. — On  emeiging  from  the  haaaJ  ganglia  the 
fibres  of  the  internal  capsule  radiate  in  aJ)  directions  to  reach 
tbe  cortex  of  the  hemisphere,  hence  these  have  been  deticribed 
hj  Beil  under  tbe  name  of  conma  radicUa,  and  the  point  at 
which  the  fibres  emerge  from  between  the  gat^lia  h  called  the 
loot  of  the  corona  radiate 

Tbo  flawing  fibres  may  be  distinguisbed  in  the  cruatu  and 
iolenuU  capsule:— 

(1)  TIm  noMiy  pedii&eallur  trMt  and  optic  ndlUioiui  of  Gnttiolet,  th« 
lattxo'  Jtiiniof  the  internal  capsule  from  tbe  optic  thalamus;  (S)  tba 
[ryrasddsl  t«iel;  <3)  fibres  in  the  cnut  Go&n«cting  tbe  csntrtl  grey  tube 
and  tbe  corpus  striatnm :  (4)  flfafea  iaming  from  the  external  suifnce  of 
tha  optic  tlulaniu  to  join  tbs  ioterosl  espsol* ;  (&)  flbtee  Issuiog  finrni 
tbe  ■atsRisl  sashes  of  the  caudate  nucleus  -,  (H)  fibsss  sscsnding  from  tbe 
mapmar  and  intsmal  surGus  of  the  leatioulsr  nnelsos ;  (7)  films  alnady 
dsBsribsd  BsosDdiBK  from  the  superior  iwduuols  of  ths  oei«l>«Uum  i  (8) 
fifatva  from  tba  eoepos  osUosam  (WemloksJ. 

(1)  Snwvrjr  pedamattar  ^nt  and  optic  rocUstioiu  of  OratioM. — ^Ths 
peMksrior  root-iooss  sod  oolmans  of  Ooll  tsrminsts,  as  we  have  alnady 
lu  Uts  triaugulsr  and  olsrsto  nucld ;  and  tbe  ooutwetjou  bstirssn 


L 


400      ANATOMICAL  AND  PHTSrOLOaiCAL  ISTBODCCTIOS. 

these  Dual«i  uid  the  olirarj  body,  Rud  of  the  laUcr  with  the  ocnbdhn^btl 
idnkdjr  Hmq  sufficiently  ducribcd.    It  hu  oIm  been  m«d  thftttbs  MOMifj 
fibres  ctOflB  ia  the  spinal  oord,  but  Uojroert  describee  a  aoomtij  ermb^ 
wbiob  tohea  place  iotholoimr  port  of  the  meduIUobloBgsbL   AeootdiiigtB 
-tide  witbor.  fibres  iwue  fVom  the  nuclei  of  the  cuneata  aod  deoder  titiM& 
whioh  panu«  an  fLrcua.ta  coarao  r(niadtheoentndgre7eoIitinn,isdbe«DBi 
mixed  with  tbo  fibraa  ot  Uib  lateral  column  m  thajr  beixl  fonrftri*  lo 
de{iu3fi«t«.     A«  ftlreodj  noticed,  Fleohaig  thinks  tlut  tbeM  fibr«i  ant 
round  the  oliru-j  body  of  the  aame  aide,  and  enter  ita  sabatnaoe,  vb^ 
Ueynert  thinks  that  thoy  fonn  the  outer  faaeleulua  of  the  uifatvior  ^jnutid 
of  the  iDcJulIa  oblongata,  and  nsoocid  vith  the  latter  up  through  the  pont 
to  reach  the  orua  eervlu-i.     DebOTO  and  Oombault  deecribe  an  addttjaul 
oroesioK  of  seiuoiy  fibroa  higher  up  in  the  modoll^    Tbeaa  Bbna  pmt 
an  arcuatti  coiine  from  tbo  triangular  and  elevate  nuclei,  pan  lomudi  to 
the  oQteidi;  of  the  oUrar^  body,  oad  then  boooow  eubdirided  into  a&»D 


Flo.  221. 


R'  Ci 


■JV 


v. 


>C 


O 


nt 


JTlC.  •Illi.ifnm  llrale't  AnAtoRiie).  Traamrn  and  (Miqit  Sieti-m  «/At  *id 
Owuitia  itoatutg  upmrdt  and  /tnaardt  finm  lAt  nnifn'or  «4|k  i>f  U«  Ami  iV)- 
B,  OnMl  of  the  enuoraebri;  B".  Radiiriion  d  tlw  pedmicular  Atiraa  luted* 
hmauiilim;  Sn,  T»cuBai{^j  Nig.  K«d  naaUm  of  tlu  tccmeainmi  '.UBf* 
purlioa  of  the  fiiruuttiQ  ntiaiiarU:  Tbo,  Tbaboau  opMui  Ck  QhkH' 
aadnej  U',  Optio  tmeti  Hp.  Blppoumptu. 


AKATOMICII.  AKD   PHTSIOI.OOICAL   INTHODUCnON.       461 


fnctculi,  which  ptDfltntU  into  Ui«  pMUrior  anil  sxtsnwl  «speota  of  ths 
tateior  pyruaid,  and  Aotilf  eoirv  npwarcU,  boMUDiag  mixed  with  the 
netor  fibrML  It  is  wry  probable  tliat  these  Mnaory  fibns  oooitii^  tba 
pot/tmnot  aud  «s:t«mal  |>orU«a  of  th«  py raiuidal  tract  iu  Ha  aocvut  thrtragh 
Um  pKM,  inMmiieb  as  bondlM  of  fibraa  adit  hen  which  are  BOl  m>  dia- 
tiDdly  awiiiilUI«d  id  a  oiae  mooLha  human  embrr«  aa  thoao  Ijiug  m 

Fio.  822. 


rs^v 


h 


(AfM  IMwM  aad  Uombatili) -SeetiiMt  of  iXi  Anurior  J'mimid  (P)  of 

(kc  JlirfNtbi  OUamrata,  m  •  Irrtt  mWt  Iht  itUMU  part  ff  Oc  enttint  of  |A< 
JhMHV  Mr«--'9,  ScBMnr  ^bwat  ■'SA.  PaateriM  and  txtonal  mucmv 
hwlBBhw  whkb  doM  »al  pui«trmt«  tale  tba  ntbatao«  of  the  ^ajmnid ;  K, 
OMiai  o<  tbv  MMMT  fibna  i  O,  Nticlcmaof  ibcpyramJil;  Z,  tjtrainm  sgnkW. 


ftant  of  them.  It  has  baao  at  laaab  uc«rtauiDd  tlut  the  Munoiy  fibroa 
oeeufij  th*  tstamal  fourth  of  tba  cnuta,  and  about  tbe  {wstorior  third  of 
Iha  poatacior  segnMiil  of  th»  wt«rual  capeule  iu  their  aaccDt  towarda  ths 
aortas  of  tha  brain.  Tbaaa  fibrea  do  ooC  appear  to  Ui  iu  an;  way  ood- 
oastad  wHh  tho  opUo  tbalamua  aod  laoticalar  uucloua,  but  iiaaa  anwaida 
bakwvH)  tfaera  to  r«ach  the  c«itax  of  tfao  brain,  ta  the  poaterior  third  nf 
Iba  pvtatior  aegmsut  of  tbe  intaroal  capnik  tbo  scusory  QbrM  bead 
tbmfOf  hackwaida,  aod  tbeo  radiate  to  nutch  th«  oanvoIutioBs  of  tba 
MMpitai  and  tetuporo  spbeDoidal  lobaa.  Tho  fibrea  of  thia  tract  are  uarar 
oaddDatotl  in  an  embryo  of  nine  montha,  and  cau  be  roodily  ttaoad 
Bpwarda  ia  the  tntcr  aegstcut  of  tbe  crastA  sod  poaterior  acfuacDt  of  the 
intanal  apatilft  In  addition  to  tbe  fibres  which  aaceiid  fnooi  tbe  spinal 
oord,  moduUa  oUoogaU,  and  poua,  the  eeDeory  tnct  in  the  iaUmal  capsule 
cootatatt  ftbrva  which  onuneot  tba  flmt  aiid  second  oeretml  uerrw  with 
Um  eortas  of  the  bfain. 

Tb*  oftic  tructi  tain  origia  m  tba  baaal  ganglia  by  ta  internal,  middle, 
and  4art«rnal  root. 

Tba  internal  not  conaiata  of  a  bandlo  erf  fibm  which  pacna  betWMO 
tbe  exterttal  geni«ulat«  body  and  outer  edge  of  th*  cnuta,  and  peostntaa 
into  the  mhrtanoe  of  tbe  totemal  geniculate  body,  ap|«arii>g  to  aod  io 
tb«  Aotcrior  pair  of  ocwpora  (jnadrigemiim.    Uaguamin  has  iwceiitiy  main- 


I 


462      ANATOMICAL   AND  PHTSiOLOGICAL  INTRODCCTJOS. 


lamtd  that  this  root  ia  coDoeotetl  with  Uw  poaUnor  poii  of 
quadrig«miiiA,  either  directly  or  thraugh  the  m«dium  of  tbs  esttridl 
gauiculate  hody. 

The  nxiJiiU  root  t«rmitiBt«a  in  the  ext«ruiL]  genicniat*  YioAf, 

Tbe  e^unuU  root  patses  to  tbe  out«id«  of  tti*  «xt«nHl  gtokoktel 
ftud  panetrAtiM  the  iuferioriwlaRole  of  th*  optic  tbaUoma  kbout  lSiiiiB.1 
frout  of  the  ]i<Mt«rior  bordor  of  the  inilvimr.  B;  «stirx«tiag  tb*  «7«btlli 
of  young  hums  Oulilcii  found  thst,  irb«i  the  auim&la  vera  Idlled  TOW 
montba  BttbMfiuontly,  tho  Atitorior  pAir  of  corpora  qaAdrig«&ioft,tti«o0k 
tlialami,  autt  tha  ext«raid  genicaUt«  bodio*  wsre  atjopbied ;  whila  tlw 
poAterior  ^mt  of  corpora  quodrignniua  uA  tbs  intomal  geoieolxtc  boiiH 
wen  noaflected.  lu  man,  hoveTor,  botli  Uio  anterior  and  pooteriot  pMr 
of  corpora  v-]uadngemitia  havo  beou  found  diminiihod  in  «iw  ia  ouMof 
long  ataDditig  atrophy  of  tbo  optic  twrree. 

These  variouH  roots  of  the  optic  nerves  appear  to  bs  ooDueotcd  «itk 
tlie  cortex  of  the  brain  by  meoue  of  tbe  fibres  nbich  bsTe  been  uanA 
tbs  optic  radraiiom  of  OratioUt.  This  bandit  of  fibres  fosuss  Aon  the 
poHt«rior  ouil  eiteruol  bordor  of  til's  optjc  thalamus  and  ia  closely  sppM 
to  tbo  peduncular  senHury  tract  in  its  paoMge  throogh  tba  Inlimul  ttf- 
eule  ;  thoM  tibrea  mdinle  baukwiinin  aud  tipwda  to  bo  oonoected  vilh 
the  coti volutions  of  the  occipital  lobe. 

The  oifactory  {nbe,  occurdiug  to  Moyuert,  divide*  in  front  of  tbe  sutninr 
perforated  8))ace  into  an  ititeruol  ind  exterual  (dfactory  coondotiotL  Tbe 
flxtemal  eouvulution  Goalesces  with  tbs  temporal  oxtncoity  of  tJie  gjrua 
fomicatoa  or  the  aubiculum  oomii  ammoiUK  Tbe  interual  oonvolation  i* 
oontiououa  nit^  tbe  froiitjd  eutl  of  tbe  {f'^u  foruicataa,  beoesUi  vfaidi  it 
may  be  ruooijiuuil  for  aumo  dintouoe  as  a  dbitiuol  loo^tudiuol  sIsratiooL 

A  oonsidemblo  portion  of  the  wliito  eubetsnoo  of  Um  fUttieJ^rrj  lobe 
travsraeA  the  corpus  striatum  uutil  It  UMOta  the  otittfrior  eoianueaatv 
ooiaing  in  the  oppoeito  direcAioo.  Tbo  ol&Gtory  fibne  m«  suppossd  to 
oroas  in  the  Eiutarinr  commiMure,  oomspoiKlitig  to  the  oroaoiiig  of  the  flbne 
of  Ihu  ojitic  nervea  iu  the  ohioanu.  After  oroeaii^  tbese  fibres  apfHarte 
osci^iid  upwurdH&iidbackwarilaaiid  to  join  the  fibres  of  the  optic  ndistioas 
of  Gratiolot,  and  powt  olvng  with  tbvtn  to  tbe  ouuTolutiooa  of  tha  mil  lei 
of  tha  iKcipital  or  toai|ioro-aphei]olilal  loba.  Tba  poiiteriiir  third  o(  the 
po4t«rior  «cgiaetit  uf  lli<;  iutvrtiol  oopmile,  therefore,  contain*  tbe  podauoulir 
secjiory  &\fnn  and  the  fi^TM  which  oounect  the  optic  nerves,  ood  tbe  olbc- 
tory  bulb  with  the  cortox  of  tbe  br&iu. 

(i)  The  Pyramided  7Wict.— The  courae  of  the  fibres  of  tbs  pjmBtUal 
tract  bos  already  beon  traocd  upwards  throaj[b  the  apiiitl  oonl,  mnlllBl 
ottlougata,  Hud  poos,  1 1  rewaina  to  trace  tlie  course  of  tbsss  filns  tlu«i|h 
tbe  cruata,  int«rual  capaule,  and  corona  rodiata  to  their  dnrtioatjop  ia  tbi 
convolutions  of  tbe  cortex.  We  have  also  found  that  the  grsoter  Boaiter 
of  tbe  fibna  of  tbe  pyramidal  tract  id  the  cord  ore  meduUkted  iu  a  itio* 
nootha  butikon  embryo,  while  a.  tarne  i)ropartioii  of  tbe  fibres  -wbicb  join 
tbs  ti«ctiu  the  medulla  oblongata  aud  poaa  are  o(iD-DkedaU«t«d.    TbetS- 


MrmI  portion  of  tba  luitorior  p/rotnids of  tb»  msdullaoootaiiMion  tliooiia 
iiuil  nsdallated  without  maj  admUturs  of  ooa-medullatcd  fibres,  tho 
iat«nMl  and  •otvrior  nur^iD  of  tbe  pyramid  on  th«  other  hand  coutaJnti 
Don-tnedoSiled  witboat  atij  iwlniisttiro  r>f  itie<)ulUt«d  flbres,  white  au  are« 
Bm  brt— u  tbeu  in  which  tb«  two  Idadi  of  fibrea  ore  niiicd.    Th«  first 


FIO.S23. 


Flo.  sn  tUoAAH)  frocn  KnimV.  Truartnc  SeUia*  of  (Ac  Crti  Ctnhri  m  a  toil 
«M  lA* ••icnlvr  JMI> <y  C^rjxm  Vu«ifn;(waii»ii,>om  a  aiatnonM*  mtryo,— 
«■  cmrt>  ;  P,  (nodMnMiUl,  f,  bIxmL  sail  p,  Mwcvatj  pnrtioD  M  tli*  Mn> 
ndkl  mot:  Llf,  loonnigrr:  /UV, red BocUtM of  Ikt Mfnaslnm ;  £i.  ncMWii'mi 
1itTliiiliiw1fiii[nnlM.  iii mil  m*.  upwaid oooti]iiutl«ii of  Ih*  [ntamiu ood ex- 
ta«B*l  jmCImm  n«pMtir«ly  «(  ib*  ■aUnar  rooMniM  nt  lb*  apliiAl  «ofd ;  tit, 
tUid  narvs ;  UT,  aaobnM  ot  iba  Ihird  nom ;  tr,  fgoitb  ncrrc :  iV.  nacfami  of 
tka  iMnb  n>rt« ;  it',  croanoc  of  lh«  fibra*  d  ihm  fourth  ncrvci  to  opiwaita 
•Uw:  Jl,  J»MdiBero»t  oftbetrigMBiimii  <g,  fcqpwdnrtrfSyNiiu;  s,  cnw- 
!■(  M  w  tbnt  p<  tht  rapoiot  wJironlw  of  lb*  Mrabullom :  af.  furioslM  of 
iBwIiiHalwl  Bbroi  fncttttag  M  m  aaMrior  pair  of  ootpun  qiiMliicvBiiiw. 


of  tiuM  ngioaa  a»f  b«  called  the  fwuiamejUai,  Uie  Mcond  tbo  acMMory, 
■al  tb*  third  the  nu'-rnf  arra.  We  hir«  alrwulj  mwi  thrt  in  the  pane  tba 
•eoMNCT  portion  of  tfa6  pTtwoidal  trvct  Uea  int«nia]  to  the  fund&awotal 
pactioc,  KDd  in  the  crvutA  tbty  occnpjr  ths  rants  tvlotire  poiitioiu.  Tb« 
ftiadMBaobd  portion  of  the  Lrsot  oocupiea  tho  i7«ikt«r  iKrti'on  c>f  the  tniddlo 


464       JkNATOMICA.L  ASU   I<U VSIOLOOIC&L   INTRODTJCTIOII. 


1 


tbiitl  {Fia.  iS3,i^,  bud  tbe  aoc«M0i7  porttOQ  tbo  l«rg«r  put  of  Ui*  ititeul 
tbird  of  tb««ruBtft(f^.  223,^).  Tbe  oiixed  tra  of  tfae  tenet  Iim  |arttj 
in  tbe  middle  third  of  ttie  crunl*  betweea  lb«  fandAineDtal  um  aad  (bt 
locuM  nigsr,  and  vrivda  round  to  th«  insids  of  Lbe  fbniUmeaUl  ud 
twtVMtk  it  Hud  tbo  occwwoiy  atm  (/^.  223,  /*').  SpMldng  bro*(U]-,tki 
taoduneDtAl  fibres  ucead  in  tbe  middla  </Tjr.  224,  P)  uid  tbo  maA 
fibrM  ia  tbc  ftatorior  third  of  th«  poatecior  MUBMatof  tb«  iat«ra&i  Mfvl* 
(/'I'jr.  2  J4,  V),  while  tbe  accoaaor;  flbns  uoeod  to  tbe  uitericr  wagmAd 
the  cftp«ule  < /'•V^,  SS4,  p). 

Fia.  884. 


n. 


^^ 


TM 


/'■'  ; 


Fto.9SI.  iTorwnMf  SMlim  fftki  Brual  Oais^ia  «i47alm«(  CMMJlt^sJM 
aronrtj  SVR6iyn.— LN,  Linti?iilM-  nncleiM ;  II,  HI,  B««o(id  Mil  iMi<w%im*i 
of  ths  nuelvua  rMpMllrelj ;  SC,  Cuadue  Biielnu  j  Th,  Opijc  Dubam  b. 
ItUnd  of  Jt«il ;  m,  P«iluiionUr  aetuvry  trMt  kod  optie  rtMBuioBe  it  Qntidrt : 
F,  FnitilftmiHital.  P*.  Mixed,  And  p,  Accunrj  imrUon  of  pynmidal  tnct;  '^i 
Flbm  from  the  oorptut  «»IInntiu  (T). 

Th«  Gbroa  of  tho  pyntaidftl  tnut,  oa  omersbg  firom  betnvm  tbe  b*^ 
ganglia.  Ascend  in  tbe  csorona  rtdiita,  and  an  distributed  to  the  caBi» 
luUocie  Qf  tha  cortex  in  the  foIlowiQg  muou :— Tlie  fuadaonntal  Ibn* 
pasa  to  the  central  convolutions  near  the  marpo  of  the  gnat  ]tm^ta- 
diual  fiaaiire.  Those  coDvoluUooa  are,  bneflj,  tbe  parietal  tobolc,  tfci 
paraosnlra]  lobule,  tbe  superior  utremitlea  of  tbe  MMDding  firontol  uJ 
pmrntal  oourolutious,  and  prob^bl;  alio  tb«  poMwior  utmuity  at  ibi 
first  frontal  coDTolutton.  Tbetie  conrulutiona  an,  aa  we  have  alna^f 
•aau,  thoae  la  wUcb  tbe  largeat  pyramidal  o«Ua  of  the  fourtli  bf«  tl 


AHATOJIICAL  ikSO  PUYSIOLOOICAL  INTBODOCTION.       4S5 


ban  beoD  tomd.  Tb«  tcoeasorr  ftbrea  on  JintribttUd  to  tbu 
iTohitiona  ttaat  ootutitate  Um  operculiim.  The<M  convotutioiw  an  th« 
natarW  utnmify  of  lbs  tliird  froutal  aiid  tbo  uironor  oitrcoiitiM  cf 
laeeoding  boaUl  and  pvieUI  oonrolutions,  and  omwimnd  to  thoM 
bidk  th«  aaaallcr-Biied  iiyraiuiilol  celU  with  ftiu-erUnder  procwH 
been  abeemi.  Tbe  mixed  pyramidal  tract  ia  dutrtbtttwl  to  tba 
mroloUoo*  betwoen  tbe  two  other uma.  Tlieov  oonvolntioDs  an  tbo 
itariar  citranitf  of  tbe  uoond  Ckoiital  aud  the  middle  of  tbe  asoending 
1  parish  oourulutivuoL  Wbat  ooDutration  exists  betw«eii  the  pyramidal 
ct  and  tlie  iiufin-DurKutal  mkI  angular  gfri  baa  not  be*ii  aacerudued. 
(3)  t\bm  cma^tituj tht  CtttnU  Ofev  T'udd  uilA  C^  0>r/mi  Striatvni.^ 
'b«  firat  aiul  wooud  dirtsionii  of  the  leuliiTular  uucleua  an  coDoecled  witb 
>  cnuta  hj  a  bttod  of  radiatiug  HhrtH,  wbtvb  iu  tbair  aacaat  are  diaposed 
two  tluo  bandit  naiDed  tlte  una  mtdMUarm,  and  wbiob  ran  parallel  to 


PlO.  226. 


'mFi 


-Tta 


:-.^^. 


ft(— ' 


[;(a. 


m  (Froo   Ocola'a  ABatomia).     Tnnitflm  nnd  f'lrtitnl  Smian  tfOu  BnM 
Om^it  Pit  a  Imf  mlA  lit  Cvrpora  i:\ia4icnttti: 


B,  Cvtpova  alUcaniia. 
,  l*immBaf  tntAa  -J  U>«  TirnU. 
B,  i1  murina  fimaiiilairt 
1,  Tenia  oi  Um  npiie  tbaUoma. 
,  OaMbunelMa. 

KK 


Kl,  Lsuticiilai' nucinu, 

Cfl^  C-atfma  nubthalMiiiciBn. 

II',  OpiklnuU. 

D,  CriNl  oI  tht  otrabnl  pednaole. 


46C       ANA.TO)rTCAL  AND  FHYSIOUXHCAL  IMTaOOTfCnOX. 


ttM  oattr  muHta  cf  ths  nooleus,  and  divide  it  iato  thrM  mom. 
lit  tbMO  flbna  terminate  iu  th»  wibuieoM  of  tlw  DDd«tl^  vhife 
pMi  tbiougb  it  pmbabl;  withoat  iuterraptioa.  A  large  number  at 
tOmt  at  loaat  pau  trau«v«noly  tbrough  tlw  tutenjal  copeulv,  to' 
with  its  tuModing  flhros,  snd  beoommg  coiuiiK:t«d  vith  tb«  optic  1 
aud  uau<lat«  ducUiu.  P'ibres  spiwar  to  aaUsr  tbe  cmsbi  from  tbt  htt 
oi^,  and  it  is  uot  imprab&bl«  tbot  tfao  latter  noolaos  U  to  b«  nptid 
M  tlw  moaue  of  oamniunicaiioa  betwMD  tb«  aolonor  root-*ODft  «t  tb 
•pl&Al  oard  «iid  tb*  oorpus  xtnatuiu. 

(4)  fVbnt  uming  /root  (Jm  Extemat  Surfact  of  the  Optw  7%ilammt  *• 
join  tite  Jntfmal  CapmiU. — Th«  o]itio  ndtatkui  of  OntioUl  kliwy 
doHribod  balocg  to  tbi>  ^stom  of  &hn*,  iaanuttab  a*  Uwy  uvu*  frtm  i^ 
«xt«niiL]  Kiirfaoe  of  tb«  pMtarior  ^rtion  of  tb*  tbalamiia.  Othtt  Ami 
i«suo  from  tbo  external  turiaoe  of  tbo  utwior  two-third*  of  the  Uubnoi 
aud  join  tbo«u  of  th«  pynunidal  tnct  oa  tlieir  wajr  Lo  tbe  iM 
Tbe  aatori«r  rMJiating  fibrwa  of  tho  thaUiatu  are  prolMblj  Ariri- 
butted  to  tha  oonvulutiuna  of  tbo  frantal  lobe,  ami  tlic  ooatrm]  nJiilaf 
fibn»  to  th«  cotiTolutiana  of  tbo  parietal  lobe,  vbile  m  -w*  bave  abi^ 
WOD  tlie  i^oaterior  redintiiis  fibna  an  diatxibuted  to  tbe  ootiTolotiaM  d 
the  oooipital  lobe, 

(&)  FArr-t  inuity  from  Ut  E^tmal  Smifaot  ttf  tke  Catidate  Xwiint.- 
Theee  fibres  are  dascnbed  as  iasstng  from  the  ezt«nial  surfaM  al  thf 
caudate  nudeun,  aud  aa  paadDgiutotheooronaradiataimioedialdfafan* 
and  Lutentiil  to  the  radiating  flbrea  of  the  optic  ""^'""v 

(6)  Fibir^  iauirtj/rom  t/teSajttrior  and  /ntmud S>tr/ac* oftht  itmlMar 
Jfuclittt  lojointli*  Aiornding  fibraoftht  InUrnat  Caftstd*. — A  iaiglBUB- 
ber  of  fibres  iMue  from  the  au[>erior  luid  iotcroal  eurfJioe  of  tbe  Intiiriir 
nuoleua,  and  pats  traiiHrereel/  throngti  tbe  iotamal  e^wole,  tatsdadlH 
vith  Ita  loDg^tudinal  tibroa.  Other  flbraa  aro  deaoribed  a»  piin«la(M 
aaceodiug  c«um  paraUel  nith  the  longitudinal  fibne  of  tho  intenalta^ 
9ule.  Tlie  latter  fibres  are  supposed  to  radiate  in  all  dtrectioDs  oa  gakiis( 
the  oorona  radiatA  to  become  coouected  with  the  cortex.  It  is  li^n; 
howei-er,  to  odd  that  the  Uteat  aaatooiical  renanthes  throw  oaaaUHafai> 
iloubtn  a\MM  the  exisleuce  of  the  rodiatiag  fibrea  wbiah  anataniiite  bn* 
deacribcd  as  ounuootLng  the  tutuilate  miclei  and  the  third  diriaiaa  rf  IW 
lentioular  uuuluns  with  tbo  cortex.  Wemioke  ntatvH  that  B«titW  tb* 
oandate  ducIciu  northe  third  division  of  the  lenticular  oucUus  an  ^inctjj 
couoected  with  tbe  cortex  by  radiating  fibres,  and  he  ihinlcs  thai  ther 
must  bo  rogarded  as  indopendont  gangUo,  liko  tbe  groj  matter  of  tbt 
cortex  itjwif.  The  first  and  second  divisions  of  tbe  Leotioalar  Dndns 
form  gaaglia  of  iiiterruiilioti,  wliioh  ooaiieot  the  caudal*  nuolMia  atal  tt* 
third  division  of  the  lenticular  nucleus  with  the  central  grey  tabe. 

(7)  /^iUt*  AsM'Kiiny  from  Iht  Suptrior  J'tdurxi*  t/  Um  Cwiiifl— - 
The  red  nucleus  of  tbe  tegmentuiQ  iaooaneot«d,aaalreadjrd«Kribed,«ifch 
the  fibres  ascending  iu  the  superior  peduode  of  ths  oereUUiMB  «f  tl* 
opposite  side.     Fibrea  appear  to  ascend  from  tbe  red  miclaui  tetbl 


ANATOMICAL  AND  PHYSIOLOOICAL   IKTRODUCmON.       467 

ftk  thakmnc,  wxl  Fl«cluii(  tapposw  that  wnM  ot  the  flbrw  of  th« 
lor  peduMle  of  lli«  «enb6Uaia  o(  tba  oppont*  aide  paM  aiuat«r- 

Bptedlj  tliniu^h  the  ml  nuckos  and  aloDg  ths  Internal  surface  of  tli« 
raa  of  tho  pjmtniilal  tract  to  b«  dktributtd  to  tbo  c«atra]  coovola- 
oa  of  Uia  cenbram. 

<8)  I'lirtt  utmi^/rcm  (A«  Cvrpm  CttUontm  and  DetefneUn^  into  ti* 
Mraat  GaptuU. — Wsmicke  stataa  that  the  fibrea  of  tba  cor^uii  oalloaam 

bkb  fans  tha  antartor  vail  of  tfa«  aotarior  bom  of  th«  Utoral  rantricle 

but  badnrarda  along  the  external  border  of  the  caudate  iiucleaa,  wiiere 
gr  beeo^a  mized  with  the  longitudinal  fibiva  of  the  tnteraal  capsule 
I  la  onabla  to  trace  tlieni  furtlier. 
(0)  J'ibru  of  tkt  Srttmai  CapttxU.  — Th«  fibras  of  the  external  capaule 

Utier  aaceod  from  the  cruato,  paM  along  the  ioforiar  aurEuce  of  the 
ticiilar  nucleus,  aad  beod  abruptly  upwarda  rotind  it<inforior«xtanial 
[W  to  reach  the  ejrterual  Barraoo,  or  (Jioy  take  origin  in  the  ooUb  of  the 
elsoa,  a&d  after  iaauiuj^  from  ita  uiferior  Hurface  punne  the  course  just 
Theas  fibns  aaeond  aloog  the  cxteraal  aurfaco  of  tho  taaticalar 
alsita  fnmiiiig  Ike  thin  stratum  of  vhito  matter  botwnoii  it  and  the  clatM- 
BB  (/\jr>  290,  EK),  and  on  nocbiag  tho  corona  mdiatn  thej  ndiate  bo 
leh  tbe  ouavolutioofl  of  the  OorUx.  The  pitemal  eurTiioe  of  the  lenticular 
ohoa  and  tlM  cztcrual  capeule  are  aimply  in  contact  with  one  aneUiar, 
3  tbare  appear  to  be  uo  oonoectioDfl  formed  between  the  fibres  of  the 
■  aad  Iba  cells  of  the  other.  Tho  two  isurfaoes  are,  indeed,  separated  in 
o*  plaeee  by  blood-TWWiili  asoendLng  from  the  middle  cvrobrai  art«rf . 

BendM  tbose  of  tbe  intenml  capsule  and  corona  radtata,  other 
brea  coanect  Ujo  bawl  gnnglia  and  the  oortox  or  tho  brain, 
licse  fibres  consiai  of  the  fornix,  Ujenia  semicircuiaru. 
tedtineulas  aepii,  aod  a  cooaiderable  proportion  of  the  fibres 
rbicb  cDiutitute  tbe  aAlar  or  fUUt  o/the  ems. 

Aa  fornix  arisee  in  the  optic  thalamos.  Its  fibnai  of  origin  are 
CnBecleJ  with  tbe  iaitia  atmicireiilari*  and  the  psduncloa  of  the  pineal 
ad.  Thaj  dsaoand  to  the  iiudn'  eurfactt  of  aaeh  thalaintu,  and  after 
Ming  a  loop  la  tha  wrpon  albiaaubia  Ihsjr  ascend  upwards  and  forwarda 
IW  walla  of  the  third  reutrtda  as  ths  anterior  ptUars  of  the  fornix. 
•  flbfcs  of  eaeh  crua  then  pssa  backwards  ia  the  bod;  of  tbe  fornix, 
1  Mid  as  the  tamia  hippocampi  in  the  gyrua  of  the  same  naoM. 
The  lenua  mmieirxruIarU  oormecte  the  apex  of  the  temporal  lobe  with 
i^Ktlaleofthof  the  internalmarginof  the  caudate  naoUfUSL  The  fibrea 
bkb  petietrate  tato  the  aoterior  regiou  of  tbe  head  uf  that  nucleus  are 
mad  tiria  eunua, 

Tbe  ptdmtmlma  ttpti  oounocte  Ifae  cortical  sabatanoe  of  tho  sepliun 
■ddan  with  the  hanid  mnsa  of  the  imr^nia  striatunL 

nmC«Uatorf\UHo/iUCrtuCerii,ri.—h  btuidleof  fibres  foTDM  at  tbe 


403       AVATOHICAL  kVD  PHYSIOliOOICJLL  INTBODUCTtOS. 

posterior,  inToriar,  and  •xt«nMl  unglo  of  Ifae  optic  UikluniM,  vldehn 
downwardB,  omtmnla,  ud  forwaids  nnud  tbo  pc«lcmr  inwipD  rf  tk 
uoeodingfiliKwof  thecnuU.   TbaMfibiMaMijaa*dtlw  ii\/eri(rf«kaA 
of  lbs  optic  thaUnus,  and  oonstitat*  tlie  poaUrier  porttixi  of  tba  oda 
or  flUet  of  the  crua ;  they  sprMd  out  on  th«  roof  of  tli»  dewxadiog  «(N 
of  th«  Utenl  raiitricla  and  p«AB  forwuds  tv  Uw  ooDT>ahitioii*  ti  tk 
anterior  extremity  of  tb«  temporo-splMDoidal  lobii.     U  is  piobabU  te 
niinitf  of  them  nW)  rmlinte  Vinclntanla  to  tMcfa  the  oouToltiUoai  «ttl 
iiiferior  surface  of  Ihe  occipital  lobe.    Otli«r  flbiM  appear  to  unM  tm 
the  uutcrior,  iiifcrior,  and  external  aiigl*  ot  tb«  th«di>tniv»>    wlucli  «ioJ 
rotuid  th«  anterior  bonlorof  tbc  onuta,  and  tcnninote  in  tiM  lantiadB' 
unclvtia,  or  paAa  to  tbo  conrolutioiu  of  the  tettiporo-nphMMndil  Ma 
Thaw  fibres  funn  tlie  anterior  portioo  of  the  collar  of  Dim  cnm. 

S  081.  DtiMihptntnt  q^  IA«  JSrdMi.— The  csMbral  end  of  tlw  Mnln- 
•yinal  tube  ih  at  fin>l  iiuifonu  iu  appearance  with  the  spinal  port,  bit  H 
•oon  expand*  into  tliree  veeioular  ditatatiooa—  Mit  primary  cerdirat  miAt 
ThaM  vwiclM  ore  named,  fnioi  their  relatire  pooitioiis,  anterior,  aUik. 
and  posterior,  and  the  atnioturM  which  go  to  fora  the  aeveral  mI^ 
diviaiouH  of  the  ouofpholoti  are  |>n>(luonl  in  their  mdlK. 

Th«  pomrMt  etrtbrui  vaaidle  first  beckda  fjnrarda  to  form  llic  nwJi^ 
oblongata,  and  then  badnrardn  to  fonn  tbo  oerelmllum,  tlie  |iotu  haa| 
developod  at  tho  angle  wber*  tbeae  twn  [larta  are  ooDtinitmu  wiih  en 
anotlier.  The  oerebellum  cooaists  at  drat  of  a  central  lobt^  aad  ibi 
Ut«ral  lobes  are  only  dovelnjMid  in  the  maiMnaalia 

The  middit  onniraJ  Twiclo  bouda  fiirwarda  from  tbe  poalorior  <bI|II| 
central  hollow  becotaiog  the  aquedoct  cf  Sjrtviiu ;  the  of$ic  Ua  «t 
furmed  in  ita  roor.  and  tbe  cntra  ecnkri  in  ita  floor. 

The  aivtfrittr  e«ftbn»l  vesicle  bend*  dowovarda  ftom  tha  middle  rwitli. 
aud  its  oenLr&l  hollow  bocomoa  tbo  tfaiid  Tentricle.  Tb«  eptio  tholMd 
form  in  its  Uit«ral  waiU,  and  tbe  ptocal  body  in  iU  upper  and  posknv 
vail.  The  lamina  cinerca  doses  the  ronde  iu  &out.  Tbe  poetatMr  part 
of  tbe  anterior  rceadei  gircaoff  from  tadi  side  a  tlaMk-nhapcd  [wolongatioa— 
.the  t>rimiiiy  a;itia  Tesicle — wbieh  subwqiMiiU/  foruu  the  optie  traol  nUi 
the  optic  nurve  and  reUufi. 

The  antero-Iat«ral  part  of  the  oerabrol  raskU  '»  prolonged  fonwd* 
into  two  hollow  proL-OH-H^  tho  Aestirjattce  itMitlu,  ftom  which  tba  wrahill 
benispberos  ore  mibevquantljr  developed.  Tbeee  veeide^  are  aopanlad 
from  one  another  bj  a  meiiioii  longitudinal ^vit*,  whihtt  the  boUow  lu 
the  interior  of  ouch  foruu  the  lateral  ve^UricU,  On  tbe  floor  of  thl* 
vaaifile  a  grejr  mass  fonai  which  may  be  named  tbe  hoMol  mwctniM,  and 
wfaiob  atttMeq,uauUy  d(f«lop«  into  the  corpus  atriatiim.  Thar*m«iiuu( 
portiona  of  the  walla  of  the  veaicle  form  the  cortex  nf  tbo  bmin,  tbi 
basal  nodeus  and  corUx  being  contiiinoiu  in  the  part  whiob  oubae^iHvUy 
r»rm«  the  anterior  perfomted  spacp.  When  aTlor  a  time  fibrao  rikotf 
dowu  from  the  cortex  to  reach  t)i«  central  grey  tuW,  and  aboot  i^FWMds 


A!rA.TOVICAL  ASO   PHTSIOI.OOICAT.   I  .ST  ROD  OCT  lOS.       4*19 


Ut*  MDind  gnj  tab*,  oorporit  <|UA<1ng«DaiQfc,  and  optia  Uuluaua 

VMcti   th«)    cortex,   they    punu«    tlis    «hort«st    oaima   by   ixunoij 

tb»  6a«a(  MuittUf  «o  that    the    laU«r  booamM  dividod    into 

ftrior    wkI   cxtnual   (tha   looticulu-),    sod   u   naperior    imd    in* 

pnftion  (thft  eiud&to  nucLeiu},  the  two  b«iag  ooutinuous  with  sue 

uid  with  thft  cortex  of  the  cEtrebnim  in  tbe  antsriar  perforated 

Tb«  daralopment  of  the  Acwcl  niuUut  thsrefon  rend«n  it  prob«blp 

llhvooipas  striatum  Maniodiliod  portion  of  tho  cortex  of  the  brain, 

t«onfinning  tho  Tkm  rsoontly  adopttfd  byWomick*.    The  Sbne  of 

I  tho  fornix  cooMti  now  appear  oa  tbe  itmet  wall  of  tbo  boioinphsn- 

white  th»  tfaci»T«n*  fibres  of  th«  corpw  caHotum  |)a-<a  above 

of  thft  fornix  to  coaoact  the  cortex  of  one  hamiaphera  with 

roTtlM  other.    Between  the  eoipua  ootloaam  and  the  apper  NTfioe  of 

I  fiwnli,  outeriorlf,  two  thin  Ujura  of  grey  mattor  beluiigiuft  U>  tho  iuner 

vt  Mwh  ktmuplun-paieU  are  eaalo«t)d.     Theas  togatliar  form 

turn  of  tlu  aeptam  luoEdam,  and  tho  cority  which  sofArates  tbem 

tho  fifth  roatriol*.     Each  henlaphen-Tseiole  girea  off  from  its 

'  ]i*it  a  hollow  proccM  whioh  derelopa  into  the  ol/kctory  bvib. 

Ttw  iM^tudioal  or  oollotenl  ajatsnt  of  fibre*,  whioh  eonneota  tha 

lobo  OD  tho  one  hand  aud  the  temjMnal  and  frontal  lobei  ou 

t  other,  fiMia  a  rotatiraty  tliielt  wUita  Liyer  lu  their  paaaogs  through  tbe 

ilDfaotwfaioboutaoS'tha  fifUifromthareDaaiiiiaglayenof  thooortez 

rtba  Uaod  vt  Keil,  the  detached  portion  being  Imown  oa  the  efaiurrum. 

,  ofl  we  have  bbod,  of  fiuiforoi  oelU  analojous  to  thom  found  in 

I  fifth  iaTor  n  other  oreaa  of  tbo  oortex,  and  whioh  are  probably  aaeo- 

1d  tho  latter  with  tbe  aystem  of  arcuato  ftbrae. 
Tht  Oantietviiaiu. — The  wiUa  of  the  ceretMal  hemispheTea  canaiat  at 
[  Ink  «f  two  nnooth  ehell-Ulu  kawU*  which  iaolado  the  cavilioa  aft«rtrarde 
I  named  the  klend  veatriclu.  The  Brat  tnoes  of  the  oonrolutiooa  appear 
[liboat  tbe  foorth  mouth,  tbe  primary  mtiei  appearing  ui  alight  depresaiouit 
[m  the  omaoth  anrfaoei  The  Sylriao  flaaure  be^ua  aa  a  cleft  between  the 
iaotarior  and  middle  lobes  about  the  fourth  moi^th,  and  w  the  fint  fiaaure 
tonake  ita  a|)pearanoa  after  tbe  great  Itiiigituiliit^  flMiire.  Soon  after* 
I  worda  tha  Saeun  of  Rolando  oppeom  ;  it  u  followed  by  tho  poriefai-ooei* 
oad  at  a  aoiaewbat  later  {leriod  by  the  caUono-Durginnl  ftaaure. 
the  fifth  moath.  tho  Mooodaiy  fioaarea  develop  rapidly,  and  all 
iTotatioDB  and  &Murea  molca  their  ^ipeonnoo  toward*  the  aeveuth 
lii^tith  BMMithfli  Tbo  heraiaphavoa  do  not  oovar  the  optio  tbaUmi 
thft  third  ctoatb,  at  the  fuuith  they  reach  the  corpora  (inodri- 
'ipuiioa,  and  at  thenxLh  month  tbeycovura  gntotiuriof  the  ourebeUum. 
The  eoDTOtutiaDB  of  tho  bunuio  brain  on  diridod  into  primarjt  or  fim- 
[  f'—  — '"'  and  tttandary  or  aeoMory.  The  disposition  of  the  fondamental 
[  I— raliitipna  la  fixed,  and  correaponda  oloaely  with  the  arraugoaunit  of  the 
latiana  la  the  broiii  of  the  inoDkey ;  but  the  diapcMition  of  the  aoeeo- 
|aary  oeonlations  is  Torioble,  and  they  muet  be  regwdad  h  being  anper- 
.lotbafiocmHrio  thecooraeoferolatioa.    The  oRwigniHat  of  tbe 


47S      AJiATOMlCAIi  AND   PHTSEOLOQICAL  INTHODnCTIOiC- 

tbat  a  Tsrtical  line  dr&wn  from  it  would  paas  thioiigh  lb*  pcaUriil'tu  j 
treiaity  of  tbo  faorizonUl  limb  of  Ui9  Sylvifto  finon.   During  Um  i 
tuttDt  of   the  humui  bniit  tbo  ouperior  eilmuitj  of  ths  nlcoi 
RoUiido  tfaarefore  suSera  a  bocktrard  diBplaeement  in  ord«r  to  mtk>  i 
far  tbe  In'onuising  tiiz«  uf  tlie  Ulterior  area  of  tbe  oortei ;  ioA.  i 
io  the  evolution  of  the  humkn  bcnin  ftom  the  eimiui  type  tbe  oedpll 
lobes  hare  tindeTgoue  a  posterior  dUplaoemant  io  order  to  make  i 
the  r^tirel;  large  faeroiiM  of  siM  of  tlie  ftootal  lobee^  heooe  lbs  I  ^ 
nf  tbo  oervbeltuin  is  not  cmaed  directly  hj  an  ioaraaaed  aiw  of  tbe  t 
pilal,  but  iadtrwtlj  hj  an  inomwed  imn  of  tbe  rraatal  lobas. 

Tub.  237. 


Fia.2ST  [Fram  Quftin,  sftor  U'asncf),  ffnfr-nit  '^rn'irr  r/ iV  fnfiil  Bini«#Wt 
JTonfAf.-F.  KmntalbU.  P.  Panvlal  lobr.  O.  OcditlUi  Inbe.  T,  T«HfDnJ 
bbn.  a,  a,  it,3li(Utftpp«uww*of(h«uTa*l((4ioUlouaTottitKn».  fl.  afnia 
Gmhi*  ;  S',  iu  AiiMrior  divUnn.  C,  C»nf  nlTitlrtu  at  Ui«  itland.  r,  timm  m 
Keiando.    p,  Extornal  pan  <<  tbe  nrtUal  (iaun. 


Another  reiuorlcable  faotura  in  which  the  buman  faimiu  diflai  finn 
that  of  niiimaLi  is  tlie  manner  io  whid)  tho  Islaud  of  lUtl  in  cMafU/ij 
AUTTOumleil.  Atid  liitlduii  out  of  rieir  by  deepcaiirolntjaiui.  Tbia  ta  bfeagU 
about  li/  tbe  large  doveli^ment  of  tho  poelerior  oitrsmjtj  of  tbe  infehcr 
frontal,  the  inferior  oxtremttim  of  the  aeoending  frontal  and  i»ri«y 
onvuluUoDB,  and  of  the  iiu[ira-Riarginal,  angular,  and  iufanor  tomjw» 
BpbtUMidal  gyri.  U  appcara  to  mo  that  tbe  cortex  of  tbe  eootrsl  laU. 
Btsrting  ftom  tbu  gru/  matter  of  tbe  anterior  pevfmtcd  epaea^  ia  tbi 
embryonic  portion  of  tbo  cortex  of  tbo  bnin,  jost  as  Uu  central  fiar 
column  ia  tlie  emtu^ooic  portion  of  the  grey  matter  of  the  spinal  eauL 
The  ooterior  jxiforated  spaoo  ia  a  point  «h«n>  tbo  grey  matter  of  tbe  tve 
naolei  of  the  ooqiua  striatum  and  of  tbe  cortex  of  all  tbe  lobaa  of  tbe 
brain  moot,  and  it  way  tbemforv  bo  r«giirdi.-d  aa  the  aUrtiug  point  uf  the 
vhulo  of  the  grey  matter  derived  from  the  primaiy  cerebral  Toelciaa 
Uu  tbe  auppoeitiou  tiiat  tbe  pottioD  of  tbe  oeotral  lobe  which  Jia*  u 
thelinoofdietribatioaortbeSylnanartarytatheembryoniciiortiooaftlie 
oonrolutiooa  of  tbe  central  or  motor  area  of  tha  brain,  it  may  ba  axpaebd 
that  the  earlier-formed  portions  of  these  oonroluttons  viU  be  thmsC  «|» 
Yards  toiraids  tJie  great  longitadioal  ft•eur^  while  tbe  later-fomtsd  per- 
Ijotu  approach  oeanr  and  aearer  to  tbo  root  of  the  art«ry.    Aocordbgla , 


AHATOUtCAL  AND  PBTSIOLOOICAL   INTEODUCTIOS.       473 

tUi  BopfMaitioii  thersTore  th«  funduiuntal  porti<>EUi  «f  th«  ooqtoIuUodb 
Mpplied  bjr  tits  Sylvian  arter;  will  Ih<  fi>uni]  nvar  the  jfreai  lonsiLudinal 
Hwiiiii,  ftod  tli»  aeeaMOTj  portion  low  ctonn,  »i»ir  the  root  at  tli«  (k>t&ry, 
tfa*  UUtr  ocvmpoDiling  to  tho  convolutions  nameil  the  operoulum, 
libieh  la  to  highlj  dorolopeH  in  tuan. 

Tfae  gTMt  dcnelopuuiDt  of  tbe  auprfrm&rginal  and  oogolar  gyri  U  iIm  • 
eltaf«et«natio  feHtnTooTthv  bniin  ofnuui. 

nrNcnoNs  or  the  EycEnuLox. 
Tbe  fuoctions  of  the  medalU  oblongata  havo  already  becD 
dflteribed  ia  deuil,  and  those  of  the  poos,  corpora  ()undri- 
f^emina,  and  crura  cerebri  ia  a  general  way. 

g  6S3.  FunditrM  of  the  Cerebellum. — The  cerebellum  is, 
•ceording  to  the  view  ndopted  'm  them  pages,  an  organ  of  com- 
pound  eo-ordiaalioa  in  space,  and  rogulatea  the  conliDuona 
mtiscular  actions  which  are  neoesaaiy  for  the  maintenance  of 
oartaio  attitudeif  to  spnoe.  Ftourens  observed  thtit  when  a 
■mall  poniuu  of  the  cerebellum  w&»  removed  from  a  ptgeoo,  the 
aaimal's  gait  became  unaleady,  and  that  when  larger  portionii 
were  taken  «way.  the  movements  became  much  more  disorderly. 
Section  of  tlie  middle  pedimclc  gives  rise  to  a  forced  movemeni, 
the  animal  ratling  round  iU  longitudinal  aiis,  aod  the  rotation 
being  generally  towards  the  side  operated  upon.  Injury  of  the 
laUiral  lobe  of  tbe  cerebellum,  and  probably  of  the  Bbrca  of  tliu 
peduncle  as  they  poas  transversely  through  the  pons,  prodacea 
the  same  forced  movementa  oa  section  of  tbe  middle  peduncle. 
yoibnagcl  concludes  from  oxpcrimcnta  on  rabbits  that  losious 
which  injure  the  fibres  uniting  the  two  sides  of  the  organ 
occaaion  the  grealcst  amount  of  motor  disturbance. 

Ferrier  found  that  electric  stimulation  of  the  cortex  of  tho 
aerebellnm  in  animals  caused  movements  of  both  eyes,  with 
anociated  movements  of  the  head,  limbs,  aud  pupils. 

§  684.  FttTuHonao/flie  Basal  Ganglia. — ^TTie  most  generally 
rsceircd  bypotheiiis,  especially  in  England,  with  respect  to 
the  functions  of  these  ganglia  is  that  the  optic  thalumi  are 
eotkcefned  in  the  upward  tratumisaiou  and  elaboration  of  cen- 
tripetal impuUes;  and  the  corpora  striata  in  the  downward 
UmosnuwioD   and   elaboration   of  ceotrifugol  impulsoet     Tbo 


474       ASATOMICii.  AND   PUTSIOLOGIC&L   INTRODUCTION. 


itnpulses  elaborated  hy  the  tUal&mi  may  either  be  UantmUiel 
Biitortorly  aad  laterally  to  the  corpora  striata,  or  upvardi  to  thr 
grey  matter  of  tbe  cortex,  wbile  the  incitement  to  action  mi; 
oome  to  the  corpora  striata  eitber  from  the  thalamt  directly  tr 
from   tlid  cortAx.     When  tbo  impuiiicB  are  tranamitted  direct!; 
from  tbo  thalami  to  tbe  corpora  striata,  aud  from  tbe  btttn 
dowawanU  to  tbo  cord,  then  tho  basal  gaaglia  may  be  reganletl 
as  the  superordiaates  of  tho  coQtrat  grey  tubo ;  but  when  tlu 
impulsoA  are  transmitted  from  tho  thalami  to  the  cortex,  tad 
from  tbo  latter  to  tho  corpora  striata,  the  basal  g&Dglia,  altbon^ 
still  the  superaniinatoa  of  the  central  grey  tube,  are  the  jobof- 
diaatcs  of  the  grey  matter  of  the  cortex. 

Vary  aoriouti  objoctiooa  have  boea  xir^tA  against  th«  v'wv  that  tin 
th&IamTiB  is  tho  wowry  gftogUoo  of  tlu  «ppo«it«  half  of  the  body,  bal 
theoe  hjiTfl  beeu  CUrljr  aiumrod  l>]r  Dr.  Broftdbwit,  to  whose  vritinfi 
we  ire  ind«bt«d  for  ttto  loMt  fruitful  JlaHxrariw  in  Um  applkatiMt  «f 
physiological  prinaiplea  to  tho  elucidatiou  of  the  phcnoaienaof  (EaMMi 
of  the  n«rToiiA  KyiA^zo. 

The  Snt  objcctioa  ia,  that  lenoa  of  th«  UuJamuB  dow  tiot  impair  ns* 
aatioa  in  the  sune  degree  th&t  motor  paralysis  ia  caused  by  iojtuy  at  tk 
corjiiM  ntrintum  ;  but  the  nply  la,  that  oeatiipetal  oanenta  an  Don 
diffosivly  couduotAd  than  oentriftigal  curtenfee,  and  that  this  toatora  U  M 
cliu-a«toriHtio  of  the  gray  toattor  of  tho  ponbsrior  h'nus  of  Um  oocd  ii  it 
ia  of  the  thalamna.  Anothor  ohjectioii  ix,  that  if  tb9  thalamus  be  tte 
common  neaaorj  ganglion,  teaioQ  of  it  ought  to  cauw  not  only  ban- 
aoiDBthaaia,  but  aUo  nnilatoral  bUndneas  and  deafoeaa.  To  thia  ebjeetiaa 
Dr.  Broadbeot  nplies  by  exUndiag  his  (irinoiple  of  tbe  bilateral  aiaodaUon 
of  the  nerre-Quclet  ef  tdiugIm  bilatoml^  uaoeiatMl  in  action  to  tlu  tu^ 
tioosof tbcDcrvtMofsitecialaenM.  Bjlateralaaaociatjooof aeoaatioooa^ 
to  iavolve  fuaion  of  aenaoiy  uuolei,  and  tho  vombi&ation  oF  eonnda  naafc- 
iog  the  «are,  and  of  light  naohing  the  rottua,  being  oompletdy  head  into 
DM  sonmtion,  th«  tna  auditory  and  the  two  optic  uuclei  ought  to  be  tvmi 
praotioally  into  ooa,  m  that  unilateral  deafneae  or  blindoaea  from  iqjay 
to  one  tbsJamiM  beooiDM  thus  impo«ble.  Aootlur  otgeotion  to  tbt* 
view  ia^  that  while  laaiea  of  the  tbatanna  ia  freq,ueaUy  utMooampaniad  bj 
ooraplebe  taemiaoiestbeaia,  it  ia  somettmee  aooompeaied  by  motor  patal|w 
of  the  opiionte  aide  of  the  bixly ;  fh)m  tlua  It  ha*  been  ax^nad  thai  tk 
tbalamuft  tx  n  aupefior  centre  for  reltaz  action  (Cricfatoa  Browne^  R 
nmBt,  bovT«T«r,  be  reutembored  that  Um  pyramidal  fibraa  of  th«  Urttful 
oapatile  lie  abuoet  inunodiately  external  and  inferior  to  tlw  thaJaowM^  ai 
that  diaeaea  of  the  latter  may  readily  iaplicate  the  foimari  end  tfc« 
paralyaia  of  the  oppoette  aide  result 

The  hypotheaie,  tbeietoe,  that  tbe  thalamua  is  a  centre  fiw  tfa* 


AVATOiaCJLL  IHD  PHYSIO  LOGICAL  IHTBODUCTIOK.       475 


^^■md  oo-erdinttiim  of  oe&tripet&l  impolws  ia  cot  op«i  to  utiy  tniopinbltt 
flbJMcMooii,  ud  AcoonU  better  with  Eicia  tfaw)  anj  other  thoorr  of  its 
fluwtioi)-    Tbt  comiwund  eo-ordiaated  contripetsl  imprudona  maj  bo 
tnnmaitted  dinctl;  to  the  cotfina  atriatum,  aitd  reflocled  downwards  to 
tbo  nttarior  haras  and  anterior  root-sonea  of  th«  cord,  thoB  catudng  a 
Mopontid  rcflax  aotlnu,  or  upwanla  ki  Uio  oortas  of  th«  braia,  when  tbo 
impn8d<MLabaooiiMeorT«Ut*(l  with  fooling.  ThaMaroDoauffldoDtgrounda 
fbr  baltOTing  tlub  tba  aofivit;  of  the  thalamua  impliea  MiUMtiouMtoaa^  er«a 
of  tha  moat  niiIiiiuiDt«r7  Icuid.    A  coicpound  diffim  from  a  >implo  nflez 
asttoo  ool  only  aa  being  mom  complex,  but  alao  as  ooDautiog  of  a  mo- 
of  diftrtnt  ftctiona.     Tho  act  of  nukitig  in  an  infant  ia  a  comjilox 
but  it  coDMftt*  of  a  sariw  of  rimilar  oompUi  actioiia  ta  rcapouae  to  ■ 
of  mmilar  iia[>r«nionB,  and  tliia  action  ma^  be  taken  as  a  good 
of  raflax  actiotu  \a  ^cucraj.     But  when  a  diivkeu  has  just  burat 
ahaU,  and  almoet  immedlatal;;  begitia  to  jiick  grains  of  food  off  the 
groQod,  the  uiKMaaar;  asUoov  are  iiot  Duly  compI«x.  but  conaist  of  a 
■OBOwaicn  of  difftnnt  oomplax  aetious  ia  roapoaao  to  diflamtt  oomplei  in- 

fooas.  Tbaie  i»  oo  reaaon  to  b«U«T»  Uiat  tho  latter  action  ia  a  con- 
la  ODO,  any  mora  tluui  that  of  anclciag  in  aii  infant ;  but  wbilo^bv 
r  is  a  simple  nOox  actiou,  and  WHwdtDfttod  in  tha  eentral  f^y  tuba, 
fanner  ia  a  compound  nd»x  action,  and  co-ordinat^ul  in  the  bowl 
fut^  acting  in  aaMoiation  with  tho  crntnd  grey  tuho  and  probably  slao 
vtth  the  oenbeUum.  When  impretvuona  aro  mul«  ujioii  a  largo  number 
of  the  and  organs  of  tha  afforvnt  nervM,  ih«Mt,  after  boii)g  tirst  co-ordinated 
hi  tha  poatenar  part  of  the  grey  matter  of  tha  central  grey  tube,  nudergo, 
on  ■acudiag,  a  aaoood  oo-ordinatioa  in  tho  thalami,  wharebj  they  are 
iatagrabed  in  rariooa  ways,  and  r«duoed  to  aometbing  like  aerial  order. 
Wbn  tha  oeotripetal  impulaee  ao  amngod  aro  tranamittod  to  tha  eMi>ora 
■triata,  and  reflected  dowuwaida,  thoy  giro  riaa  to  a  aucoaarian  of  muacular 
oQDtnetions;  when  again  thayare  traiumittod  totheeottox — which  la, as 
w«  hare  already  roonrked,  the  organ  of  douMy  compound  co-ordinatkn  !u 
tinft—thcir aerial  order  adapt*  them  for  evokiag  the  rhythmical  seqneoees 
of  «ootri/agsl  iapalaea  which  regnlabe  conplax  payohlcal  actiona 

The  coTpwt  gtriatum,  oa  tbo  otber  baud,  is  a  centre  Tor  Ibe 
CDmpouud  co-ordination  of  centxifiigal  iinpuUes  for  the  opposite 
half  of  tbo  bott/.  Wlien  it  acta  in  obedience  to  impulsGS  received 
from  the  optic  tbniamus,  il  la  ao  oi^u  of  coinpound  reflex  action. 
An  the  actions  which  are  regnrded  as  inherited  inatincta,  or 
which  through  loDg-cootimied  repetition  hare  asRumed  tho  cha- 
racter of  aoiuired  ioBtinctB,  otc  of  the  nature  of  compound  reflex 
actiotu;  tbejr  &ro  or  bare  become  independent  of  conscioua- 
oeaa,  and  arc  co-ordinated  in  the  ba»al  ganglia.  But  the  corpua 
itauL  is  cuppo&ed  to  act  in  obedience  to  impulses  received 


476      AKATOUICAL  AKD  PHYSIOUXIJCAL  INTBODOCTIOF. 


through  the  cortex  of  the  bnuD.  We  have  olreadjr  aoea  tliit 
there  u  an  uiiiii  terra pCed  oonDection  between  the  cortex  and 
grey  matter  of  the  coni  b/  raeaos  of  the  pyramidal  fibres,  asil 
wo  toiiiit  now  endeavour  to  diBvrcDtl&te  the  fuuctioos  of  tbo 
cortex  vrliea  it  acts  through  tbe  latter  6br«8  and  through  tbo 
corpus  striatum  rospE>ctirel/.  A  simple  illuatrattoa  will  make 
thin  clear.  When  a  child  is  learning  to  write,  the  musclet  vf 
the  thumb,  index,  and  middle  fingers  are  moved  in  eepanw 
groups,  so  that  the  fingers  are  ultimately  brought  too  proper 
(ittitudo  for  holding  the  pen.  Subsequently  the  Mp«rtu 
groups  of  muaclea  are  bronghl  eucceatiively  into  action, 
whereby  the  point  of  the  pen  h  moved  upwards,  dowswardi. 
and  laterally,  no  as  to  produce  the  elementary  stroket  ot 
tvritiug.  These  actions,  described  in  subjective  terms,  are 
not  simply  conscious,  but  involve  that  active  cooscioujoett 
u-hich  oonstituteti  attention,  and  they  are  altso  deUberat«,  th* 
uulwurd  s\gn  of  tlelibetation  being  slownew  of  execntion.  The 
centrifugal  impuUes  which  initiated  these  movements  may  be 
presumed  to  have  passed  through  the  pyramidal  fibres.  After 
long-continued  habit,  boworer,  the  actions  involved  in  writing 
arc  to  a  lar^  extent,  if  not  wholly,  unconscious,  and  demsoil 
no  deliberation,  and  this  absence  of  deliberation  is  accompanied 
by  extreme  rapidity  of  execution,  The  centrifugal  impalM< 
regulatiugthc«e  actions  arc  coordinated  in  the  corpus  striatum, 
under  the  guidance  of  a  relatively  small  number  of  impulus 
from  the  cortex.  This  illustratioD  also  abows  that  the  progres 
of  education  in  from  actions  which  arc  at  fint  regulated  throogb 
tho  pyramidal  Hbrea,  to  actions  which  are  regulated  through  the 
corpus  striatum. 

Th«  chuwctariiitios  of  the  lujtions  rvftalatiKl  tfaroogfa  th«  p; 
film  aiv,  that  tbcj  an>  complax,  slowly  execabed,  aod  grouped  ii 
usual  oiuiiisr ;  «-hili>  tlie  charaotoiutica  of  Uw  actinna  which  ars  r^nlaUd 
through  the  curpuH  etriutaia  are,  that  th«j  are  quickly  execotsd,  mi 
arrangsd  in  frwiuently  tiepcat«d  combiDstions.  Now,  tJia  slowly  eteart«d 
movempnta  grouped  iu  uuusual  ways  procodo  in  tb«  order  »f  derelopiMot 
thti  (luickly  exeouted  and  labitual  movetnents,  and  the  stmctiiral  oan» 
latiTB  of  thia  bu>i  is,  tlutt  iu  Uio  coufm  of  d«rolo|MiMDt  tha  pynaaSti 
filim  uaume  a  tnedulUr>-  Hhi^ath  mute  time  before  the  fibna  hi  Lht  ouati 
which  ooDDdct  th«>  ciird  with  the  cuipua  striatuu.  AU  ths  complex  iao»- 
mraits  which  aaiiiiala  laanifiMt  in  reapoQM  to  emotioaa]  distorl 


AKATOUICAL  ASD  PHTSIOLQOICAL  IKTBODUCTIOM.        477 


«i|pBlMd  is  tba  ooqnm  Btriata.  The  attitude  eipveMire  or  roiur  kekI  kngn- 
•MOOMd  hf  ■  Mt  wbw  thnMitcuod  li;  s  dog  hm^  1>o  litkcii  as  a  familiar 
cxaia[il«  of  web  actious.  Mr  Dm-win'a  dosoriptioD  of  tfaisattitadfl  is  that 
tbs  cat  "  arcbM  ita  bock  in  a  sorprising  tootinor,  crwta  its  hair,  opoDS  its 
asoulb,Mi(t  •i{>iU."  Thfl  regulation  of  the  inusoular  moretnunts  concerned 
ill  pcffdoouig  ttiia  attttudo  is  wrgauised  oiauilj  iu  tb«  corpora  striata,  but 
Ihaioaitaiuant  totlw  accion  at  theae  centres  ia  sucb  a  oaae  oomes  frota 
IbaMrtu. 

My  friend  Dr.  Noblo,  of  Ua»«heat«r,  wbow  work  "  Ou  tba  Human 
UukI  ia  it»  mUttons  vrith  tba  Brain  atid  N«rvoua  System  "was  so  maoli 
IU  adranee  of  the  time  iti  wlilcli  it  waji  writt«u,  mu  tbe  fint  to  auggest 
that  tb«  tamcTacnta  wbi«h  arc  in  rcUtioD  with  the  deoirM  and  omotione 
are  regolatwl  thrangfa  tbe  baaal  ganglia  ooling  io  aubordiuation  to  the 
wttei  of  th4  braiQ  ;  but  Uua  ri«w,  like  nanjr  of  hia  other  opinioos,  did 
iKit  then  attract  the  attention  it  dMcrred. 

To  tUoMtrate  tba  fdiicUoiui  of  the  haMl  ganglia,  let  u«  aui>l)oeo  that  an 
iumraaaioo  i«  made  on  the  retina  by  a  minute  olijwt,  auoh  as  a  fly, 
apfroaebing  t)io  eye.  The  <yelids  itnmodiatoly  clorc.  Thia  action  m 
p*m\f  rr0QX,  and  b  dstsmiined  by  tba  corpora  quadriKemiua  and  cord, 
wifoiAie4ic«<L  by  the  baial  ganglia  Part  of  the  distnrbanoe,  horever,  is 
OMireyed  to  tlie  0|)tk  thalami,  aud  by  them  coKiidinated  in  aucb  a  «ay 
i  OB  teaching  tlM  oortvx  of  the  brain  they  ^r»  rlaa  ta  a  Musution,  or 
to  ail  iiidiatinct  peR»|>tioa,  bub  the  clomiro  of  the  lida  i»  iiuita 
In^pendent  at,  and  prior  in  tinM  to,  the  aoniaation  or  |ii!rc«pti>^n.  Let 
m  now  inpfKno  that  the  impression  on  both  ivtioai  m  made  by  a  larger 
bod;,  aucb  ai  a  crieket-ball,  at  a  conddenble  diilanoe  ftom  the  eyes,  bat 
avriDg  toiranla  them.  The  dititutliaiHMJs  produced  an  oondueted  iawardh 
ligrth*  optic  tierreaaod  theafTcrentnerTesof  the  ocolarmiaoles,  and  after 
Wng  elabormlwl  by  tW  tensory  |<art  of  the  grey  mattor  of  the  pona  and 
•dtpara  qnadrigeinina,  some  of  them  poaa  upwarda  to  reach  th«  cortex 
tbroogh  the  aenaory  fibrvs  of  tho  inl«nul  capnule,  wbilr  otbera  ore  cou> 
doeted  to  tb«  thalatni,  and  aftar  having  uiideTgone  a  acecnd  ftlaboratiou 
and  rvdoction  to  nocnethiug  like  ocri&l  order,  tbey  also  arc  transmitted 
to  the  cortex.  The  mental  eonelative  of  the  cortical  diKturbance  is  a 
perception  of  the  object  and  of  ita  poeitioQ  in  hinicc,  and  of  the  rate 
and  dincttOD  of  ita  motion.  Centhfugal  iinputuM  may  nnw  Im  sent 
ftnai  the  eartex  to  the  inferior  centres,  vbich  will  ovrntuatc  in  a  eerlew 
'  of  noveiDenta,  eitlier  to  catch  the  ball  or  Io  aroid  ooUiaioii  with  It 
Oac  tnan,  ttt  whom  no  aiiecial  aptitude  baa  boon  orgauised  with  renpeoL 
t/i  the  raotinu  of  the  ball,  may  almply  more  hie  bead  to  one  side  to 
avmd  eotliaioo.  Tho  alowcr  tba  execution  ia  the  mora  sure  we  are  that 
it  haa  not  been  llrwiiientiy  rented  to  the  pr-vioua  experience  of  the 
bidtTidaal,  and  that  it  baa  been  determined  by  coosoious  and  volilioual 
mpnltrt  Iu  auch  a  case  the  volitional  or  centrifugal  impulaea  are  ooo- 
diwtad  outwards  throogh  tfae  pyramidal  bbrea,  and  the  coriwra  striata 
b»n  bad  nothing  to  do  wHb  it.     Another  man,  or  rather  a  woman,  on 


478       AKATOMICAI.  AND  PHTSIOLOCICAL  IKTRODUCTIOS. 


•Ming  th«  1>all  mhj  «zhitHt  tb*  cutwArd  maoifeetctioaa  of  nUnn  hj 
bfiial  •xp'reanon  or  screaining,  and  exeoat*  a  aenum  nf  locomoUre  actku 
for  grafttcr  than  noc^mory  to  ftvoid  oo!lim«ti  with  th«  b*Il,  nod  Ui«  gnaUr 
thaw  outward  maoifestatioita  on,  the  mora  certala  we  maj  be  ttuO.  ihe 
a«iuor7  impnatiotia  on  reaching  the  oort«x  b*n  oauoed  •  profmnd 
amotion^  dUtorbonoe,  aiid  Uut  the  centrifugal  iiii|>ula(9i  raacb  tl» 
par^bei7  tbrough  the  corpora  striata.  But  a  third  tuui,  inataftd  <l 
andeavouriitK  tu  avi^td  culiiiiioii,  may  jiut  u]>  both  hai)d«  ao  aatocatda 
the  ball.  Nov,  the  c«Dtrifugal  impolaea  may  paiu  in  thla  cum  «lther 
throuich  the  pyraiuhlKl  fibres  or  corpora  striata,  aocordiag  to  circun- 
itanoOB.  If  the  actioo  have  been  frequently  reptatad  so  that  it  la 
done  with  preciaiau,  and  without  a  ftwliug  of  oooscioiia  vB\Jtt,  iu  reguk- 
tion  la  oigaiiMed  iu  the  corpora  Ktriata ;  and  if  it  be  doiia  awkwardly,  ud 
with  the  inward  feeling  aod  oaiwanl  maDifeHbatwo  of  a  oooacUiaa  afirt, 
thou  the  coutrifugal  Iminilaaa  bara  passed  through  tha  pyramidal  fihtoi 

It  muat,  howDTer,  bo  atlmittod  that  tho  forc^in;  acxxiuxit  of  the  foac- 
tioui  of  the  hMMii.1  ganglia  is  tiy  iio  nieaiia  fully  aKULliaho'l.  We  haw 
already  atatcd  that  the  iuternul  euriaco  of  the  optic  thalamua  ia  lined  by  a 
layer  of  grey  Mibxtauce  which  mjiremata  the  upper  end  of  th«  omitnl  gny 
tubo,  and  that  tho  upward  ooutiimatioiu  of  tb«  aoterior  root-atiwcf  tfa* 
cord  teriuitiAtod  in  this  gaoglioo,  aud  oonaequeutly  it  most  be  pranuMd 
that  a  [HirtiOD  at  I«ut  of  tiie  tbalauus  ia  eadowed  nith  mutor  f^uutiooa 
The  opinion  that  the  optia  thalatui  ia  a  high  reflex  c«utre  baa  Umo  aUj 
aiMtaiucd  by  Dr.  Crichtoa  Brontie  oa  pathological  grouoda.  Tlw 
aoatouicat  diflicultien  wUioh  aUiid  in  tb«  way  of  ngatding  the  oocjoi 
■tnatUDi.  aa  an  int«nDedi&t«  gaoglion  b«tw«co  the  cortex  of  tbebraiaaad 
th»  oeutnl  gitiy  lube  are  alao  very  great.  The  Uteat  raMorchee  of  W«^ 
niolce  appear  to  ahow,  aa  wa  hare  aean,  that  neither  tba  lenticular  nor  tba 
oaudate  uudaua  poneaa  radlotltig  flbroa ;  nod  if  ibis  be  the  caae,  tbe  oorpo* 
atriatum  muiit  be  regarded  oa  a  nerve  centre  eo-onltnata  with  and  not 
mibordiuate  to  the  cortex.  Farrier  obnervixl  that  when  the  corpora  otnata 
were  itiniulated  by  a  atroog  lutemiptod  current,  the  uuncIom  of  the  oppa- 
aite  aide  of  the  body  became  strongly  coatncted ;  but  it  in  ioiiwanhh  le 
prevent erea  w«dt  eurreata  ttitviugh  tbeeot^maatriatum^maiftctiiigtb* 
fibres  of  the  internal  cai>eule,  oud  thaepanm  of  the  opposite  aide  would  be 
probalily  oausud  by  irritation  of  tbo  bbrea  of  tbe  pyramidal  traoL  We  ahaSi 
hereafter  eve  that  nhoQ  hetuiplegiaoccuTafroni  hanuorrboge  isto  the  oorpoii 
atriatuiD,  tbe  patient  i«caver«  if  tbe  fibres  of  tbe  pyraaudal  tract  remoiB 
unii^ured.  Nothnagol  fuutid  that  deetmotioD  or  iqjuij  to  a  particnlar 
part  of  tbe  caudate  Duoleua  gave  rise  iu  the  rabbit  to  nmaitabie  fianed 
uiovenwute. 

§  6S5.  jFiincf  iOTM  0/  the  Cortex  of  the  Cerebruin. — Tbe  oortei 
of  the  cerebrum  is  probablythe  exclusive  seat  of  psycbicAl  actioD, 
aud  tbvre  seem  to  "bv  uo  gcuUDiIs  for  believiDg  that  tbe  acUvit;  ol 
ADj  oth«r  portion  of  th«  eucephaloa  iti  ueoessariljr  ocmaected  witli 


AKATOXICAL  AND   PHTSIOLOOICAL   tHZBODVCTIOV.       479 


emi  the  cnidest  coaKioaanoaa  Biitbefitre  vecAn  refer  certain 
statM  of  cooaciousness  to  defioite  procesBu  in  tbe  cortex  of  tlic 
eerabnim,  it  is  necetaftry  to  hare  n  classi^cntion  of  meotal 
pfaenomeDa,  for  no  (leaded  progren  can  be  mtuiis  iu  liitvrpretiog 
tbe  results  of  experiments  oq  tbe  cortex  of  the  brain  tinlil  the 
true  nature  of  a  ps/cbical  action  is  deBned  and  some  rational 
claa>ification  uf  ps^vcbical  Hlatett  is  adopted  hy  phyaiolagists. 

NtUwre  of  Paychicat  Actions. — Wc  have  already  seen  that 
aimple  reflex  adapted  actions  consist  of  aseries  of  fftm-i^r  complex 
movemeots  evoked  b;  a  series  of  similar  impressions,  aud  tbat 
oocapoaad  reBcx  adapted  actions  consist  of  a  series  uf  different 
complex  movemeatH  erotced  by  a  aeries  of  different  iraprcssiona ; 
and  we  must  now  eodcorour  to  abow  wbereiu  true  pnycbical 
action  difi«rs  from  eiinplo  and  compound  retlox  actiona.  Keflex 
itctions,  both  simple  and  compound,  consist  of  three  factors : 
(1)  eondnction  to  n  nerve  centre  of  an  impreaaion  made  on  tbe 
surface;  (2)  redurtion  to  order  of  ihesB  impressions  in  tbe 
cvDtro ;  and  (3)  cooductiou  of  tbene  outwarda,  with  tbe  Diuscular 
eoDtiactiooH  reaitlting  from  them.  But,  as  has  been  freciucntly 
stated  by  Mr  Herbert  Spoucer,  four  factors  may  be  diKtiii^'utshed 
in  erery  psy<:bical»ction.  To  quote  Mr.  Spenoer'sowu  language, 
"there  is  (a),  that  property  of  the  external  objecu  which 
piTmarUy  affects  ibe  organ iHm^ the  taste,  smell,  or  opacity ; 
and,  connected  with  such  properly,  there  is  in  tbe  external 
object  ibat  ubaracter  (&)  which  renders  seizure  of  it,  or  escape 
from  it,  beoeScial.  Within  the  organiHm  tbere  in  (c),  tbe  im- 
preMoD  or  seDsatioa  which  the  property  [a)  produces,  serving 
BB  stimulus;  and  tbere  is.  connected  witb  it,  the  motor  change 
(<i),  by  wbicb  eciziire  or  escape  is  effected.  Now  psycbology 
is  chiefly  concerned  witb  the  connection  between  tbe  relation 
ah,  and  tbe  relation  cd,  under  all  those  forms  which  they 
aarame  in  the  course  of  erolutioa  Each  of  the  factors,  and 
cMb  of  tbe  relations,  grows  more  inrolv-cd  m  organisation 
advances.  Instead  of  being  single,  the  identifying  attribute  a, 
often  bvcomw,  in  the  environment  of  a  superior  luiiniai,  a 
eltistw  of  attributes,  sucb  aa  the  size,  form,  colour,  motions, 
displayed  by  a  distant  creature  that  is  dangerous.  The 
factor  6,  with  wbicb  this  distant  combination  of  attributes  is 
aasoaated,  becomes  tbe  congerie*  of  characters,  powers,  habits, 


480       ANATOMICAL  AND  PBTSIOLOGICAL  INTBODUCnOV. 


wbtcb  constitutes  it  an  enemy.  Of  tbe  subjectire  fadon,- 
becomes  a  complicated  sot  of  visuoj  soosatioos  co-ordinauol 
with  one  another  and  wilh  the  ideas  and  feelings  estaUiihed 
by  experience  of  such  enemies,  and  constituting  the  motive  U 
escape;  while  (2  becomes  the  intricate,  and  often  prolonged, 
aeries  of  runs,  leaps,  doubles,  dircs,  &c.,  made  ia  eluding  ibe 
enemy." 

Classitication  of  PoyohUal  StaUe. — Vanous  daanficationa  gT 
mental  atalMts  might  bi;  oddptcd,  but  tlie  bt-st  ia  clearly  thai 
wbicb  iuvulvx-s  the  fewest  osHumptions  and  theoretical  impJica- 
ttOQs,  and  which  will  euable  ua  at  the  same  time  to  coiuiect 
mental  pbcaomeoa  vitb  the  fftct«  of  development  and  expeti- 
mentol  physiology. 

"  It  would  be  the  greatest  benefit  to  mental  science,"  says  Uax 
Miillcr,  "  if  all  such  words  oe  pcrccptioa,  iotuitioo,  romembtr- 
ing,  ideas,  conception,  thougbt,cogmtiDn,  oooties,  mind,  intelleeti 
reason,  soul,  spirit,  etc.,  could  for  a  time  be  struck  out  of  ovr 
pfailoeopliical  dictionaries,  and  not  be  admitted  again  till  Uia; 
bad  undergone  a  thorough  purification."  This  passage  expresKS 
a  slate  of  mind  which  has  been  felt  by  almont  everyone  wbo 
bas  seriously  engaged  iu  pBychological  study;  aud  Ur.  Herbeit 
Spencer,  whose  great  works  have  formed  an  era  iu  pbiloaopliy 
and  psychology,  bas,  with  liis  usual  breadth  of  treatmeot, 
adopted  a  cIuseificatioD  which  does  in  a  great  measure  avoid 
tbc  use  of  these  words,  except  indeed  where  the  use  of  tbeai 
admits  of  accurate  dL-liniliou.  We  shall  avail  ounelves  of  tbil 
claabiftcatiuu  iu  our  future  remarks. 

Mr.  Spencer  subdivides  all  meutal  ^tntee  into  w^itionti 
tiitions,  a.odf6ding6i  and  the  first  of  tbcse  subdivisions : 
be  disposed  of  in  a  few  words.  "  Will."  says  Mr.  Herixtt 
Spencer,  "  is  a  simple  homogeneous  mental  state,  formiag  tlut 
link  between  feeling  and  action,  and  not  admitting  of 
divisions." 

"  Cognitions"  aays  Jdr.  Spencer,  "  are  those  mo<lea  of  i 
in  which  we  arc  occupied  with  tb«  niations  ibat  subsist 
our  feelings."    They  are  divisible  into  four  great  sub-claeaea. 

(1)  "  PrtMfitalive  cognitions,  or  those  in  which  coDscioos- 
ocBs  is  employed  in  localising  a  sensation  imprestiod  on  th* 
organism." 


AXATOHJCAL  AND  PQTSIOLOOICAL  IKTBOOUCHON.      481 


)  "  Preaeniaiive-1-epreeentatiw  eoffntiious,  or  thowo  in 
which  ctmscioiisDces  is  occupied  with  the  relatiuoa  between 
a  BeoBatioD  or  group  of  aensatioos  aud  tlie  rcpreseotatioiis  of 
UlOM  varioUB  other  8CDi>atioD«  that  acoompauy  it  m  experionce" 
Cperccptiona]. 

'  (3)  " Repreaent'.ttivi:  eognitwne,  or  tho»c  in  which  coiiHcious- 
lnesB  ia  occupied  with  the  relations  among  tdeaa  or  reproaeDted 
MQMtioDs,  as  in  all  acts  of  recollection"  (concrete  ideaa). 

(4)  "JU'TepreKTUcUive  eognUiom,  or  thoac  in  which  the  occu- 
pitioD  of  consciousness  is  not  by  represcotatioo  of  special  rela- 
tions that  have  before  been  preseated  to  coaaciousneea,  hut  those 
in  which  such  represented  apecial  relations  aro  thought  of 
meroly  as  comprehend etl  in  a  geueral  relation — tlioHe  iu  which 
tbe  ooocrete  relationti  otioe  experienced,  in  so  far  as  Uiey  become 
■oligoctB  of  coDsciousDess  at  all,  are  i  ncidouttdtf  represented  along 
mill  the  abstract  relalioo  which  formuUlee  ttiem"  (abstract 
Usm).  "It  Is  clear,"  Hr.  Spencer  adds,  "that  the  process  of 
nfVMeDtationiscarried  to  higher  stages  as  the  thought  becomes 
mora  abstraoL' 

'  J^teiinge,  or  those  modes  of  mind  in  which  we  are  occupied, 
nol  with  the  relations  subsisting  between  our  sentient  statea, 
liut  with  tlie  seutietil  irtates  iheuuclrea,  arc  divisible  into  four 
jHiallel  sub^lassea. 

(1)  Prtaenlative  j'ttliiiga  arc  those  iu  which  a  corporeal  im- 
)pr6HioD  is  regarded  aa  pleasure  or  pain  (scuEations). 
'    (S)  pTtaerUaliv^-rtjpiitaerUativeJ'etlinga  are  those  in  which  a 
laoaation  or  a  group  of  soneations  arouses  a  vast  group  of  rcpre- 
aeated  feelings  (emotions). 

\  (3j  Mepiyju-ntative  feelings,  comprehending  the  ideas  of  the 
JM&otions  when  they  are  called  tip,  apart  from  the  appropriate 
external  excitemenU,  such  as  tfae  emotions  excited  by  a  vivid 
ideeeriptioa 

.'  (4)  Iti~Ti!pre»e7Uativt  feelvnga  are  tboso  more  complex  seu- 
U«BL  states  that  are  less  the  direct  results  of  external  exdte- 
DeatH  than  the  indir&ct  or  reflex  reaulta  of  them,  such  as  the 
low  of  property,  which  coDsisla  of  the  rupresented  advantages 
bf  poBWssioD  in  general,  which  is  not  made  up  of  certain  con- 
cme  representations,  but  of  the  abstracts  of  many  concrete 

DtatHOI. 


48S       AKATOHICAi.  A}4D  PHTSlOt-OOlCAL  IKTltODUCnON. 


"Tbe  climi(ication,"  Kr.  ^leooer  proceedB.  "here  toi^l; 
lodicated.  and  capable  of  further  cxpaniuon,  will  be  fiMiDdii 
harinoay  with  tbe  resulta  of  decided  aoalysia  aided  hj  dere 
ment.  WhcUii-T  we  trace  m«Qtal  progression  through 
grades  of  the  animal  kiogdom,  through  the  gradee  of  manldi 
or  through  tbe  titn,ge»  of  individual  growth,  it  ia  obvious 
the  advance,  alikv  iu  coguitious  and  feelings,  is,  and  mu6t  bef 
from  the  prescntntive  to  tbe  more  and  more  rcrnotely  reprewn- 
lative.  It  ia  uudeniabie  that  intelligenea  aacoDds  from  thoK 
simple  perceptions  in  which  conBciotwnesfi  is  occupied  in  locab- 
Hiiig  and  clafistfying  aensations,  to  parceptioog  more  and  roon 
compound,  to  irimple  reasoning,  to  leoaoning  more  and  moT* 
complex  nod  ab^trocti  more  and  more  remote  from  aeotatioa. 
And  iu  the  evolution  of  fvelioga  ihore  is  a  parallel  aeries  of 
Ktepa  Simple  aenaatioos ;  seotiations  oombioed  together;  Hn> 
satiomi  combineil  with  represented  Rensatioos;  repreaeated  acif 
Rations  organixed  into  groups  iu  which  their  separate  cbaraden 
are  verjf  much  merged  ;  represetitalions  of  those  represenlative 
groups  in  which  the  original  compoDCOta  have  become  otill  m<n« 
vague.  In  both  cases  ttie  progress  has  necessariljr  been  frooi 
thti  eiuipie  and  concrete  to  tbe  complex  and  abstract ;  and  u 
with  the  cognitions  so  with  tbe  feetiugs.  this  must  be  the  baaic 
of  claesilicatioD." 

It  is  uot,  pt^rbaps.  possible  tu  tbe  preeeot  state  of  our  knoir- 
ledgo  to  neparate  the  cortex  of  tho  brain  into  oroM  exactly 
corresponding  to  Ibe  various  Biibdivisione  of  Mr.  Heibert 
Spcnccr'e  claasificattons  The  coriox  majr,  however,  be  ffub- 
divided  into  areas  which  will  correspond  with  the  leailiiij 
features  of  this  clai<»ticatton. 

1.  Tbe  cortex  of  the  hrain  must  maintain  some  coooectioD  with 
the  Hiirface  of  the  body,  by  means  of  which  impreBaioas  msds 
va  the  latter  occasion  molecular  changes  in  tlie  former.  Tbe 
parts  at  which  the  cortex  is  connected  wiih  the  coDtrip«ial 
aytteiTi  of  nerves  may  be  called  aensoTy  i-nUU,  and  if  the  pomoo 
of  tbo  cortL'x  contaioiug  these  inlets  can  be  isolated  from  tbe 
remaining  portionH  of  the  cortex,  there  can  be  no  serious 
objections  to  calling  it  the  Mngory  area  of  Uu  cortex.  And. 
indeed,  if  the  ioleu  from  the  various  senaee  can  be  nwre  or 
lesK    isolated   from    one    another,    eacb    may    be 


■r/  ecntrt.  W«  have  already  seen  that  the  posterior  third 
or  tbe  posterior  dirinioa  of  the  ioternal  <apaule  cont-ains  can- 
(ripetftl  fibr«8  for  the  opposite  htUf  of  the  body,  and  thnt  these 
ndiftte  id  tbe  ceatrum  ovale  to  terminate  in  the  convolutioos 
of  ibe  occipital  and  temporo-splienoidul  lubes,  or  the  Hrea  of 
tKo  cortex,  which  in  supplied  by  the  posterior  cerebral  artery. 

That  the  fibres  o(  tbe  tract  which  asceads  id  the  external 
(bird  of  the  crusta  and  posterior  part  of  the  exteriud  captiute 
are  iietuonr  ha«  been  proved  by  tbe  experiments  of  Veysniire, 
and  oonfirnied  by  Carville  aod  Diirel,  RaymoDd.  and  others. 
Vfiywtrt:  showed  that  section  of  the  posterior  part  of  the  in- 
lemal  capsule  lying  between  tbe  lenticular  nucleus  and  optic 
Uiatamos  «nui  followed  by  heminD,TSthesia  of  the  opposite  side 
of  the  body. 

Fic.  238- 


..m  (After  CwilUuid  I>tif*t).  TMUitnrtt  Smtitm  of  Oir  Bnntiafa  Dofi&Ha 
Am(  nU  thi  Corvtmt  Atliitantia.—O,0,  Optto  tbaluai :  ■V.  Cr.  ('auiluiv  nuo1«i ; 
ft,  /.,  \jea\\ctiU*  nuclei ;  P,  P,  Vcmtmnr  ragiDn  of  tb«  intcntn)  c^pHilo  : 
m,  SBcticB  of  ib»  piitttnor  p*rt  of  Um  i&t«ratl  c*p«u)*  <l«I*rBiinin|[  Iwaii- 
ktaU ;  A.  A,  Carnii  AnuiNid*. 


S.  Tbe  cortex  of  tbe  brain  mast  be  connected  with  the 
muacalar  »}'steai,  in  order  that  the  reactions  of  the  organism 
apoo  its  environment  may  bo  r^^Iated  in  oorrcf^pondeoce  with 
tb«  intprMuona^odc  upon  it.  The  parts  at  which  tbo  oort«x 
w  cooneetM  with  centrifugal  fibres  may  be  called  motor  tmttdt, 
■ad  if  the  portion  of  the  cortex  which  conlainfi  these  con  be 
■iloUtcd  fmtD  tho  remaining  porlions  of  the  curlex  it  may  be 
called  Ibe  motor  arta.  And  if  the  motor  outJel  for  a  partioular 
morement  can  be  isolated  from  tbe  outlets  for  other  movements 
(bora  can  b«  nit  great  barm  in  calling  it  a  fnotor  centn. 


4M       AHATOUICAL  &yD  PUYSlOLOQICii.  IHTBODUCTIOS. 

A  cortical  motor  oantre  than  oonstitutei  tlie  link  betwHRi 
cortical  activity  on  the  one  sitie,  and  voluntary  niusculai  cod- 
tractions  on  the  other;  and   volition  being  the  link  between 
feeling  nod  action,  the  cortical  motor  centres  mtty  be  regardijj 
aa  the  structural  counterparts  of  Tolitions. 

We  have  already  seen  that  the  pyramidal  tract  coDtainj'^ 

ceatrifugat  fibrei  from  the  cortex  of  the  brain,  and  tbi»  lias  alao 

beeu  determinod  experimentally  by  Voyasiere,  who  found  Hm 

fiCCtiOD  of  the  anterior  two-thirda  of  the  interaal  capeul«  «u 

followed  by  hemiplegia  of  the  opposite  side,  UDK«ompaiu«d  by 

MQiorT  pondyfiia. 

Fio.  S28. 


A, 


'Tft. 


Fio.  339  lAf ter  C*nil1»  md  Dnrnl).  rraiumw  Staia^  of  Ut  BntU  ^  tkt  ft- 
llc(  miUimiiru  in  Jnmt  ^  M<  vptie  cvnntwwv.— 5,  H,  Th»  ooilaU  — ahj  tf 
llie  oorprirn  Htriatk  :  F,  P,  FednnimUr  flbrw  itha  iaURul  oifavle) ;  L,  LMfr 
oal»r  nuvlena :  A,  Htjridt,  bjr  DMiuuf  irUcb  VeyMUrc  pradMrd  Mcllsatllbr 
intsmil  c«|Nulc  U  |s)> 

But  tbo  [t}-nuuiila1  tnutt  is  cot,  aoooiding  to  Duet  ■'"tlT'—t.  lk*a^f 
atitlet  fmrii  thr  ixitU-.x  ut  the  bnifat  LeariQg  out  of  Monrat  the  onlrf- 
itagaX  ^hrfs  nhich  |)raKn,hly  enonoet  the  oortcx  of  th«  ccrtiiritta  wiUi  tt* 
Mrelpellitn],  them  still  renu^  the  fihm  whiofa  coniic^t  Ibc  corlei  i4  iW 
CGrobnim  wjtli  tho  ccntriU  gmj  tiitM  thnmgli  Um  intonuedution  at  Uh 
oorptu  fitmtutn.  The  corticnl  nctioas  which  an  (sgulaled  Umq^  Ikr 
(w>q>u8  Htrintiini  hih)  pyramicial  tract  sni  oflMii,  aHhoogh  not  alwAy^w- 
togoniotic  to  ouc  onotbcr.  The  oxcitatioo  of  tht  oortax  which  ta  tb«  cv- 
TOlative  of  fwllog,  whether  tho  latter  he  plMCumUe  or  pRlnful,  aimjt 
tends  to  find  ±  vent  in  iii)m«<l)ato  action,  while  a  snot  pnrtiaa  rf  otf 
voluntary  eSbrts  ore  direoted  to  restnin  aotiaii,  and  to  jitMt[na«  tbi  i 


AXATOHICAL  AMD  PHTSIOLOOICAl.  INT&ODUCrtON.       4S5 

oMdiatd  gntificstioa  of  the  feelings  in  onler  to  kooompltiih  remote  diiiIk. 
ExcilAti<Ni,  fnr  itKitaiuw,  of  tite  oelk  in  tlw  cortex  wbiflb  an  ia  imtnediatc 
oontact  with  the  tenmiulionB  of  the  centripetal  nerve*  in  the  Bummits  of 
Uh  coan4utw«iM  of  tlw  jxMtcnor  ami  uf  tUu  ourtttx  t«aJe  to  be  ooodticteil 
mnawtktelj  oat«anl»  nknis  tlui  oontrifti^id  fibrao  whidt  oaiinect  thaw 
MttTnlutioiu  witli  the  ooipiis  strijittum.  If  (heno  exoitatioaa  are  ooniliuAed 
«t  flooo  ontvarrU,  tliey  give  rim  be  niowuientJt  whicli  Um-d  Uwn  nuned 
wwtH'f-motor;  but  if  the  ezcitationa,  iuEtood  of  bciog  conducted  at  odcv 
oittmnb.  inn  flxmi  the  cella  ia  cotmiKtioii  with  the  letTiuiiatioa  uf  otic 
bnaifie  of  ivttriiwtHl  6bcee  (viinon}  tu  thoea  ia  connootton  with  aootbcr 
boodle  (t»ctilL<),  so  thut  the  relatum  Iwtvireeii  the  two  feelings  oomw 
inlO  praatueaci.',  Utuu  a  {nveentative  oogiuti«li  i«  fomoed.  When, 
fcr  itmUtaoe,  the  centripi-tal  inipube  received  Id  a  oonrobition  twnm  the 
oritMioa  cMBed  hy  n  tbom  to  the  finger  ia  brought  into  ooiui<.-«tJou  irith 
tbe  tmprew«ionii  received  through  the  optic  oad  other  coutripetol  atm», 
toA  wbich,  an  rbachttif;  tho  oirtos,  bctioioee  the  oormktiro  of  the  con- 
of  the  &i)(vr  ttat-lf,  then  ■  cognition  of  the  relatiomhip  of  pre- 
Te  fMllng  in  fonucxl.  Now,  a  prueatatire  cognition  dooe  tiot 
like  m  pivacDtAtiim  feeling,  iiiimfdwtj^ly  rrault  iu  action.  The 
eifxod*  iteelf  in  the  fonucr  iu  pnxlticing  excitation  of  other 
froopa  «f  celbi  in  the  cortex,  the  truMitioii  horn  one  fcroup  to  another 
^nog  roe  to  other  preaentatiTc  and  repreaontatiTe  eogmtiono,  itntU  Hnall; 
ifca  OKitor  ana  u  roadxul,  lut  J  the  eicitatiou  [otnwe  out  along  tile  pjramidal 
ihna.  Kti>'jectivelf  oonsidemd,  the  oognition  nf  ttw  thnni  nnd  Angw  Kvold 
mS  op  oiIkt  cngnitinns  cotmected  wiUi  Ihems  by  prci-ious  uxpericnoeB,  aa 
uf  a  pill,  and  |v<ob(ibI_v  the  highly  repreeentntive  ooj;iiitiuna  of  the 
pit>{icrtice  of  the  lerur,  until  finally  the  pin  b  votuntArily  grasped 
and  Hghtiy  applied  tor  the  removal  uf  the  thora  This  action  is  verj- 
diflfannt  tram  that  which  impelB  a  dcg  to  lick  with  his  tongue  the  foot  in 
wiriali  a  thorn  ia  lodged.  The  latteriaaaeaaori-iuolororilouhlyooaipound 
nrfha  aeUon,  and  in  Imnmliate  relation  with  Uw  cortiad  cicitaiion  irhicb 
tmatm  the  feeling  of  [niti,  while  the  funner  ratdta  tmm  n  mtim  nf  et>ai- 
plex  oartiokl  excitatioiu,  some  of  which  obuck  the  tendenoj  io  inunedtale 
aclkNi,  uattl  b^-wul-hjr  eomiplei  nctiooj  rexult  whieh  mv  guidoil  bj  wida 
■sparieooe  and  adafited  to  iviiinte  vndn.  Tho  ciovciueiitH  whiuh  tuniU 
Iv  fhnn  the  feoUDga  have  been  called  seiwuri-ini't'ir,  |wrdpdo- 
',  and  i4le»-BX)(or,  un  the  ouppoaitioD  that  tiicy  oocunvd  in  lespoose 
ongDitioaa ;  but  it  would  be  better  to  call  the  amvementB  wbiob 
frna  a  preoanLod  feeling  a  duuUjr  compouud  leflei  action,  that  tmoi 
a  {wokentatire-ivpfeaentative  feeling  n  iruMy  nompound  n4!cz  action,  and 
tnMa  a  rvprVMutatira  fiNiling  a  <)UiHlraply  oampound  te6ex  adion, 
on  in  so  aMendiog  acale,  aooirding  t4>  the  dqgno  of  the  ooDipleiity 
tacUog.  When,  however,  a  aeries  of  oognitians  intervene  in  Lhn 
opeFatinnn  IwtweMi  the  filing  which  prompts  »  movfnient  and 
jtbm  morebtent  itaolf,  the  reeolting  muscular  iMljuutnMut  ie  a  rulmiiorj- 
aod  ia  Rgohited  throogh  the  pymmMitl  fibres.    When,  for  inntanT, 


486       AKATOMICAL  AND  PHT310L0OICAL   INTRODCCTIO!!. 

Lcnmior.  pn>ni)rtMl  hy  Uw  b^hljr  re|<n«ctitati^'v  R^dU^  ot  »  done  fo 
Aisoareryf  iMrwHtnl  his  telMOOpB  to  a  eorluiii  ffH  in  tbc  livnt-oiM,  uul  ^ 
•xirerod  Koptunc.  the  rDqunite  nnuculAr  «4Ju«tiaeQt»  Dwouwy  br  canj- 
iog  out  this  ac-tiuii  wure  [trooodod  in  his  oiiiiil  by  a  long  avrles  or  inmlnl 
and  higMy  ropruoQUtive  cogDitioiu;  tni  tbaai  anucular  adiotnamet 
thflEoselTtjM  were,  to  k  Urga  Kbent,  Toluototy. 

3.  The  regioD  of  fhe  ooHcx  Biipplied  fay  tbe  anterior  cer»bnl 
artery  still  remains  to  be  connected  with  some  kind  of  meoul 
activity.  We  liave  ieen  that  the  area  supplieil  b_v  the  pooteriot 
cerebral  artery  U  the  sensory  area,  and  coiuequeatly  excitation 
of  this  area  is  ihe  correlative  of  the  prwentative  aod  preMOta- 
tivo-repreiseutative  coguttioas  and  feeliogs,  while  excitation  of 
the  area,  supplied  hy  the  midille  cerebral  artery  is  the  cot* 
relative  of  volition.  Excitation  of  the  cortical  area  supplied  by 
the  anterior  cerubral  urtcry  is  the  correlative  again  of  the 
repreneatative  and  re-representative  oognitions  and  feelinga  It 
is  aumowliat  difficult  to  find  a  name  which  will  he  expressive  ot 
the  fuDctioo«  of  this  area,  and  if  wo  cooseot  to  call  it  tlN 
ideational  area,  it  must  be  romembered  that  it  is  no  l«aa  likdy 
to  be  lii«  aitatoniical  substratum  of  the  higher  ctootic 
of  the  higher  intellectual  opcratiooa 

§  686.  ATUttorai(xdSuh8traiwmofConacioiLme88.'—li'awd\ 
recognised  that  a  large  number  of  psychical  actions  may  take 
place  in  an  uuconsciouB  manner.  Leaving  out  of  coDsideration 
the  phenomena  of  dreaming  and  somoambulism,  we  may  in- 
stance siicb  a  familiar  fttct  as  that  a  man  may  read  aloud  whole 
pagea  of  a  book  while  his  mind  ia  engaged  in  solving  a  difiicalt 
problom,  and  he  it  wholly  uoconacious  of  what  he  is  saying,  yd 
the  muscular  movements  engaged  in  reading  are  co-ordinated 
iQ  the  cortex  of  the  ccrebnira.  If,  under  those  drcumstaaces,  tl« 
eye  falls  on  an  uuuaual  word,  oonsctousuess  is  directed  to  it  for 
a  moment,  and  the  reading  may  then  go  on  uncoDBoiousIy  u 
before.  It  would  therefore  appear  that  iaiproasiona  which  ban 
been  fretpteutEy  repeated  in  experience  may  pass  ap  to  the  carta 
nnd  give  rise  to  complicated  motor  impulses  froDi  the  cartel 
without  ^eing  attended  by  conaciousness ;  but  that  when  the 
impressions  made  on  (he  sensory  organ  pre-ient  an  unosnil 
cumhination,  consciousness  is  aroused.    Unusual  combii 


liUXDUICAC  A.ND  PHTSIOLOOICAL  INTRODirCTIOH,       487 


>f  Meaaary  impraMioiiK  arc,  therefore,  probikbly  coaducUMl  to 
ind  through  the  cortex  in  chaouela  TrbicU  ikra  ouly  partially 
>pen.  wbilo  the  h»bitiial  combinationti  pas»  in  channels 
•hich  are  opeu  aod  well  deHaed.  lu  intellectual  efforla  tbe 
ugheat  coosciousoess  ia  aroiued  when  the  miad  is  coDtem- 
vlatiDg  new  coiabloatioQB  of  prcaootativo  and  TCpresentattve 
mprea^ona,  or,  to  translate  this  into  the  laaguage  of  pliysies. 
vheo  tbo  organism  k  adjusting  itself  to  new  combinutionH  of 
itrcamstaaces  ajid  events.  In  otbor  words,  the  highest  inte]> 
BClual  oooaciousneas  is  aroused  during  tbo  time  tha.t'a  new 
•gKointioQ  in  the  cortox  of  the  bmin  U  being  sitpemHded  to 
he  exUting  one,  while  excitation  of  the  portion  of  the  cortex 
vhich  is  already  thoroughly  organiHed  in  attended  by  little 
IT  DO  couAciouiness;. 

It  cannot  be  supposed  that  the  largo  celU,  with  the  distinct 
irocene«  and  definite  connections  found  in  the  internal  division 
tf  the  third  layer  of  tlie  cortex,  will  readily  undergo  alruclural 
iluuif^  in  the  healthy  adult,  and  it  is  much  more  probable 
bat  any  new  alieralinn  of  stntctiire  in-the  cortex  will  proceed 
rom  the  amall  culls  of  the  ext«ruul  Uycnt  of  the  cortex.  The 
int  layer  may  probably  be  regarded  as  an  embryonic  layer 
rilLout  any  active  nerve  functions,  and  cooiietiutiatly  the  second 
ayvr  and  external  portion  of  the  third  layer  of  the  cortex,  the 
wUs  of  which  do  Dot  pobsees  de6Ditfl  conneetioos  with  one 
uuXber  or  with  nerve  fibres,  must  be  regarded  at  the  areas, 
txeiution  of  which  is  attended  by  the  highest  ooDSciouwess, 

Experimanta  on  animals  have  proved,  as  we  have  seen,  that 
he  fibres  which  paw  through  the  posterior  third  of  the  posterior 
iinnoo  of  the  internal  capsule  are  sensory,  but  the  sensory  area 
tf  lite  cortex  is  aliw  connecteil  with  the  periphery,  through  the 
»pdc  thalamus  and  iu  radiating  fibres.  It  is  probable  that 
mpcoBoous  which  hare  been  frequently  repeated  in  ezperieoce 
MM  through  the  optic  thalamus  and  its  radiating  fibres,  and 
hat  they  give  rise  to  little  or  do  coDsciousness  on  reaching 
liQ  cortex.  It  may  be  presumed,  on  the  other  hand,  that 
iDusual  combiuationa  of  imprenioos  are  conducted  through  the 
HSterior  fibres  of  the  internal  capsule,  and  give  rise  on  reaching 
h«  cortex  to  disttnct  oonsciouBneasL 


488       ANATOMICAL  ASD  PBYSIOUXIICAI.  INTRODUCTIOK 


§  687.  JSxp4rime7tt<U  DeUrmituitvin  of  tlte  Fandiontt) 
tfit  Cortex  of  M<  Brain. 

1.  Jfoior  Ctntrt4. 
Rcptrvtrnt*  by  SHmidctHon.—^hm  Ute  oerebrota  u  ruaortd  i&wo) 
mIico  tbvns  m  a  (ndua]  lost  oS  liit«ttis«i3«a  aod  vulitioa,  ud  toamxpMf 
FlouKiw,  who  oondoeted  the**  «xpenmeint»,  <!Oa«liid»d  tbafc  tin  hm 
sctiHl,  M  H  wbole.  without  any  H[M)oiml  fuoctioiu  being  Mngned  to  ifMiil 
parU.  IIughlings-JaolMon,  howorer,  drew  ikttoaUoo  to  Uw  fact  ttutfool 
diaoaw  of  Uio  cort«x  of  the  brain  nutjr  oocauon  epilepttfonn  ooothIm^ 
localiite^l  to  i>&rtioitiftr  groupe  of  muacloa.  tlitrig  and  Fritwli  ahovvd  Ihi 
tlt«  lucal  itpplicmtioD  nt  the  {-klvftrtlo  ciimiit  to  putioulir  poita  «f  tt* 
curobro.1  couvolntioiu  givM  n»e  to  dcftnite  aonmeots  of  Tariotu  grxtjitf 
iRUHcloH.  TlifjiQ  eiperinients  vera  extended  uid  rendend  toon  dtU 
hy  F«irn«r,  nbo  ua«iI  llie  fu«dio  iutood  «f  tin  gRtriuitc  cumntM* 
mcuis  of  atimuklioii.  The  motor  oentm  ■■  detormiued  by  KcrrtfrB 
tba  monlcey  4r«  ropresontMl  jn  Fi^.  £30  ud  231,  while  th«  oormfwo^ 
parts  in  the  human  bnin  an  shown  in  Fi'ys.  232  and  333. 


FiQ.  SM. 


>'ia.  29D(AfUrF«nW).     The  Itft  ITaHtttAert  tff  At  M<f 

Butdon-SandersoD  Rtat«a  tlut  ths  motor  reactiooR  to  oortkal  I 
■IV  not  preventtiil  from  Uldos  pisoo  hj  &  boritont&l  incinoa 
dtntwiMi  from  the  wirfaoft.     Thi«  simply  nhowa  th*b  a  fandk 
ftpplicd  to  the  surfnco  of  the  brain  ia  coiidiict«d  in(o  the  cwtlmKl 
Kid  stimuUtiM  the  ends  of  the  dividod  pTrunidal  Sbnn    but  it 
show  that  the  oortes  is  noii>«xoitable. 

BiirdoH-Saiiilomon  ftlso  found  tbjit  local  atimulatioc  of  thowUtai 
immodifttely  mrrouQ^Ung  the  oorpos  striattim  produces  localbad  I 
ment«  siroikr  to  thottscAumd  h7«tianilationof  thocorrwinoadiiwa 
surfaco.  Thia  oxiwriment,  Eks  the  Iwst,  ahowa  that  the  Qlmi ' 
pjrramidAl  tract  are  eicitaUe,  but  it  praveit  nothiag  with  njuji 
exsit«bilit7  «  noa-exdtAbilit;  of  tbo  cortex.     U  the  tnolor^ 


AXATOHICIL  AMD   PHTStOIXHlICAL   INTRODUCTION.      48y 

aortex  be  ntnotad,  exoiutian  of  tho  oulijikMnt  whiU  «uhituiM  euiMa  Uu 
auM  movBiiMnta  m  esciutton  of  ttw  inobir  cutitnt  it-wlf.  t»  Huch  ■  cms 
the  «fHl»  of  the  fibra  of  tha  pyrjinidk)  tnct  which  ImdmI  fram  tho  motor 
oMitn  w  nowupOMd,  uid  exdtatioa  of  tbam  catuu  tho  anmv  kiDd 
of  moAor  rsAotioa  m  th»t  etawd  b]?  esctt&tion  of  th«  motor  contra 
Maolf.  If  tbe  utcul,  bonvvor,  mirrive  the  operation,  tbo  pyiMnidal  fibros 
Bsdago  MC«ndii7  descending  degeaentios,  oad  exeitation  nf  thd  wcer  or 

Fio.  S3I. 


^ 


OJtfMr  Stn^act  of  Ik*  ff*mupKtit  0/  the  Monlmi- 

Adnan  of  tbo  appatlt*  ]irg  u  in  wvIUkk. 

Conrpln  tBovenunn  tt  tlw  lUt;)),  l««,  ood  foot,  with  ftd«til«d  movomciiUof 

lbs  Intnk. 
Stnntiunu  nf  Uw  UiL 

lUtncUoB  ttnd  »ddDCtUn  ti  tbo  oppotito  foo  llaib. 
KKhniioti  forwud  -A  tbe  »p]>oml«  tava  ftod  bsnil,  m  IT  to  mch  or  toodb 

■oanrttny  tn  trvmt. 
be  («),  ()i.  (ci,  |W>,  IndiwidoAl  end  oombined  nioT«iii«iita  nf  tbo  finffora  and 

vriito,  ndins  in  cknohhtt  of  tba  fiat, 
BBflMliBM  and  B«si4a  et  l£o  fflcwnn,  b^  ntiioh  th*  hud  ia  nuwd  tnvird* 

ibo  oKNith. 
A'*t'~  of  Um  iTgomatNa,  bj*  wbkb  Uw  anule  of  ib«  numth  *>  rctroeled  and 

•Icralod. 
Bf  voUon  ol  Ui«  obt  of  thv  ikmo  oad  npirr  Up,  wilb  diprwwoD  of  tht  lomr 

UpL  00  00  la  BXpcM  ibe  coniiiF  ttvtb  on  tho  oppodle  M». 
.  Oywitug  ol  tb«  mnatli  with  prntrtiaiin  rj  tbe  t^mgiia. 
OpCDte  of  tbB  Boutb  wilb  nitnctian  u(  Ilia  tungna. 
Botneno*  of  ibo  oagla  of  the  moath. 
^fN  op«UD(  widalf,  |»|«la  diUting,  baod  and  470a  tuming  lawftrd*  Ibe 

oniMltalbt. 
lad  IV,  XjwbaUa  motuMC  lo  Ibe  ofipaito  liJa     Tuiialo  jccuerollr  coalnctiad- 
flwddM  nteMltoo  of  tbo  oppowk  ear. 
SolaeidnB  oonw  Ammeiua.    Totwrn  of  tbo  lip  and  aootril  on  tbo  faiso  nd«. 


490       IMATOUIC&L  AND  rHTSIOLOQICAL  tNTBODUCnoS. 

Ita  uelghbourhood  no  loagor  prodaCM  tbo  parUcuUr  moTvoteata  clant- 
Umtio  of  iko  dwtrojed  area  (ALb«rtoDt  and  Mictu«L). 

ExperinrrOi  bg  Dettrudion  of  Portiotu   of  the  farter. — It  h»  bMi 
olMtrrwl   thftt  remorid  or  doAtraoUoa    of  &  motor  OMtre  u  tbUml 

Fto.  232. 


U 


r. 


:C\ 


'^ 


®®, 


® 


\ 

l^KM,  232<in<J333(A(l«rF*rriw).    Sidtand  Vpftr  Vitttt iif  tJU  Onii,  ff  Mwt. 

Tlia  SgitTM  u«  ootutnictrit  by  markiiig  an  tbe  brain  id*  nuB.  in  lk*tr  raqactln 
wfTiitiniii.  Itininnrnririiiiiif  llinhrnfafif  thiiimiilrirMrilrliimilnitlij  >I|iiimwiiI, 
ud  thi  (MKripdan  of  th«  ^tlt^ota  of  utimvUtlas  tb»  wioui  aMN  r*tm  to  Um  taiii 
of  tlw  maakey. 

1  (On  thm  iMwUroraTlrtal  lobulw),  Adruioo  of  tli«  oppoyU  biad  Uab  M  ia 

waltduK- 
%3,  4  lArouad  tbv  uppervxtrenutr  of  (he  fi*nii«of  Ralwido',  ComptoiBavf 

mMiU  uf  tbo  oppoidto  Ug  anil  xm,  aa<l  of  cba  inwk.  >•  is  airimmtex. 
n,  fi,  c  d  (Oa  th«  awaaAuis  pariatal  cnnrdnbon),  Indindaal  and  oomImiI 
uoTcmval*  uf   lb«  SoRoa  and  wrlat  ol  lb»  «pp<Hil«  batiU.     ftitiwiBi 

5  (At  Lbo  punteriDr  Biimnit/  of  tbe  aupnriar  franla)  cuutraluUaa),  F-'Mitt™ 

forwhnl  of  biw  oppotite  ami  and  baud. 

6  (On  tbo  upiHir  part  «(  ths  atcendiag  froatal  MOivoiDlioa)^  Supinatlo*  aaii 

flasion  M  Chfr  oppoalta  tottmrm. 

7  [On  iba  uinlian  iHirkiimof  iht  an-imtltor  froatal  oonvolutioal,  Retraetinfi  aad 

elcvntiob  o(  th«  oppiwitc  anglo  oF  tb?  month  bf  mpan«  ot  tb*  VfontlM 
iuu»cl«a. 

8  {Lower  dawn  on  iha  niidc  coDTolnlJ^Dl,  EtcratJcm  of  the  abt  nait  and  apfm 

U|i  witfa  drpfvoaivu  lA  tht  IwwOT  lip,  9n  Uw  u|i|>iiMta  aide. 


AIIATOHJCIL  ISD   PaYSIOLOOlCAL   ISTBODUCTION.       401 

Fii»bilil7  to  uccuto  the  moroioBnU  uiigiMcl  to  the  atm  (Uitzig, 
[  Twfitr).  but  it  baa  siibm(]uoQttj'  boon  found  tlut  On  puvljrtJc  «/mi>UnDB 
idiMppMr  vboo  Uh  aninitl  operated  iipoti  earvirea  aonio  lUjti  (N^gtluia^l, 
[BMUMaa,  0<dti].    Heruiuiu  removixl  oortlcal  motor  ceuti-es  from  i(yg», 

Fifl.  233. 


12 


e 


Y 


V. 


/ 


7^, 


^ 


U.  I4  (At  Uwiiif(riarexU«iBitrorthoMMi»llm[froiiiklBQ(lp<Mteri<>texli«Diltjr 
of  tb>  thiid  lianUICMiroIulion  ^,  OpenlBg  of  ThemaulliwtUl  (V)  pMtnuiOB 
■III)  1 101  ratrwtinB  of  tb*  iuti(Euc.    Kipian  nf  Aphatia. 

11  <Aillwiaif«rlar«itrMBl(rof  tlM>HocDdiDgp«rirUlooa*9lutlra),  lUlraetliw 
of  tba  oppimU-  MiiH*  <t  Iht  nualli,  Um  h*»4  tur««^  tiliiililljr  to  na*  md<w 

13  (On  th«  jwiUriur  p<vtinu  tit  ibt  auiwriur  «nd  mlitdl*  frouul  Movdntkaii). 
EjM  openloK  mitij,  noinU  ililatiag,  tuid  tbo  lic»d  uid  «]«  tuninc 

towBtda  lb*  Oppnal*  aldr. 

P,  IS*  (Ob  iha  «Bpr*-mBiipul  Inbnls  and  angnUr  gl^rtM).  Ths  bjm  dwvIiic 

uwamli  ibF  oppiicale  tide  wlili  au  upwanl  113)  or<lowDvard(l3^  dsi4B> 

Uoit.    Pu[>il*  sciwimIIt  ooatnotto^,     ^Centra  uf  THmn.1 

ll   (On   tk*   Ufik'tiiarftiikl    or   auptnor    teniwro^iitienaiclBl    novolntjaio), 

Priddoff  np  ct  til*  o|)()Oait«  car,  bead  mm  am  tniniiiK  to  Ui«  oppoatt* 

aUa,  aM  iMpUa  dilatiiw  lawlj.    (C«Dtn  ef  SaaHiii.l 

Kawiw  mtworw  nlaiCe*  tlw  wtraa  of  Uale  aad  aOHll  at  tha  tztreini^  ol  tha 

'  t— pc»»aph»BiiM»l  tobt,  and  tliat  of  tonch  tn  tlia  Qmia  niKniiaIni  aad  hippo- 

lOMWMIMiat. 


4 


494       AXATOMICAL  AStt   PinTSIO LOGICAL  IKTBODCCTIOH. 

Vo  tun  alretily  uen  tU»t  jianilysia  of  the  »it«rnal  rvctua  muada  of  tim 
OM  «d«  aud  of  the  iut«ruitl  of  tho  «t]]«r  oocun  in  mMt  casta  of  aoiUa 
hemiplegia  iu  mui,  ca.iuiug  k  oot^tigou  d«TiAUaii  ot  the  ejTM  smj  bom 
tbd  [HU>AlyMd  H)>ld.  Tliiit  fanljaia  duuipiwAra  in  »  f«w  dAjn,  wid  tt 
ultuoiit  ex&ctl}-  .HJiuilar  tu  what  oceuis  iit  tbt  iwraljrsM  of  corticiJ  iMooa* 
MUAod  in  tint  dog.  Aud  wra  injur/  to  Uw  dowp  wrtixt  part*  ol  Xht 
Ijnuti  iu  i)i«  dog,  soob  u  Ibo  crua  oonbri,  doM  uot  causn  a  hiiini|ilnii 
at  all  coR^iMTiLbla  to  tha  hainipl«gta  wHicb  oceuTa  iu  maa.  In  Imm 
of  tha  right  cnu  oarvbri  in  tba  dog  thens  in  only  a  ver;  ptutial  btmi 
plagia.  Whan  at&nding  tha  ftaini&l  cotriaa  hia  bodjr  towanla  tba  ligiil, 
his  ^ea  ON  directed  to  the  right,  and  hia  head  i»  alao  rotated  to  tlie  rigtttt 
aud  if  the  atiimal  move  be  goea  rounil  iu  a  circle  after  his  tail  (Bmadheal^ 
It  would  not  l>e  mi>re  ])K|)aBteroii3  la  tell  lui  that  becauae  iajnr/  d  tba 
omiB  oec^ni  eauses  a  mamiemtttt  lit  nuuUfft  in  the  dog  it  cannoC  thenAm 
oauae  betaipleKia  in  uuo,  m  to  sajr  that  becaoM  fatnd  reconrj  firon  tha 
)iaralj-iiiji  caiuwd  b^  oorttcal  lesions  takea  place  in  the  dog  tha  affaeltoai 
OBHisad  bjr  niuiilor  laniuo.-!  in  man  is  not  due  to  the  d«atraiCti<Mi  of  a 
oortioaL  oeiitru.  'I'lie  dL»a])[>uarauc4]  of  jiaralfsia  of  tba  Unsba  in  tbadof 
OMTMpoiida  MBcClj  tu  tht  diBoppaarMK*  of  ooiijugate  doriatioo  of  tba 
6766  in  man,  and  the  ciplautition  wbiob  eoffiees  for  the  uno  <nU  probsU* 
aullice  fur  tbe  other  (§  90).  But  «Teu  Uolu  aduula  that  wime  moTansiAi 
111  cbe  Aag  become  more  or  leas  ^>ermaiieiiUy  paralfHod.  fur  instaaae^  bt 
ma;  UHc  liiit  forcpnw  to  drag  bones  and  other  uonwU  of  food  froui  oadsr 
a  table,  atui  he  luay  also  be  taught  to  perform  ^wcial  Inoba  with  hia  |«as  e 
all  suchepcciat  niuvamciit-  bucume  luure  ur  leas  {leraiamDllj  lost  afisr 
porttoua  of  the  cortet  haw  been  mnoveA.  Tbia  sbovs  that  tha  pan); 
virluntary  actions  are  more  or  loss  panaanentljr  loat,  while  paialj^rf 
the  automatic  actions  ooiioerned  Iu  ordiuar;  loouraotion  lapidljr  dieappeaiik 
Gultx  found  tbst  llw  auiiuals  o|)crated  mi  oould  after  a  time  b«  tnBBsd 
or  oilucstiMl  to  iwrroriu  H|)ecial  aottons  with  tbotr  [ntwa,  a  faet  wliMi  dun 
that  A  new  orKoiiieatioii  Ukcs  ploca  more  readily  in  tba  brain  of  tbe  dog 
ihsii  in  lli»t  uf  tiiiiri,  but  it  is  quite  prabsble  that  new  stractund  amaf^ 
ineots  maj'  nUo  take  pla«e  to  a  certoiu  extent  in  the  brain  nf  taan  aftir 
partial  injury. 

2.  iS«n»ny  C«iib-cA 

It  has  already  been  ewii  that  1li«  c«ntrt|ietal  fibrea  termiuat*  aiWD^ 
tbo  cells  of  the  eocond  aud  third  Uyen  of  tiiv  cortex  without  fomii^  VJ 
direct  coDDection  with  them,  while  the  fibres  of  the  pTramidNl  tract  tska 
urih'iu  iu  the  aiiA-cylitider  prooeeaee  of  tb«t  gi*ut-<«lU  of  the  InUtnsl 
portion  of  the  third  lay«r.  It  may,  therefore,  be  suspected  tbal  tbi  cw- 
tri|Ktal  conenta  will  paae  in  a  much  more  diStiaed  mmntt  throafh  tt* 
oort«x  than  tha  oantriruj^nl,  jii«t  aa  ilia  found  that  tha  foTTDerpwalaa 
toon  diffused  toauner  through  tlto  i^al  oord  than  the  lattar.  U  i*  V" 
therefore  lilcely  tliat  the  waaorj  inleta  are  as  defiuitelr  localiavd  aa  tb* 
motor  outlets. 


ANATOMICAL  AMD   PUTSfOLOQICAL   INTRODUCTION.       495 

Ejjurimumts  hy  Stimutattim. — On  ■UmnUtiRg  Uia  angular  gynn 
Fcrrlvr  obuiuej  Tuiotui  ntoroiDenU  of  tho  ey«  and  Moociatvil  uiove- 
ments  of  tb»  boail,  ofxl  h«  ngwdecl  th«  [ihenamatui  obsBrvad  am 
tmug  **  msrelf  reficx  moTcmoDti  on  tb*  viciUtioD  of  iiulqvotin  naiwl 
MMMtioD."  tie,  ttwrufura,  ooucludod  tint  tiiv  uigular  g^rus  and  Kiir- 
'OVbdinB  gtvy  luitttor  ooustituUd  tho  contra  of  visioii.  Oa  aaxaeiibat 
•IcniUr  gitnincb  ba  planil  tfas  \U(litory  ceutre  in  the  superior  Utmiioru- 
■^niviilal  oouvoluboD,  tbo  cwtroo  of  tuto  bud  amoll  «t  tiw  vxtramity  of 
Ibe  t«tii|ioro-«|ib«ooidKl  lobe,  nad  that  of  touch  in  the  g/rua  uucinstuB 
amI  hippocut^iw  nuqor.  But  tbeso  eiperimenlB,  altli«ugh  «xo««din^]r 
Wl  Moating  and  Inportant  as  being  the  first  to  break  ground  iu  ■  oeir 
tarhtor;,  at*  b;  do  oieaiu  coucluvire.  I>r.  Fcrrier  binuel^  i&d«od,  did  cot 
ran  MtiaflBd  with  -them,  but  iirooeeded  to  vorily  his  hji)otb«aea  by  tba 
■itiffiMtion  or  dectlructiou  of  Utp  portioo*  of  tli«  cortex  wliiob  bt>  *u[>i>o«ed 
Id  be  ibc  seiuory  oeiitna. 

Sjrptrimtnit  by  £xtu-patiMi  «p  JUdnution  of  •5«Mi>ry  Crobw.— Tb« 
aoaA  rMurkablv  remit  obtunod  by  Fcrrier  in  hia  firat  exinximeutB 
■■■  a&itdad  bgrdaalnietioa  of  tfatuiguUrgyniA  Whsntha  Angular  gyrus 
ef  tile  left  hetim()bcn}  waa  doBtmyed,  it  n-M  found  tbst  tbu  sninud  ms 
bUiMl  Ml  tho  nght  ajra  sooa  kfter  tho  opsmtiou,  but  reoovarad  aigbt  eoto- 
pletely  ou  tbe  fotlowlnig  day.  In  auotbur  caae  ttie  suguUr  (tyri  of  both 
hscBM^lMns  wen  deatrojed  and  tb«  auimjJ  beoanw  completely  blind  %a 
both  mjm».     Id  do  case  was  any  motor  paralyais  obe«r\'ed. 

Th»  admitted  obyectiooa  to  tbes*  «xp«ria<4it«  aru  that  Farrier  did  not 
k««p  bu  aoiniala  alivt  a  aofficiently  long  tune  to  aaoortain  if  a  reiom  of 
tiaOB  Oocurr»il.  Uolti  found  iu  hix  exp«riuimt«  Ibat  tih«u  a  ooaaiderable 
porliou  uf  the  cxtrtvx  of  the  brmin  was  remuTvd  the  animals,  altboogb  uob 
Uind,  uiajttfet.t«d  A  [w«u!iAr  imperfocUoo  of  Tisian.  The  auioial  operat«d 
■poucoubl  uM  hUN^L  ui  aTDiditigob«lsoiea,butofl«u  failed  to  ncugulse 
Wm  food,  and  ^pearad  tjuilA  Indiffennt  whan  threateuet)  with  the  whip. 
Us  aIdo  fbuud  that  recovery  frotii  tliin  cnnditi^ui  vua  [Kwaible,  at  least  to  a 
eoOirtdaTabJe  «s1«nt,  by  meuu  of  eduo^tiouai  etcroiiMM. 

yank  believes  again  in  the  oiietcuoo  of  a  "  vioual  arva,"  aituated  in 
tba  ood[>it«l  lobaa,  and  of  muofa  larger  extent  than  that  of  Famor.  H» 
ifr*'"**""  that  removal  of  tbia  area  causn  bliudueaa,  and  that  cxtirpa- 
titm  of  saall  poctMOs  of  it  givos  rise  to  blindiMM  of  ioctlised  anas  of 
the  rvtiMh  Hu  belierea  that  thera  are  tliriM  tImmI  sfihereB  in  the  oortes 
of  Dm  occipital  lube  oomMixtiidiiig  to  three  rlitual  areas  in  the  retina. 
Tbe  ntemal  |«rt  of  the  retiua  of  the  left  eyu  m  oouueotcd  iritk  tlm 
«at4T»ial  {>art  of  the  corUcal  Tnual  ccuiiu  in  tbe  left  hamtii|>tii:r«,  tthtlo 
tb*  iutomal  aud  ceutral  portioua  of  the  retina  of  the  right  eye  arv  r«speo- 
tinty  cDiinectnt  vitli  tbg  ititanial  and  oautral  ixwliona  of  the  visual 
aoDtra  of  the  u|(|NiBita  or  left  bumiaphere.  He  also  tbiulcs  that  tbe 
a}if»r  )«K  of  tb«  ntiita  ia  eouuecled  with  tbe  frotit,  and  tbe  lower  part 
vith  tbe  poaUrior  asfMot  of  Ifaa  visual  oeutre  of  the  opiiueite  aide. 
BomAval  uC  both  visual  esntren  canses,  aixordiiig  to  tbia  obaurvor,  cem[)lsta 


496      ANATOMICAL  AND  PBTSIOLOQICAIi  ISTBOOCCnOS. 

gr  nbjolufa  bltDdoeM.  PftrUoI  ntmoval  of  then  RrvM  on  Ibe  other  I 
givaa  riw  to  th«  viatial  dufoct  called  ottontiou  to  b;  Golta,  i&  «lii«k  tlit 
Auiioal  caa  wo  aud  Avoid  obJMto,  bat  doos  nob  ncogoiM  his  food  am  mik 
ThU  Aluuk  c&U^  /ifycAiocd  bUadaeas  (SertaidMnnnngsn,  SMleobltodbdt). 
He  fiiiiU  th&t  afW  a  Uoia  the  animala  raoorar  from  psychical  blimluui^ 
provided  the  whola  tUiuI  areti  be  not  femofod.  Us  thiaks  thAt  tt» 
rccorery  Li  dua  to  &  ptooeH  by  which  then  La  •  defnaitioo  of  usw  Tiand 
ASporioacea  in  the  rMt  of  Ui4  rinul  arM.  Tb«  ph;nc«l  part  et  Ifct 
rMtoration  might  probably  bo  Hpokon  of  with  groiicr  jtuiioe  aa  tbt 
farmatian  of  now  structural  armngvinaiita  in  tbe  visDal  aiwM.  Mtnk 
deacribes  an  auditory  &r«a,  vbicli  huw»ror  dEflers  from  that  of  F«sior,aoi 
h«  tegards  th«  whole  fruut  part  of  tke  brsto  aa  rorming  a  targv  "  aWMMf" 
araa,  iu  nbtcb  iwinunto  iwQaory  ociitrod  way  be  dtaUngaiahed. 

Fi<i.  a34. 


■cd-j 


H 


Klo.  V*>  |.\rt«r  Muiib).    Upper  S'irfatv  o/ Ihr  Brttim  of  tkt  MimlUr.—Stitttrf  Anm 
A,  of  the  eye*-.  B,  ol  cbii  »rai  C,  of  tbo  Mniwitrtf  Uwtffwwr  wtwilTt 
D,  AaUnw  DxtmuLty ;  K,  llexl )  F,  OouUr  BMMUlat  appanttu  ;  G,  B«(Ma 
of  Mra;  U,  Kacki  I,  Bod}-. 

An  cUborato  paper  on  tbo  cerebral  Tiaud  centre*  wa»  read  btfaf* 
the  phyBiologic&l  atiution  At  tlt«  meeting  of  the  Brituh  Medical  Aaaociaticih 
at  Cacubridgo,  iu  Aoguat  hoi,  by  ProfiNKK-n)  Ferrier  and  Osrald  7.  Tm. 
Larg»  portioDfl  of  th«  brains  of  monlMy*  w«re  remorod,  the  opentiaea 
being  ^ouducted  aatiaoptioaUy,  ao  that  there  vaa  a  total  abMOM  tf 
eucephalitia.   Tbe  following  ia  an  abatract  of  tho  cbi«f  raaolbi  otrtsLoad  ^' 

1.  Ktiiaovad  of  both  oocipitAl  lob««  did  not  cwiao  an^  nwosaiHUa  fc 
torbaiioe  of  TiHion,  or  other  bodily  or  mental  deTaiigenwiit>  proridcdtka 
l«dii>Li  did  nut  «itaad  beyond  tbo  jMiriot'^-oeoipitAl  fiamro. 

i.  Oumplute  dttfttrnctiuii  of  oae  angular  gyiua  «anaea  teniMHVy  loa  rf 
vinon  of  oii«  eye,  Lutitig  only  a  few  bourn.    Tbe  rurtoratioo  of  viaiea  i* 


ASXTOinCAI  AND  PHYSIOL 00 IC A L  INTRODUCTION.      497 

tnt  due  to  the  iotogrity  of  the  otbar  aogolar  Kjmis.  If  both  angular  gyri 
ba  dartnysd  timidltantoiul}/  total  blindnem  eoeuev  in  both  ejos,  but  doM 
BtA  iMt  man  than  thres  dajs,  althonch  viaioa  may  be  impaired  lor 
wmtiu.  If  tbo  angular  jTri  be  deatrayed  niMMnM/^,  several  weeka 
ikpaim  batvaeo  th«  opanliotu,  tb«  aouaal  aeu  quit«  well  wiUi  both  «jM 
tosbwlioan. 

a.  8unuItaaeoaBd«itruct)oaof  tboangQkrsTToaa&doocipital  lube  ou 
oaa  dda  cautea  aridint  loaa  of  vlaloo  In  both  ajaa  towaidi  ttio  Kide  opin- 
«t«  tbe  lanou  (bemivpia},  but  nnovtrj  (roui  thw  condition  take*  plat*  at 
tba  eod  of  a  wmIc. 

4.  I>«atnictioDOftl>oI«ftaiigtiIar27mi(BMOT«i7),  andaubseqnoatlyof 
th*  right  aiigular  gjrux  and  occipital  lobe,  prodncaa  left  heiiiiopi&,  from 
vtucb  the  aninial  r«ooT«tw  in  a  fortoigfat. 

ft.  DMtnuitionof  bothoocipital  loh«a,f(>lIo««daft«ratimeb7da>tiao- 
ttoo  ct  th»  kft  BDgalar  gyrua,  oausM  tranaiant  bUndfuwa  IblUmad  bj 
bdtatiiwIiHaa  of  riatoo  of  right  ayn,  with  aukaeqaont  oomplota  recorei;. 

5.  Dertraetioe  of  both  angular  g^ri  and  occipital  lohM  causae  total  and 
^■■i^MBt  blindnoM  ia  both  eTea,  withinib  an;  impainueDt  of  the  other 
mamtm  er  of  not«r  po  war. 

3.  Pra-/ivntat  m-  IdtaHoiui  Arta  of  Ikt  Cortex. 
a^trimgnU  hy  SAwadation. — EbetiJcal  faritatioii  of  ths  pno-firootal 
n|Ha  of  the  cortoc  io  Mm  DMokaj  oauMa  do  motor  naction  (FtRier). 

Btpinwtenu  by  Xxtirpation. — Ooinplet«  dcatnution  of  the  pne-frootal 
lobaa  In  the  moukejr  catuea  cio  iionljoia  of  motion  and  oo  aenaor;  dia- 
■^rtMVT,  but  tha  character  of  tha  auimal  aaffcrn  poat  jlatarioratioa  Bab> 
jOQiHtDtly  to  the  opemtioii.  "  Rsmoral  or  deatnction  by  tbe  untorj  of 
ilaro-froDlal  lobea,"  aaya  Dr.  Ferrier,  "  ia  not  follaned  by  any  deSoita 
muha.  The  "■'"'^l"  retain  thoir  ap|>etiUHi  oud  Juatinsta, 
tad  are  e^iabla  of  axhibiling  aeaotioual  feeling.  The  aanAory  focoltiaa— 
li^A,  baariog,  touch,  taate,  aod  amell— moaia  animpaired.  The  povan 
tf  ninotazy  motioa  an  retained  in  their  integrity,  uid  then  la  littla  to 
laAaaito  tha  proaeoeo  of  auoh  an  exbonaiTe  leaiou,  or  a  rvmoral  of  ao  large 
of  the  brain-  Aud  yet,  notwithatanding  thia  apparent  abaoQce  of 
ayntptoma,  I  could  porooive  a  mry  dacided  altontion  in  the 
I'a  character  and  t^ehaviour,  thou^  it  is  difficult  to  stato  in  precise 
tha  oaton  of  tbe  changv.  The  aoim&Ie  oporatod  oo  mro  aelvcted 
oa  acooont  of  their  intelligeat  charactor.  Aft«r  tbe  operation,  though 
thejr  oiigbt  loein  to  one  who  had  not  oenpared  their  prewut  with  tlw 
f«t  fairly  op  to  tha  aTenga  of  monkey  intaUlgenoe^  they  had  aodergooa 
a  oQMidarBblo  payebologjcat  altcntion.  loitaad  «t,  a«  before,  b«bg 
lyiotaraatod  in  their  aurroundiaga,  and  curloualy  piyiog  Into  aU 
vithin  tha  fiald  of  their  obaemtion,  they  remaltwd  apathatte 
doll,  or  doaed  off  to  aleep,  reapuoding  only  to  the  aoiiaationa  or  imprea- 
of  the  neioaat,  or  vatyiog  their  liatUaaDaaa  vith  reatloaa  and 
wanderinga  to  and  fra  WhOo  sot  artaally  daptiTed  of 
00 


498      ASATOMICAL  AND  PHYSIOLOGICAL  INTaODCCTIOjr. 

mtelligoDra,  they  luul  lout  to  &!!  kppMnaoe  the  bculty  of  sttAittin  ■! 
intqlligeut  oboserTAUaa."  The  ooncliuioiui  which  Dr.  Fcrrier  bM 
flrom  his  exporimenta  on  animalii  arv  fulltr  Ixinie  oat,  Mt  iro  whAll  m\m- 
qoentlf  BM,  by  the  recolts  «f  diseases  and  injarioe  of  the  prn»-fin>atel  Mn 
in  nuu].  The  whole  cvidenoe  ■hows  that,  ftltbough  dMtracttOD  of  lb* 
1«bes  ii  not  follovcd  bj  deoided  eensorjr  or  motor  distorbaneei^  jit  Ori 
the  Ltktur  oralved  (rvpraaenUtire  ftad  re-repreMat«UT»)  ooguttiooi  ltd 
emotions  u»  seriotulj  Impured. 

S  Odd.  LocaUaaticnh  of  the  Mtcha*U»ma  wUcA  rtgukOaOia  FvndativDttmi 
Aaauonf  JLctiont. 
We  hnvv  nlroiuly  itcon  Uut  the  fuajhansnta]  portioos  of  ths  ooQitdattM 
of  thtt  mator  uriM  of  Uiu  brain  u«  toaai  hoat  tho  gnat  lopgitadiMi  I 
whiln  tha  accoBnury  poitiona  of  thase  oonvolutiona  no  fonnd  in  tfai 
lutianaof  tb«ai)crculum;andit  maj  therofore  be  sxpected  that ti» 
mental  motor  actiouB  will  be  regulatod  bom  the  formBr^  and  the 
functiona  (nui  iina  Utter.    Bevenl  liaaa  of  evidenoe  oourerge  in 
of  this  view.     The  large  glant-oella  ars  found  in  the  oonvotatiou 
greiit  loujcitadio^  fiauun),  while  thme  cells  diminish  in  aiM  as  «t 
towards  the  u^avolutiuiis  of  the  fl{>ftrciilum.   But  va  hare  alraadjr 
tho  aixo  of  tbu  motor  ganglion  colls  of  tho  uit«rior  grey  horns  of  tbil 
is  dstsnouied  b;  the  atie  of  th«  musolSK  whose  moTcioeafai  they 
more  than  by  any  other  circamBtauoe,  and  it  is  tqtjt  likely  that  i 
rcktion  axi«ts  lietwaeu  the  giaiit-cellit  of  the  eortax  and  the 
which  th«y  !iro  i;ouiioGt«d.     lint  the  fundamental  aotioos  an.  Ml 
{iriiduoail  b^  the  ooiitraotions  iif  Urgv  musolas,  such  as  tboae  of  ths 
and  lower  extremities,  and  ooii»o^ueiitly  iro  may  expeot  that  th^ 
rsgulatod  by  means  of  the  Inrgs  cclla  of  the  central  couvotaUooi 
groat  longitadionJ  fissuro ;  wbilo,  OD  the  otlier  hand,  the  aawsoiy 
Mf  produced  by  small  muscles,  such  as  thom  of  the  haod, 
face,  and  vo  may  espsct  that  th«y  will  b«  resulated  thnngb  thi 
cells  of  the  convolutions  of  the  operoulam.    Again,  the  Bbni 
pyramidal  tritcl,  wlii<;h  aro  meduUsted   in   a   nine  naoottia 
the  fundamental  llbrea— are  connected   with  the  central 
near  the  great  lougitudinal  flasoro ;  while  tbo  uon-modullaled 
the  aocflnsory  &hn»  of  tho  tract — are  connected  tritb  the 
of  the  operculum.    The  dbret  which  connoct  the  posterior  poitiil 
third  frontal  cnnToliition  with  the  intsmal  cipmile  and  craxta  are  i>"^Fl 
duUfttod  before  fmirtoen  wMks  after  birth  (PlochsigJ.     We  hsTt  " 
Men  that  a  largo  proportion  of  tiio  accessory  fibres  of  the  p; 
tniot  torminato  in  the  medulla  obloogats.,  and  in  all  prei 
majority  of  them  ore  ooocemed  in  regulating  the  apeclal  mo 
artioiitation  and  facial  expreasioo.    A  glonos  at  Dr.  Ferrjer^ 
(FC^i.  iii  and  333)  of  tho  motor  oeatres  of  tho  human  lirain 
the  uovouioiit«  of  the  ItvdIe  and  lower  eitromttiee  are  re^lattl 
central  oonvolutions  near  the  great  loiigitudiual  li«8ure  ;  that 


A5D  PHYSIOLOOICiJ.  INTBODUCTIOH.       409 


I  nfiilBlad!  ftoa  Ui«  middle  of  tbo  uoending  frooU]  and  parieU 
ri  and  tlut  thou  at  Um  bc»,  toogn*,  and  hnnd  irs  regn- 
I  tbo  coBTotutiaiu  or  tbo  opcrcatum.  Tho  TaotH  of  devclopnteoi 
of  edqMrimaiiUl  phjatology,  tbenfon,  cuticur  U  tihow  tttat  the  funds- 
ital  KitioQs  an  nipiUted  from  tha  oMitnl  conrolutioits  netix  the  %mX 
llladinal  fionin,  vtA  th«  toewMory  funcUotw  from  the  coiivtilutioni  of 
Dpavuloffl.  It  must  klao  bo  romcmber^d  tl»t  tii«  grojr  tnattor  Bt  tht 
iam  of  tfa«  fiMuns  isderalapedaubmiquBntly  to  thnt  of  tfav  sumuiitii,  (tud 
nqOHitlr  Um  Uaaa  niinMaU  an  orgaoiaBtiou  nhich  htui  bovn  aupai> 
■dtottwhtlOT  inthcoounwufttvolutiua.  But  tho  portioD  of  tlie  oartex 
IwIllttMlof  lUil  wlucliadj&iiiatiificaiivolutiuiiuurttieaparciilum  iatlte 
Kknvainwhiob  new  ■tni«tu)re  UsuperKd<l«dtothQ  motor  region  of  tlte 
ba&  At  Mm  grey  luatUr  in  tbo  aeigbbourbood  of  tbo  luitcnpr  perfontod 
B>  {uextmnem  in  ■uperfioi&l  ext«ut,  tbo  «it«rtuil  ujieot  uf  tba  eortes  of 
MDtnl  lob«  u  throst  apvuds  Awt  outwardii  w  ao  to  derelop  tbo 
mhitiiODa  of  the  oporculum  ;  and  tmcix  Ktlditiou  of  gny  matter  to  tbs 
lar  MKinhttiomi  rrprweut*  an  addittooal  wmpltxit;  in  tb*  pn-«xisting 
ortva  c(KrM{M>ndiii({  to  an  additional  oomplvzitj  of  praviuuii  muMolar 
JBtmaDlN.  Eaah  inoreuAnt  wliiob  v*  addMl  to  tb«  inferior  ditrtttnittaa 
tha  omLral  coiiTobitiouii  b;  thv  upward  growth  of  tbo  cortox  of  tbtt 
|Md  cf  Red  iaeraoaaa  th«  loogtb  of  the  former ;  but  aa  xXmit  upper  az- 
|iiilHia  are  pnrciitod  from  moring  fraclj  u|iwat(Ui  lij'  the  alcall,  their 
Mr  Mtr»mitia«  an  tbrown  into  a  fold,  and  oooMquantly  tho  dapth  of 
■nlcuN  wfakbaapanteBifaa  laland  of  Rail  ftom  the  oonralutioiu  of  tba 
MsliuD  nay  be  aooeptad  aa  ao  indieation  of  the  dogr««  of  davalopmaat 
Ilka  Mxxmory  portioD  of  the  motor  area  of  tlie  corteoL 

■L  Xo«iifiWi«a  o/ (A«  CvftU^  C*iH^*t  0/  0*n^'^<*'vi  Spt^i'ii  Smsatumt. 
I'Wa  baTO  aeM)  ttuit  in  Ibe  spinal  c«rd  tbo  eonducting  |)ath8  of  the 

EDO  aauatioQ*  poaand  dLrecUj  into  the  poatarior  gref  born,  tbnugb 
UiUa  of  the  fan  fomud  by  tbe  fibrM  of  the  poatenor  roota  on  their 
Uilo  the  oord  ;  wbile,  00  tbo  other  haitd,  tbe  conducting  patba  of 
l^iyeeia]  cutaDaooa  aanaatiooa  are  tbrart  iowuda  and  outwarda,  ao 
pj  poattiona  ootodo  tbe  tuargiaa  of  tbe  poaterior  homn.    A 
;  iindar  proceaa  appears  to  tak*  placo  during  the  daTelopment 
:  Id  nIafcioQ  to  tbe  cotninoa  and  epecial  cutanomtv  aeiiaatioDa 
I  apaeial  Beoaaa.    AeoonUDg  to  tba  latest  axporiniHiitH  (jf  Ferhar 
tba  centre  of  rlaiou—tba  most  qteciat  of  all  tbe  aenaea— ia 
1  GO  tba  out«r  oaovox  nurface  of  tba  occipital  Ijjbe  iu  the  area  of 
1  diatnhutioti  of  the  poaterior  oerebral  artery,  nhilo  ttw  oeotra 
r  acoartioa  U  aitaated  in  tbe  kippoMa^ai  region,  cloae  to  tbe  root 
I  artcTf .     It  ie  pmbable  that  tlie  aeoaatioa  of  pain  ia  too  much 
in  tha  oortai  to  admit  of  any  dednite  loealiaation.    Both  the 
otatn — tha  auperior  tampoio-aphaaoida]  oourolutioo— and  tba 
oentn— the  auhkuluu  curau  Ammouta— although  attuated 
Fifae  root  of  the  artery  than  tbo  Tietiol  centre,  yet  occupy  ponttona 


500       ASATOMICAL  AND   PHYSIO  LOGIC  At   INTflODUCTiyK. 

aaur  thti  t^rtnitiftl  dirtrtbution  of  mow  of  tfa*  bcatiebee  of  the  postcnt 
cerebral  arteiy,  and  c«rUtiUjr  fiiriber  lemored  from  its  not  Xhih  tb 
M&tn  at  tactile  «en»tioo, 

S  GOO.  LoMlUatiMHtf  Fvnetion  in  tf>t  Pnt-fronMi  Arva  of  tX«  Corv^ 

If  the  higher  mental  operations  be  corriect  on  in  th«  •ntetior  »itk4 

the  cortex,  Utia  region  must  ooiitfun  the  pleuBXa  of  oelk  and  fibna,  itbtfL 

when  oxnitA,  b«ooms  the  eorreUtiven  of  tiw  npTMeatatiTt  tad  R- 

roi«oMt]tativ«  GogiiiLions  uid  feeb'Dgs.     Ko  progrm  baa  bo«o  nad* 

in  localising  tbo  fuDOtiona  of  thin  Arm  of  the  oort«x.     It  Is,  howiw^ 

probable,  that  the  lBtar«:quind  omotjcins  and  oogaitioDs  will  be  nfn- 

nantod  io  th«  oortoi  bjr  tho  grt;  raatt«r  in  the  bottom  of  tha  dsaarw,  uA 

\>j  iho  gray  matter  of  tha  ooarolntioaa  of  the  orbital  aurfaoo  vhiii 

adjoliJH  the  aut«rior  perforatad  s^ttCQ  and  which  are  Bituat«d  cIom  \a 

the  root    of   the  antcrioT   corcbral  artery.      Pathotogwal   obaenatioa 

beart  oiit  the  tdm  that  disetue  oi    tha  oortei    of  tbo    oftiitai  wfiwi 

produces  much  Iosh  mental  diattirbauce  tban  diaeaoe  of  tha  aupakr 

coDvei  aurface  of  tlie  |iT(»-fr>antal  area.    And  this  is  only  what  ndfht  b 

espected  if  the  former  la  d^valoped  at  a  lat«r  period  thai)  the  latter,   lb 

conTOlutiona  of  the  orbital  sorfaoe  would  then  reipraamt  the  lat«r4oqaiNl 

ooguitione  aud  emoti'^ma,  aiid  abolition  of  them  wooU  caoM  laaa  nwBllI 

rli»tiirhiui<.'e  than  Abolition  of  thom  which  are  earlier  acquired  bat  bmr 

ftiudamoutai.     A  maa,  for  inaUnoo,  lOAjr  iiro  what  ia   regarded  as  • 

reapeotable  life  when  he  ia  deatitute  of  all  r«ver»ocv,  and  is  wboUjr  uh 

ca[>able  of  doin([  au  uii«el&ih  action,  wbilo  tb«  onl;  aelf-retftraint  te 

places  over  hid  appetites  and  paariooa  is  that  which  the  most  calmlatJni 

iieltiahuetis  suggests.    Vet  r«vereutial  foeling,  UDsel&shoaas  io  acticxi,  m1 

aeir>reatratiit  are  the  latest  acquisitions  in  the  dardopDWot  cf  tba  famiaa 

tuisd.    If,  however,  a  ria»,  instiad  of  buiu^  lacking  in  rwverviitial  featia;, 

bacomea  opetily  profaiiR,  and  instniul  nf  not  beiug  unsel&ah  he  oummil* 

deeds  of  riolenos  in  order  to  deprive  others  of  their  rightful  proper^.aad  tf 

instead  of  curbniig  his  {HutNioiiH  ereTi  by  a  calculating  selflshneas  lie  gtati&B 

thorn  without  shame  and  regardloss  of  coosequeaeea,  it  is  eridanl  thil  i 

lowor  stratum  of  mental  degmdatton  haa  been  reached,  and  Ibe  portiea  d 

tha  oort«i  now  diiws««d  is  a  mom  ftindamentol  one,  whieh  moat  hat*  boa 

dsraloped  at  an  earlier  period  than  that  which  waa  diaeaaad  io  the  lot 

in  stance. 


501 


CBAPTEB    U. 


lOBBID  ANATOMY  AND  CLASSIFICATION  OF  THE  DISEASES 

!0F  THE  EXCEPHALOJJ. 
P       lT->-UORBn>  AKATOiTY  OF  THK  KNCEPHALOK. 
K  <^ntioD  of  the  law  of  evolution  Laviog  been  already 
^■oed  in  the  coDstructtoa  of  the  bmio,  va  must  now  endea- 
lODr  ta   trnco   the   action   of   the   law    of  dtfisolutioo  in  tlie 
inakiiig  down  of  structure  the  result  of  diaease. 

,  $  G91.  ^UlUogical  Morhid  Changt».—Th<i  hUtoIogical 
jbu^BB  which  ooeur  ia  the  timu  of  tho  bnuQ  during  diseased 
we— ■■  ore  ossoatiall;  the  eame  as  those  which  have  already 
Imb  deacribed  in  the  case  of  the  spinal  cord  (Jj  387).  and  it  is, 
herefbre,  uooecessarj  to  repeat  the  deKription. 

i  §  <t92.  Morbid  Alterationa  of  the  Oiretdalion  vrUhin  Ou 
P^OHMun. — It  was  first  pointed  oat  bjr  the  second  Monroe  that 
be  ctrculation  within  the  cranium  differs  from  that  of  other 
luta  of  the  body.  The  cranium  forms  a  bony  caae,  capable  of 
tMtstitig  the  atmospheric  pressure,  and  no  substance  can  be 
lUo^sd  from  it  without  some  equiraleot  taking  its  place; 
ihUe,  oa  the  other  hand,  no  subet&ooa  can  bo  added  to  the  con- 
laoti  of  the  cranium  without  dialod^og  an  c<[uivalont  hulk  of 
oma  other  subetaoce.  This  opinion  waa  experimentally  tasted 
ij  Kellk,  mod  defcodtd  by  Abercrombie,  Reid,  and  Watson. 
[>r.  Burrow*  endeavoured  to  coml>&t  this  opinion,  but  bo  only 
Iwved.  what  wan  never  denied,  that  the  quantity  of  blood  io 
be  brain  could  be  increased  or  dimioiahed  by  various  circum* 
taocc*.  The  doctrine  of  Uonroc  aimplj  asserts  that  if  the 
joaatity  of  blood  iu  the  cavity  of  the  cranium  be  iocreaBcd, 


502 


iKKBBID  JLNAT0U7  AND  a^ASSIFICATIOK 


gome  other  flaid  must  be  dislodged;  while  if  tlie  quiDlit;  (f  i 
blood  be  diminished,  some  other  fluid  must  fill  up  lb«Taanj 
space  The  quaDtitjr  of  blood  in  the  brain  can  aodouUtdif  I 
be  increased  or  dimiaished,  but  this  coii  oulf  take  pl&ce  \jji\ 
oorrespooding  dimiDutioo  or  JDcrease  in  the  quaotit;  oCdilj 
oerebrO'Spioal  fluid  and  of  the  Quid  coataioed  io  Uie  pcii>| 
vasctilar  l;mph  spaoea.  Wbca,  boweTer,  the  tDtracroDtal 
sura  is  reodered  still  greater,  as  by  eztravnaatioii  of 
from  rupture  of  a  blood-voesel,  room  is  made  for  tlw 
gtance  superaddeil  to  the  cootests  of  the  cranium  bj  a  ovtu 
qunntit;  of  blood  being  Bquoczod  otit  of  the  iot 
arteries,  veins,  and  siDu&es,  in  addition  to  the  displacemsot 
the  cerebro-spiual  6uid.  Tlie  circulation  within  the  crauiumi 
liable  to  be  dinordered  by  occlusion  or  rupture  of  one  or  more 
of  the  iutracephalic  vessels,  but  the  reader  is  reterad  to  tin 
acctioTiti  on  emboliton,  thrombosis,  and  cerebral  bmuxrhap  I 
detailed  deecriptioas  of  tbeae  procesaee. 

Ttimoui-8. — ^The  groirtb  of  intracranial  tumours  of  all  kt 
must  ucceesuril/  ho  attended  by  great  disturbosoe  of  tlie 
bral  drculatiob.  In  order  to  make  toom  for  tbe  inoTMstoff  bulk 
of  tbe  tumours  tbe  ccrebro-cpinal  fluid,  as  well  as  Ibe  fluid  df 
tbe  perivascular  lympb  spaces,  is  first  squeezed  out,  the  bloed 
is  then  compressed  from  tbe  intracnuiial  blood-vessels,  so  tbai 
tbe  whole  brain  is  rendered  ansmie. 


§  G93.  Secondary  DegmenUumM. — Long-standing 
rbagic  and  other  diseased  foci  give  rise  to  Tarious  ateoiukKf 
changes  not  only  in  the  surrounding  tissues,  but  also  in  distsot 
parts.  These  changes  are  of  two  kinds:  Brstly,  thoK  which 
involve  tlie  entire  moss  of  the  brain;  and  ssoondly,  tkcm 
limited  to  certain  tracts  of  conductJng  Bbres  wbicb  are  iDtflr> 
mptcd  in  their  courae  by  the  h»morrhage: 

(1)  Qeaeral  Atrophy.— Vi'iih  regard  to  the  former  of  these 
kinds,  it  is  found  that  the  brain  fret^uently  undergoea,  ersB 
after  on  insignificant  ba:morrhage,  n  slow  and  geoexai  atnpbjr 
which  occoisionally  afTects  both  hemispheres.  This  cooditioa  is 
eepecially  common  after  oxtraraaatiaoa  into  the  cortex.  A  p«- 
natent  alteration  of  one  bemispbere  of  tbe  brain  may  after 
ft  time  induce  atrophy  of  the  oppoAle  hemifpbon  of  lh« 
cerebellum. 


OP  THE  DISKASBS  OP  THE  EKCEPHiOOIf. 


503 


(3)  S^ttemic  D^tneraiion. — As  has  been  frequeatly  stated, 
wbeoever  the  fibres  of  the  pyramidal  tract  are  Injared  in  any 
pwt  of  their  coarse  from  their  origin  la  the  cortex  of  the  brain 
doira  to  their  termination  in  the  npinal  cord,  the  portions  below 
the  seat  of  injarjr  undergo  descending  degeneration. 

k  toeai  ImtcD,  liniitMl  to  the  middle  third  of  tba  iiotitETior  wgment  of 

At  iBtenwl  o^Mile  (^.  X37,  F),  b  fnlloved  b;  dowooiUiiK  dcgcnemtioii 

il  U»  fthm  of  tha  nuddle  thari  ot  the  cnufcs  (Pif.  SS8,  Z.),  and  of  u 

I  pirtiao  of  the  loogitadiBal  fibres  of  tbe  pane  and  anterior  ii^nuuiU  of  tlio 

lu  llie  lower  cud  of  tlie  mmlulla  tlic  greater  iiait  of  the  d<:gcni.'r»t«id  fibrat 
cRM  aver  to  the  Ut«ml  coliunu  of  the  oppcwite  side  of  the  vnrd  (Mj^  S39, 
&;,  oliiW  Mimu  of  them  |nu»  down  tbe  oolumu  of  Tttrck  of  the  nme  eidi- 
.SW,B).  TbeoouraeputsuodbytboMoonduydegeDcnliaaiiitheoaM 

Tio.  S37. 


na,  S9T  tCbanot).     Bvriiontat  Btttivn  of  t\f  Biyhl  ffemiiphrrc  poratld  mUk  At 
Kturt  v/  Hflriit*.—il<s,  C'4ad*t«  niioleiu ;   H«.  .lulonor  Mgnast  of  tb*  fa. 
tmul  caiMw*;  2)1,  LentieiUar nnclcna;  G,  Kntc  of  tlulat«rai]enpMil«;  Sp. 
Pnterior  MgaMdl  e(  Ui«  iatcnud  eitp*aIo ;  Co,  OfHc  th*lainiia ;  F,  A  foml 
~    .  in  ibe  niitdle  ttrird  ol  tlu  poMmor  put  et  tM  Inttinwl  eApan]*. 


54H 


HOSBID   AHATOMT   AND  CLABSJFICATIOH 


FlO.  23S. 


rLI> 


no.  S88(C1iM«at)i     iTariMneal  Atfion  </ U«  O-MT*  C0yM  !•  «  MM  qf 

Oqrawnation.— r.  Tdgmoatiun:  F,  Cmte  of  tk*  hMltbr  mA»;  h.  U 
nlgrr ;  Z>,  Tfca  desanontod  tvnm.  oocopylDg  ibout  di»  mUdl*  lUra  « 
owU  1  J*,  llw  fibrM  wbi«li  nad«fgo  MoondMy  d«g«aat»ttoa  oalf  *tM 
Sbrtacif  Ibe&otmarMd^mBoeftodUitfcnMof  UuinUaBsl  npnbanAM 


rn.  3M 


^VMt  a  cut  </  iMimi  of  lAc  hMot  otm  </  Me  cortex  4<  Uc  mifwtfc  ' 


A.  DtSBMtatknof  HMpjiMiJdaltraciti  B,  DfcmnObBoltbadml 
0,  D{notMnb«lUr1nuli  D,  laUm^JJai*  fAn  b»l*— d  tfc«  y lilM) 
bora  ioi]  Uia  ivmnidal  tnct.  tbe  &bna  o<  wUelt  do  Bot  Md«m  dm 


doBBMnUco. 


OP  TBK  DISEASES  OP  THE  EKCEPHAJ.ON. 


505 


jurt  dMcribed  «>msp(»d«  to  that  of  the  Aiii<UmeQt&l  fibnM  of  tho  pjia- 
nidil  tnct  iluriug  llmir  iWelojuni'iit  {Fig*.  223aiMl9S4).  A  cow  boif 
lw&  dflHribad  by  BriMaud  iit  nhicb,  olon^  with  cxtonsive  teoeot  Boft«ii»g 
of  me  bembpAcrc,  an  old  foau  of  noAcniiig  mm  otwervcd  UimtccI  oxaotl; 
teltelmeecf  theint«niA]a^«uto(^S^.  £40,  D).    A  atreak  of  degenemtioD 

Fio.  340. 


^  M  (Brinnid).  Bitrnd  Befteains  vj  tht  KraibU  Ltiijt,  tkt  Iiland  </  StU,  and 
KiHU  mrd  if  OuLatladar  Nutlau.- t>,0]d  focim  of  w>(t«iuiiK  nocnpflDg 
tU  )□»«  o£  Um  i>t«n»l  (Mp*uIb  :  A,  U&uiUu  iiucWiia;  It,  Uptic  ttuluau; 
C,  Antwior,  ttnd  S,  Futader  didilaii  of  iht  internal  tsiBolr. 

^paobKn'cd  Ij-iug  Iietir«en  the  internal  And  middle  tliinlf  <>f  the  onata, 

BiDf  tlw  Mitorior  {MMticm  of  tbe  urea  which  has  alniiulj  Ixwn  iLiMcribed  oh 

^1  mUed  arctt  of  OMdiiUiitud  and  noii-tutkluUiited  Glmn  iu  b,  due  uionthn 

nbtTti  {F^.  S23).    Aocordlog  to  Briwaad  degenemtii'ii  i.iociira  in  Uiu  knw 

i(  the  tntanwl  oapmle  in  eamm  of  lDDg<«t>uitIiDg  (iph;hni.i. 

Aaolhcr  impottaat  cmo  hw  beon  obeonrod  hy  UtuMniid  in  which  an 
(U  bcOB  of  aoftentog  wm  foaud  iu  the  autarior  half  rf  tbe  lenticolaj 
BKlnu,  doattofiuir  s1m>  the  ontenor  aof^meul  of  th«  iutvm&l  c»paule 
{Hfi.  S41,  F).  A  «ti«ak  of  degenention  was  oljaerred  in  th«  iDternAl 
Uinl  of  tlie  cnMt*  (A9.  841,  P),  but  aU  the  fibrea  of  tbui  uea  wen  not 
implicated  in  the  defeaerntlon,  a  unall  buodle  of  tbe  innonnoat  fibres 
'""■fntng  nonufll.  Th«  degeoenited  fibres  in  this  cam  tx>ni>8]uindi<d  T61; 
Mod;  to  tboas  vdiich  we  have  dmcritwd  lu  the  accesaory  fibroa  <if  the  tnOi. 
Dig«MnitJ«fi  of  tho  Lbtcmnl  trnct  of  tJtc  cnisto,  accarding  U>  Brisaand, 
i|fcan  to  be  alwajTB  ooaoochxl  with  intcUu'Ctuul  dimttltm. 


606 


UORBID  ANATOMT  AND  CLASSIFICinOK 


The  foIl<Mng  buiiiile*  of  fibres  may,  thcrefimi  bo  dirtngBiibad  is  lb 
internal  ca|wiilt-  (BniwaiK]}; — 

(I]  A  jKitirior  or  teiuorjf  f<uHe¥iH*  {oeea^jiBgtiibetbenaiixiiiiiHW 
cruata;,  wlilcli  \n  never  tbe  acat  of  nemadary  iBgauamiion. 

(S)  A  middU  /aKKuliu  (oociipying  the  oudiUe  tJtinl  of  Uw)  tnihl. 
which  ia  Uir  iisunl  seat  of  Beoondorjr  dcgsneratlao. 

(3)  A  fftnundate  faaeieulta  {oocapjrtng  tlw  point  of  aniOB  of  tbe  tailk 
luiil  iuteniiil  Uii  nln  vf  ilie  cnwtB),  which  hM  ermooouaily  b«co  rapvU  « 
mcQimble  of  rl<^^>iiitmtu»i.  Thin  fnsciculiw  oMttain*  fibra  wfaitih  wt  fr 
tritiubeil  Ut  Lhu  IiiiIIhu-  uciitiMi  sud  aiv  orincenioil  iu  tbe  |inxliMtioil  of  Hi 
voliintiu-y  QimviiiuiiU  of  the  isux  nutl  toiigtie. 

(4)  An  atUerior  fatcieiUttt  (otxnpfmg  the  int«nial  tiiinl  of  tbr  anM, 
ilegifrQentiou  of  wlticb  oppe&nt  ouly  to  be  iinnAriaIr*  with  intcDxtatl 
diKwdera. 


Fio.  241. 


Flo 


Vnj^lii*:  ,      f '.     Lil'nL'iEj    1.11     til*.'    jilf  t-7l  1"!     1^ i|  1  L*T' ti »     -  hi       %tjv     *-m\^.i^  ,     i  ,    ^  ■■*    v 

•eating  llir  (nrm  of  the  lunUcuUu  naoleaii  I*,  trinininllni  \4  llit  isia*' 
fibMa  of  Iho  onurl*. 


or  TDB  DISEASES  OF  THE  ENCBrHALOK.  507 

Congenital  Mal/omuiiions  of  th*  Skull  and  Drain. 

d)  Anaw^haiia. — Tn  ihis  mnditinn  the  upper  poctioo  of  tbe  nkuU  and 
Mta  it  initiieljr  atMent  This  eatulttian  ia  sonvrtinim  awncinbcl  with 
njvlu,  »  ooDditioD  la  which  the  rerteUal  oolumn  remainfi  imdonal,  and 
hfl  •piitft]  eonl  18  wwiting  (FttostM). 

(2)  B0mtraKia,—Tbe  aotflrior  portJoD  of  the  ekuU  ia  absent  ohd  ihn 
min  deficiant. 

f3)  fffmiujMl^—Tbn  Uicral  half  of  tlio  )>raiD  and  sicull  ix  'IcHciviit 

{*)  ffottmetpkaba. — The  upper  part  of  the  Rkull  is  iloft«i«.-nt,iiiiiI  ).lm 
i!ft«bRtl  crtiumn  i»  not  entinly  olosed  iui  whilw  tb«  brain  dcrclApn  in  tbc 
canal  idsImmI  of  the  skuU. 
ffylrtnetphaUc^ — lu  tliia  ooDdiUuo  tb«  buuea  of  tho  skull  ato 
at,  on  opening  being  left,  ijeneralljr  at  one  of  the  fontuiellea,  tlirough 
'hidt «  ecA^  fluataating  (amoiir  projects.  Tho  ttioiwir  oantoinB  fluid,  nud 
lo  swHnll;  W  emptiml  by  cttuuty  jimeaimL  Tb«  w&lU  of  tfa«  tumour 
MUBSt  of  tlw  soft  ooveringa  of  tho  ulnill,  Aiid  tho  distended  tncmbnuiea  of 
laebnila.  The  tumour  oommunicala  with  Ihvgeneml  vmtriailArmvity 
rthebmia 

(6)  EnrephalootU.—'The  boura  of  ttc  »lnill  oro  again  ilcflcteiit  at  Borao 
Mt  In  thik  otmditionf  but  throngfa  the  opming  fonned  a  portion  of  the 
ndn  Itwlf  projects,  fomiii^  a  brood,  flat,  solid  bumoiir.  The  tumour 
n^oontlf  oecnplM  the  forehead,  orUt,  or  side  of  tho  noM. 

§  695.  Ths  Law  of  DmolxtHcni. — Althougli  the  law  of  disso- 
jBjMfcAi  probftbly  destmed  at  some  futiird  limo  to  throw  more 
pfttk  tli«  tnorbid  oaatomy  of  tbc  braia  tban  oq  tbst  of  aoj 
Iher  otgan  of  the  body,  yot  it  maat  be  ftdmitt«d  that  up  to 
U  preeept  very  little  proji^resa  Hm  b««n  made  in  this  direction, 
la  lav  has  been  applied  by  Dr.  Hti^hltngs-Jackeou  witb 
lucb  ingenuity  and  ra«oeBS  to  the  intorprctotion  of  diiiordered 
erebral  functions,  but  it  has  yet  to  be  applied  to  the  eluci* 
fttioD  of  morbid  cerebral  litructures.  The  histological  elemeats 
f  the  brain  doobttesH  cocfortn  to  this  law  in  their  degene- 
itions  ID  a  raaQoer  similar  to  that  already  described  with 
igard  to  the  histological  elements  of  the  npinal  cord.  And 
ran  when  the  diwaae  is  ditTiined  in  the  neuroglia  the  small 
Ellis  and  thin  fibres  of  tho  oooessory  portion  of  the  brain 
itui  suffer  injury  more  reiulily  than  the  large  cells  and  thick 
bres  of  the  fimdamental  portion.  This  a  priori  neccaaity  has 
ot.  however,  been  verified  as  yet  by  a  i>osteriori  obeerratiost. 
Ivcu  ia  tucb  a  coansc  lesion  as  that  caused  by  occlution  of  one 
'  the  cerebral  aiteried — say  the  inferior  frontal  brancli  of  the 


506 


HOEBID  ANATOMT  AHD   CLASS  IFICATtOK 


lefi  Sylvian  artery — the  operation  of  this  law  may  pn>)nbl;bc 
traced.    If,  as  wo  have  already  oodoaToured  to  provo,  tb«  ]»M- 
formed  celU  and  (ibr«s  of  Broca's  coDvoIudon  lie  near  the  ntt 
of  this  jirtery,  while  the  cArlier-fonnod  cells   lUid  fibrtt  W 
thrust  upwards  and  forwards  towards  tbe  terminal  twigs  of  Uc 
Tesael,  it  isi  manifest  that  the  earlier  ia  in  a  much  more  favoai- 
able  p(uitioD  than  tbc  later  developed  portion  to  obtain  ooaraib- 
ment  from  the  neighbouring  vascular  territories.    But  this  cm* 
dusion,  although  there  i>  much  probability  in  ita  favoiar,  hai 
not  yet   been   confirmed  by  careful   dissectioo.     Thece  briai 
and  imperfect  remarks  are  all  tliat  we  feel  justified  in  making 
in   the   present  state   of  our  knowledge,  with  regard  to  the 
applicability  of  the  law  of  dissolution  to  the  structural  alteiv 
tiuns  produced  by  disease  in  the  braia. 


(n.)-0LA£SIFI0ATlON   OF  TUS   DISEASBB  OF  THE 
ENCKPHALOy. 

It  is  impossible  to  give  a  full  and  sctenttfic  classif 
of  the  diseases  of  the  encephalon,  inasmuch  as  a  large 
tion  of  them  are  beyond  the  scope  of  this  woi^  It  is  not  oni 
intentjou  to  enter  upon  tho  discuBsion  of  the  wide  class  o( 
dieeases  of  the  brain  comprised  under  the  gensral  term  insanity, 
and  yet  do  classification  of  tbe  diseases  of  the  encepbalon  cid 
be  considered  satis&ctory  which  does  not  comprise  them.  In 
eudeavouring  to  classify  tbe  diseases  which  remaia,  we  shall 
proceed  oq  tho  principle  of  coasideriug  first  thoso  which  gin 
rise  bo  the  fewest,  and  leaving  to  the  last  those  that  occasloe 
the  most  numerous  and  complicated  symptoms.  Now  as  d>fC«M 
of  the  membranes  can  hardly  ever  exist  without  prodQCU^ 
secoudary  disease  over  a  large  area  of  the  sarfaoe  of  the  favaio, 
the  symptoms  eharaoterising  tho  former  may  be  expected  to  be 
OD  the  whole  more  complicated  than  those  of  the  latter,  and 
ooQBequeotly  the  diseases  of  the  oncepbalon  will  be  consideTed 
prior  to  thot»  of  the  membranes  Of  the  diseases  of  the 
eooephalon,  the  lesions  which  give  rise  to  the  least  compUcated 
symptoms  are  the  /oeal,  and  those  which  give  rise  to  the  most 
comphuited  symptoms  are  the  difuMd  lationM.  It  is  kaowo 
that  a  focal  lesioD.  as  a  tumour,  may  by  uiCT«ftslog  the  intra- 
cranial pressuro  and  in  other  ways  give  rise  to  diffused  effects, 


Of  TKB  DISEASSS  OF  THE  ENCEI'HALON.  509 

It  a  difiueed  dlscftsc  like  encepbalitis  may  by  termicating 
in  abscess  oocaaioo  local  symptome.  The  divisioti  iaio  focal  and 
digumd  lesioDs  is,  therefore,  not  a  icicntific  but  a  priLctical  dift- 
tinctioo,  and  must  be  judged  entirely  from  a  practical  8tand> 
point.  The  symptoms  cnused  by  focal  iliseaaea  depeod  partly 
upOD  the  nature  and  partly  upon  tbo  locdlity  of  the  lesioD. 
Corebral  hsmorrbage,  for  instance,  occasiouB  a  grouping  of 
symptoma  vhich  enables  the  aflfection  to  be  readily  distinguished 
from  tbe  symptoiQS  produced  by  the  alow  growth  of  an  Intra- 
amniaJ  tumour;  yet  tlie  symptoms  caused  by  destruction  of  a 
certain  portion  of  tbe  internal  capsule,  for  instance,  h  the  t>anie 
wbetiier  the  injury  be  caused  by  tuemorrbage  or  by  tbe  growth 
of  a  tumo'ir.  The  focal  dtseaaes,  therefore,  admit  of  cooHidera- 
tioo  under  two  atipccts:  (I.)  according  to  the  symptoms  common 
to  the  pathological  state  in  general;  and  (II,),  according  to  tbe 
^tecial  functions  of  the  region  affected.  With  theae  few 
remarks  the  following  ctassiBcation  may  be  allowed  to  explain 
itaeU:— 

A.  IH9«as$»  of  the  Eacephalon. 

Bocal  diannica 

(l)  Qeueral  cousideration  of  focal  diseaaea,  according 
to  tbo  nature  of  tlic  k'sion. 
h  Oooluaion  a!  intracrauiol  vcaaels. 
S.  [ntracranial  fattmotrbnge. 
3.  LitraciBDial  tiunoun. 

ftl)  Special  coouderation   of  focal  disease^  according 
to  the  loealiaatvm  of  the  lesion. 

I.  AiTecbiiiiw  of  podunoiUar  fibres  and  iatcmal  cujiBuIe. 
a.  AfifcctioHB  of  the  jii-ramidal  tract. 
[L)  HemiplegiiL, 
(li.)  Hf-miat)a.-uii. 
h.  Aflfac.'tiaiid  of  the  Hviumry  |)e<luiiculAT  flvw  and  optic 
tBtliatiunii  i^f  Onitiolvt. 
(i.)  IIcmuunMttieaJA. 
S.  Lodons  of  the  cortci  at  tbv  bmiii  iu»l  of  tfae  subjaoezit 
lurtiuii  of  the  ocntruiu  urulo. 
a.  LoiuoQB  iu  lliu  nivii  of  tlie  middk  ourebral  Brtoty. 
(I)  UoilabcmJ  coBvuUioiu,  and  moAoepoBma. 
(iL)  UoQo^ilegiw. 
(uL)  Cortiocd  (tficcttoHi  df  il|>Moh. 


510       ChASBiriCXTlOU   OF   DISKJL8B8  Of  THE   BXCHrBlLOir 

h.  Leaioua  in  tbo  uea  of  tbu  (MKiteriar  eerebtal  utt 

c.  Ixiaiuiu  iu  tin  at««  uf  tbe  anterior  ocrUsI  ulf 

3.  Luuan*  In  the  boMlgnnglu,  external  oo{«d1k,«1«wM 

KDil  Imm)  of  tUe  bntin.  1 

4.  Lwioas  locflli«od  in  th»  atttictiira*  sHaatad  Mo^ 

tentorium.  ' 

a.  LanMUtn  tbepeaaandpediuicIcBflf  the 
11   Ijiip««»  ill  the  [Tflniwlr^  of  Umi  oereLeUtaa. 
e.   TiiiriiTiw  ill  ihe  ooreboUttm. 

II.  Diffused  diaeas«a  of  the  enoepbaloo. 

(l)  ADeomia  aud  bypem-'mia  or  the  brain, 
(ll.)  Atrophy  and  hypertrophy  of  the  brain. 
(ill)  Shock,  and  ooucusaioo  of  the  bmiu. 
(iv.)  £D06phAUti& 

1.  Geoonl  ooceiilialttifc 

2.  Partial  etnvphalitu. 

a.  Acute  eDoophalibia,  oaiii|Jl(»tiog  nttectiaim 

petrous  portica  of  ttw  t«p|K>r«l  Aod  ottnr  1 
of  the  nknlL 

b.  Acuttt  pynmic  aooapbalitia. 
c  Kioephaliiia  wmtoaiary  to  other  oerebml  laia 

d.  Chroma  abeoem  of  th4  brain. 

R  Diaeaeea  of  tlie  Mtmbnna  of  Ike  Brain. 

I.  Diseaftefl  of  the  dura  mater. 

(I.)  External  pacbymeningilia 
(ll.)  Xutertiftl  pachyinsaingitii. 

II   Diseases  of  thd  pia  mater. 

Acute  inflammation  of  the  pia  mater, 
t.  LeptameDinj^itia  Itifiuitum. 
%  Tubercular  uMiuuifilJe. 

3.  Meniugitu  of  the  hwe  of  Iba  brain. 

4.  U«QUigitu  of  tlM  cwunadiy  trf  the  Imlu. 
&.  Uctjutatto  inuntDgitis, 
ft  Tnumatic  mcauigitiB. 


sn 


CUAPTEB  m. 


I 


(t.)  OESERAL  CONSIDERATION    OF  FOCAL  DISEASES, 
ICCORUINU  TO  THB  NATURK  OK  THE  LESION. 


1.  OOCLTTSION  OF  THE  INTRACRANIAL  VESSELS. 


arteries,  veina,  sinuses,  and  capillAries  of  the  bmin  are 
ii>bl6  to  become  occtuilcd,  a  circumstanco  which  gives  rise  to 
nnooB  pathological  chaogos.  Tbe  occluding  body  may  be 
ftcned  OD  the  spot,  couHtitutiog  thrombosis;  or  may  be  carried 
&aa  diflt&Dt  partA,  coDstJtating  embolism. 

^K  (a)  Oeclu»ion  of  the  Cerebral  ATteriea. 

B|  696.  Etiology. — Emboli  consist  ot'  fibriaous  masBCS  va^wl 
Hif  from  the  left  cavities  of  tho  heart,  the  aortic  and  mitral 
wires,  the  arch  of  the  aorta,  and  occasionally  from  the  pulmonary 
"ttDL  In  cases  of  carcinoma  of  the  lungs,  a  cancerous  masH 
naj  posaibty  be  carried  from  the  pulmonary  veins  and  pass 
ioto  tlie  cerebral  vcsaels. 

Atterial  thromboHis  is  delennined  partly  by  general  causes 

^dmg  to  diminish  the  force  of  the  heart's  action  and  to  alter 

^e  quality  of  the  blood,  and  in  part  by  local  degenerations  of 

vecDsta  of  the  Tesselii  themRelvEM.    During  couvali^Hceuce  from 

*citle diseases  and  other  exhausting  processes,  the  heart  is  weak, 

^  the  blood  becomes  so  altered  in  quality  that  it  is  specially 

Pnae  to  ooagulata    This  process  is,  of  course,  much  favoured 

f  tbe  beatt  have  undergone  dilatation  without  proportionate 

hypertrophy.     The  local  cauwis  of  lUrumboaia  ore  allL-mtious  of 

tbe  walls  of  the  arteries,  whereby  their  lining  membrane  is 

'toghooed  aud  their  calibre  is  oarrowud.     The  coogulatian  of 

^brioe  IB  favoured  by  changes  in  the  walls  and  inteniaJ  surface 

^  tha  vessel,  8ucb  as  those  due  to  atheromatous  and  oalcarooua 


512 


FOCXL  DISEASES,   AOCOBDING   TO 


degeneratioiu.    Tbromboeia  ia  particularly  liable  U)  oocor  wlw^ 
general  caus<»  and  local  dcgcnorotiou  act  together. 

ThromboBiB  may  takd  place  in  aoy  of  the  artenes  at  the  I 
of  th«  brain,  orinscvcralof  them  at  the  same  time.  Athnno) 
not  uofrequeotly  forms  in  one  of  th«  internal  carotid  ait«nii, 
and  the  clot  then  often  extends  into  the  middle  and  a&toicc 
cerebral  arteries  of  the  satno  side,  aod  ttometimeK  eveu  iota  thi 
posterior  communicatiDg  and  the  posterior  cerebral  artery. 

Of  the  predispoaiag  causeH  of  cerebral  thrombont  age  ii 
probably  the  most  importanl  Thrombotis  occum  aion  f» 
quentty  in  advaiic«i  age,  owing  to  the  degenerative  chugN 
in  the  ve^els,  ahbough  it  may  occur  at  all  ages.  Bmbotifln. 
on  the  other  hand,  ia  met  with  in  relatively  young  pentm 
although  it  may  aloo  occur  in  persons  of  advanced  years. 


§  697.  Symptoms. — The  ayraptoma  which  characterise 
UtOT  atagcs  of  thrombosis  and  embolism  are  the  some,  bat 
of  the  early  period  differ  conndeiablj. 

The  symptoms  of  embolism,  ore  veiy  sudden  id  their  < 
and  are  not  preceded  by  any  premonitOTj  signs.  The  patieoti 
suddenly  attacked  with  dizsiness,  utters  an  inTolnntoiy  ciy,  or 
oomplnins  momentarily  of  headache,  and  Ibon  idmoet  inuw- 
diately  iusee  cousciousness.  The  symptoms  occaaiocied  by 
embolism  of  a  cerebral  artery  are  in  their  general  char«el<n 
and  mode  of  onset  almost  identical  with  thoae  of  oenfanl 
hsamorrhage,  but  the  uncoosciouBDesB  caused  by  emboKam  is, 
as  a  rale,  more  transient  than  that  produced  by  bRmorrbagei 

In  many  cases  there  is  no  coma,  but  only  some  dinioeet  or 
slight  confusion  of  mind  fw  a  minute  or  two,  along  with  the 
sudden  advent  of  paralysis.  Tlie  attack  is  sometimes  nahend 
in  by  epiteptifonn  convutaions,  which  may  sometimes  be  geoenl 
like  an  ordinary  epileptic  attack,  but  are  at  other  times  Umtted 
to  one-half  of  the  body,  to  one  extremity,  or  one-half  of  Um  hoe. 

When  general  convulsions  arc  present  tlioy  occur  limill- 
taneously  with  the  loss  of  conscioosnees,  and  are  followed  by 
paralysis  immediately,  while  unilateral  and  partial  cooTaUoBs 
may  recur  repeatedly  before  paralysis  is  fully  established.  In 
some  cases  the  attack  is  accompanied  by  vomiting,  and  Hamawnd 
reports  a  case  in  which  active  delirium,  and  SAOth«r  io  ^tefr 


TBE  NATCRE  OF  THE  LESION. 


»9 


Iiallncinations  and  delusions  were  preseDt  for  some  lioura  after 
»  suddeo  attack  of  hemipU-gio.  Th«  preseucc  of  diseoJM;  of  tb« 
MKtie  uid  milml  valvcH  in  Hammoud's  caece  reodered  the 
dUgnosu  of  embolism  very  probable. 

la  miuiy  cases  sudden  spcucbletseuees,  &  condition  which  will 

be  uib»cq»eDUy  described  m  aphatia,  coosUtutes  the  only 

•jfuptoio  vf  tbe  affectioa,  atid  ia  these  cases  the  symptom  ma; 

diaappear  in  a  few  days  when  oollftternl  circulation  is  estab- 

Ittfaad.     Aa  a  rule,  however,  the  nphnsia,  is  associated  with 

rigbt^ided    hemiplegia,    which    poaat^ases   the    same    general 

chantct«re  as  thnt  which  resulu  from  bu^mi)rrhago  into  the 

kuicular  uucleus  and  iieigljbouring  parts.     Tho  right  side  is 

meio  frequently  affected  with  paralysis  thuu  ihu  left,  owing  to 

the  greater  hability  of  the  left  niiddio  cerebral  artery  to  he 

affected  by  cmboHsm.    The  state  of  the  pupils  during  the  onsst 

d  ibe  attack  has  been  variously  described,  and  it  probably 

mm  in  dift'cieot  ca»es.     Eilenmeyer  states  that  the  pupils 

nmaia  eeDsitive,  being  ueitlier  contracted  nor  ditnted,  while 

Hutmood  has  fouud  dilatation,  contraction,  or  irregularity. 

1^  »tfmpt<n)is  of  throfnbo6i$  are,  as  a  iiile,  more  gradual  tu 

their  d«Telupaiei)t  tbaa  those  of  embolus.     The  more  usual 

pcnonitory  aymptonis  of  tbromboeis  of  a  eerebral  resael  cod- 

<■(  of  head&clie,  which   muy  be  diflused  through  the  entire 

Wid  or  referred  to  tbo  neighbourhood  of  the  morbid  process 

i,HuiiitioQdj,  dizziness,  and  a  sense  of  general  confusion.    The 

plttieDt  may  complain  of  Dumbaci»,  coldness,  or  fonntcation  in 

''■*»  extremity  or  throughout  tho  distribution    of  ono    nerve 

w  i»  the  entire  half  of  the  body.     Ai  limes  there  may  bft 

Mniderable  mental  disturbances,  and   failure  of  memory   is 

often  a  marked  Bymplom.     Motor  diftlurbancai  are  usually  of 

liie  nature  of  more  or  leas  extensive  pareKiii,  but  occasionally 

die  loss  of  motor  power  is  preceded  by  slight  convulsive  more- 

iDeotJL    Faraiysia  may  occaxioually  supervene  suddenly,  but,  as 

a  rale,  ita  dcvelopraent  is  slow  and  gradual,  its  progress  being 

Harked  by  successive  remissions  and  ezaceibatioDs.    Tliis  mode 

of  devel(^»aeQl  appears  to  be  due  to  tho  fact  that  thrombosis 

baa  a  tendency  to  extend  backwards  and  to  implicate  more  and 

more  of  the  artert&l  bEanch.  in  whose  ultimate  twigs  the  prooeas 

may  have  firvt  begun.     The  duration  of  tho  prodromal  stage 

uu 


6U 


FOCAL  DISEASES,  ACCOKDISO  TO 


may  vary  from  a  few  hours  to  several  montliA,  and  cpccuionillj 
apoplectic  sjinptoms  may  come  oa  auddeoly,  as  id  embolun. 
WheD  once  the  vessel  bai  become  compleicly  occluded,  ^ 
further  progress  of  thrombosia  is  like  ibat  of  embolum  io  tk 
Kame  situation. 

When  fliiftening  occurs  the  temporaturo,  according  to 
vitle,  risee  ou  the  eecond  or  tbird  day  after  the  attack,  and  i 
two  or  tlircu  days  may  b«  as  liigb  aa  W  C.  (1(H°  F.).    In  a  (e« 
days  longer  thv  t^raporaturc  sioks  rapidly,  its  docliae  beio§ 
more  rapid  than  that  which  takes  place  afler  the  period  of  r^ 
action  in   cues  of  btcmorThage.     When  onco  softeoiog  hu 
become  thoroughly  established  the  symptoms  are  those  wbit^ 
rciiult  from  lucalised  cerebral  diseaae  geaerally,  and.  indeed  ili« 
symptoms  of  Roftening  and  of  hivinorThiige  when  regarded  u 
lucalisQii  ilisyases  oru  often  identical. 

Contractures  of  the  paralysed  limbs  are  not  so  oommoo  ia 
cases  of  occlasioa  of  vessels  aa  in  euee  of  haemorrhage,  but  tb^ 
occur  8ufHciently  often  to  make  their  presence  or  abtciwe 
destitute  of  diagDOfttic  significance. 

The  xeniory,  trophic,  and   vaso-motor  disturlNUioea.  u  arell 
as  tlie  affections  of  the  special  senws,  with  the  exception  of 
vision,  are  the  same  as  thoae  which  occur  in  connection  wtlii 
cerebral  ha-morrhugea.    In  some  cases  of  embolism  (be  opfaUMt 
mic  artery'  ban  become  occluded,  giving  rise  to  sudden  amaoroaa 
On  opbtbalinuiM:opic  examination  the  arteries  of  the  retina  arc 
seen  to  iio  empty;  tbcy  appuiir  like  Bnc-  threads,  but  sUU  ta-    , 
tain  their  red  colour.    The  veins  are  not  much  diminiabwi^B 
size,  and  are  filled  with   dark  blood.    The  rotioa  pnMDM^^ 
greyish  or  white  opacity  which  is  most  marked  ftrooDd  tlw 
macula  lutea,  but  the  fovea  centralis  temuos  of  a  bngfa(  nd 
colour,  forming  a  marked  contrast  with  the  pallor  of  Um  mi* 
rounding  portion  of  the  retina. 

Yariuuti  disturbanoes  of  tlie  mental  faculties  may  roault  boia 
embolic  softening.  Probably  the  most  intoresting  ot  thtm  is 
aphasia,  which  results  from  embolism  uf  the  middle  ccfebod 
artery  generally  of  the  left  side,  but  this  oonditioo  will  ba  dt^ 
citased  at  greater  length  io  a  future  chapter. 

In  itoine  cases  of  ooclusiun  of  cerebral  ^rieriee  tbe  Rynptuns 
bejjin  to  improve  at  an  early  period,  and  the  patient  mif 


TBE  NATCHE  OF  THE  LESION. 


515 


ultimately  recover  completely.  Id  these  cases  it  is  evident 
titat  the  collateral  circulation  baa  been  established  before 
eoftenin^  bas  comoienccd.  Id  other  c&ses  the  imticnt,  after 
partial  or  complete  recover)-,  vt  nttockeJ  again  with  einbulism, 
aaJ  Lhcro  may  be  a  eccoud  recovery.  In  some  cases  of  throm- 
b«M)3  the  first  symptoms  niay  be  of  moderate  severity,  and  may 
ifterwards  become  by  sudden  accc^ioQs  more  and  more  severe. 

la  some  few  coses  death  may  follow  immediately,  but  as  a 
mie  it  is  Dot  so  sudden  aa  in  hft-morrbage. 

Diseases  of  the  mitral  or  aortic  valves,  aortic  Aneurism, 
oleerative  endocarditiB,  and  inflammatory  or  Aypbilitic  a€ec> 
tioos  of  the  mtiscular  substance  of  the  heart  are  the  compli- 
cstioDs  usually  met  with.  In  cases  of  thrombosis  evidences  of 
degeoeralion  of  the  vaijcular  syHtera  can  ii&nally  bo  detected  in 
tbe  radial  and  other  arteries.  Important  symptoms  may  arisu 
frwa  embolism  in  the  spleen,  the  kidneys,  and  the  arteries  of 
the  extremities. 

§  tiSS.  DiagjumB.—The  problem  of  diagnosis  is  to  distin- 
gtusli  cerebral  embolism,  thrombosis,  aud  bsemorrhage  from 
otw  another.  This  must  be  done,  not  so  much  by  means  of 
ibe  cerebral  as  of  tbe  associated  symptoms. 

When  sudden  licmiplegia  occurs  id  a  young  or  middle'agetl 
ftmm  who  ia  Buffering  from  valvular  disease  of  the  heart  or 
•Deurism,  tbe  symptoms  are  in  all  probability  due  to  embolism. 
The  probability  of  embolism  of  a  cerebral  artery  is  rcuderod 
nil  greater  if  there  be  a  history  of  previous  seizures  in  tbe 
btaio  or  other  organs.  Right-sided  hemiple^a,  viiih  aphasia, 
remits  more  frequently  from  embolism  ofthoieft  middle  cerebral 
vtery  than  from  any  other  causo,  and  consequently  in  such 
tscsi  the  presumption  is  always  in  favour  of  occlusion  of  the 
vnsel  rather  than  bivmorTbage,  provided  there  be  the  neceRsary 
oindltioas  for  its  occurrence.  There  are  uo  absolute  m<^auB  of 
•iistingiiishing  between  bicmorrhage  and  tbrombosiH,  and  it  is 
occdleei  to  diseass  the  various  diagnostic  signs  which  have  from 
time  to  time  been  proposed. 

§  699.  Morbid  Anatomy. — Embolism  aSccte  cvrtain  vessels 
with  special  frequency,     The  mode  of  origin  of  tbe  left  carotid 


£18 


FOCAL   DISBASBS,  AOCORDIXO   TO 


directly  from  tho  orcli  of  the  aorta,  and  the  angle  ai  v^idi' 
leaven  the  arch,  vei^r  mudi  favour  emboli  being  carried  iato 
it.    These  emboli  usually  pass  the  circle  of  Wiltis  and 
their  way  into  the  left  middle  cerebral  artery^,   which  it 
direct  continuatioa  of  the  tDtemal  carotid,  and,  oockseqi 
this  artery  is  more  frequently  occluded  by  on  embolos 
any  other  vessel  of  ihe  brain. 

Thrombosis  does  cot  appear  to  have  a  Rpecial  prefervDCc  tm 
any  one  artery.  The  middle  and  posterior  cerebral,  and  Ten»- 
bral  arteries  are  equally  liable  to  be  occloded  by  thrombow. 

^lien  cue  of  the  cerebral  arteries — the  left  middle  rewtnl 
artery,  for  example — is  obiitnict«4l  close  to  the  circle  of  Wfia 
the  circulation  through  the  nutrient  arteries  supplied  by  il  Is 
the  basal  ganglia  is  anrealed,  aud  as  tbeae  are  terminal  artcbsi 
rapid  soHeoing  occurs.  When  one  of  the  vea»l»  of  tb«  bois 
is  obslmct^  on  the  cardiac  side  of  the  circle  of  Willi*,  tbe  tm 
anaetomoaia  of  the  Iatt«r  rc-cstabliabcs  the  ciKuUtioa  aoqoidd; 
that  no  pathological  changes  occur  id  tbe  brain.  If,  agais,  tb^ 
embolus  be  curried  forwards  past  the  boaal  portion  to  the  artoul 
syst«m  of  tbe  cortex,  it  is  qait«  possiblo  that  the  fre«  taatUh 
raoeia  of  tbe  latter  may  prevent  decided  patbologkal  rfisiyt 
from  taking  place.  Jn  many  cases,  however,  a  oertaio  anoul 
of  softaoiag  does  occur  uuder  such  clrcuunstaucoa,  because  iW 
anastomoais  is  not  always  so  free  as  to  compeuHstc  for  lbs 
blocking  up  of  a  Urge  branch  of  tbe  artery.  When  liw 
embolus  is  lodged  in  one  of  tbe  terminal  arteries  of  the  hMsl 
arterial  system  softening  always  occars,  owing  to  theabMDOi 
of  anastomosis  with  neighbouriog  arteries 

Tbs  fint  «9«ct  produced  by  oodosioo  of  a  t«niuaiJ  artery  ia  <s«lMn  rf 
the  part  snpplied  by  it.  Tbe  venules  tnd  art«riolea  of  tbe  psrt  im  hE^(^ 
r«ctly  DOtuubed  MO  thiit  their  wslU  dilsto  and  5v]uetitly  rU[4t)i 
rile  to  hypanKotia  attaoded  by  ixdemaUKu  HwelliDg  utd  h»u»urrbj»^. 
tiwues,  not  being  aj|)p|kli«d  with  Doumbraeut,  brMlc  dvwn  aod  nsJayv 
softenni^  Wben  tbe  sottcniod  tiaauea  became  mixed  with  axtrmnatnl 
Mood*  they  give  rise  to  rwj  ti-fUniiig.  Tbe  hypflramiR  aad  biinMibif 
may  fail  to  occur,  end  then  alinple  neerobMa  reaoUa  tmu  tbe  ulcjwm 
of  the  re«sei,  giving  rise  to  a  softened  taua  of  a  yeUowUi>w1ilt«  m  <iMi 
oolour.  ThesecbaufEeiiKcneralljr  )iegin  in  tbecourveof  tbeKenadtwmtj- 
four  hMin  Aftor  tbe  obivtvuetiOB  baa  occurred,  altbough  cmw  an  ref<i»«J 
in  nbich  the  oonsiricooe  of  thv  bnUi  tiaaus  was  oonaal  aftar  lkski|MW 
two  days. 


THR  NATTRB  OP  TSB  LHSIOK. 


517 


JfiautBOpk  ttamxmiuion  reveals  the  prattenoe  of  a  larf-e  number  of 

I  blood  eerpuiolw,  whioh  U  the  only  abnotmal  appoarAncc  ohiwrved 
Iniiog  Un  firat  tmntj'-fuur  tiuura.  At  a  UWr  |>orioi)  the  norvu  eloiaenU 
Biulargo  gracliaii  d«g«iieratiou.  The  miMt  ])mtiii  tioul  uiicnvtcoiiic  i>ocu- 
iuity  ODUAints  of  granular  cor|)utM;liM,  which  nro  probabl;  dorivcd  rrom 
lagm«Tattoa  of  murogLa  and  gaDglinn  colU  of  tbo  gny  eub»taiic«,  and 
Tarioiu  other  Boorowk 

ExperitmmUaX  Jnveitiffaitiofu. — The  first  esperimeutal  feeeaKbea  with 
ngqiect  to  the  embolic  prooeoB  was  undertokcu  by  VirchoT,  and  great 
addttioiukl  light  baa  beon  thrown  upon  tbti  atibjoct  by  the  important  ei> 
parimcatal  and  micmacoptc  ioreatigBtions  of  Cohnheim.  Paoum  atiidied 
ez{>erim«»t«])f  1h«  ro«uIt«  of  ooclusioa  of  cerebral  vestiel«  witti  the  view  of 
detemiaiDg  the  manatr  in  which  doath  is  caused.  B.  Cohn  iiivcatlgatfld 
uparimeBtally  Tarious  clinical  and  anatomical  points ;  Kett«  studied  the 

alto  of  capillary  omboUain  ;  vhilo  I>rcvobt  and  Cotard  made  a  seriw  of 
nperimanta  with  the  view  of  dutorminiug  tliQ  reLatiou  of  ocoluaioa  of 
ccrefaial  TeaselD  to  aoftoniug. 

§  700.  Morbul  Phyiioloff!/. — The  most  difficult  problem  to 
■olve  wilJi  respect  to  the  morbid  pLyaioloj^y  of  tbc  affection  is 
WW  occlufiion  of  only  one  of  tlie  cerebral  nrteries  produce*  losa 
of  coosciousness.  Browu-S^uard  has  recently  dwelt  upon  tbe 
lact  tbat  local  tcaious  cxcrl  au  iofluouco  over  remote  part«  of 
ifae  uervous  sytiteni.  and  the  auddeu  arrest  in  the  ctrculatiou  in 
one  of  the  arteries  of  tbe  braju  is  likely  to  pioducc-  widely- 
Spread  effects.  Heubcer  and  Buret  have  shown  that  although 
ibe  abuodaDt  aoastomoses  between  tbe  arteries  of  the  cortex 
kfter  a  time  esitablisb  a  collateral  circulalioo,  yet  at  tbe 
momeat  of  obstruction  great  diaturbauces  of  the  circulation 
and  marked  cbaage»  iu  pressure  may  occur  in  and  around  tbe 
implicated  region.  We  have  already  seen  tbnt  sodden  depriva- 
tion of  DoarisbmeDt  increases  tlio  irritability  of  nerve  fibres, 
and  it  is  probable  that  tbe  abrupt  arrext  of  tbe  arterial  drca- 
bition  induces  a  powerful  outgoing  discharge  from  the  cortex. 
"niat  tbis  occurs  in  certain  cases  is  undoubted,  inasmuch  as 
tbe  ooaet  (^  the  attack  in  marked  by  gcuural  convulsions,  A 
powerful  discbarge  of  tbis  kind  would  bu  followed  by  vsbaustion, 
aotl  temporary  loss  of  function,  or  in  other  words  the  attack 
-vroold  bu  characterised  by  toss  of  couBciousnees.  In  tboae  caaes 
in  which  there  is  an  abseuce  of  coavulsioDS  the  cortical  dift- 
sbarge*  may  ha  supposed  to  neutralise  one  another  in  the 
nervous  system  without  producing  their  usual  visible  cffeots. 


518 


FOCAL  DiaEASBS,  ACCORDIHO  TO 


§701.   Proffntms. —  Doth   orabolism  and    thromlxiat  ii* 
alwaya  serious  affGCttans.     When  embolism  oecura  io  &  yuoof 
p«rBoa  recovery  from  the  tmmetliatu  eSecte  may  be  npiilidd 
complete,  but  the  underlying  affection  to  which  the  fttluk  m 
due  will  still  be  preeeut  and  may  cause  s  simiUr  attack  io 
the  future  or  give  rise  to  other  grave  symptoms.     TbromVait 
is  uMially  associated  with  advanced  age,  eafeeblement  of  tlie 
heart's  action,  and  degeneration  of  orteriea,  and  during  \kt 
attack  there  is  great  danger,  howerer  slight  the  symptoms  ■>; 
at  first  appear,  that  the  oocluaion  will  become  more  and  amn 
exteuiiive. 

§  702.  Treaim,ent.  —  Fropbylaotic  mucoreB  am  only  U 
adopted  when  premouitory  symptoms  are  prMMt  for  a  long  time 
io  cooneclioQ  with  a  alowly-forming  thrombofiia.  la  nieh  cam 
the  heart  should,  according  to  theory,  b«  sttmalated  by  difitafiit 
ammonia,  and  alcoholic  iittmulaots;  but  siuco  it  is  impowUe 
to  diagnose  this  couditioa  during  life  from  haDmorrbago.  it  vill 
be  b«>tter  to  be  content  with  adopting  the  sama  treat—t 
as  that  recommended  fur  hfemorrbage.  During  tb«>  atags  of 
coma  bIhu  the  same  mcang  should  be  used  as  in  bffimorrfaa^ 


(b)  l^romhoeis  of  the  Central  Sinuses. 

§  703.  Fuiory.—Sftcul  att«ation  wm  fint  direolcd  t>  th»  mhpAii 
tbromboois  of  the  uerebrA]  ■iuuaM  by  tfas  obaerrations  a(  Toon^.  Uki; 
vaJiuUe  clitiiool  obverrations  with  nsgard  to  the  dueue  wet*  mad*  bf 
Fochel^  ftod  tl«  att«iiUou  of  Lebvtt  vru  aiao  directed  to  it.  Tfat  tttathw 
of  Vou  Duocb,  B.  Oohn,  and  ot  Lui<»niMi  helped  %-nMj  to  eatnltDl 
to  kj&tt)mati««  our  kuowlodge  with  respect  to  tbia  Ibiotnboaia ;  uri  is 
more  recent  times  our  knowled^  baa  bean  further  incraaHd  by  tlw 
Uboora  of  Qorliardt,  Qrie>[D(sr,  Coruaa,  Beabner,  and  Uopitftihi. 

§  701.  Etiology. — Thrombosis  of  the  rinuses  may  be  dJviM 
into  two  groups :  the  Btst  comprising  the  oaaea  whic^  iiiM  in 
the  absence  of  any  affection  of  the  walls  of  tbe  Toiofl,  and  the 
second  those  which  origiuate  from  phlebilia 

Tbe  oases  of  thn  first  group  arise  in  condiuons  of  ■maratmmM, 
ID  which  the  quality  of  tbe  blood  is  altered  and  the  ctmttation 
enfeebled.  Under  such  circumstances  coagolatiou  of  the  Uood 
is  specialty  prone  to  occur  in  the  sinases,  inasmuch  as  tJwy  aie 


fHE  KAn'RE  OF  TUB  LESIOH. 


519 


rigiJ  tubes  and  tacap»ble  of  collapsino: ;  they  are  also  tlestltuto 
of  muaciilnr  valU,  aod  arc  traversed  hy  buadii  of  cDnnectire 
tuNue. 

Thrombosis  of  the  amuses  fryio  marasmua  is  particularly 
apt  to  occur  in  children,  especially  during  the  Brst  six  months 
i>f  life,  wliGD  they  are  liable  to  suffer  from  collapse  induced  bj 
severe  diarrhisa  It  also  occurs  in  adults,  in  caQsc([UCQCc  of 
profuse  suppunition,  caooer,  sonilo  noarasmus,  and  other  con- 
ditions of  debility.  This  form  of  thrombo^iis  occurn  with  special 
jrequoocj  in  the  longitudinal  and  lateml  KinuneR.  Obstruc- 
tion to  the  return  of  Ihc  venous  blood  towards  the  heart 
iDcreases  the  liability  in  the  fonnatioa  of  tbrombosi^j  of  the 
UQUSoa,  but  it  U  not  likely  that  venous  stasis  can  give  rise  to 
it  ID  the  abiieace  of  other  favouring  conditions. 

The  sefoad  group  of  thrombosea  is  cattaud  by  inflammatioa 
of  the  aiouses,  the  result  generally,  proliably  always,  of  disease 
or  injury  of  the  cranial  bones.  Caries  of  the  petrous  portion 
of  the  temporal  bone  ix  by  fur  the  moat  cuminuu  cause  of 
taflammation  of  the  onuses ;  the  lateral  and  petronal  sinuses, 
which  lie  in  the  vicinity  of  the  temporal  bone,  are  tbeu 
particularly  liable  to  be  affected,  altliuu^L  the  procuse  may 
implicate  the  circular  and  ca^enioiis  sinuses  as  well  as  the 
upper  part  of  the  iutcroal  jugular  rein.  In  most  cases  a  real 
phlebitis  is  taducod,  followed  by  the  formation  of  puralent 
thrombi.  Throiuboois  of  the  sinuses  also  frequently  follows 
blown  on  the  bead,  or  inflammatory  condition.?  of  the  scalp 
and  cranial  bonc«.  EryBipelas  of  the  head  and  face,  and 
farUDCulus  of  the  face,  especially  of  the  upper  lip  and  fore- 
bead,  not  unfrequentty  give  rise  1o  thmmbofiiH  of  the  sinuHes. 
Cohn  observed  a  caw  in  which  suppurative  phlebitis  of  the 
cavernous  siousoi  occurred  iu  coDuectlou  with  puruleut  inflam- 
mntion  of  the  deep  muscles  of  the  neck. 


§  705.  Symptoms. — The  symptoms  of  thrombosis  of  the 
cerebral  aiouses  are  generally  marked  by  complicating  diseases, 
so  that  it  is  mrely  possible  to  diagnose  the  affection  during 
life.  The  symptoms  also  vary  greatly,  both  iiccording  to  the 
Beat  of  the  occlusiou  aud  according  as  Ihc  tbramhosis  is  or  is 
not  the  result  of  phlebitis. 


6S0 


FOCAL  DISEASES,  ACCOttDINO  TO 


Thrombons  of  the  sinases  id  childnm  almost  alwmjn  traa 
durtiig  the  maraiimus.  c&iued  hy  eibaueting  diarrh<Ea,  aajtlw 
s}'mptoms  produci^  arc  the  a&rac  ax  tbotic  of  cerebral  iDCtufc 
1>eing  such  as  Dr.  MarBliall  Hall  described  andcr  UienuMd 
hydreuoepbaloid  disease.  In  addition  to  tbe  collapse,  eona*- 
lence,  and  cotna  of  pure  cerebral  aooiinia,  moUir  diaordvit  M 
oODVulHions  or  pamlysis,  are  generally  preeent.  Rigidity  of  At 
niiiHcleB  of  tbe  Deck,  sometimcfl  ako  of  thoM  of  the  badt  fend 
«TeD  of  the  limbs,  occasionally  nystagmus,  strabinntM,  pUtni, 
and  paresis  of  tbe  fncial  masclee  have  been  obeerved. 

Thrombosis  of  the  sinuses  resulting  from  mansmuA  in  adulu 
gives  rise  to  Tery  various  and  indefinite  e^'mptoms,  and  at  tinsR 
a  slight  degree  of  apatliy  and  general  depression  are  tbttooljf 
symptQmft  observed.  The  pntient  at  the  outcet  may  oompliis 
of  lioadacho,  nausea,  and  vomiting,  but  ibose  soon  give  plsos 
to  coma,  while  iu  a  few  cases  loss  of  consciousnefts  may  ba  pre- 
ceded by  delirium,  which  may  assume  a  «i*.ni^f^l 
Tbe  condition  of  the  pupils  is  variabia 

Motor  diHturbancen  are  nsually  present,  tbe  most  usual ' 
strabismus,  trismus.  coDtiactures  which  may  invoire  on«-balli 
the  body,  or  both  legs  and  both  arms,  tremors,  aod  epileptilbrB 
coQvulHiuna,  cither  limited  to  ooe  or  involving  tbe  finur  extfaai- 
ties.  The  motor  disorders  may  assume  the  form  ol  purosis  ar 
paralysis,  which  may  bo  limited  to  the  facial  nerve  or  to  iW 
motor  oculi,  or  may  involve  one-half  or  both  sides  of  the  body 
At  other  times  both  paralysis  and  couvulstoos  may  be  asso- 
ciated, one  extremity  being  the  seat  of  contracture  and  the 
other  of  p&r&lysis.  These  sj^mptoma  may,  however,  be  prtaeat 
in  «AS«i  of  cerebral  amemia  or  of  venous  hypertecoia  of  tbe 
brftin. 

A  valuable  sign  of  tbe  diMUM  is  sometimes  affwled  by 
swelling  of  the  veins  outside  the  skull  which  are  in  Moufto- 
nicattou  with  the  obiitructed  sinus.  Tbe  superior  loBgit»dinsJ 
sinus,  r^r  instance,  communicates  directly  with  tbo  veins  of  the 
nasal  cavities  and  with  those  on  tliu  uppt-'r  surface  of  tbe  skull 
The  occurrence  of  epixtaxts,  therefore,  favoun  tbe  idea  sf 
obstruction  of  this  siau^  and  in  children  tha  praMooe  of 
distended  vessels  running  to  the  anterior  fontanelle  fran  tbs 
nmgbbourhood  of  the  temples  and  ean  on  boUi  ades  of 


THE  NATUBB  OF  IKE  LE810S. 


5£1 


j||ttd  alao  &Toun  the  same  view.  Cyanosis  of  the  f&c«  limlbed 
Vtbe  part  siipplieil  W  the  anterior  facifil  veins  is  alno,  Bcconling 
Id  OerbAnH.  of  diiignoatic  significance. 

The  lateral  biqub  commuDicntes  with  a  »ina.ll  vein  vbich 
InTenea  the  mastoid  process,  aud  io  tfarombosi^  of  the  sinus 
localised  cedema  behind  the  ear  may  make  its  appearance. 
This  sign  is  occasionally  valuable,  Ijut  is  rarely  met  with. 
SimultAueoua  occlusion  of  both  lateral  sinuses  ^^ives  rise  to  the 
same  srmptoms  as  occlusioD  of  the  superior  loDgttudiual  sinua 

The  caverDous  sioufi  communicat&s  with  tlte  ophthalmic 
veins,  and  in  thrombosis  of  this  sinus  venous  hypeTccniia  of  the 
fundus  oculi  has  been  observed,  aa  well  as  cedema  of  the  eye- 
lida  and  conjunctiva  and  prominence  of  the  eyeballs,  due  to 
eongestioD  of  the  retrobulbar  veins  and  of  the  froutat  vein. 
Paralysis  of  the  motor  nervea  of  the  eye,  trigeminal  neuralgia, 
and  neuroparalytic  ophthalmia  may  also  be  presttnt,  owing  to 
the  disturbance  ia  the  nntritioD  of  the  nerves  which  pass  along 
the  aide  of  the  cavernous  siuun. 

In  thrombosis  of  the  sinuses  in  infants  the  fontanelle  is 
depressed,  and  at  times  the  edges  of  the  buti€<>  pushed  uuu  over 
the  other ;  but  during  Uie  progress  of  the  disease  the  fontanelle 
may  again  become  tense  and  prominent,  and  the  craiii&l  bones 
pressed  apart  (Qerhardt).  This  increase  of  the  contents  of  the 
skull  is  caused  cither  by  RtTusion  nf  iterum  from  the  tense  reins 
givtDg  rise  to  a  species  of  hydrocephalus  or  to  extensire 
mcaiogeal  or  intni<cerebr&l  hcmorrhagB  resulting  from  throm- 
boais  c4  the  sinuses. 

The  -pitldjiiic  variety,  as  already  remarked,  is  generally 
caused  by  otiUs  interna  or  injuries  to  the  head.  These  alTec- 
tioDS  also  give  rise  to  meningilLs  aud  cerebral  abscesses  as 
well  as  te  porulcnt  thrombosis,  and  inadmuch  as  these  patho- 
logical oonditions  are  frequently  combined,  it  is  very  difficult 
to  distinguisli  clinically  between  them.  In  a  few  reported 
cases,  however,  suppurntivo  thrombosis  was  alone  present 
uucompliciited  by  meningitis  or  by  leeions  of  the  cerebral  sub- 
stance. The  affection  »oraetimes  pursues  a  latent  course,  and 
is  only  discovered  after  death.  The  symptoms  are  usually 
siniilar  to  thoee  observed  in  cases  of  septicarmia  with  specially 
prominent  cerebral  symptoms.     The  attack  frequently  begins 


Uft 


FOCAL  DISB&SES,  ACCORDINQ  TO 


with  chtlliDesa,  which  jit^erally  recurfi  repeatedly  duriog  tb« 
course  of  tlio  discMC,  nod  the  patient  hivt  a  chftract eristic  typhoid 
look,  with  dry  tongue,  logs  of  appetite,  and  mental  eonfunaiL 
After  a  time  tlie  patient  falls  ioto  a  Bomnoleot  condition,  wbidi 
givea  place  to  complete  coma,  terminntiDg  in  death.  Uild 
delirium  is  present  in  a  few  comb,  and  more  mrely  the  deliiinD 
auumea  au  active  form. 

Suppurative  thrombosis  ia  frequently  associated  with  rootot 
aod  seQSory  dixturbanoes  caused  by  the  accompanying  menis' 
gitisL  These  consist  of  paio  in  the  head,  hyperalgesia,  paimt, 
paralyUB,  and  convu]atOD& 

§  706.  Dia^wsis. — When  o  patient,  stifferiog  from  caridof 
the  internal  ear,  fnrunculua  in  the  face,  or  who  baa  recetvod  ui 
injury  to  the  bead,  develops  eymploms  like  those  of  f^son, 
with  marked  disturbance  of  tbc  cerobral  functioas,  panileM 
thrombosis  of  the  sinuses  may  be  suspected.  The  diagMM 
will  be  further  corroborated  by  the  disturbances  of  tbc  dm- 
lation,  which  have  already  been  described  from  the  tbrombw 

g  707.  Course  ami  Pro^nosia. — ^Tho  duration  of  the  dlMUi 
is  diFBoult  to  determine,  and  it  may  probably  extend  occaidoailly 
O7or  several  weeks,  although  usually  tennioatiug  itt  ■  waA 
shorter  time. 

The  prognosis  ia  very  unfavourable,  but  recoveiy  ii  nil 
occasionally  to  take  place  (StUillot,  Lebort,  and  Oriesioger). 


§  708.  Morbid  AiKotomy. — Any  sinus  may  become  tbe 
of  tbromboius,  but  some  of  them  are  much  mure  liable  t«  bi' 
&6fected  thau  others.  The  superior  longiltidinal  sioua  ii  llu 
one  which  ts  usually  implicated  la  cases  of  thrombosis  fttm 
marasmus,  and  the  sinuses  in  the  neighbourhood  of  tbe  petmu 
bone  in  the  phlebitic  variety.  The  veins  which  empty  tbeoh 
selvcs  into  the  tiiuuse'j)  become  enlarged  and  gorged  «ilk 
blood,  and  arc  ofleu  Bltcd  with  thrximbotic  maaaciB.  so  that  tlil5 
look  like  large  earthworms  when  lying  on  the  surface  of 
braia.  Ruptures  of  the  resseU  nut  unfrequvntly  occur,  c«br: 
meningeal  hBomorrbage,  but  sometimes  oooaUto  only  of 
hnmorrbagio  spots,  while  at  other  times  may  amouBt  to 


«h4^ 


TBE  NATUKB  OF  THE  LE?ION. 


6S8 


fuse  barmorrhage.  The  cortex  of  tins  bmia  ia  also  frequently 
the  seat  of  capillary  hii'inorrliagfe,  uud  Lojiccrcux  biuitlescribed 
small  spots  of  ^^fteoing.  The  phtebitic  variety  is  frequently 
aocompaoied  by  meDJagitis,  caused  by  the  primary  lesion. 

§  709.  Treu/ment. — No  treatment  ha5  bitberto  beeu  found 
of  any  avail 

(o)  Ooctvaian  of  the  Ocrehrtd  Capillariu. 

§  710.  ExporimeDlal  iuTestigations  have  shown  that  marked 
diaturbaaces  of  the  cerebral  fuactions  may  be  caused  by  occlusion 
of  the  cerebral  cupillarica,  nud  dtotcal  records  aluo  poiut  to  tbe 
•aiue  ooDclusioQ. 

§  711.  Etiology. — Id  severe  cases  of  malarial  and  iutermit* 
leut  fever  ihe  cerebral  capillaries  are  liable  to  be  obstructed  by 
dark  ma&ses,  u  conditiou  which  btui  becu  called  pigment  env- 
6olum.  The  cerebral  capillaries  may  also  be  obslructt-d  by 
<trops  of  fat.  The  fat  is  iisually  swept  into  the  blood  current 
by  the  breaking  up  of  atheromatous  formations  in  tbe  interior 
of  tbe  larger  blood-vessels.  lu  cases  of  injury  to  bone  the 
ffttty  tissue  of  tbe  marrow  may  be  carried  iutotbeblood-veaseU, 
giving  rise  to  emboli  in  the  lungs  and  possibly  in  tbo  brain. 

Chorea  has  been  supposed  to  he  due  to  capillary  embollem, 
but  the  subject  will  be  subsequently  discussjed,  The  cerebral 
C4{Hllarie8  are  said  to  be  occluded  by  lime  becoming  deposited 
in  their  walls,  a  process  named  by  Yirchow  Htm  metoMatii. 
Some  dioeaae  of  bono  is  usually  associated  with  this  condition, 
and  Virchow  thinks  that  th«  lime  is  first  absorbed  from  the 
di««asod  bone,  and  afterwards  depoMited  iu  tbo  vessels. 

§  712.  S^ptmiis. — The  eiperimcnts  of  Foltz,  and  of  Frt^vo^t 
and  Cot&nl  show  that  extenuive  embolism  of  very  fine  particles 
may  rapidly  induce  death  in  animals  by  causing  diffuse  aotemia 
of  tbe  brain.  Nothing  analogous  lo  this  is  known  to  take  place 
tij  diseased  conditions.  If  the  embolic  niftssps  are  few  the 
symptoms  which  thi^y  give  rise  to  are  ho  slight  as  not  to  be 
recoguisuble  during  life.  Such  is  known  to  be  the  case  in 
certain  instances  of  fat  embolism.    In  other  cases  a  considerable 


&24 


rOCAC  DI8BASI8. 


territory  of  tbebmin  may  bo  auddenlj  deprived  of  its  DutrimcuO 
aud  upoploctic  symptoms  may  tben  b«  produced,  roUowed  bv  xhs. 
asuol  Hymptoms  of  a  loc&li&od  c«r«br&l  disoMO. 

Tbe  symptoms,  bovever,  are  usably  sucb  as  arise 
diffused  cerebral  disease,  the   more  common   of  tbem 
dizziness,  headache,  nausea,  tn>mbliD^,  Rod  weokDcu  io  tiu 
extremitiea,  and  mental  diiiturhance,  as  marked  loss  of  : 
and  other  signs  of  mental  decay. 

{J  71S.  JHorliul  Anatomy. — Ca^nllaryoootuaiooaar^of  < 
ooly  to  be  detected  with  the  microscope.  Delacoor  says 
iu  cases  of  lime  metastaxis  a  iBHistance  is  felt  to  ibe  koifeia 
cutting  thrnijgb  the  brain,  and  rough  prominences  may  be  felt 
on  the  surface  with  the  finger. 

'Hie  nature  of  the  secondary  changes  in  the  brain  vonn 
acoording  to  the  number  of  the  vessels  obstructed,  and  it  is 
only  whoQ  a,  Earge  uumbcr  arc  occluded  thai  distuibance  of  the 
circulation  will  not  be  compensated,  stmctural  chsngee  tku 
oooarring  analo^us  to  those  following  obstruction  of  the  laigt 
arteries.  Experimental  inrestig&tion  has  sbowa  that  tbe  tiist 
effect  of  the  occlusion  is  to  cause  aiia>mia,  and  in  tbe  fartb«r 
progress  of  the  affection  the  various  stages  of  necrobiodis  may 
supervene,  ending  in  complete  softening.  The  centra*  of 
softening  are  often  of  small  size,  but  several  are 
present. 

§  714.  Tbe  couTM  and  progiUMM  depend  upon  tbe 
and  nature  of  tbe  occlusion,  bolstod  capillary  emboltsms  ut 
of  no  significance;  but  if  they  are  numerous  the  reaultlng dii> 
turbances  are  in  every  respect  similar  to  tbe  coTrespomHay 
secondary  effects  of  the  occlusion  of  tbe  larger  arteries. 

§71^    Trt4Ument, — ^The  treatment  must  be  conducted  as 
general  principles. 


5SS 


CHAPTEli  IV. 


(I.)  GENERAL  OON'SIDERATION  OF  FOCAL  DISEASES, 
ACCORDING  TO   TUK  NATURE  OF  TilE  LESIOK 

(COUTIHCEb). 


S.  INTRACRANIAl.    IL£M0RRHAOE. 

Iktracraniai.  hsemoirhage  may  be  divided  into  C")  cerebral. 

Id  (&)  fMnirujeal  hemorrhage. 


(a)  Cerebral  ffcemMTkagi. 
§  715.  Dejinition. — By  cerebral  btemorrbaRO  is  here  meant 
extravasatiou  of  blood  iolo  tho  eubatance  of  the  eocepbalon 
or  into  tho  ventricles  of  tbo  brain. 


{  717.  tlUtvry. — HiciiicirTliii|ji,'  ititii  ttiu  Milistaiitw  of  the  uueui'haloii  in 
freqoeiiU;  t«miiKl  nifopk-iy.  Tbt*  wunl  aimA^ooH  wcniia  "  1  ntrikc  ilowii,'' 
bikI  n  jenou  who  luul  suiltlvtil^  [nlkui  tiuwii  iutmmuhli;  woh  etii')  ki  bo  in  a 
omditicai  of  JaiMA4{u.  It  vtm  |N)Uit«d  out  by  Wcpfor  that  this  coodittOD 
«iu  frequently  ouMod  by  cnobruJ  haemorrhage,  oiiil  aSXer  a  time  the  name 
fif  the  group  of  symptoms  which  aiguifiL-d  eitddeu  uucuusctuuaiioea  was 
transferred  to  the  atialomicu]  conditiou  wliich  wns  the  muMt  EVei]tieiit  cailflv 
<4  thot  ix:cum'ii(?«,  Th*  ptvweo  did  uot  »l«p  hurc  ;  duriu;;  tbt  wurw  it 
tiuvNligatiou  It  wiu  aeon  tlmt  hmiunrlutgit  ink)  tho  HiilHtjiiior*  i>f  other 
ui>^TiB  «a»  uot  uooommon,  and  after  a  time  thu  uicauiiig  »r  tbt:  Uitin  h-iw 
eitetxlod  ao  aa  to  include  these  haniiorrhB^m  aL«o.  Tliv  UsTia  thereAjiv 
hariDg  cotDc  to  aignify  conditiont)  so  diftcrcnt,  it  will  be  wcU  t«  avoid 
itg  uae  OS  ntich  as  ponbl«. 

§  71S.  Etiology, — Tbe  circumstances  which  predispose  to 
cerebral  hiemorrbage  are — (I)  Diseaae  of  tbe  vessels,  (2)  In- 
crease of  tbe  arterial  teoaion,  (3)  Diseanv  of  tbe  tissues 
nirroaoding  tbe  vessels,  and  (i)  CerttUQ  diseasea  of  the  blood 
it«elf. 


5S6 


FOCAL  DISEASES,  ACfORDIKQ  TO 


(I)  I>i$etue  of  the  VaaeU. — The  great  najorrtj'  of  nttagiyo  liMiionti^ 
into  th«  subetance   of  the   bmin  are  doe   to    taUf  degtamaUm  i 
bnuichca  of  the   Sjlviajt   tuierf,   wbidi   pnw  tbrN^  \bt   •otmr 
peribmtMl  s[i»w  U>  nnudi  tha  oor|ras  striatani.     VuMy  dcgvnwatin  4 
■rlMios  BMf  be  iirimu^r  or  Mxontluj',      Pnitury   fatljr  (ItfctHntM, 
ig  a  pwniva  pI<ocM(^  not  being  praoeded  b^  uif  iocruaed  outfitla 
setJTit;  of  the  oScctod  parts,  but  the  seooiiilary  farm  of  the 
is   prooeded   by   an    iiiRituimatory   oeUiUnr    infittntJoD    of    tba 
eticliithi-lial  ououective  timuc  »f  the  ventHilii,  ami  muetitutae  atltcnua 
It  waa  formerly  believed  tliiit  wlieii  tlie  uieriea  at  tbe  Inoe  a(  tht 
bruiii   ^VK  fouuiJ    in    a   coudititju  of  atlutrumatoua  degAOctatioB  tbt 
euatcDCe  of  a  similar  condition  of  the  Teattela  in  tbe  mtehor  of  lli« 
bnia  migbt  b«  itifmnxl,  uoJ   tiiat   intmccrebinl  hmuonbafva  ui^ 
in    mcxit  iiutonoea    \xi  nttributvd    to    tbe    brittlcMM  of   tbe  JtmAt 
Tbii  belief  u  uvw  grov>-tiig  tlmt  the  uiBtwiKv  «f  atberaiiaat«ua  dnsMt 
in  tba  cnuaation  of  contbrnl  hamorrbi^  u  indirect  mtbor  than  dincL 
AtbeioRia  of  th«  Tends  may  ocoMiouoUy  Utdd  to  aotdruiua  of  tba  Ur^ 
nMwla  at  lh«  Iumi  of  the  braia,  but  tbey  an  not  oftoi  Ilia  cawa  id 
heemorrbogo.    B««ide«,  ruptuie  cf  an  oneuhsni  of  one  of  tJ»c  laiftcr  "nrntk 
would  give  riw  to  bsmoirhage  between  tbe  meninges,  uhI  nut  into  tk 
eabetauoe  of  tbe  brain,    Atheromatous  degeoentioB  nay,  however,  tsum 
tuBmonbage  indirecUy  by  rviideriug  the  ifaDa  of  tbe  larger  web  rip& 
m  tlukt  tbe  |iuls«  vave  roAoliea  the  arterioks  iritiKmt  bcang  modified  hj 
tbe  uonnal  elsKticitj-  of  the  art«nea. 

By  far  tfao  nuMt  ftnjuent  caiiee  of  iutnM«nbral  hmmorriug*  )■  tJMl 
condition  of  the  arterioles  which  has  been  dosoilwd  by  Chaiout  aad 
Bouchard  a«  tniiiary  aitifurimu.  Them  aneurisma  an  sititaiMl  ou  t^ 
aiitfiolca,  am  o(  a  roddiah  colour,  oud  vary  in  aire  from  that  of  a  nuUsi- 
•Md  to  a  pins  bend.  SometinieB  a  fow  only  are  fousd  in  the  vicinity  of 
the  ni^itiu^d  vewwl,  while  iit  olber  times  tbey  are  acatbered  in  taif^ 
tinmbere  throughout  tho  wholu  bnun.  The  jiarts  of  the  fanio  iti 
they  are  aitiuitvd,  taken  in  the  order  of  tlieir  decrvaong  fmtiwnoyt 
the  leiiticiilAT  nucloua,  tho  o^i<!  thnliuni,  the  pan*,  the  eonrolutliiBa, 
caudate  nucleus,  the  cerelwUum,  the  mcdidla  oblongata,  tlw 
peduncles  of  tlw  canbdlum,  and  the  oriitr^un  ovnia 

Miliary  aneurisms  oocur  mroly  bcfora  the  fortieth  yor,  bot  an  toad 
OTth  inoreasing  frequency  after  that  ago.  They  result,  aooordiag  bi 
Charcot  lutd  lluuubard,  from  a  kind  of  arterial  ecleroalB  of  the  DaLura  ti  s 
chmnii'  iierinrteritisL  This  alteration  cotiatirta  to  uiultipiicatkm  of  Um 
nuclei  of  the  lymi'ltsheatlia  and  adventitia,  a  ptncen  which  is  (sosnl^ 
accomiMiiiod  by  atrt^jJiy  of  the  nmscuhir  onat  Wbeo  atrD|ihy  of  Ilia  lattv 
oconrs  without  a  romiieaafttory  thiokenlng  of  tlw  advootttU,  lupturs  rf 
thON*  oneurtnus  very  readily  tjdcos  pteee. 

Tlio  pnit  which  primary  fatty  degeneratioa  of  tbe  ninlii  fi^jv  hi  thi 
causation  of  cofofcnd  homiorrbafe  baa  been  insiat«l  upon  by  VtifpA.  Xtm 
oonditioo  of  the  t'esels  ts  fbuud  at  all  agas,  and  in  oadiectk  chiUtcn  viw 


THK  KATtJBE  OF  TIIE  LESION.  531 

tlegtutition,  tbe  Utter  being  generally  retained  an  regaixls  the 
pbarjTDx  ftad  aanpbagas. 

Wbeu  this  coodition  has  been  Kroogbt  about  bj  a  severe 
leaion  of  tbe  bmin,  tbe  palicut  may  die  after  a  few  minutes,  a 
few  boars,  or  a  few  days.  In  the  slighter  forra?,  bowcvcr, 
tbe  apoplectic  state  may  last  only  a  short  time,  and  tben 
gradually  give  place  to  other  related  symptoms.  When  tbe 
coma  is  not  rery  profound,  powerful  irritations  cniisc  reHex 
moTements,  and  in  tbe  lesser  degrees  of  the  apoplectic  siaU.; 
the  patient,  when  loudly  spobcu  to,  miitf-s  h\s  eyelids  for  a 
momeat  or  two,  and  nmy  oven  reply  in  a  monosyllable  when 
loudly  pressed  with  any  i^iiestion.  In  such  casen  a  diB'creneo 
can  be  detected  between  the  two  hakes  of  the  body;  the  ex- 
tremities of  one  aide  offer  a  certain  resistance  to  ptusivo 
RiotioD,  while  thnne  of  the  other  sink,  when  uusupported,  like 
toert  maues;  tbe  comer  of  the  moutb  on  one  side  in  lower 
than  OD  tbe  other,  and  tbe  opposite  na&o-labial  fold  is  strongly 
tnafked. 

(u.)  Th<  Epiiepti/omi  07i«t — The  epileptiform  is  a  m«re 
Tariety  of  Iho  apoplcctifono  mode  of  onsu-t.  The  pntient, 
either  with  or  without  pnxiromata,  dropa  down  insensible  in  a 
kind  of  epileptic  fit,  and  after  a  time  it  la  discovered  that  tbe 
patient  ia  paralysod  on  one  side  of  tbe  body.  Temporary 
hemiplegia  may  follow  severe  attacks  of  uuilikturul  convulHions 
due  to  a  molecular  Ie«ioD  of  the  cortex,  but  in  the  coses  under 
preaent  consideration,  the  haemorrhage  destroys  a  cortain  por- 
tioti  of  tbe  brain,  and  tbe  paralysis  initiated  ia  more  or  less 
peniEteot,  Although  prodromata  may  be  absent  altogether, 
yet  tbe  epileptic  attack  is  very  frequently  preceded  either  by 
pftins  in  the  head  or  by  muscular  twitohingn,  or  the  initial 
attack  may  be  cbaractorisvd  by  unilateral  convulsions,  and  in 
these  cases  tbe  half  of  the  body  couvulaed  corresponds  with 
that  which  is  subsequently  paralysed.  But  when  cooviilsions 
ooctir  after  paralysis  has  become  established,  it  usually  happeus 
that  the  non-paralysed  side  is  the  one  which  is  alfecteil  with 
donic  spanma,  and  in  theHO  cases  there  in  probably  co-existing, 
but  uoequai,  damage  to  both  hemispheres  of  the  brain. 

Sonie  of  tbe  patients  whose  bemiplegic  condition  is  ushered 
in  by  convulsions  speedily  die,  whilst  others  remain  liable  to 


6S8 


FOCAL  DISEASES,  ACCORDtNO  TO 


■apenor  vena e»ra,  odiI  alTectkius  of  tbo  langn  aa  <iiii|ihjimnii  uA  AWoil 
pbthisin. 

(3J  CowJttion  of  lAe  TVtfttoi.—  Boobotu  wIvnDnxl  Uie  Uicot;  UhI  fm- 
tODVOiu  hmDorrhage  is  ifenertdlj  preoeded  lijr  m  iirooa^tifaoAadflf  <f  tb 
oambrnl  tiasuo,  to  wbioli  bo  gnvc  to  this  procnn  tb«  patue  «f  mmattlmmmt 
Mntrrhagipart.  Id  ecnwoquunn  of  tbs  ahangB  of  amnstmoB  «f  ttt 
nervoua  tionue,  the  bbibU  naBols  lose  their  uaturol  mitiinrt,  and  baooi 
twabls  to  PMUt  tba  prawnie  of  the  blood.  It  w  ncnr  gowndlf  Misral 
tiuit  tbe  Kciftviiiiiic  is  a  anootuWj  fitoceuK,  tbe  nnult  pautlr  of  tite  ibU- 
ItiUou  uf  IJuoit  scnuu,  and  parti;  of  inflammatinn  nuiiud  tiy  tbt  «■• 
tnvaMtiun  til  tliu  nurruiititliiig  timtioik  HaauuiTbiie*insj^hiM»pnjt«ef 
■■  a.  result  of  nufu-tiiiitj  of  tliQ  lisNUoi  lii  esiw  of  nmlioUnp  nnd  tlimuitod^ 
but  thin  LMDtlitioti  will  be  twticcd  beroufter.  Some  autfaoni  tbink  tlat 
lunnorrhage  b  dtw  occarinoaUy  to  atnqibjr  of  tlw  oenbnU  aalMtanoi^  mA 
betiero  that  the  vCMok  tlMU  ru|Aut«  id  oomwqiwnw  oT  tbair  tanai^ 
diUbvl  ill  nnlcr  u>  fiU  cbe  vncaum.  But  t\w  mliiction  in  tli«  mm  \i  Ik* 
bivin  {iniooxlii  fnr  k>»  nlov);  for  inucb  dilntMtiun  of  thu  yanaaU  to  iwA 
feaax  it :  an<l  tbo  atmphjr  is  oompeuHatMl  to  aome  extent  by  UoctoMmyrf 
tbe  skuU  ikud  iaoraoM  lu  tbe  eiw  of  the  fruutal  eumecB,  bat  ohiiflj  I7 
ItiovaM  of  the  verebnMiiiiiud  flidd. 

(4)  Stau  of  the  BUxxL—Vanwm  dJunatui,  Uie  iwiiitjil  oMalilina  ti 
wbidi  ii]i|>un.rs  tn  bu  «niwo(l  tiy  sntno  dungo  in  tbo  oompaitiao  of  tta 
blood,  oonuiunully  loud  Ui  cctrvtmil  hoiDiurrbofte.  Cvnbml  baaDORlH^ 
haw  Unni  otmirved  m  iiyouaja,  iu  ttie  Ly|ibiud  «tatc<,  actirliatua,  pavjan. 
oblorovis,  lencocj^hamia,  pernicious  aiunaiit,  and  icfairasi  btit  an  eBap- 
tiooallj'  met  nith  in  these  diaeRaes. 

§  7IU.  Othrr  Predisptm-ng  CauH» — 8orao  fnmjliM 
a  prediapotiitioa  to  cerebral  ba'inorrba((v,  hence  it  hu' 
&sfmmed  that  tbe  disease  is  hereditary.  The  action  of  ha^Q 
in  proJispoaiDg  to  ba*morrhage  is,  however,  only  nn  iodinet 
result  of  tbe  iuberited  tendency  to  arterial  degi.-i)crutio[L  II 
wan  fonnerly  believed  that  some  iodiridiialii  inlierited  un  apiip- 
lectic  constJtutioD.  This  was  supposed  to  be  cbaractvmed  br 
broad  chest,  sbort  neck,  largo  abdomen,  powerful  [m»colar 
system,  and  Horid  complexiou.  Cxact  statistic^  Iiuwevet.  ptvre 
that  cerebral  heeoiorrbagc  does  not  spare  any  cooatitutian, 
and  that  poorly- uuurisbcd,  thin  pcraons  aie  aa  fraqa«otty 
attacked  as  the  plethoric. 

One  of  the  most  important  predisposing  cauace  of  tbe  disMM 
is  C^.  Cerebral  haemorrhage  is  rare  befure  the  fortictli  yiar. 
relalivcly  frequent  aftorwonls.  It  must  not  Ue  foi^goltea  that 
tbe  disease  attacks  young  penoDs,  and  it  baa  been  obaerred  tb 


THB  SATUBS  OF  THE  LESIOV. 


oSl> 


its  and  «ren  At  birth.  Meningeal  htemorrhage  is  relatively 
ion  ID  early  cbiMhood. 

Set  uniioubtedljr  oxerciKeti  a  certaio  degree  of  indtience  ia 
piedtBposiog  to  cerebral  ba>[norTbage,  probably  owing  to  the 
ifsct  that  men  arc  more  freiiimntly  oxpoitod  to  the  excltiog 
canaes  of  the  diBeas&  The  proportionate  frequency  with  which 
laeD  and  women  are  attacked  hoA  bees  variously  estimated  bj 
diStrent  authors,  but  it  may  safely  bo  asserted  tliat  the  ratio 
ef  2*1  rather  nnder  than  overstates  the  proportion. 

The  ioflaence  of  occupati/m  \a  predisposing  to  cerebral 
tomorrbage  has  not  yet  been  satisfactorily  dotermtned,  and  the 
tame  may  be  said  with  regard  to  the  indueoce  of  climate,  since 
thfl  immunity  from  the  diacase  once  attributed  to  wivrm  cLinnatca 
Jus  recently  be«n  called  in  question.  In  Kurope  the  iJiBease  is 
'moat  common  in  winter,  then  in  autumn  and  spring,  aud  least 
■o  in  summer.  AttUtuIe  appears  to  exert  some  influence  in  the 
production  of  tho  affection,  atuce  it  ia  very  common  in  the 
tdevatvd  regions  of  Mexico,  of  the  Cordilleras,  and  tlie  Andea 
Certain  substances,  as  alcohol,  predi^WM  to  hjemorrhsge  by 
^Ddncing  fatly  degeneration  of  the  vesa^ 


I  §  720.  Symptomg. — The  symptoms  vary  greatly  according  to 
the  situation  and  ext(>nt  of  the  lesion  ;  but  the  mode  of  onset 
being  sudden  and  the  lesion  of  a  deslractive  character,  the 
initial  group  of  symptoms  bear  a  general  similarity  to  each 
ether  in  all  CMC& 

1.  pTcmonitory  Symptoms.  —  The  attack  is  frequently 
ushered  in  without  any  premonitory  symptoms,  and  in  no 
linatauoe  can  any  symptom  be  relied  upon  as  an  invariable 
«Dt«cedent  of  hicmorrbagc.  Premonitory  symptoms  may,  bow- 
ever,  manifesl  themselves  days  and  even  weeks  before  the 
actual  on.4et  of  tho  attack,  and  thcso  are  no  doubt  frequently 
caased  by  rupture  of  minute  vessels  prior  to  the  graver  event 
which  ushers  in  the  apoplectic  ooDditioo.  The  usual  fore* 
muners  of  the  apoplectic  attack  are  dizziness,  headache,  ringing 
in  the  ears,  musca--  voHtontea,  numbness  in  the  hand  or  foot, 
muscular  twitchings  of  the  foco  or  of  some  portion  of  the 
upper  or  lower  liinba,  especially  of  the  fingers  or  toes,  mistakes 
in  talking  or  writing,  vomiting,  mental  irritability  and  drowsl- 
ii 


5M 


FOCAL  DISEASES,  ACCXtRDHia  TO 


decreases,  and  is  eToatually  lowef  than  that  of  tli«  wand  i 
When  no  tedema  exists  tbe  skin  majr  be  diy  Mnd  scaly. 

Aotttt  jS«i-«ure.— Tliin  in  au  iicute  [irocctw  of  sloo^iiQg,  vbiofa  ttooMMaOj 
■KcunKirtT  Uiocmitru  of  thu  glutooi  rcgiaii  im  the  )MsJ]r«ed  aidt^aAtt 
L'en.'lird  Iiiciiuirrlu^  ur  itotUxniag.  The  iifedton  ban  nlneailj  fa«a 
MiJBck-iiUj-.]cacriUd  (§  lU). 

CongaitMmt  ami  Bvnutrrhogti. — CtnigwitiniM  uul  Mtuol  lumicrtHpa 
ioto  Uiv  subBtonn  of  Uw  lungB,  nzimraMkiooii  iu  ur  bcmalii  tlw  jikM, 
fiiiilooinlium,  aod  tbe  mucDtw  membnuw  trf  tlw  ^*m™^i  h  nil  ■ 
into  tlio  substaDce  of  ibs  aapra-raoal  capanlas  and  lddiM7>,  frwyiwHT 
liocijiDtiiuiy  cerebral  hoBtDOFrhago:  Schiff  and  BrDwa-S^ciaard  pradasnl 
•a|)«riiueiitaUy  liTptntinia,  or  btnuorrfaase  uf  tbe  [ilvura  anil  Inap,  t^ 
cotaJD  lenoiu  or  the'  \K-mi*,  middle  oeivteliar  |ieduocbn,  ntitl  iha  a(ibe 
thaliuni  and  oorppnuttrJata.  TJiCae  hyuenmiiio  oooililioga  and  tuamcii  ihmw. 
whether  in  the  lower  tmlmali  ur  in  niui,  an  nocoetbittH  fwitiiwl  t*  ifat 
pandjnod  side  uf  the  b-jdjr.  The  diminatHQ  of  tlia  uotttawtik  pom 
nf  tho  walls  of  thu  art«riolu«i  oil  thu  |iamlj'aud  ndAoftau  givH  riaeba 
pcK«[itil>U;  dilliiivtico  l>ctwu«i)  thu,^  DuliAl  [>iiUcN  of  tbc  two  nidoa. 

Iv^mmation  of  th«  JoifUa.— SoniB  of  thu  joints  of  the  pand^wl  ^it 
ot  the  bod;  maj  hooomo  the  Mubjecta  of  a  sabacuto  infUimiuilio*,  vfeMb 
uaiudljr  h^ijM  fnjtu  the  third  to  the  aaxtb  week  after  Uw  bmi)il4». 
alihoiigb  BouietiuK<it  Ihv  joints  infioiDO  at  a  atiO  lat«r  )>eni>d  aftci  M» 
baiciiiiuiig  iif  thu  attadc,  ax>d  uocaaioually  the  aflocttMi  almwa  Hadf  a* 
early  aa  the  hft^jitb  dajr.  There  an  tbe  two  i-arietiea  of  thia  artiadi' 
inflammation,  tbe  onv  nciito  and  the  other  chroidc.  In  the  fint  ranri; 
tho  jwiit  kMomM  red,  but,  ewoIlAn,  and,  after  death,  acute  t^tioviiia,  In- 
qiieiitly  wiili  miimdetralile  enulBtioii,  ia  Aiaoawml,  Thia  hna  a^nod 
eicluairelf  attacka  the  larger  jotiit«.  A  chmoic  joint  afliscCMia  haa  l«* 
deecribed  by  Hitdg  which  acems  to  be  pectdiar  to  the  ahuuUer.  TW 
joint  U  nlmcfft  iiiunovaUe,  piunrnl  (■»  jiroMuroi  atid,  owing  to  pvalyw' 
Uu)  muiidcB,  the  humenia  scmi'dialocated. 

Ckmign  in  Xtrvc  Tnuikt. — Oumil  hna  abowii  that  in  a  eertatn  vtaxt^ 
of  ouMthera  ifl  a  aub-tnflamBMttoty  byportniphy  cf  the  uomaorcf  (t« 
abaatha,  aud  in  such  CMm  thero  is  pAin  on  praanim  of  tb*  pnalji"! 
timls  oapociallf  tuarkc<l  along  tbo  ooaraa  off  Um  praKapal  aanw-tnria 
At  othn*  ttmm  thp  whole  i«ra]ywd  aide  inny  he  geiuuBlly  tendar,  witb^ 
any  apocdal  timitatJoa  of  the  tvadcroon  to  tbe  juiola  and  Uiipc  noma 

JftitciUar  AOvpAj/. — In  irnne  rare  caaea  an  oariy  auil  nyid  waMat. 
take*  |daoe  in  tbe  Bauaclu  «f  ooe  or  both  limbe  a  lew  wmIeb  after  i^ 
ooael  of  the  paralyiis,  but  to  theae  oaaeH  there  ia  toMoa  to  bfiaf*  dtf 
th«  fihrm  of  the  yiymaiM  btaol  have  undeisoM  eeooBdary  dtfHMK**> 
iinil  ihnt  tho  uiohir  odbt  of  tbe  anteriw  buma  uf  the  conl  Ian*  beetv 
I  mplicntcd  in  tlic  procon. 

Amu  or  Rflariiatiom  o/  OniwtA  Hi  Paratj/itd  Zim6a.— Vliao  haB>- 
ptogia  occiin*  in  cliddhood,  the  arm  and  kg,  «r  tlte  ann  only,  aa  tb»  p^ 


THE  HATL'RE  OF  THK  LESION. 


585 


}fweA  ilde  grow  mon  slowly  than  oo  tite  uoiuul  fiiili),  tn  tlut  lut  gfoirtli 
aJTUiCM  tho  limbs  of  Um  pnialyMd  ramun  penniuicatly  amoUer  thou 
ihrmo  at  the  oppnilte  ilde.  Tho  ana  h  ainre  huciuently  nfi^ctod  thui  th« 
Itg,  and  Utcn:  u  alinji  a  certain  niSDunt  of  muocular  rigidity  of  the 
aflficlnt  nxtrraiity. 

Siin,  Hair,  and  JfaiU. — The  akiu  of  tbo  iMmiyaod  side  nometamm 
aadaguw  tntpbio  ehaogee,  wliioh  involve  the  cutis  aud  suboutatiMua 
liBiiB,  flo  Uut  a  fold  lunched  ap  \ij  the  6ng«n  feeU  tbiiiker  tUou  iiarmaL 
Th«  hair  grtiva  Ijetter  on  the  .iffecttM)  Ht'l*',  nnd  ttte  iiaiU  beoiDtc  y^lowlsh, 
mifcmt  with  nolgttit  bnUlc,  auJ  ourrud. 


§  72S.  Morbid  Anatomy.—MothUl  ADatonuBU  usually  divide 
oerebnil  hicmorrhsge  into  two  vamties,  named  respectively 
ptnetiform  aud  masaive  livmonliagea 

Punctiform  KanrnorrJiagca  uccur  in  tbe  form  of  a  number 
of  minute  points  of  the  size  of  a  pin's  head,  or  even  smaller 
lliey  result  from  rupture  of  capillary  vesKcU,  aud  arc  iuvuriiibly 
noltiple.  Capillary  hu^morrhagetit  are  obscrvixl  in  tliQ  tissues 
nuroQiidiiig  massive  ti.'emoirhagfs,  or  in  parta  which  are  the 
ttat  of  Bofteuiug.  aud  titey  are  mot  with  iu  coDiiiderabtc  uuuibfirs 
to  the  cortex  of  tbe  braio  id  coosequeuce  of  thiomboais  of  the 
»MK)»is  sinusea.  At  other  times  extravasations  of  blood  are 
found  ta  the  lymph  Bheatlis  of  the  vessels,  aud  they  must  then 
be  regarded  na  raiuor  degrees  of  the  masgive  huBmorrhagc& 

Jfosnus  hamurrrhagts  may  b«  of  various  sizes,  beiug 
■ome^mes  as  small  uk  a  pea,  at  ollivr  tim«a  large  enough 
to  destroy  almost  ao  entire  hemisphere.  The  hemorrhage 
may  either  aeparate  the  nerve  fibres  of  tbo  white  substauce  or 
rupture  them,  the  latter  event  beiug  by  far  the  more  freiiuent. 
Wheu  the  nerve  Bbrcs  are  pushed  aside  by  Uie  lieemorrbage 
without  rupture  the  form  assumed  by  the  clot  will  be  deter- 
uiaed  by  the  direction  of  the  fibres,  but  when  tbe  fibres  are 
ruptured  tbe  clot  la  round  or  oval.  Iu  the  cortex  the  form 
MsaiDod  by  the  biemorrhogc  is  largely  determined  by  the  dis- 
position of  the  coDVolulious  and  membranes,  so  the  etTuston 
Qioally  HpreaiU  out  laterally  and  assumes  an  irregular  form. 
Uasaive  hajmorrhagos  are,  as  a  rule,  Hinglc,  although  Reveral 
foci  may  occaaioaally  be  observed,  aud  it  la  not  uausual  to  find 
traces  of  mauy  extravoNttious  of  various  ages  in  the  samti  braiu. 

Haimorrhagic  foci  may  occupy  any  part  of  tbe  braiu,  but 


586 


FOCAL  STSEUES,  AOCORDIKO  TO 


thej  are  much  more  frtKiuent  io  certaiu  paru.     Tbe  favourili 
Hats  are  tbo  caudate  and   teotioubr  nuclei,  and   Uto 
tbalami. 

Recent  Focua. — Id  the  nccot  oondition  tbo  apopleetie  focoi 
forms  a  dark  red  clot,  which  is  eott  and  uniform  in  charuter 
throughout.  It  is  frctiucotly  mixed  with  the  <Ultri*  of  tlw 
nilrstatice  of  tho  hrain.  The  iatemal  eurfkce  of  the  cavity  ii 
irregular  and  oouusts  of  torn  shreds  of  oercbra]  tisnia  Tbii  b 
sutmunded  by  a  Eone  of  variable  tbickDtwB,  avonging  a  Sem 
liue»  in  depth  and  gra«lually  merging  into  the  beaJlby  (nm^ 
composed  of  softened  tistiue  saturated  with  blood  eenim,  lol 
fre<]iieDtly  Uie  seat  of  punctiform  hieoiorrbages.  If  tbe  nam 
fiVires  have  been  simply  separated  from  one  aiiotlier  witboul 
rupture,  then  the  detritus  of  cerebral  tissue  in  tbe  iutemil 
luiface  of  tbe  walU  of  the  cavity  is  abaeot,  and  tbe  HoftMung 
and  punctiform  hjomorrhages  of  the  surrounding  tisniM  are 
much  less  marked.  1/  the  clot  be  floated  out  andor  water,  it  b 
sometimes  possible  to  detect  tbo  oiiliary  aneurism  from  wljtfc 
tbe  prinuury  extravasation  took  place. 

Period  of  Ahaorpiiim  and  Repair.— \f  tbo  ha:;DMiiiliag» 
does  not  end  fatally  after  a  fow  hours  structural  cbangw  talt* 
place,  both  in  the  clot  and  sarrouoding  tiasues,  wbkh  letd 
to  the  absorption  of  the  former  and  to  a  certain  aDOmt 
of  repair  in  tbo  latter.  Tbe  btood-clot  after  coaguUtMO 
parts  with  it4  serum,  and  tbe  injured  tjasues  surrounding  tbf 
clot  become  softened,  partly  by  imbibitioo  of  seram,  (xrt 
chiefly  owing  to  a  retrograde  fat^  metamorpbona  af  ibt 
torn  fragments  of  brain  tissue.  The  aofVened  tiamiei  beoone 
mixed  with  the  clot  so  a«  to  form  a  dark,  chocolaM-eolooMl 
mass,  of  tbe  consiatenoe  of  gruel,  tbe  more  fluid  coostitueati 
of  wbich  are  soon  abvorbed.  The  bii:matine  is  dinolved.aa^ 
soaks  into  the  ti«ue  round  tbe  clot  to  a  cousiderable  iHftaitft. 
until  it  is  absorbed.  As  a  result  of  this  procoaa  the  pulpy  mat«fiil 
filling  the  canty  passes  from  ila  lirst  dork  rod  to  a  bngbtef  ral 
aiid  fiunlly  to  a  t^affron  ootour.  A  reparative  procesB  ncnr  beyiH 
by  means  of  which  tbe  hajmorrhagic  focus  ifl  cooTertcd  \bI»  • 
ey^  The  firsfcstep  in  the  reparative  process  ia  the  foniiatiuaof 
a  fibrinous  capsule  round  tbo  entire  periphery  of  the  clui.  It  i< 
at  first  a  line  or  aor«  in  thickness,  soft  as  jelly,  and  of  a  tiaiii- 


THE  HATOBE  OF  THE  tEBIOS. 


537 


luceot  yelloimfa  UqL  At  a  later  period  this  capsule  becomea 
converted  into  a  mucli  thinner  but  stronger  lajor  of  tibrillftr 
ooaneciive  ttagne,  which  permanently  abuts  off  the  apoplectic 
deposit  from  the  surrounding  iiubiitaiice  of  the  brain.  The 
fluid  OMitaiaed  in  the  cyst  is  at  f\tnt  turbid,  bat  after  a  time 
becomea  iransporeDt  and  limpid.  These  cysts,  however,  coiitain 
not  Buid  merely  but  also  a  loose  spongy  connective  tissue,  which 
ia  susptmded  in  the  fluid  tike  a  film.  But  the  reparative  pro- 
cen  does  not  always  end  hero;  the  wbolo  of  the  fluid  may 
bMome  gradually  absorbed,  and  the  opposite  walla  of  the 
ean^  may  ultimately  cumc  into  coutact,  and  adhere  to  one 
another  by  a  connectire  tisnue,  which  usually  contains  a  consider* 
able  amount  of  pigment.  This  constitutes  the  haemorrhage  or 
•pop(«etic  cicatrix,  which  consists  merely  of  a  thin  strip  of  con> 
Bcctive  tissue.  Superficial  foci  in  the  cortex  pass  through  similar 
phasea,  and  after  cicatrisn-tion  they  appCRr  m  yellow  indurated 
^wta  vhieh  have  beeu  taken  for  ve^ige^  of  encephalitis. 

Ihtration  of  the  JUparatize  Process. — ^Tbe  clot  1b  soft  and 
bomogeneoun  during  the  first  three  or  four  days.  At  this  time 
the  process  of  softening  and  separation  of  the  internal  surface 
o(  the  cavity,  and  the  absorption  of  the  fluid  contents,  reach 
tfaeir  iDAximum  activity  at  the  eleventh  or  twelfth  day.  The 
reparative  process  which  leads  to  the  formation  of  the  capsule 
begiiu  usually  Irom  the  seventh  to  the  ninth,  tlie  cj-st  is  com- 
plete about  the  twentieth,  and  the  liuiag  membriuie  ia  organised 
from  the  thirtieth  to  the  fortieth  day. 

Circumatanoea  tvkioh.  prevemi  the  Heparaiive  Proeeae.—' 
Various  circumstances  delay  c»-  entirely  prevent  the  reparative 
proceW;  The  principal  of  these  arc,  a  too  extensive  ecro-eon- 
gutnwus  infiltration  of  the  surrounding  tissues  followed  by  a 
co-extensive  are«  of  softeniog,  an  excess  of  the  irritative  pro- 
cew  necenaiy  to  repair,  which  gives  rise  to  geootidar^  tTuxpha- 
Litis,  a  frwb  faismorrbage  and  dropsy  of  the  cyst,  leading  to 
distention  and  consequent  preasure  on  the  surrounding  tissues. 
Bqwir  of  injury  to  the  brain  from  hirtnorrhage  may  bo  pre  ■ 
raited,  like  repair  of  injuries  of  every  part  of  the  body,  by 
the  general  state  of  the  health  in  various  conditions  of  debility. 


'  723.  Pn^^iuwisL— -The  prognosis  io  any  given  case.depends 


5S8 


FOCAL  DISEASES,  ACCOEUtNO  TO 


upon  tlie  opiaion  formed  of  tbe  extent  and  Bitu&UoB  of 
tbe  tesioo  t&ken  ia  coDJunctton  with  the  age  and  preriooi 
state  of  healUi  of  the  patient.  Death  not  nQhw)aeittty  takn 
place  (luring  the  apoplectic  coudition.  If  tbe  patient  cannot  be 
roused  at  all.  if  tbore  be  no  aigoa  of  reflex  activity  when  tht 
oonjuDCtivti  is  touched,  while  thcra  is  involunlary  paMag*  of 
fnces  and  uriae,  and  well-marked  sterlor,  the  patient  ouiy  dia 
rapidly  within  a  few  bouin,  or  even  a  few  mioates ;  and  the 
peraistence  of  a  slighter  degree  of  these  Bjmptoms  withoat 
abatement  is  a  sign  of  great  grarity.  Laboured  respiration  urf 
quickness  with  marked  irregalarity  of  tbe  pulse,  are  also  an- 
farourahle  sigtis.  A  mark«d  and  persistent  dcpreasion  of  the  tem- 
perature is  regarded  by  Charcot  as  an  almodt  certainly  fatal  sign. 
If  the  patient  has  recovered  from  tbe  apoplectic  condition,  tbeo 
tbe  prognosis  will  greatly  depend  upon  the  age  and  geoeiil 
condition.  Granular  disease  of  the  kidneys,  a  gODerml  sUta 
of  raaloutritiou,  ur  evidences  of  senile  degeneration  of  tb« 
arterial  system,  will  render  the  altimate  prognosis  gn** 
in  cases  where  the  extent  and  situation  of  tbe  ba;morrbact 
itself  would  cause  no  danger  to  life.  A  sudden  rise  of  tempeia- 
tnre  in  cases  of  cerebral  luomorrhage  is  a  very  grave  iadicntioo, 
unleea  some  iuBammntory  complication  be  present  to  aeeooat 
for  it.  A  sudden  depression  of  temperature,  with  inereaieor 
renewal  of  a  pre<exietiog  comatoae  condition,  indicating  as  it 
does  cbe  occurrence  of  a  fresh  liumorrbage,  is  aUo  of  seriom 
import. 

Acute  tdougbiug  of  the  buttock  on  tbe  paralysed  mde^  oea- 
Dioncing  within  a  few  days  after  the  onset  of  tbe  apoplfldiB 
attack  is,  according  to  M.  Charcot,  of  fatal  sigDiticance.  Decided 
di£&culty  of  deglutition  and  articulation  is  also  a  terioM 
symptom,  being  indicative  of  marked  intorfontoce  with  tlie 
functional  activity  of  tbe  medulla  and  pons.  When  tbe  paluct 
bau  outlived  the  apoplectic  attack,  the  period  of  reactive  inflia- 
mation  brings  new  dangers,  when  death  may  reault 

When  the  ioflamaratory  period  is  passed  there  is  oompva- 
tivoly  little  reason  to  expect  a  fatal  result  from  the  braift  IvJo 
itself  or  from  its  more  immediate  complicalioos.  In  middle- 
aged  and  old  people,  however,  there  >s  a  constant  danger  efi 
recurrenoe  of  the  bienutrrbage.    The  dangers  of  the  a 


TBE  NATURE  Of  THE  LRSIOV. 


53d 


sttoclc  having  been  aurmounted,  the  point  which  bos  to  be 
detcnniocd  is  the  degree  of  improvomeDt  likely  to  take  plac« 
ID  the  patient's  mcQtftl  faculties,  in  his  power  of  articulutioD 
uid  speaking,  and  a.%  re^rdi^  the  probability  of  re»toratiea  of 
motor  power  to  his  paralysed  Hmbii. 

In  the  QiAjority  of  instanoes  wboa  the  lirat  losx  of  cenBcioua- 
nara  bas  paased  away,  the  patient  is  left  free  from  any  very 
decided  mental  defect, except  a  cortnin  amount  of  mental  weak- 
ness and  a  tendency  to  emotional  displays.  In  rare  cases  the 
hemlplegic  attack  is  followed  by  a  chrutiic  niani.ical  condition, 
which  may  puss  into  a  state  of  complete  dementia.  Thiji 
condition  is  apt  to  follow  limited  cortical  hcemorihage  of  the 
occipital  lobcH,  especially  in  elderly  people,  but  the  hemorrhage 
may  iteclf  be  only  an  efloct  of  previously-existing  degenerative 
cbuiges. 

Large  IcBtons  occorring  in  infancy  or  at  the  time  of  birth, 
either  in  the  subetonce  or  ou  the  surliicc  of  the  brain,  often 
illdace  a  »cmi-idiotic  condition. 


7Si.  Trcaiment. — The  aims  of  truatmcnt  arc  (I)  to  avert  a 
threatened  attack;  (2)  to  treat  the  apoplectic  couditiOQ;  (3)  to 
allay  excitement  during  the  stage  of  inflanimator>-  reaction  ;  and 
(4)  to  restore  power  to  the  pnralysed  limbs,  and  to  improve  the 
other  morbid  conditions  which  accompany  the  hemiplegic  state, 

(1)  ProphylaxUt. — In  devising  meBKnres  to  prevent  a  threa- 
tened attack,  each  case  must  be  mndc  the  subject  of  special 
study;  and  much  depends  for  the  auccesij  uf  thvue  uu  the  age, 
general  slate  of  health,  and  hereditary  teudenciea  of  the  patient. 
Bodily  and  mental  rest  are  absolutely  nece-^Bary.  The  pn-tient 
onght  to  be  kopi  cool,  with  his  bead  aud  shuulders  well  raised. 
If  the  patient  bo  beyond  middle  age.  with  signs  of  arterial 
degeneration  and  a  weak  intcrtnittL-ul  action  of  the  heart, 
stimulantfi,  cardiac  tonicH,  and  the  frequent  udmiuiiitration  of 
eaaUy-aAsimilat«d  fluid  nutriment  is  necessary.  In  the  presence 
of  a  modenitv  amount  uf  granular  disease  of  the  kidneys  with 
cardiac  byperliopby  and  high  arterial  tension,  saline  purgatives 
are  indicated. 

(2)  Within  the  lxu»t  few  years  our  treatment  of  the  apoplectic 
condition  bas  undergone  a  great  change.    Bleeding  was  regarded 


a40 


TOCAL  DISEASES,   ACOOBDINO   TO 


as  the  great  remedy  for  the  apoplectic  cooditioo  from  the 
of  HtppocratcB  dowo  to  witbio  a  few  yean  ago,  vben  tki 
te«cbiDg8  of  Todd  and  Trousseaa  produood  a  roaction  ui  tin 
opposite  directiuD.  Wbcn,  liowcTer.  bnemonliage  takes  plaot 
in  a  case  associated  with  high  urtoriol  tooiiiou,  a  aniiiLU  bleeding 
may,  l>y  loweriag  the  blood  pressure  and  (bus  diminitbiDg  the 
intracraoiat  pressure,  avert  for  a  time  tbreatening  Bymptona 
If  tbe  heart  be  feeble,  witb  compressible  paUc,  then  bleeding 
is  entirely  iaadmtssiblc. 

If  there  be  much  heat  of  tho  hwid,  witb  violent  throbbiiif 
of  vessels,  pounded  ice  in  a  bladder  or  iodia-rubber  bag,  ot 
evaporatiog  lotions  should  be  applied  while  tbe  bead  aod 
shoulders  »re  raised,  aud  evorjlhiog  about  tbe  Deck  loostood. 
In  tbe  present  day  it  h  superHuoua  u>  coademn  the  barbuooi 
practice  of  applying  mustard  plasters  to  the  calves  of  the  legL 

A  stimulating  treatment  is  required  when  the  heart's  acUM 
is  feeble  and  the  respiratory  ouutrc  is  threatened.  In  sod)  » 
case  the  patient's  face  is  cold  and  clammy,  tho  pulse  feebk. 
ftnd  the  Tespiraiioo  hesitating  and  intermittent,  or  it  may  ba 
asBuming  tho  Cbeyne-Stokes  character. 

If  the  disease  be  characterised  by  recurring  epileptifona 
attacks,  bromide  of  potassium  may  be  Bdmiuiatc-rud,  ondif  tb«t 
be  a  restless  condition,  with  more  or  lees  of  delirious  waadnin^ 
the  same  drug  or  bromide  of  camphor  may  be  us«fn].  If  the 
boweU  bo  consttpntod,  an  enema  containing  castor  oil  or  eaitor 
oil  and  turpentine  may  be  administered,  or  two  drops  of  cmtoo 
oil  may  be  given.  Tbe  state  of  tbe  bladder  must  also  be 
attended  to,  and  a  catheter  used  if  necesBaiy.  In  many  caaoaoo 
drugs  arc  required  during  the  apoplectic  stage,  and  purgatiiss 
should  not  bo  resorted  to  on  all  occasions  its  a  routine  treatmest 
irrespective  of  the  nature  of  the  casa 

(3)  If  the  patient  survive  the  6nit  shock  of  tbe  apoplectic 
attack  the  less  we  interfere  during  the  Gist  few  days  tbo 
better.  He  must  be  kept  as  quiet  as  possible  both  in  bod; 
and  mind,  and  his  diet  and  secretions  must  he  eaiefvH? 
regulated.  When  tbe  reactive  febrile  symptoms  ^ipear  coU 
should  be  applied  to  the  head,  bat  tho  old  practice  of  Ueedl^ 
at  this  stage  is  to  be  strongly  cnndentned.  If  headache  ba  pit- 
sent  along  with  persistent  wakefuluecs  or  delirium,  it  mtf^ 


TBS  NATUfiC  OF  THE  LESION. 


A41 


MCOKAty  to  adDaituster  a  full  dose  of  bromide  of  potassium  or 
wStta  an  opiate  or  cbloral.  During  tWia  time  great  care  muHt  be 
takes  to  prevent  bed-sores  od  the  paralysed  side,  by  paying 
ooostaab  aUcotioa  to  tbe  state  of  tbe  bcddiug  and  si^curiug  ex- 
treme oleuiliness.  Id  severe  caoes  tbe  patient  sboukl  be  placed 
OD  a  water  bed  from  tbe  Brst  wbere  this  is  possible. 

(4)  The  moat  efficient  means  of  promoting  the  iniprovemont 
of  the  oondttion  of  the  p&ralyscJ  nerves  and  muaclus  is  a 
thorough  atteatioQ  to  tbo  general  bealtb  of  tbe  patieot.  Tbe 
trefttment  which  it  will  be  necessary  to  adopt  will  depend  oq 
tb*  age,  habits,  and  constitution  of  the  patieot,  and  on  tbo  pre- 
WD«o  or  absence  of  any  epecial  concomitant  diseaaa,  Tbe 
general  prineiplea  of  treattnent,  however,  are  to  take  care  that 
tbe  patient  hiui  eajiily-digestiblo  and  mitritious  food;  that  all 
dreumstances  which  might  cause  mental  excitement  are  avoided; 
and  that  the  patient  bait  a  due  amount  of  repose  auJ  sleep.  In 
the  bemiplegia^s  of  elderly  people,  which  are  usually  ajiHociated 
with  miliary  aneurisms,  great  care  must  be  taken  tliat  the  ctl^ 
eolation  is  not  subjected  to  any  sudden  strain,  and  with  this 
object  it  is  necessary  to  take  care  that  the  bowels  do  not  become 
oonattpated.  lest  tbe  straining  at  stool  should  induce  auotlier 
attack.  Iodide  of  poto-saium  is  often  beneficial.  The  patient 
dioald  also  take  open-air  exercise  in  a  chair  or  carriage  wben- 
erer  thu  weather  is  suitable  i  and  much  good  noay  be  done 
at  a  later  period  of  the  disease  by  epuni^iug  with  salt  water, 
eiilier  tepid  or  cold,  or  even  by  shower  baths.  When  there  is 
advanced  degeneiatioa  of  the  arteries  or  high  arterial  teosioo, 
great  caution  is  necessary  in  the  use  of  cold  sponging  and 
shower  buthn,  since  the  sudden  iropresston  on  tbo  cutaneous 
stirface  will  be  followed  by  contraction  uf  the  arterioles  di»- 
tribated  to  the  surface  of  the  body,  and  this  will  be  followed 
by  Bodden  increase  of  the  arterial  tension,  and  consequent  risk 
of  tbe  rupture  of  another  vessel.  It  may  indeed  be  laid  down 
as  a  rule  that  bemiplegic  patients  should  only  line  baths  of 
cnotleiate  temperature. 

These  general  measures  should  after  a  time  be  followed 
by  local  beatment  of  the  paralysed  limbs.  Tbo  first  local 
measures  to  be  resorted  lo  are  passive  raovemenLs  of  the 
limbs,    and   friction   of  the   skin    by    means  of  a 


542 


FOCjU.  1>I3EAS&3,  ACCOKDiyo  TO 


flesb  brtis]],  flaaD«I,  or  Uie  palm  of  the  band.  When  t 
paralysed  limb  is  paioful,  gentle  mbbiog  is  very  soothing  no 
grateful  to  the  pnlieot.  The  patient  may  be  directed  to  mtiu 
voluntary  eilortii  to  more  the  limbs.  KLectricity  is  one  of  tbc 
most  valuable  agents  we  possess  in  the  treatment  of  panlysni 
limbs.  Both  the  fanulic  uad  galvanic  currents  have  U-et 
employed,  but  the  latter  appeara  to  lie  the  more  generalli 
useful.  The  coustaul  current  has  been  employed  in  thrc« 
different  ways.  According  to  ouo  method  the  current  is  paaed 
through  the  brain,  in  a  second  it  h  passed  through  the  cerrual 
sympathetic,  while  iu  a  third  it  is  directly  applied  to  tb» 
paralysed  limbs. 

The  pmctical  rules  which  must  be  observed  in  oarryiag  ow 
the  treatment  are  the  following  : — 

(a)  Tlu»  method  of  troatiuent  «b«dd  not  It  adopted  in  the  mHj  aUf* 
of  hemiplegia,  a«  ii^iu^  may  Iw  iIodv  I>)'  »rt>r-«ftinitiUUuD  of  tlir  Imic 

(i)  The  duration  <^  asch  application  throogh  the  hnhi  uvi^l  W  b( 
abort,  not  cxnolitig  thrae  ininutca. 

(c)  The  cuniiDt  «boiit<l  b«  weak,  laoiv  esiteanllf  in  the  ctMe  el  alihs^ 
people — such,  fur  inntancu,  iw  thnt  dunrvd  front  fiw  ta  t«o  or  rt  maS 
fiitean  l^oLuiob^'a  ctii]*. 

(J)  Tbo  okctrodos  aic  bi  bo  pUonl  on  the  matfioid  imiceeaMy  i*  «■» 
on  the  mastoid  piooma  and  tho  other  on  th<  ttactc  of  tho  acck. 

(<]  The  elocbodea  should  be  fAaxxA  in  poMtioii  vbco  tha  inkx  h  M 
aera,  aud  the  «uneet  ia  then  gmduallj-  inoraued  iind,  after  tvn  iir  tfciw 
iniiiutea'  upiJicatiun,  graduaUy  diiuIiiinfaMl  beRm  tbe  electrodoa  arr  n- 
luox'ed.  Sudden  Intemiptiana  uxd  r,i|iid  reruaala  cf  lh«  vurrsnt  ouj^  k> 
lie  avuided. 

Ill  tlie  Bootml  method  tlio  curreut  is  paaaod  thruu^i  tb*  ovml 
Hjiaimtfaetic.  In  this  method  the  electrodes  kk  yXmaed  over  tha  count  of 
tha  8f  mjMthetic  in  the  iicx^,  nud  It  nfipenm  to  be  iudifferunt  wliethv  ikr 
anod«  itf  obvvc  aud  tb»  tatb»dv  bckm-  or  tho  rvvene.  Tho  comsils  an- 
|)1nyud  iiuy  In  iitronger  than  wlieu  Uie  Wain  waa  dtreoUy  aolad  nfaa 
Fruui  fi[W:ii  lo  tu-entj-five  Leolouciifs  oella  may  be  naed. 

Iti  the  tliird  tiiRtliod  Ui«  «lectK«ka  an  uied  along  iha  ooune  €f  da 
ncTv-cM,  the  lu^gatiTc  italt  being  phioed  near  tbe  [ilexua  to  which  the  tlfct"! 
iicn'e  belonge,  or  onr  the  conTspanding  part  of  tiw  Tertebral  o^liiam.  Md 
the  [Mttitive  file  over  the  trunks  of  tha  norvM.  Hoto^  however,  real*- 
mend  deaccudiug  instead  at  aaoonding  ouncnta,  but  it  dona  not  a[4iatr  to  b 
«f  much  oooBoquanc*  which  is  used.  Tbs  eumnt  btva  thirty  Ladaae^ 
cdln  may  be  used  for  about  eight  minutes,  and  in  order  to  iucnaM  to 
ntimukting  aotioo  the  intensify  may  be  aJtematdy  inrrnssml  auJ  dn*- 
niahed,  white  the  einmit  b  kepi  doaed.   Interraplianaatid  ramHl  Ylli 


THE  NATURK  Or  THE  I.ESroN. 


543 


Hiioiild  onljr  be  used  for  tbe  puri>aae8  of  iliagiiosia,  Tliif)  iikhU'  of 
tffljiiif  golrftiiiaiD  to  the  poinlynni  liiulm  d<N»  guul  Id  cjuwn  of  clonic 
!i|)wm  Aftor  tiieini|<li<gin,  aiid  in  mm»  citsm  uf  "](iU>  rigiility  ;"  but  when 
tfas  fuQtmcltin:  ha»  bi-oomc  {loniUUtQllti  ea  tliot  it  docs  not  iutonoit 
ttnriog  riw^i.  it  k  lioiwlon  faj  cipoct  an;  btniefit  rnmi  trmlnient. 

Faradic  curreubi  liave  Wen  employed  iu  ccnlractures  for  the 
purpose  of  acting,  not  on  the  coDtTitctcd  muscles,  but  upon  their 
«iitagoDist8,  but  it  does  not  appear  that  much  benefit  baa  ever 
resulted  from  thi«  trcatinenL  The  iliHturbances  of  nejiMbtlity 
on  the  paralysed  side  do  not  usually  require  any  special  treat- 
ment, since  the  measures  which  are  directed  to  mitigate  the 
motor  paralysis  exercise  a  favourable  intiuence  on  any  existing 
ttoaoTj  impairmcuti.  IF  there  be  hemiaosestbesia,  metallo-thera- 
peotics,  as  employed  by  Chajcot,  which  will  be  described  in  the 
section  on  hysterical  kemianxBtheeia,  ma.y  be  adopted,  but  our 
knowledge  of  this  subject  is  too  recent  aud  too  imperfect  to 
enable  us  to  form  a  dcfiaitc  opinion  of  its  merits. 

t(b}  ifeningeal  Uimtcrrltage. 
tJiniHon. — By  meningeal  haemorrhage  ia  here  meant  an 
extTarasabioo  of  b]ood  between  the  metnbranes  or  on  the  surface 
of  the  brain. 

§  725.  Eiioloyy. — The  most  frequent  causes  of  meningeal 
apoplexy  are  injuries  of  the  skull,  by  means  of  which  the  maiu 
meciDgeal  arteries,  the  sinuses,  or  the  ressela  of  the  pia  mater 
arc  rupturud,  but  this  subject  belongs  to  surgery. 

Ancurisma  of  tlie  arteries  at  tlio  base  of  the  skull  may  by 
rupture  give  rise  to  meningeal  bfemorrhage.  In  a  cose  which 
came  under  my  observatiou,  a  large  meningeal  haemorrhage 
was  caused  by  rupture  of  an  aneurism,  about  the  size  of  a 
pea  on  the  left  Sylvian  artery,  altout  an  inch  from  it<t  origio. 
Another  aneuriiim  unrtiptured,  symmetrical  with  it  in  nize  and 
posilioD,  was  found  oo  the  right  Sylvian  artery.  Next 
to  the  middle  cerebral,  the  basilar  artery  is  moat  fre^juently 
affected  with  aneurism.  Hieroonrhage  may  also  take  placo  from 
the  v^ns,  and  large  meningeal  ha'morrhftge  may  result  from 
thrombosis  of  the  sinuiies,  especially  the  siipenor  longitudinal 
sinus.  Blood  may  make  it«  way  from  the  substance  of  the  brain 
into  the  meninges  through  rapture  of  the  cortex.    Meningeal 


544 


FOCAL  DISUSES,  ACCOKDKO  TO 


hsmorrlmge  may  result  in  the  coiine  oT  infectious  <]isMiei,ud 
chronic  dyscraaiffi,  and  frequently  occura  in  tbe  coQiseof  Ik 
chronic  degeneralioo  of  tlie  cortex  of  the  brain,  irhich  oixleriiH , 
progressive  paralysiia  of  tlto  iunnct. 

Tbo  meninges  apoplexy  of  newi-bom  children  is  couaed  ^ , 
certain  accidents  attending  childl>irtli. 

§  726.  Symptoms.— It  mil  suffice  if  wo  point  out  hen  tWI 
ditforencG«  which  exist  botwceo  tbo  symptoms  of  cerebral  uul 
meniageal  hiemorrhages.  The  clinical  hinlory  of  meni&gBil 
hemorrhages  of  traumatic  origin  is  usually  compUcatod  with 
other  cerobral  symptoma  directly  resulting  from  th«  iitjaiy. 
such  as  ooDoussion,  and  the  same  may  be  said  with  reganl  to 
the  cases  where  an  intracerebral  hiemorrhage  haa  made  it> 
way  to  iho  Eurfoce  of  tbe  brain,  as  well  as  with  lef^ard  to  the 
haMnorrhage  vhich  accompanies  general  panilysia.  Hfemorrfaip 
caused  by  rupture  of  an  aneurism  foinis  tbe  least  coai| 
class  of  cases. 

lu  scvero  cases  tbe  patient  becomes  auddeofy  a; 
without  any  waroing,  or  with  only  slight  premonitoi;  symj 
such  as  headache,  dizziness,  and  vomiting.  The  paralyias  is 
commonly  general,  atTecting  all  four  extremities  unifunuly,  and 
only  iu  rare  cases  ia  hcmtpU-gia  met  with.  Epileptiform  ooonl- 
sioDB  are  also  frequent  in  luemogeal  hiomorrbage,  and  Tomiting 
ia  another  aign  often  observed.  These  casea  arc  accompuueJ 
by  profound  oumu,  and  deutb  results  in.  a  few  hours,  or  at  nuSt 
ft  few  days. 

In  less  severe  cases  the  patient  may  partially  reoovcr  alters 
few  bourn  from  the  apoplectic  state,  and  Chen  mar  complaift  tf 
heailache,  be  delirious  or  somoolent,  until  he  become* 
comatose. 

In  other  cases  the  patients  do  not  becomo  immediately  i 
Icctic,  but  complain  of  headache,  dizziness,  wenknoas  or 
ness  of  tbe  extremities,  on  one  or  on  both  sides;  th«re  is  alia 
more  or  Ibm  stnpor,  but  the  &tal  coma  inay  not  saparrMM  Itf 
a  long  time;  Iu  these  cases  the  bsmorrhage  mppean, 
small  at  first  and  gradually  to  iocreiaseL 

If  an   aneurism  of  cunHiilerabte  size  have  existed  fbr ' 
time   before  tbe   uccurrenoe  of  haemoniiage.   tli« 


THB  XATCRE  OF  THE  LKSIOK. 


5M 


attack  ma;  be  preceded  by  some  of  tbe  symptoms  which  in- 
dicate the  exiateace  of  a  cerebral  tumour.  Tbe  motu  usual  of 
Ihcae  symptoms  are  headache,  double  optic  oeuritie,  paraLysia  of 
the  facial  neire  in  aneunsm  of  tbe  iotenial  carotid,  of  the  third 
oerrc  in  aoeunsm  of  the  posterior  comtnunicatiag  artery,  and 
romitiog,  epileptiform  coavulsioos,  and  disorders  of  deglutUicw, 
■peecb,  aod  respiration  in  aneurism  of  the  basilar  artery. 

In  tbe  meniDgeal  btcmorrbnges  of  the  new-bom,  the  childrou 
are  either  born  dead  or  in  a  condition  of  asphyxia,  and  die  soon 
afterw&rds.  If  respiration  be  establixLud  tbe  infant  remains 
weak,  socnoolent,  or  comatose,  and  die»  after  a  few  days  fi-om 
OQDTuUious.  Somelimea  the  children  are  we»k  aud  somuolent 
at  birth,  and  remain  in  thiH  condition  from  one  to  three  weeks, 
when  vomiting,  dyspnoea,  ccJOTulsions,  and  coiua  supeiveuu  and 
soon  prove  fatal. 


§  727.  Morbid  Anatomy. — The  blood  may  roukt;  its  way 
into  the  arachnoid  itpace  in  consequence  of  injury  to  the  dura 
mater,  oi  from  the  vesaeU  of  tbe  pia  mater,  or  from  the  cerebral 
TMBcla  and  subsequent  rupture  of  the  pia  mater.  When  the 
extravasation  is  large  tbe  bu;morrbage  spreads  extensively 
through  the  arachuoid  apace,  so  that  an  entiro  hemisphere, 
or  exeeptionally  the  surfaces  of  both  hemispheres,  may  be 
ooverad  with  a  thick  layer  of  blood.  When  a  large  collection 
of  blood  has  formed  at  the  base  and  around  the  pons  varolii,  it 
mfty  make  its  way  into  the  veutriclea  ihmugli  the  great  trans- 
verse fissure,  and  poRt  down  through  tbe  aqueduct  of  Sylvius  to 
the  fourth  ventricle.  Tbe  quantity  of  the  effused  blood  may 
vary  firom  a  fi-w  drupa  to  hidf  a  litre  or  more,  llie  pigmented 
ipotA  sometimes  found  on  the  meninges  and  surface  of  the 
braiD  seems  to  indicate  that  small  menmgeal  ha>morrhages  may 
be  absorbed,  but  large  h»tmorrhagog  invariably  prove  fatiU. 

Tbe  appearances  presented  by  tbe  brain  vary  greatly,  accord- 
ing to  the  amount  and  seat  of  the  hemorrhage  and  the  time  at 
which  death  takes  place.  HsemorThage  from  the  dura  maler,  if 
large,  compresses  without  rtipturiug  the  brain.  In  such  a  case 
tbe  gyri  are  found  Hattenetl  and  tbe  substance  of  the  brain  pale. 
Efsmonhage  from  rupture  of  the  vessels  of  the  pia  mater 
or  of  the  bruD  itaolf,  and  especiBlty  rupture  of  an  aneurism 
JJ 


MS 


POCAt  D[SEXSBS,  ACCORDrKO  TO 


Ladame  208  were  mate,  95  female,  and  in  SO  tbe  sex  wu  not 
stated,  80  that,  accordiDg  tu  Uus  computation,  the  proportMs 
ix  rather  more  than  two  to  one,  Injuriea  of  tbe  akutl  act  u 
exciting  causes  in  the  production  of  cerebral  tumoura.  SeTcnt 
cases  have  come  uudur  my  own  observation  in  wbicb  tbe  diMaw 
dated  from  a  blow  on  the  head,  and  tbe  tumour  iu  tboK  camt* 
frequently  ^ew  at  a  place  oorreepondJn^  to  tbe  neat  of  injury 

Viiscular  tumoura  oonwAt  of  anctirwww  of  tbe  cerebnl 
art«ric8  and  i^-cctiU  tumours.  Aneurisms  aro  observed  at  a*i 
ages,  but  tbey  are  more  common  between  the  ages  of  forty  tad 
sixty  years,  when  tb«  vcmcU  begin  to  undergo  atbcr<>niatoti«_ 
degoneratioD  ;  the  causes  of  erectile  tamoura  are  unknowiL 

The   parasites  met  witb  in  tbe  brain  are  tbe  cystlcanosi 
echinocoGcus. 


§731.  i^ym^fnimL— H«i/ia«AeiB  one  of  tbeaarlieataiuli 
striking  of  the  initial  symptoms  of  intracranial  tut 
Ladame  found  this  Hyinptom  in  two-tbirds  of  tbe  caaea  collected 
by  him.  Headache  is  more  violent  in  istracianial  tumunr  tlian 
iu  any  other  disease  except  meningitis  and  the  unemia  of 
chronic  Bright's  diseaae ;  it  consists  of  an  acute  lancinatiag  or 
severe  boring  pain,  which  may  continue  many  weekn  witboat 
intermission,  and  is  aggravated  by  impreasiona  of  light,  notaea. 
and  all  movements  of  tbe  bead.  Tbe  pain  aomotimea  occupcs 
the  occipital  and  at  other  times  the  frontal  or  temporal  regioai. 
but  its  seat  has  no  necessary  relation  to  tbe  aituatioo  of  tKe 
tumonr,  although  constant  occipital  pais  is  often  MBOCMtri 
witb  cerebellar  tumour.  Neuraljjic  headache  from  irntatioci  of 
tbe  fifth  nuty  be  associated  with  the  more  profound  hoadacibf 
of  general  pressure.  Ti.-Ddemcas  ou  percussing  tbe  tkuU  may 
sometimes  be  observed  at  a  point  corresponding  to  the  MtuCWB 
of  the  tumour  (Ferrier). 

Ditsineai  is  a  frequent  initial  symptom,  and  it  may  bf 
present  with  or  without  cephalalgia.  Poroxynna  of  bad* 
■ohe  and  dizzinms  may  be  tho  only  symptoms  praNat  kK 
monthi,  and  the  patient  may  feel  well  in  otbar  raapwli. 
Dizziness  is  probably  caused  by  alterations  in  tbe  drctUaUoa 
of  tbe  bmin  induced  by  the  growth  of  tbe  tumour;  bat  tbe 
insecurity  on  asauraing  tbe  erect  posture,  which  is  ooe  of 


547 


CHAPTER  V. 


,     (L)    GENERAL    CONSIDERATION'    OP    FOCAL    DISEASSS, 
B         ACCOBDIMG    TO  THE    NATURE   OP    THE    LESIOK 

^B  (COBtWlIB)). 

l^onbed 


&  INTRACRANIAl,  TUMOURa 

729.  DeJinUion. — lotnicranial  tumoure  oonaist  of  circum- 
■onbed  pathological  growth*  situated  within  the  cavilj  of  the 
all 


i 


^  7S0.  Stiotot/y. — Tiimonre  of  the  brain  arise  from  Bimilar 
causes  to  iboee  which  give  origin  to  tumours  in  other  loc&litiu. 
For  the  sake  of  convenience,  cerebral  lumoum  invty  he  dirided 
iato  (a)  New  formations  ;  (ft)  Vascular  tumours;  (c)  ParaBilc*. 
Hereditary  predisposition  plajre  an  important  port  in  the  pro- 
daction  of  new  formations.  Caocerous  and  tubercular  tumours 
and  STphilitic  gumm&ta  depend  upon  a  general  constitutional 
taint,  aud  it  ia  alao  probable  thai  glioma,  sarcoma,  aud  other 
tumours  ore  more  liablo  to  arise  in  some  families  thati  in  others. 
Cancer  is  one  of  the  most  common  tumours  of  the  brain,  and 
is  geoerally  primary.  When  secondary  it  often  follows  cancer 
of  the  orbit.  It  is  a  disease  of  adult  and  advanced  age,  the 
largest  number  of  cases  being  found  between  the  ages  of  thirty 
sod  sixty  year*.  Tubercle  on  the  other  band  ia  rarely  primary, 
but  is  generally  associated  with  tubercle  of  the  lungs  or  cheesy 
glands;  it  is  easenttalty  a  disease  of  youth,  being  most  common 
between  tbe  ages  of  throe  and  thirty  years.  It  is  probably 
the  raoet  fr«quent  of  all  cerebral  turauuni.  Syphilitic  gunimata 
may  be  met  with  at  every  period  of  life. 

Cerebral  tumours  are  more  freL{ueut  in  men  than  in  women. 
Out  of  S20  cases  of  cerebral  tumours  of  all  cases  collected  by 


350 


rOCAT.   DISEASES,   ACCORDIKO  TO 


tioQB  of  the  special  seoeea,  those  of  light  arc  hj  f&r  tbe  no*^ 
importaDt  Calmeii  fouad  amblyopia  io  two-fifths  of  bis  caau. 
and  Lailamc  foiini-t  tinmiirosi!!  iQ  one-Brih.  Tbo  optic  disc  nwf 
proeout  tbu  appeuranca  kuowu  as  "choked  disc"  (Staaan^ 
papilla^,  or  there  may  be  neuritis  (§  SOT).  The  former  ii 
by  far  the  most  important  aign  of  cerebral  tumour,  aa  it  ti 
geaerally  pretteut  whenever  there  in  increased  inuvcraaial 
pressure ;  and  although  this  condition  is  aaid  occadoaslly 
to  accompauy  fluid  effusion,  yet  tbe  uioal  caate  is  a  iolid 
growth. 

It  is  of  the  utmoat  importance  for  regional  diagooais  to 
examine  carefully  for  coutractious  of  the  Beld  of  timoo.  and  for 
the  different  varieties  of  hemiopia.  Diplopia  is  also  a  freqcwnt 
symptom  of  tumours  at  the  base  of  the  brain,  caased  by  as 
affoctiuQ  at  t)io  origin  or  pressure  in  the  course  of  the  third 
fourth,  or  sixth  cranial  nervea 

Tbe  pupiU  vary;  they  may  oocasionally  be  cootmctcd  or 
unequal,  but  vrhen  by  the  growth  of  the  tumour  tbe  iatracraatal 
pressure  becomes  greats  thoy  aie  always  dilated  aod  reset  fe«bly 
to  light. 

The  senGo  of  keari-ng  is  also  frequently  affected.  GUnatl 
fouDd  some  disturbaacea  of  hearing  la  one-nintii  of  his  chm; 
Ladame  .s-iyn  that  the  sense  of  hearing  is  affected  only  oot 
half  as  often  aa  tbe  sense  of  vision.  The  auditory  distorbanMS 
usually  conaist  of  dulnesa  of  hearing  and  rushing  Doisa^  hot 
complete  deafness  is  sometimes  observed. 

The  injection  experiments  of  B.  Weber  have  sbovn  that 
there  in  a  communication  between  the  ancbnoiil  cavity  and  tbe 
labyrinth  by  means  of  the  aqueduct  of  the  cochlea,  ajid  cob- 
sequently  increased  intracranial  pressure  may  produce  ao 
affuction  of  lliu  auditory  apparatus  simitar  to  that  which  ocean 
in  tJie  eyes  under  the  same  circumstancea  Alt«mtiotis  of 
licaring  may  likewise  be  caused  by  pressure  on  the  trunk  of 
thti  auditory  nerve  or  on  its  nuclei  of  origin  in  tho  niedalla  aod 
pons.  Pressure  on  the  labyrinthine  libree  of  the  auditory  Dcm 
may  oocuioa  vertigo  and  disorders  of  motor  co-ordination  •ioiilai_ 
to  those  observed  in  Meniere's  disease. 

The  <en«0  of  sm4U  is  relatively  aeldom  affected  in 
tumour  of  the  brain.  The  sambor  mootiooed  tn  Ut«nitu^  I 


THE  XATUKE  OF  THE  LtlSIOIf. 


551 


ever,  U  cot  a  true  crLtoriou  of  tbe  teal  number  affected,  siace  the 
patient  is  very  apt  not  to  mentiou  tbe  loss  of  smell  uutetss  it 
be  GDtirely  lost,  and  tbo  phjaiclaa  is  apt  oot  to  make  any 
special  inveetigation  of  it  Ladame  found  the  Hense  of  amell 
distioctlydimioigbed  or  entirely  lost  in  ten  only  of  his  collected 
caaea,  and  never  praeent  an  tbo  only  symptom. 

The  anue  of  iaaU  is  likewise  only  rarely  affected.  In 
Ladame's  collected  cases  menlioD  is  made  of  alterations  of  this 
fuDction  only  geren  limes,  once  the  affection  wa8  unilateral, 
and  the  senae  waa  only  rarely  completely  loet.  There  are  good 
grounds,  however,  for  believing  that  if  taste  were  carefully 
terted  in  all  casee  of  cerebral  tumours,  alterations  would  be 
more  frefjueotly  found. 

The  organic  /unctions  always  become  more  or  lean  injured 
in  intracranial  tumour.  The  intense  cephalalgia  alone  preveats 
the  patient  from  sleeping,  and  the  eootinual  wakefulnest  reacts 
OD  the  general  health. 

Vomiiing  ii  bequently  associated  with  paroxyBme  of  head- 
ache and  vertigo,  but  it  may  occur  ludepoudeutly  of  these. 
It  is  oftvn  extremely  obstinate  and  may  coutinue  for  hours,  and 
when  it  recura  frequently  tbe  general  nutrition  suffers  f^eatly. 
CoostipatioD  is  usually  prcecat,  but  in  some  cases  it  may  alter- 
nate with  diarrhft'x  Irregularity  of  the  heart'*  action  and 
olowoees  of  tbe  pulse  have  been  frequently  obaerved,  probably 
from  irritation  of  the  va-gas.  Towards  the  end,  however,  th« 
pulse  liecomcs  very  frequent. 

Tbe  TtspirtUory  function  is  not  often  disturbed,  but  the 
rhythm  maybe  quickened  by  irritation, and  rendered  slower  by 
[pressure,  of  the  brain.  Vierordt  and  Hegelmaier,  by  recording 
tbe  movementa  of  the  superior  abdominal  region  of  rabbits  on 
tiie  dram  of  the  kymograph,  found  that  a  moderate  artificial 
pressure  oa  tbe  brain  diminished  tbe  respirattons  by  one-half, 
while  they  were  iDcreased  in  number  by  a  stronger  pressure. 
With  mudutatc  pressure  the  inspirations  were  fewer  and  tha 
expirations  longer. 

Polyplta^ia  is  an  occaaiooal  symptom  of  cerebral  tumour, 
but  it  does  not  prcvoat  the  pn^ressivo  emaciation.  Ilosentbal 
mentionj)  a  case  vbere  the  polyphagia  was  acoompauiod  witU 
diabetes  mellitus. 


S52 


FOCAL  DISEASES,  AOCOKDINO  TO 


Polyuria  and  taaJiaritu  unrie,  eilW  separately  or  com- 
tined,  ar«  freq^uecOy  mot  with.  Id  tbeae  cmok  it  is  olmtM 
oertaia  that  there  must  Ite  irritation  of  tfa«  floor  of  the  foortb 
ventricle,  but  the  irritation  need  not  be  direct.  Roiieathal  relata 
the  history  of  a  case  where  diabetea  was  caused  by  lumoor  <rf 
tbo  pituitary  body,  and  I  have  seen  a  case  wb«re  polyaria  wat 
occasiooed  by  a  tumour  Hituated  at  tbo  baae  of  ibe  ikall^ 
tbe  right  cavernous  sinus. 

Fever  is  not  a  usual  symptom,  but  it  ia  wmetims 
during  an  attack  of  cerebritin,  these  complications  being ' 
frequently  observed  in  the  iocipieDt  stage  of  tubercular  tuauMU: 

Tbe  nutritim  disturbances  do  not  maiDtoia  a  doe  pin- 
portion  to  the  gravity  of  the  cerebral  phenomvoa,  Dor  dOM 
the  nature  of  tbe  tumour  appear  to  exert  a  marked  iodaeoce 
on  the  gODer&l  health.  Ca.ies  have  been  observed  ia  wbiefa 
cancerwf  the  bnun  bad  existed  for  some  months  vithoat  pro- 
ducing a  perceptible  Influence  on  tbe  outrilioa  of  the  bodj, 
and  those  suffering  from  mrcoma  may  even  manifest  a  tendescy 
to  obesity.  As  a  rule,  however,  the  subjects  of  loberda  and 
cancer  sooner  or  later  exhibit  traces  of  cachexia.  Tuiaatirrf 
tbe  brain  may  act  injuriously  on  nutrition  in  several  wayi  A 
state  of  great  marasmus  is  sometimea  induced  by  fre^neiitlf 
recurring  vomiting,  while  at  other  times  tbe  vital  powers  of  the 
patient  become  exhausted  by  incessant  headache  and  sleep- 
lesBDees, 

Peyddoal  didurhancea  are  frequently  observed  in  cerebn) 
tunaoar,  but  the  statements  of  authors  differ  ooosidorably  vitk 
respect  to  the  rebtive  frequency  of  Llie  symptom.  Aodnl  sad 
Duiand-FardeL  assert  that  mentaldtsturbuioes  oc«ar  very  mUoo, 
whileCalmcil  observed  psychical  disorders  in  ooe-balf.Friedrdcb 
ID  4S  per  cent,  Lebert  in  oac'tbird,aDd  XiuUine  in  rather  nun 
than  a  third  of  their  awes.  Symptoms  of  mental  irritatioe  fre- 
quently precede  those  of  depreesioo.  Tlie  irritative  symptw 
conaiHt  of  mental  excitement  and  those  emotional  disturbaaoci 
which  are  usually  known  as  hysterical,  ideas  of  grandeor,  with 
consequent  extravagance,  hallucinations,  delusions,  and  oat- 
barsbs  of  pasHion  which  may  amount  to  maniacal  fury.  Tbs 
symptoms  of  depresuon  consist  of  drowsiness,  apathy,  loss  of 
speech,  and  imbecility.    The  affeclaons  of  speech  which  oobbt 


THE  NATURE  OF  THB  LERION. 


653 


ia  cerebral  tamoar  are  variable  in  cfaarootcr.     Ladame  found 
iflMiJRW  of  speech  in  ^  of  his  collected  caeee. 

Ttrminal  Phenomena. — As  the  tumour  grows  in  gize  the 
brain  beoomet  oompressfMl  to  Hucb  an  eiteot  that  lU  functioDs 
beCDDM  gradually  abolished,  and  the  tenniaal  phenomena  of 
the  affection  are  ushered  in.  TheHeconHiiit  of  extreme  emacisr 
tioo,  widely  spread  anaBSthesia,  blindness  and  diminution  or  loss 
of  one  or  more  of  the  other  special  scnseH,  motor  paralyiiiB 
often  implicating  all  the  extremities,  imbecility  and  deep  and  .^ 

enduring  coma.      /^  lu^%/^Uy<Ly\u,^i  »    «     ^-v^-^CXt-**-   *t<-^''*— 


/-^k^^2w\4o^i.  0- 


§  732.  Morbid  Anatomy. — The  morbid  growths  which  eon- 
etitutc  iotrncranial  tumours  are  very  variable,  and,  roganled 
from  the  standpoint  of  pathological  anatomy,  have  little  or  do 
affinity  with  each  other,  but  are  conrenieutly  grouped  together 
for  practical  purposes  on  account  of  their  clinical  afiinitiea 
The  brain  is  surrounded  by  unyielding  osseous  walls,  and  the 
derelopmeut  of  any  foreign  body  within  the  cranium  encroaches 
upon  the  space  occupied  by  it,  and  consequently  there  is  a 
close  similarity  in  ttie  symptoms  caused  by  intracranial  tumours 
faowever  ditTerent  in  nature. 

(a)  Varietia  of  JrJraeranial  Xew  Fortaaltont. 

(1)  OHoma. — The  glionmta  form  tumoure  which  raiy  in  siie  firom  a 
f^tOM  la  that  of  the  cloaed  fiat ;  thejr  are  vaaonlar,  of  n  wbite  or 
-red  ocJnur,  and  sre  never  (ljHtiiii7t.lv  i;irc-.uii»crit)er]  fnirii  ilii;  tJnKiieM 
brain,  tbo  grey  matter  of  which  tbey  much  resemblo  in  coniUBtence 
culoitr.  Tlie  hemitfphettft  of  tlit:  hnhi  are  the  fiLVuuritt!  HeAtn  »r 
gUomala,  althou^  tb«y  may  (^pear  in  any  part  of  the  brain  or  apinal 
axd.  OliMoaU  aro  oomfWifecl  uf  a  matrix,  vihich  varittt  bt  coDftiateDoe, 
and  an  atnuulsst  ailmixturo  of  oellii  and  uucltii.  Tlii!  iwIIh  vary  in  uhapc 
oaa;  they  ore  somctiiiicit  round  or  ovnl,  with  gnuitUur  contunUi  au<l 
or  two  undvi ;  nt«th«r  tuuox  s[iiiulU>-«lmiitvl  or  HLrlbiW,  ami  ^niviileil 
with  &D0  pcwwcMt  which  •»  cootinuous  with  thotw  of  niljoiiiiog  ocUs. 
There  are  two  princtpsl  variotHs  of  glionn&ta,  ttie  kard  anJ  tbn  sn/t.  En 
the  Katii  gliotitMa  tho  ooUs  are  ocaoty,  and  usually  contais  Mveral  nuclei. 
The  matrix  is  ft)nii«d  of  fine  fibriUw,  which  are  man  or  1ms  patdIIp]  to  one 
ODbUier,  and  can  eometimw  be  isolated  into  l&Dg  tbr^oda.  In  tKe  hiutlwt 
foniM  the  matrix  is  no  longsr  formed  of  lonjt,  sepsiablo  fibrillEc.  but  «f  r 
faxXy  rHicuUf  iiu)wtauoi>,  which  cod  only  b«  acparated  inUi  ubi^rt.  stiff 
Abrw.  At  limta  partonlj  of  the  tumour  Ih  hard,  and  it  then  contain.-^ 
one  or  more  hanl  lumels,  wiiich  may  equal  in  density  tibro-eartild^oiu) 


554 


FOCAL  ClSSiSEB,  ACCORDrKO  TO 


luinoiUH.  Tnie  carUlsginmis  Binit:tiini  hm,  bowevcr,  tiev«r  b«ca  tani 
in  thnw  tiimoura.  The  bnrd  gUonmta  an  aUiod  in  gnwnl  ebmlcn  i* 
tlw  filironiittA,  aud  tiittirmediatv  tartaa  are  met  with  wfaicb  an  Unmi 
Jibro-tjtionalii. 

In  Ihc/Ar^^tomof  a  the  matrix  conaifte  of  fibres  fomins  thkk  bandbn 
or  esbibitJDg  a  strntifonu  unngcoiMit  eiiolmiiig  ben  and  then  tnutaW 
cells. 

Tho  ae^  gtUtfivita  ooataia  moivcvUs  than  the  lianl;  tbe  oBUftvarfaA- 
mderoUy  in  aise  and  form,  bat  arc  gcDcradly  miaU  ukI  deficient  in  [ibw* 
The  matrix  ooaasta  of  a  fibrilUj;  Detwurk,  in  tlui  intnratioca  of  wbidi  tfct 
odla  an  unbeddmL 

TnuiAJtionitl  fnnua  between  the  aaft  gUotnata  and  otiwr  ttnooun  ai* 
met  with.  UIil'ii  ttic  iiuiubcr  and  aue  of  tbt!  ocUa  an  incwawJ,  tk 
tumour*  an-  allitMl  Ui  tlio  mnwiDala,  and  ore  tberafora  oalled  ffuMnrw— i; 
and  when  the  outtrtx  oiwumea  a  mwoid  chancter,  th«  tuttvMir  wwnUw 
th«  mjifmnoAi.  Tlio  glioDuita  uro  adtuffUmw  ricbty  iai|i|>tlDiI  with  rcU- 
tivsl;  large  bl<x><l-re«acLi,  conatit'itiiig  what  Tirchow  hns  namod  nUm 
jnc^tuficKlJoHin.  Tliix  form  iachaniK.'toriM-d  \>y  U>e  beiideocy to  baamnfal^ 
which  alwa^  ooouni  in  Um  «MitM  of  th«  t<itn.»ir,  and  1b«  apfnanMB 
proaented  mar  doadf  roaembla  aimi:^  app[i)vi;.  Hiiia]i>rriu«ic  gbma 
luiialljr  oflcnrw  iit  the  whit«  «ulMtAn«!  of  the  h«miiifJ)on,  wben  ahifii 
«IKi]>lo3jr  i»  nuvly  iiocn ;  and  in  the  fonocTi  even  when  tbo  tumv  b 
largel;  doMrojnl  by  liKimurrhago,  a  iiurnvw  xodc  BUtTooods  tba  dot,  «lMft 
is  suJBdeat  to  reveal  the  origin  of  the  miachicf. 

Oliomata  grow  alowly,  and  th«  tumour  j^oacrally  attains  a  lan^  mm. 
That  these  tiunouTB  undei^go  retrogrBesTe  changM  ia  abown  bf  tb  &» 
quent  ocourrenoe  of  &t^  degeneration  in  tbdr  intcriar,  bot  tha  dai^ 
iiietUuiil  of  Iciiiliti^  tc)  a  ciuatire  ptnona  an;  inuiii  morv  Ukulj  In  tmm 
hannrMThagc  im  noon  ui  th«  atMorption  of  th<  Entt^  diifit  Inweffa  ltd 
irmovcn  the  jinvuiirc  on  the  vtMnls  in  the  intariar  of  ttw  tUBMnc.  Bl 
fiitt;  motamorphoaia  and  aoAeaing  of  the  intfrwUnlar  aahatanea  miiOm 
fonn  which  may  he  distiiigaiahed  from  cjni^i  by  their  irragiular  and  noam 
««Ua  In  thi>  ncinit;  tf  tamoura  where  tha  tinUB  are  nddlak  orf 
softened,  fatty  granules,  cfaolcstarine  erpitai&t  Qeuroiilia  ouoloi.  tut  tat- 
rnenta  of  axia  oylioden  may  be  found. 

(S)  ffffWplatia  of  thejriiieat gta>*d  La,  both  in  extcnal  lilmaitwi  arf 
in  the  nature  of  iU  elonxiutrt,  vary  Hiniilnr  to  gtioma.  Vinbow  mj*  IW 
itf()msaaoIid,grejiah-red.  alightly  lobuluted.  or  a  MnooUi  imuxl  liunnTi 
which  nuy  grow  to  the  size  of  a  walnut  or  «veii  lai]^.  On  aactia  • 
uihibitfl  tho  well  known  grq^,  moist,  TMoalar  tianie  of  the-  fiamX  |^mL 
ami  ill  <ild  iXTrtwiM  a  large  number  of  the  midJiln  bodJea  mn  laml* 
aheont  Histologically,  the  cell  ehmenta  are  aotnawbat  Uiip.T  sod  fin^ 
than  in  th«  normal  gland.  Theae  tumoora  pndnce  pRMmn*  on  thear 
pora  quadrigeuina  and  vens  tnagns  Qaleni,  oud  Uiat  uo  the  llUar  la  >l* 
turn  may  gire  rise  to  seoandaty  hydroae|iba]us. 

(3)  J/i^ronwi  ia  rarer  in  Uw  bnin  than  in  tho  quiiul  ootd  and  p«i|Atfll 


THK  ITATUBE  OF  THE  LSSIOK. 


555 


nurvM.     It  Uikm  Hs  ovigin,  like  glioron,  frron  nn  ororgx^vrtli  of  the 
DBoro^u,  and  extoods  unifonuly  in  nil  din>ctions  bv  intiltratioD. 

(4)  Sotiiary  J\iiertle,  which  w  hy  tnr  the  niort  ix)nimo&  tumour  of  tlw- 
hrain,  u  regarded  by  Riiulfliniiich  iw  a  product  of  the  neuroglia,  and  ea 
haag  aStieA  to  tbejU>nmata.  They  onnsist  of  hurd  Dodtilexi,  Turing  iu  size 
from  M  |ieK  to  »  [Rg^eoDV  egg,  and  aametinm  ereo  larger,  of  grcy.  jellovr, 
or  yeUmrUh-whito  <mlanr  and  glabiiliir  forni.  On  sectios  the  int«riarof 
tbs  Dodolc  is  ycllo«-ish  and  chemy,  while  the  outer  mrtex  b  of  a  redilinh* 
gwy  ookmr,  and  wry  rasctdnr,  The  thickness  of  the  cwtical  layer  is 
fatnmly  proportional  to  the  sSee  o!  Uie  tumntir;  in  a  tnirinnr  the  fixe  of  n 
bHstnttt  whinb  I  u«  lately  it  was  a  tine  in  thickncM,  and  in  another  of 
of  a  mduiit  it  wan  not  much  thicker  thnti  bmmi  pnpcr.  The 
tianie  i«  ttinti»uouji  with  the  chiowy  iirxhdu  on  the  ono  side  and 
with  the  healthy  btnin  matter  on  the  other.  These  tuiamtra  arc  met  with 
1b  aU  |mrU  of  tfa«  brain  and  cord,  but  their  favourite  seat  ia  the  cortical 
nbHtaocc  of  tlio  cerrivum  and  oerebeUum,  elcwu>  upon  the  cortiai-nieilullary 
iary.  TliiA  tiunour  ib  fr«iueot3y  multiple,  and  then  eai^h  nodule  is 
[jreniAll;  btit  wbeii  there  in  only  oiie  timiimr  it  mn.y  attain  n  oon- 
le  aizfl.  Rindfleiech  disthiguisheB  a  tubereular  and  a  uon- tubercular 
of  tbo  solitary  cheasy  umlula 
tn  tbe  ooa-tubercular  rariety  the  cortex  of  the  iiedule  eonaista  of  a 
nvod-oMnd  crahsyoaie  tiaiiue,  iu  which  nuthiiiK  peculiariy  tubercular 
can  ba  dctectad.  The  layer  of  nervous  nm.tt«r  Hiirirmndiug  the  nmhile  in 
■Im)  infiltntfld  with  corpuacuLu-  clctnonta,  and  thus  the  nodule  incruutcif 
in  me.  Within  the  zone  of  proliferation  there  is  found  it  Urgv 
it  of  fibroa  between  the  oorpuscular  eleaieuU  of  the  embryonic 
rendering  it  deuae,  while  the  cell*  are  entirely  repUced  by  Gbns  in 

tiMC«DttV. 

The  anall  oheesy  itodulea  are  uaaally  multiple,  and  prove  on  minute 
esMDinstiou  to  bo  renlly  tubenulous.  Tho  gny  aone  of  piuliferotiou 
wUc^  Mimunda  them  Im  iteen  with  the  nalcptl  eye  to  onniriitt  of  opIiKrieal 
Dodulea,  each  of  which  (Xinv«i>oitd»  ill  >ha)>e  and  disc  to  n  milijiry  tulwrcle, 
while  the  interior  of  the  nodule  conaixtH  of  tubercleH  whidi  hiwe  under* 
gone  the  cfaeeaytTanafonuatioa.  The  y«ung  gmnulMt  nrc  cotitinually  pnv 
duced  at  llie  circiiraferenoe,  and  the  tumoiir  grown  by  Llie  oniHtaQt'  addition 
nf  tbeae.  When  the  nodule  haa  attaisfld  a  eonaiderable  eiie,  the  proeem 
of  growUi  stoiia,  ami  a  fibroiia  eurclope  gradually  forms  round  the  uuun, 
•0  an  to  oempletoly  iaolnte  it  ftvtm  the  RUrrountUng  bnun  tdsaue,  and  this 
ooodition  haa  led  some  pAt)i<>l<)giiit»  t<>  beliem  that  all  tubcrvlM)  oociar 
Id  an  encysted  oondition  in  the  bmirt.  Tho  wntre  of  the  nodide  some- 
times eoftens,  and  occaBJonally  the  whole  coutuute  of  an  oooyatod  tubercle 
may  nndef^  this  change.  Very  luvly  the  ttiltcrcular  nodule  haa  been 
found  h>  have  unden;ooe  a  prooM  of  crvtification.  The  vortex  of  the 
tuinour  eotuditU  of  ^nt-oells,  oBob  being  surrounded  by  lymphoid  eella 
imbnddad  in  a  fibriUatcd  nticuJimi. 

(6)  CaremotnafcL — Caocar  of  the  brain  feequently  appears  as  fungu 


556 


FOCAL   UISSASES,  ACOOfiOlNO  TO 


li[ra»ttu(lt«[)f  the  dm  mater.  WlunHari^notM&tni  tbeautcrwufMif 
the  dum  nui.t«r  it  ronxM  it«  vny  along  tlw  Ttnwli  into  tb*  a«mwrt  tiav 
of  the  boncii,  nnd  ultjmatvly  pvfforutoa  thniB,  protntdiag  M  •  hB0d 
tiuUflUr,  anil  piuiliing  ttu*  auU]i  iMfore  it 

Simplo  cnnour  of  thi;  bnkin  gujienJlj  ffow*  from  Ui*  nntkr  «aCN(  rf 
the  ]>ia  lunter,  anil  oven  Muuh  tiimouni  an  appear  to  lie  fa»  ia  Um  mdatmm 
of  tli«  brail)  aru  usually  coQiic4:t«d  at  BomB  point  or  other  wHb  tiw  |i» 
mater  lining  ai)  a4)uining  siilcua.  Isolatml  Uumnum,  boverer.  do  OL 
but  Ui«y  arc  alwaya  eecoodarj.  Cauccruono  oftlivaiciat  bt<qacittQ(lfr 
tncnuiiol  tumoore.  It  is  geneniUy  prinuirj,  and,  m  a  nila,  renuiia  1n| 
iaoUt£<d.  AccoixUug  to  Lobart,  out  ot  46  coma  ia  were  pviniM;,  oal  tf 
tJiew  13  exhibited  nm»ltaa«cmaly  cudaoma  of  oUicr  ergum.  Vriamif 
c*ac«r  of  the  aubetanoe  of  the  brain  i»  gvnvfaU;  nn^*!  bttt  odoirfdMl^ 
tbtr*  w  a  B/mnietriQal  appeanuoe  of  a  tumour  to  wiiiiiitiuuilim  laM 
nn  ORcih  8id«  of  the  hnia.  Several  tuuMtn  am  gonenJIy  fiMiwI  In  lb 
brain  in  the  HeoaiKlarj  form,  but  thew!  are  luually  BiuaU.  Tlw  ■biDm 
caooerouH  tumours  aro  geacmlly  fwuid  envbcdded  in  tbe  lu>i&lMt>bena  rf 
the  hntiii,  iu  the  poiM,  )imi>  of  the  brain,  ami  the  uptluUa  oUntpla 
Cuoor  tareljr  oc«u»  ia  Um  medulla  (^oagala,  ctum,  aod  eorpofa  iioad- 
riccmEoa.  reUtirely  moi»  frequent  in  the  optid  thalaml,  oorpoca  rtrie^ 
and  eweboUuDL 

CauouTDiu  tomoura  deatroy  the  neigbboonng  tiaauoa  hy  |wxina  mi 
ioSlttstion.  They  are  Burrounded  by  a  nne  of  aeA«B«l  tfaawa  of  ahDil 
a  lino  in  breedtli,  in  which  active  growth  prooeeda.  The  n^oscMof*^ 
playa  largs  Mlla  rolled  into  neota,  and  crowded  together  ift  a  aMrii  ^ 
flbrea  Aud  lilocMi-reeeela. 

Miuiv  canceiB,  eapedoll;  those  oonneetcd  with  bone^  exhibit  a  oaldfr 
catioti  at  their  ittroina.  Tbc  medullary  ronna  uiKlei(p>  a  dtaay  aria- 
morpboMa,  which  tiiny  load  l»  their  being  raintaken  for  tobarda  tl  thr 
braia. 

(6)  CiotMtcMma,  or  pear]  oanoer,  uooonling  to  Rlndllaiach,  "agnfeiaai 
tlie  atmcture  of  an  epithelioma  with  the  harmleeaDtiB  of  •  wart  or  fibnei 
Uiicketiiii{[."  It  apfware  to  be  derived  bom  the  [bu  mator,  and  fa  mmtf 
itituutcd  in  BoKoe  hollow  at  tbc  Imjh:  of  the  brain.  It  derekiiB  &Haii^ 
laled  growtlis  of  the  az»  of  a  muabml-aeed,  wbich  blnul  tn  fma  awaw 
ofitwaiaoof  a  walnut  TLu  tumour  ia  uoduaed  *-j  -  .i~»i~i~_  -_<■:-*— ^ij 
fibrous  eapeule;  it  haa  an  irregular  form,  and  ila  amflKM  |aaaeate«  ha* 
tilnl  mother-uf-pearl  luativ.  The  tumour  on  aedioD  ia  tmii,  t^ariy,  aaa- 
raacalar,  and  eompoaed  of  epidenaic  oeOa  amnged  in  comaixrie  hjmK 
wliicb  hat-e  uodoTKOQe  |»rtly  homjr  and  inrtly  Catty  tcBMAsmalMa. 
These  tiunoum  grow  mry  alowiy,  and  ci>n»e(|uontly  may  noMia  far  a  kil 
time  without  giving  rieo  to  ejmptoraa,  luul  Ibcy  oijy  cacita  inlWl* 
in  (ho  neighbouring  timica  in  tlie  later  atagea. 

(i)  PttptUmita  oS  the  ]ua  uahsr  in  oeoaaiisuaUy  QtaA  with ;  aad  •  wn^ 
variety  of  tbia  tumour,  in  which  there  ia  an  abundant  paudaeUao  «l  Baa* 
&«a  tba  auifaoe  of  the  papilla,  ia  aud  by  Riadfleiitch  t«  I*  ftvqMtf^ 


TUB  NATURB  OF  THE  LESIOW. 


557 


ItJBtRken  for  niyionia,  and  H«  propones  bo  cnU  this  variety  papUtona 
mjfTomataik*. 

ih)  SyffJi^oma^  nro  usutUy  foiinii  iiear  the  nuHiioc  of  ihv  brain  niiil 
(Vrrelop  from  tte  perivasciUm-  sheatliK.  They  ta».y  rvach  the  mto  of  o 
wiloot  or  creo  «  beo's  ffg.  In  their  intt-rior  there  ore  uausilty  Ki.'\wnl 
dHHjjr  prtcbea,  while  the  aiiviiiiirun<iiixi  in  ihdeIp  ii|)  of  Huft  JL-lly.lik«  ontl 
nry  vaecuUr  tianie,  SjphJlitio  j^uiumnta  arc  ouule  up  of  IiiKhly  nlluliir 
mabrytmia  tinue,  vith  on  abiuidont  utiuoitl  l»u«is-»ti1igtaiice,  tbe  cellH  being 
ogowatnodly  amuiged  ruurnl  tW  vwaola.  Other  mgaa  of  tlie  oyphilitio 
djacTUia  an  (ceuamlly  fomiil  ut  tlui  iiut(>|i«y. 

(ft}  Sarwnata  occur  tu  all  vwietiw  in  tiic  Lniiu,  oiid  icmu-  front  tJie 
free  Rufkcoi  of  tliti  intcmtitix]  »pitn«.  Tbey  apjiear  aa  hard,  KligKtly 
ni'iilnr.  nmiiil,  eoiii«what  iwHiulAtuil  ttimniirs.  The  soft,  celluJor  uiuucruiutA 
pnw&t  nuutytranaitionstDotlMrfoniu  of  tiimour  indicated  liy  tli«  iiunic« 
^io>«eiotinui,  myxo-MzooxDa,  Ac  One  form  of  spinillo-oell  aotcooui  grows 
hj  |tfeferefK«  fruni  tlie  dum  muter  at  tbo  baae  of  the  breiii,  foniiiDg 
bifaemilnteil  huumm  nunr  the  sella  Turcica,  and  compreseinK  the  iidjat«Dt 
(nrtB  of  tbe  bntin  uDd  the  Ctnoinl  Dcrven  nt  tlieir  [luiutH  >.<(  exit.  I:i  uniDe 
flUoocaatonB  tninoura  the  i^uidleM)eIls  Are  amtn^  in  coiusentnc  Uyvn 
***"'";  DoetA.  This  form  bos  heeii  uiuued  "  nested  MarodmA"  by  Dr. 
Gowns. 

(1(1)  Ztpimia  htut  ticco^oually  Uwii  lurt  vith  on  tbe  iuuor  mtriacQ  of 
Ilia  dun  mater  and  on  the  ventricular  uitoinlyina. 

n  I)  7*Niiiimontiiin  id  a  tumour  with  n  biuiB  of  ccaaedin  or  someUnee 
irf  mucoid  iMfflie,  distinn^aitlied  by  its  •sontAining  oaloareoua  oonovtieni. 
It  naually  grova  from  ihe  membruie*  of  Ibe  bnUn,  imd  espedolly  froin 
ttw  efaopDid  iJbxiw,  in  which  aituatJon  it  often  eontjuiu  DumBroua  cyitt*. 
Aboording  to  tbo  uoet  recent  ioventigatiuiie  iwunmnmum  la  to  be  rvxiuiK-d, 
not  e0  a  distinct  kind  of  ttimoiir,  hut  as  a  ouleoieoua  deposit  tn  timiount 
vS  wuMy  diSeroot  atructure  (Ureechfeld). 

(IS)  Outomata.— If  we  exclude  the  calciflcations  of  ottier  ttUHuun*, 
tnia  fontMtiiJtia  of  buut!  ure  tliu  rareot  of  nil  intiacnmiid  ];n>wtlM.  OtnoouB 
fannatioiu  iii  the  dura  uutttT,  uftvr  injiiriiw,  an  taatv  cuiuinuii.  MyphiUtit' 
gJtwtgaai,  although  for  the  nuwt  jxu-t  oiiaiug  from  tho  {ixtcmnl  table,  j-ot 
Mumetlmea  >)>riag  from  ttiv  intvninl  mrfiuo  uf  tho  skui),  uod  uauiw  pma- 
son  on  tbe  bmiii  like  other  tumoun  iu  tho  siuuc  looolity. 

(13)  CyUic  ffroatht  iu  the  bratii  arc  uot  so  uommon  tw  was  formerly 

They  ore  Oujet  cotumoa  iu  Ute  pitiiitury  body. 
14)  Angi»maia  generally  oocur  in  the  bi-ain  as  n  compliontion  of  other 
tumourw,  atiuh  ae  glioma.    The  yrowUui  ou  thi  iixovr  aurfuce  uf  tbe  dura 
uuter,  deecnbed  uudor  the  name  of  poohyuieniugitiB  hwrnorrhagiM  breg- 
matica,  beloug  to  tliie  cIiub. 

(&)  AneuriiJiu. 

AnctirnuK  of  the  ecrebral  art«rit>a  uv  not  rare.     They  Kie  of  vUiooiB 
but  only  tboMj  which  uriac  from  tbe  larger  veaaeb,  AieBj  St  tlu 


n 

I  aft  imMiiiL,    They  I 
of  the 


•uiii  • 

iufilii. 
a  hutt 
|ilaya 
fibres 

eation  of 

watfiiataa, 

hnin.  -^  *    ^^ 

(fl)  CTp;  ,. 
theict.niL'Trj' 
ttuckcnibg. "     !  i 
utuated  in  aorix 
l*t«U  grovrtiut  of  t 
of  th«  sue  or  a  «ibj 
tibnxis onpBitJo;  Hit 
tifiil  motlnsr-af-peul 
irasouliu-,  and  couiia 
whlcb  b&vu   ittitlei^ti. 
TboK  tomouis  grsiw  w. 
CijiM  tritbout  giriz^  rU 
intbv  Qi-if;l]t>uuriDg  tiani 

(7)  PapiU'fma  of  th«  | 
nrietfof  tluH  tumour,  in  « 
from  tbo  saxiaea  of  tho  psf 


*»  ohm]  cBvity  ara  (I)  i 

rf  ^  bniD  genenOr 
lAw  fiddjr  Mpplinl  by 

l^aaninnrea,  the  pu: 
■■•  Im^  S  tiiDM  \b  Uie  I 
K  Ai  corlK,  U  time*  ui  tha 
ItMMitiilwTmtnclm,  18 
,  ^  twin  ia  tfac  meditllii  i 
■■  *Md  B  <4l»r  parto  of  tb*  I 

K  I*9pBl>  uf  Cb0  tvaly. 
^  ^nk,  in  wb>cb  the  uiimil  1 
)  tii«d>:  ■hib  Ita  nMfc,  t 

VMK7  in  ptjum  whos 
'iliiliJ  ia  ottin  (aJJ 


:  ^  »  krfe  u  a  tr«lciiit, 
I  ndWtMt  l*y  Dr. 
■mJ>«1  lotn.  tl  UuKM  in  tl»< 
M  K  IW  vwMiUoB,  nod  oaw* ._ 

LM  »  tW  hnkphorw,  AMI  faj 

itWftiotuieliMm, 
^■0  U>k,«diat 


^   ^ 


'-^    '  •. .  r   r*_i  I 


rl X. 


Mluocd    bt 


gins  ruel 


THE   KXTURE  Of   TBX 


U9 


order  to  maka  room  for  tbe  it 
,  SBebfo-spiDaL  fiuid  is  fiivt  reoMted,  tlw 
oat  of  Ibe  vsssisU,  uod  the  vfaalt  wahatMaea  ai  tihe  faaiB  «fla» 
preasare.  It  is  erideDt.  therafan^  thai  a  pneo*  af  Aii  mtmm 
will  ultioatety  lead  to  gndaal  abolilion  of  the  faacliaaa  of  tba 
bfftia. 

But  not  onlj  is  the  braio  nlijected  to  gemeni  tomftntmom, 
jbotthetissui^  nirroaodiDg  tb«  dcw  growth  m  ti*bl*to«fweial 
ire,  vbicb  eooo  leads  to  ib«ir  JiamrtioQ.    The  ittmow 
must  probablj  always  be  ngarded  as  a  dcatraying  Irainn. 
id  cooKqueDtly  iu  direct  teadaBcy,  as  a  local  giapwth,  is  to 
pre  rise  to  depressite  symptomc.   li  most,  bowerer.  be  remem- 
tbat  the  aboUtioa  of  the  fnoction  of  a  b^ber  centre 
Vf  leave  the  fuDCtiooal  adirity  of  a  lower  ceotre  loore  unre- 
ined. 

pt  although  the  (lir«ct  lendeocy  of  tbe  tumour  is  to  destioy 
aundiag  tissues,  yet  its  iikdireci  effect  is  often  irhtattre. 
imcnir  acta  as  a  foreigD  body,  and  b  liable  to  cause  hyper- 
and  iDflammatioDoflbesDiroundii^  tissues.  lotercuirenl 
tftaoks  of  irntative  symptoms  are  therefore  reiy  Uablo  to  take 
|iljK»  in  the  coune  of  cercbiml  tumour,  but  tbej  are  geoetmUy 
Allowed  by  a  further  extensioo  of  tboae  of  deprcssioo.  It  moat 
remembered  that  irritatiua  of  a  higher  centre  may  pro- 
inbiUtorr  actioo  oo  a  lower  centre.  But  the  processes 
K>  the  aarrouading  tissues  are  not  always  of  an  irritative 
motory  nature.  An  artery  may  be  compressed  aod 
-=  to  which  it  ifl  distributed  may  undergo  i8cli»mic 
The  reioB  in  the  vidnity  of  the  tumour  may  be 
' :  ring  rise  to  effusion  of  serum  either  into  the  sur- 
nrinto  the  ventriclea  of  the  brn.in.  Softeoiog 
I  if  the  surrounding  tissues,  iu  whatever  way 
"  regarded  as  a  destroying  leaion,  and  the 
i>on  ibe  sitoalaAB^  and  not  the  nature 


568 


FOCAJ.  DISEASES,  ACCoaDIVG  TO 


baas  of  the  bmin,  will  enine  under  ranodentioa  at  pw—L  Thc7fMi> 
inlly  nriw  in  coneeqtivncc  uf  ittberotDolotu  decetientiOD  ti  the  tmiA 
Theoommoateimiuatiuu  it  In  rajitur^ 

(c)  Panuiia  ofthtSnln, 

The  nninml  t»krasit«a  which  occur  ia  the  craaiAl  cavity  uv  (1)  (^Mk- 
oi!it;UB  (x-Ilii]<.«w,  a»(l  {i)  li^chinooocros  hominia. 

(1)  Cj/uiemiu  Cetluiota. — Cyttieera  of  the  bnin  geoenllj  wrv, 
•ooonling  to  Ronciitluil,  in  the  partn  which  an  riulil;r  mipplinl  trj- 
sufih  us  tli«  TCiitrielei*,  thu  gnnglin  luiil  thi-ir  nimiiiiwunw,  tb«  ftt 
and  tic  cnrtox  of  the  bmin.  They  were  fomid  2S  timm  iu  the 
aspedallj'  the  |iin  mater,  69  times  in  the  oort«>x,  3S  times  in  the 
gaoglia  and  a4iaoeDt  oonuuissaros,  18  timeB  in  the  vcatricJ«a,  1ft  ikam  la 
tbo  cfrebcllum,  4  timai  in  the  fooB,  and  tvioe  in  the  raednlli.  tUmfiM 
(RiitwiiLlial}.  I'bo  jutnuito  ia  eametiiued  fouml  in  Mter  |au1a  of  thabdl? 
an  well  OB  in  the  brain.  Out  of  88  coaea  ooUected  by  Kunohdun^Mf, 
the  cj-HtioM-d  were  round  II  times  in  other  parte  of  the  hod?''  CMdW 
cjmUucroJ  are  uaiuiUy  cncloaed  in  a  aoft  ca|iaule,  in  which  tbcaniSMl  My 
be  scvii  with  the  unki-d  eye  oa  a  Mooll  white  tubotde;  whilo  Ha  neck,  wHb 
the  ctiii.nkclcrJHLit!  Invilcleta,  niAj  be  diacorerad  on  udcnMonpjc  ttianutiataa 
C«r«bnkl  cyrtioerci  occur  with  gixotort  fRqucncy  Ln  plaoaa  when  emn 
poature  in  lichU  xttx'wi]  with  thp  eicmnont  coUactod  in  ottMB  (CobfaaU}- 

(i)  EcMtiococevj  Huminu. — RchinoooecnKjata often  reach  alaifirfK 
Id  a  flBM  rc|v>rt«l  b^  Ur.  Morgan,  tlic  cpt  waa  na  larg»  iw  a  v«tnut,  aal 
wvighnd  647  ){nui)mi::\  Of  Torty  <>1ncn*ihtioii»  oollectcitl  hy  Dr.  tlnr^a^ 
the  cyst  won  ntimtod  lo  tiinos  in  the  oertfaml  lohc*,  8  tituM  in  Ihv  ixi»- 
lielliun,  4  tiintw  iu  the  rentriclot,  twiw  in  tho  rcntridoo,  and  aoix  in  ihr 
pons.  The  cysts  attniii  th«ir  grealent  aae  in  the  hemiapbwea,  atol  ta  tl» 
labenl  vontridea,  espooially  in  children  before  the  fantanalba  an  obni 
The  cyst  in  oonpoaed  of  an  oxt^nul  filmiia  uHOifcawte  which  eochaitfca 
panaitca;  ite  int«nuiJ  eutTbcc  is  Ijnoil  by  siuaU  bada,«a<it  about  thaM* 
of  a  millet  seed,  and  ))ro\nde4l  with  the  charaetoislia  ring  at  booUrfa 
The  cavity  of  the  cyst  ia  usually  filled  with  a  Uc|uid,  which  ia  dtho'cfav 
or  oontuna  floating  d^bm  and  fweoodary  rcMJnlia.  the  bqda  of  tfaa  tan* 
beiajt  deetitute  of  books,  oikI  called  acepiialo^rt. 

J}  733.  Morbid  Phjsioloffj/.—The  only  p«irt  of  the  pfajMobf^ 
of  cerebral  tumours  with  which  vnt  ar«  hero  C0Dcera«d  i>  ta 
connect  the  Kyioptoinn  with  the  «ffecta  prodnoed  br  thi 
growth  upon  the  qgivous  tisBUes.  The  tumoar  grow*  fn»» 
minute  point,  and  gradiiftlly  increases  in  ciTCumforvDcv,  w  tbii 
it  is  at  first  atroost  entirely  latent,  or  ooly  gives  risi  ta 
indefinite  symptoms.  As  tho  tumour  increoaes  io  iiss  it  pro- 
duces progressive  geDeral  compression  of  the  whole  bnuo.    Is 


THE   HATaSE  OF   THE  LESIOK. 


569 


onler  to  moke  room  for  tbe  iDCrcaalng  mo  of  the  tumour,  the 
cerebro-spiaal  fluid  is  first  removed,  the  blood  is  then  squeezed 
out  of  the  TMsels,  aad  tbe  whole  substance  of  the  brain  suffers 
pcwsure.  It  U  evident,  tbercforej  that  a  procoss  of  this  nature 
will  altimatcly  lead  to  gradual  abolition  of  the  fuoctioos  of  the 
brain. 

But  not  only  is  the  brain  subjected  to  general  oompreseion, 
bat  the  tissues  surrouodiug  tbe  new  growth  are  liable  to  special 
pressure,  which  soon  leadu  to  tkeir  destruction.  The  tumour 
itself  must  probably  always  be  regarded  as  a  destroying  legion, 
and  coosaqaently  ita  direct  tendency,  as  a  local  growth,  is  to 
gire  rise  to  depressive  symptomfi.  Il  niuist,  however,  be  remem- 
bered that  the  abolition  of  tlic  function  of  a  higher  centre 
may  leave  the  functional  activity  of  a  lower  centre  more  unre- 
itr&ined. 

But  although  tbe  direct  tendency  of  tbe  tumour  is  to  destroy 
tbe  aorroundiug  tissuea,  yet  its  Indirect  eBoct  is  uftcn  irritative. 
The  tumour  acts  as  a  foreign  body,  and  is  liable  to  cause  hyper- 
aemU  and  ioHammattoa  of  the  aurroundiag  tissues.  Intercurrent 
attacks  of  irritative  symptoms  are  therefore  very  liable  to  take 
place  in  the  course  of  cerebral  tumour,  but  they  are  generally 
followed  by  a  further  extcusioa  of  those  of  depression.  It  must 
also  be  remembered  tba.t  irritattoa  of  a  higher  centre  may  pro- 
duce an  inhibitory  action  on  a  lower  centre.  Bnt  the  processes 
Mt  up  in  the  siirrotiniling  tissues  are  not  always  of  an  irritative 
or  iodammatory  nature.  An  artery  may  be  compressed  and 
the  tissues  to  which  it  is  distributed  may  undergo  iiu>hn>mic 
•opening.  The  veins  in  the  vicinity  of  the  tumour  may  be 
oompreeted,  giving  rise  to  effusion  of  serum  either  Into  the  sur- 
roandbg  tissues  or  into  the  ventriclea  of  the  bmin.  Softening 
as  well  as  redema  of  the  surrounding  tissues,  in  whatever  way 
produced,  must  be  regarded  as  a  destroying  lesion,  and  the 
symptoms  depend  upon  thu  situation  and  not  the  nature  of 
the  leeioD. 


§  734.  Ormtping  o/  tlie  Sympfoms. — A  review  of  the  symp- 
toms of  intracraninl  tumours  shows  that,  although  they  are 
very  numerous  and  variable,  they  admit  for  practical  purposes 
of  the  following  arrangement: — {I)  General  and  initial  symp- 


BW 


VOCIL  OISEASI8,  ACCOKDIKO  TO 


toms,  vhich  may  he  present  in  crcry  kind  of  iDtracrukI 
tumour,  whatever  its  poaitioo ;  (2)  Symptoms  caused  br  Ibf 
localisation  of  the  lesioo ;  (3)  Xatercarrent  tymptonu  iepeti- 
mg  on  accessor;  loaiona ;  (4)  renmDAl  ph«noineDk. 

(t)  Thf  general  atnl  tntVeuE  »tfmptoim  oonaMt  of  faewlAicbei  ^Jmww 
N8tIessDi.'i^,  and  meutaJ  irritabilitf,  [anBrthewe,  ntruMH  itantteM 
«f  tks  ft]iec)&l  ttenses,  Mid  oaavuluooa.  Tbeae  ^jnptoaaa  rnaj  be  fmai 
individually  or  in  variaiu  eomUoittioiu,  aad  for  k  long  time  ib»j  m^\t 
tlw  ouly  ajiu[}topui  oompluQcd  dT. 

(i)  The  Bj-mpUiUM  whldi  dvixinrl  npon  the  loedintion  uC  the  Ivaaa 
do  uut  difliu-  flOMntiaUy  &om  the  s^inptuuui  osQead  by  otbcr  f«M>I  daaa* 
of  the  breiiL  They  nmilt  troai  (LmtnKtluo  o(  the  BorroaiMliug  |MfC»af  At 
bnkin ;  they  ore  «iiseatiully  iiaralytic  ia  their  ohencteri  oltboagb  ibe  ha 
or  ftinctioa  oi&y  aocneiooally  be  )iT*oeded  by  tnuHitory  irrttatirB  [^ 
noni«aa.    Theae  eymptonu  -irill  be  more  fully  deaorilMd  beie*fW. 

(3)  TImi  iicuuKKvy  leuionK  wliivli  ^ive  rtso  to  iutorvarrout  BymptoBe  lO 
bypenefuia  end  iDfliuauuttion  of  the  eumundtng  tinencw  Tbe  dad 
iiyail>toiuit  tniucd  by  tbees  leeioiM  ere  bAlludiiatknie,  '"■n'"t>  and  em- 
ruloive  paroxynoei  and  atta«ki  of  epopleiy  eud  ucuuigitM. 

(4)  The  tenuiiuJ  gjmpUjau  ore  caused  by  gnduel  and  laoeMiat 
oampreaeJon  of  t!ie  brain,  aad  oonniflt  of  the  progreaeini  abolitiaa  of  tie 
DMata]  fii4itiltip!i,  iind  gcnernl  ttamary  end  taatftr  perelyaie,  eodlng  in  am^ 
lu  nMQy  cmmof  cotvbml  tumoun  death  reetdtefinm  en  jntcicunBiil  iliw 
from  an  itttAck  of  oerebnd  hteraorrbage,  or  from  aodden  paralyne  ef  tk* 
rsHpiratory  ccntn  wbsQ  tiie  tumour  ie  sitoated  in  tbe  pom  or  nppsr  enl 
of  the  niMlnlln,  or  vbon  the  ventnelea  are  distended  irith  ■oratn.  Tb* 
iateoeity  of  the  Bymptonie  ia  by  no  moans  proportiouol  to  the  mae  rf 
the  tumotir,  iiiasoiucb  ns  a  growth  may  eom^tiiiKis  et1«in  a  Uip  ito 
without  giving  rise  to  marked  symptcius,  whib  at  otber  tJnoe  n  anal- 
nied  tumour  may  giv«  riae  to  intense  diaturbaooea 

The  fuUowiag  are  the  coudiUcms  on  which  tbe  diSbreooea  in  Ike  t»- 
teneity  of  the  ejnnptomH  npiiuu-  lo  depend : — (u)  Idlaeynanais  ef  lie 
peitont :  (&]  the  poeitioD  of  the  tumour ;  (c)  the  nntuxvond  nUsof  gnwth 
of  the  tumour;  (d)  tbe  cbatijpie  mil  up  in  tho  eurroitnding  Imbimb  }  anl 
(t)  tlio  fireeonoe  of  sereraJ  tuuoum,  or  the  oxiatuDOD  of  ooupUotioan. 

(«)  Idiotynerantt  of  tiu  Potimf,  —  It  is  well  Icnown  that  eeaw  ■■> 
react  much  more  MjtiTely  than  olbere  to  the  Muue  degree  of  Uiitnliun  A 
dap«e  of  initAtion,  for  fnetAnoc,  which  would  not  prodaoa  en  ept»wdaH» 
efl^  on  aduhs  miy  ooceaicm  viuleiit  couvulnone  in  idiiUrsn. 

(()  P««ili<m  9f  tht  T«m9ur.— Some  porta  of  the  twain  an  totcnnt  and 
otbnv  aiv  Toy  intokrunt  of  di^laoomcot  or  any  interfemiec  ban  wtlheet 
Tlic  white  butwtanro  of  the  bomiepheree  and  Uie  occipital  lobaa  belcag  ta 
the  Ant  categ«ry  ;  tbe  medulla,  pooa,  and  the  hitenuU  cni«nle  of  the 
leotKuhu  uucJeiu  to  the  eeovnd. 


TBE  XATURK  OF  TBE  LE8I0K. 


SSI 


(e)  Xatvrto/lA*  Tumoar  and iU Rat* of  Groutk.  —ll  iiisybo  laid  down 
u  «  geaerd  nil«  tbat  tbo  intcaaitj-  of  Mm  ajnuptoioa  in  in  tlirvct  pto- 
ptirtion  UitJie  r«(nt|jtj'  of  Uic  gmwlli  of  th«  tumour.  The  alow-grovriiig 
dutlestoiiUitnnta,  for  iimtariec.  u«uDily  attaiu  a  «oii»i(leral>l«  8i»e  befcro 
ching  riiM  to  any  distinctire  syniptom*.  Wheii  the  growth  is  mpid  there 
ia  a  greabor  flow  of  blood  to  the  jxirt,  lujd  thu  surroundkig  tm»ie«  are  uon.- 
tiaUr  to  uadtrrgo  imutive  cluut^ji,  wliilat  t.hr  limiii  tiiu>  no  tiiiiM  tu  ainxnii- 
l»odat«  itheit  U*  tlio  iww  diaiuiliiiiicv^  The  iDcrenacd  bulk  of  thu  tumuitr 
w  aamttium  caoaed  not  hy  growtli  of  it«  tiwia-  cicinvnb*,  hut  Ijj  cedenut 
or  bsnoRtuge,  and  then  it  proiIucxM  &11  Uie  ciroctri  of  x  auddea  liijiiry 
to  the  bfain.  Cbndiictin^  liltrm  which,  ir  jnuhiMl  aNidv  hjr  v.  »low-gTOwhii{ 
ttdnotir,  would  nuuiit«in  for  n  Imig  time  tiicir  fiinctionnl  int'^grity,  nrc  now 
auddeolv  nLrrtchcd,  niptiircd,  and  IrrcnicdiBM;  <Iniiu^i>l.  Rtrtrogitssivi- 
4)bui9ea  within  tha  tiitnoun  ria;,  ncvording;  to  th«tr  iiAttin*,  caiiMC  grwt 
Tariatiooa  in  the  nympbonus.  Sooiotimw  tlMuw  obangos  uiay  lend  to  bnjmor- 
rhaga  anil  aU  itn  omaequanoiw ;  whila  at  othar  timm  the  tumour  nmy  by 
tbene  oluingn  Inxnnc  dimiuiahod  in  bulk,  tbun  ivlic^ing  thtr  prcaauro  on 
Ibo  Imun  and  Inuling  to  n  t«mporarv  ntnc>liariLtian  of  the  ej-niptoms. 

((/)  Sfvrhid  Chan^t  in  iha  Sttrro<nn/iiwj  7'ijuUM.^'nii!  i?iuuigiw  lUft  u\t  lii 
Mic  titnum  suntnindtng  the  tuniour  mny  i-tUicr  rmmtHtitt^  JtncbirKiiiX(i>' 
daattoying  iMinua.  It  is  not  {xiwiihlM  la  ilmw  a  cicjir  liui-  i>f  dtiumruatioii 
blwa*  two  Idndfl  n>  far  as  tho  ejmptooiB  on;  coQOQnied,  niiicc  the 
1  of  ■  deatrojring  leaion  in  the  immediate  vicinity  of  tke  tumour  nuiy 
hy  thow  of  diitclinrging  Icniniiti  in  n.-ntoW  [uiriH,  In  the  early 
i  of  tho  growth  of  the  tiimotu-  tht?  ili»chargtiig  Icjuoum  jircdoiuiiinUi. 
The  tiiiuour  acbi  na  a  tuccboaicnl  irritant  or  foreign  body,  and  it  uihj- 
4ir»ctJy  irritatv  Ui«  port  iu  which  it  Is  oituatwl,  vr  tiidinH^tly  irritate  remote 
parta  by  rcflci  action,  or  a),iuii  ita  efibcta  niny  be  more  or  1cm  diStuwil 
and  gBn«ml. 

It  u  Tcry  important  tt>  oWrve  that  the  nymiitonia  of  intracranial 
tummm  ftvquently  intvmiit  iti  tlm  vnrly  atagen  uf  thu  diatuixe,  arid  only 
hecooMi  pmnanent  and  cuutintioiia  iu  tlie  latter  otaj^-n  when  thu  wliole 
btmiu  i«  Ruljeulwl  to  pKeaiirv.  Tlio  rvMons  for  thin  int^nuittcuoo  of 
syinptMiM  are  not  tiir  to  eock.  A  large  diaohargo  of  uervoutt  «ucncr  in 
Callmvd  by  oiltaustion,  bo  that  tbu  discharging  leaious  caumkI  Ijv  Uih  looal 
irhtaliun  of  tJio  tuBkoura  arc  followed  by  oxbaustion,  aooonipauivd  V;-  t^-ui- 
[tamj  Kuhaidanoe  of  the  nctivG  Byakjitous.  At  other  times  tho  t*yin[jt<«ii« 
may  he  couhmI  nut  mh  mudi  by  the  aiae  of  the  tumonr  aa  by  odvma  and 
ioflammutioti  of  the  snmnmding  titwuea,  am)  when  the  Uittw  auhuda  the 
*ytajt«tM  diaappeor  tor  a  tiinv,  nJthough  tU<.-  prioitLry  leoivu  still  p«ni»te. 

(e)  We  PftKiiet  of  ttttr^  Tumovrt  attd  Compticatimu.—Tbe  vnriety 
and  oiHn|ilicntiMi  of  Bymptons  an  very  Diuch  inrauuMl  when  wveml 
tuRHMira  oiv  prtwnt,  or  when  eympU^ma  uf  tooiour  are  a«M>ciat4^d  with 
cvrabral  diaturbonce  caiued  by  an  independent  affection,  such  on  llright'a 
(liaaaat. 


KK 


S62 


POCAL  DlSIAdKS,   ACCOBOINO  TO 


§  735.  Dutgnoaia. — lutracraoi&l  tumours  ra&y  b«  confoundtd 
with  other  cerebral  Iwions,  atiii  indeed  at  an  earljr  stage  il  a 
uhnost  impossible  to  be  sure  of  the  dia^osiv.  Tlie  nM 
important  gympcom  of  tumour  in  to  be  fouud  in  the  uptie  din 
Many  casea  are  recorded  io  which  tho  presence  of  double  opw 
neuritis  was  the  only  symptom  that  could  lead  one  to  tlw 
suspicion  of  cerebral  tumour,  nod  in  which  the  diatom  «u 
subsequently  juatiSed  by  the  progreffi  of  the  case.  Two  ctia 
of  this  kind  have  come  under  my  own  ob»ervatioa,  nai  tht 
occurrence  of  such  coses  bos  led  Dr.  Uugbliogs-Jacluon  to  ioma 
on  the  routine  uite  of  tbe  opbthalmoaoope  in  the  ezamixiaitiM 
of  patient* 

lu  tubercle  the  disease  of  the  brain  is  generally  a—orialrf 
with  tuberculous  affection!!  of  other  organs,  aod  a  hereditai; 
predisposition  to  the  disease  can  usually  be  ascertaiued. 

Ifydrccephalus,  iu  its  chronic  form,  is  a  frequent  aooooipa- 
uimeut  of  tumour,  cspcclidly  when  the  latter  la  aitu&ted  imi*t 
the  tentorium,  where  the  growth  is  liable  to  produce  pntanti* 
ou  the  veua:  Quleui  raagnu.*,  or  to  prevent  the  return  nl  itt 
cerebro-spinal  tiuid  into  the  spinal  canaL 

Apoplexy  occurs  in  odvancod  ag^  its  oosct  u  saddco,  and 
it  in  UHiially  associated  with  diseoso  of  the  hcut,  atlMrona 
of  the  veaseU,  and  granular  kidney ;  while  (he  panlyw  it 
sudden,  without  premonitory  symptoms,  and  freqaeotly  followed 
hy  Ut9  rigidity  in  the  extremities.  Tumour,  oo  tbe  otkwr  baod. 
occurs  at  every  time  of  life  without  being  oeeessarily  iuaociat«d 
with  other  diseafies,  white  the  pHralyais  comes  on  alowly  and 
ioorauw  gradually,  and  is  preceded  by  other  aymptomt.  such 
as  violent  cephalalgia,  vomiting,  vertigo,  and  neuralgia,  and  il 
is  rarely  followed  by  tate  rigidity.  Tbey  may  be  further  di«> 
tioguiehed  from  each  oth«r  by  the  double  optic  iieuiitii  iif 
curcbral  tumour,  in  opposition  to  the  rarer  unilateral  embolic 
amaurosis  of  apoplexy.  Care,  however,  must  be  takra  not  to 
confound  one  form  of  albuminurio  retinitis  with  the  «pt>e 
neuritis  of  cerebral  tumour. 

In  ckronic  aofiening  the  paroxysms  of  headache  are  l«n  &»■ 
quenl  and  iateose  than  iu  tumour,  while  affections  of  tlie  special 
HL-nscs  aud  anteaCheaia  of  the  cephalic  nerves  occur  noce  &e- 
tjueutly  io  tumour  tbao  ia  softeoing}  on  tie  otbcr  band  tht 


THE  MjlTCntE  OF  THE  LESION. 


563 


I 


occurreDCO  of  sudden  aad  complete  hemiplegia  and  aphaaia  is 
moTtj  eomoioa  in  softening  than  in  tumour.  Alternate  aod 
bilatentl  paralysis  occur,  accoidia^  to  Uaese,  frequeutty  in 
tumoar  and  only  exc«ptioiiiLUy  in  softoniug. 

Abacesa  of  the  train  is  to  aome  extent  eitnilor  to  tumour  in 
its  physical  rehitioos,  ioastnuch  as  it  may  produce  increase  of 
iutracraitial  pressure,  and,  like  tumour,  the  tissues  surroundioj; 
ibe  dUeased  focus  are  often  afifect^d  by  inflammatory  altaukti. 
Abvcins  uiHiaJly  oocure  as  tbc  direct  coniiequence  of  an  injury, 
such  an  fracturva  of  tbe  skull  and  uuucufisions  of  tbe  brain,  or 
aMuciated  with  some  other  disease,  such  as  caries  of  thu  petrous 
portioD  of  the  temporal  bone,  ozteuti,  foci  of  suppuration,  diseased 
Tcnels,  or  valvular  diseas«H  of  tbe  heart;  while  tumour  is  never 
more  thau  a  remote  consequence  of  an  injury,  in  tumour  the 
oepbalatgiai^ severe,  tbe  various symptomii  assume  a  progresuire 
character,  and  there  is  ii.sualty  a  gradual  extiuction  of  the 
fuucuous  of  the  brain;  or  apoplexy  may  occur,  but  uicuiugitis 
!•  rare. 

Atroptty  of  tlie  hravtl  producra  an  early  destruction  of  the 
Dietxal  activities  which  passes  gradually  into  icabecUity.  The 
praseuou  of  tremors  of  the  lipn,  tongue,  and  limbs,  of  epilopli- 
lorui  ooQVuLdioos,  hemiplegia  or  paraplegia,  and  loss  of  meutal 
power,  form  a  group  of  symptoms  so  cbaractorietic  that  they 
caonot  w«ll  be  mistakeQ  for  Iboee  of  tumour. 

Jl^ptrtiVfihy  o/tfu  Urain  of  children  gives  rise  to  syraptoms 
as  c«phalulgia  and  epileptiform  convulsions  somewhat  similar 
10  those  of  tumour.  The  largo  circumference  of  the  great 
fontaaelle,  with  its  strong  pulsation,  tbe  slow  dilatation  of 
tbo  hood,  tbe  distinct  traces  of  rickets  in  tbe  skeletou,  and 
spasms  of  tbe  larynx  combine  to  prevent  this  dineaae  from  being 
mistaken  for  cerebral  tumour. 

Hi/lJiUis  of  the  brain  may  give  rise  to  symptoms  closely 
idmulating  ttioee  of  cerebral  tumour,  and  iudecnl  the  presence  of 
a  distinct  gumma  induces  symptoms  wbidi  are  identical  with 
the  symptoms  of  other  forms  of  tumour.  Tbe  history  of  tho 
can,  pennaiient  traces  of  the  diseoae  such  ae  cicatrices,  the 
peculiar  pains  of  the  nerves  and  bones,  epi  lepbiform  coovulsiona, 
and  evidences  of  the  presence  of  more  tbui  one  focus  of  diaeuee, 
are  amoogst  the  slgaa  to  he  made  use  of  in  fonniug  a  diaguooia. 


sat 


FOCJlL  DISBASSS,  ACCOROrNO  TO 


g  736.  I}iaijru>»i»  of  the  JuUure  of  the  Tumour. — U  u  Ml 
always  possible  to  dia^ose  tbe  uattire  of  tbe  tmnour,  ftltb^a;^ 
tfaJH  may  he  done  (tomctimei!  with  a  coiuidcn1>l«  degree  v(  w- 
tftintjr.  Tbe  dovolopment  of  glioma  is  froqueotlj  preceded  b} 
u)  mjuiy  to  tbe  ekull,  tbe  proj^reaB  of  tbe  «jrmptotnji  ii  doo, 
and  the  illneis  i*  conaRquently  of  compnmtivcly  loug  dntstin 
Htemorrhngo  not  nnfreqiieiitly  occuni  iiita  ibc  (iub6tan«e  of  the 
tumour  or  into  the  surroundJag  ussuea,  and  tbe  patieot  n, 
thflrefore,  liable  to  stifFer  from  intercurrent  attacks  of  apopktj 

Tarbeixular  tttmour  luay  be  suiipected  when  the  symptoai 
of  iotrecrnnial  tumour  occur  in  childhood,  and  when  a  bem^* 
t&ry  predispositioQ  lo  tubercle  can  be  traced.  Tbe  dia^onaii 
reudurcd  mure  certain  when  evidence  of  tuberculotita  io  otlur 
organs  or  cheesy  (iegenuration  of  the  glaoda  can  be  detected. 
Tbe  tumour  is  alto  more  likely  to  be  of  a  tubercular  natofw 
vbcn  the  symptoina  iodicate  that  it  is  Hituntod  in  tlie  oar- 
helium,  «r  that  multiple  iMioas  are  preeent.  Tubeicdar 
tumour  often  begins  after  an  acute  febrile  disease,  aa  mettia 
or  scarlet  fover,  while  its  progress  is  frequontty  oompticated  by 
ftlight  nttackfl  of  meuiDgitiii. 

Caroinoma  of  the  brain  is  cbaracterised  by  tbe  rapid  pffr 
gresR  of  the  eymptoms,  and  tho  presence  of  tbe  caornooB 
cnchesia  or  evidence  of  the  deposition  of  cancer  m  other  oigana 

Sa}-com(Ua  are  not  easily  diagnosticated  during  life,  but  «h«a 
the  most  prumiu^ut  symptoms  ate  afforded  by  compreMJoa  ti 
the  nerves  at  the  haite  of  the  brain  sarcoma  may  be  aaepeelML 

Syj^iitomaia  of  the  brain  will  be  subsequently  desctibed  ■ 
■letai). 

C^/Jiticercwi  ceiluloiKv,  when  situated  in  the  brain.  oAeo  le* 
mains  latent  for  a  comparatively  long  period.  The  more  oMul 
fiymptoQiH  of  the  atfectioD  arc  hoaduche  and  vertigo,  followed 
by  inuHCuUr  spivsmis^  epileptiform  oonvnlHioas,  and  variow 
meiital  disturbances,  but  distinct  paralysis  is  rare.  Tbe  ooe* 
vuisiODS  causcil  by  the  presence  of  the  parasite  may  el  6nt 
be  similar  in  every  respect  to  those  of  idiopathic  epilepsy,  but 
in  the  terminal  period  tbe  attnckt  increase  in  uumbcr  aail 
violence,  as  many  sb  80  to  LOO  daily  baviug  been  kaown  (i 
occur  during  the  week  previous  to  denth  (KoseDtbal).  TW 
psychical    disturbances  consist   at  first   of  illusioiu,  detifisai. 


THE  KATURE  OF  THK  J.B8IUM. 


565 


iaai  attacks,  folloired  by  melaoolidj.  somnolency,  and 
Bbipor.  The  diagnosie  of  the  preseuce  of  cysticeroi  a  rendered 
mure  probable  if,  io  odditioa  to  tbo  syraptoms  juat  deocribed, 
tbe  history  of  the  case  show  that  the  patient  had  pTeviouslj 
suffered  fjram  teoia,  or  if  the  patient  be-  a  butcher  or  pork 
d«al«r. 

Bchi7u>eo^n9  homini«,  wheo  found  in  the  brain,  does  not 
give  rt3«  to  characteristic  symptoroe.  The  most  constant  ByiDp> 
toms  are  headache,  verti^,  vomiliog,  tremore,  epileptiform 
■Wrfy^  aiid  the  usual  evideuces  of  the  presence  of  an  iutrar 
RnRB^'Uimour  ia  the  optic  discs.  Id  the  coses  collected  by 
Dr.  Morgan  the  dumtioD  of  the  symptoms  averaged  one  and  a 
li&lf  ye&TB.  The  tumour  may  sometimes  make  iu  way  through 
the  cranial  bones.  In  Reeb's  case  it  made  it«  way  through 
the  parietal  bone,  while  io  a  caae  ohavrved  by  WesLplml  two 
openings  were  found  in  ihc  frontal  bone  through  which  the 
tutnour  projvct4;d ;  an  incision  having  been  made  1)0  vvtsicles 
Bowed  through  the  opening,  and  the  case  terminated  in  recovery, 
Westphal  atatea  that  tho  diugnosLa  of  tho  pn.'ixouce  uf  echiuo- 
cocci  in  the  brain  must  be  made  from  the  geueral  eymptoms  of 
iotracianial  tumour  appmriug  and  disuppburiug  alternately, 
I8d«ma  of  the  eyclida,  an  opening  in  the  cranial  bones  through 
which  a  fluctuating  tumour  projects,  or  exploratory  puncture, 

A  nturium  of  the  cerebral  arteries  gives  rise  to  symptoms  like 
those  of  other  tumours  situated  at  the  base  of  the  brain,  nor 
are  there  any  sure  signs  by  meaoR  of  which  the  former  may  be 
diattnguisihed  from  the  latter.  Even  auscultation  of  the  skull 
has  not  hitherto  proved  uf  much  use  iu  the  diagnosis  of  intra- 
cnutial  aneuriam.  If  aneuriam  of  any  of  the  other  vesueU  of 
the  body  co-exist  with  the  symptoms  of  tumour  situated  nt  the 
hue  of  the  skull,  then  aneurism  of  one  of  the  cerebral  vessels 
may  be  soipected.  It  Is  probable  that  aneurism  given  rise  to 
more  pronounced  symptoms  of  irritation,  such  as  intense  cepha- 
Uigia,  paroxysms  of  severe  and  intractable  trifacial  neuralgia, 
attacks  of  mania  and  other  grave  psychical  disorders,  than 
solid  growths.  If  a  patient,  who  bos  been  tiufTering  from  the 
aymptoms  of  tumour  situated  at  tho  base  of  the  brain,  die 
suddenly  from  an  attack  of  ingravescent  apoplexy,  it  may  be 
conjectured  that  the  tumour  was  an  aneurism  rather  than  a 


566 


rOCAL   DtSKASES,   ACCORDING  TO 


new  fonkialioQ.  If  n  cas«,  in  which  the  patient  h*s  satferod 
from  the  B^tnptotnFi  of  tumour  Bttuated  in  the  aotorior  fomof 
tbe  skull,  terminate  fatttlly  from  a  oopjous  bsemorTbage  fnm 
the  nose,  it  may  be  a*sunie<l  with  oonsidurable  probability  l\M 
an  anciirisra  of  the  anterior  cerebral  artery  bus  perforaud  (Iw 
oribrifonn  plate  of  tbe  etbaoid  booe.  If  pulsalioa  and  a  mar* 
miir  on  nuscultatioo  be  observed  in  the  orbit  inime<liatelyaAer 
an  injury  to  the  flkiill,  it  in  probable  that  a  comniuaicatioD  bu 
b«ea  ealabliabed  between  tbe  iulernal  carotid  artery  and  lK» 
cavernoufl  aiDiis  (Lebert). 

§  7S7.  Prxiipioitui. — With  the  eiceptton  of  sypbilitic  caao, 
cU-ath  is  the  usual  conseijuence  of  cereliral  tiimoara  Kvett  a 
syphilitic  tumour  may  uut  be  amcuablu  to  treatment  if  it  be  sf 
Ion;  standing,  aioco  irreparable  mificliicf  to  the  brain  may  ban 
already  been  caused  by  iL  Casesof  cerebral  tuiuour  mAy»orn«- 
times  terminate  io  sudden  death  through  an  attack  of  apopleiy 
or  of  conmlfiions,  or  occaoionally  without  erident  catue.  b 
other  ca30»  the  symptoms  may  become  nuie»cent.  the  vomiting 
cease,  the  amaurosis  evon  diuippcnr.  and  the  pattest  regard 
himself  cured.  After  a  time,  however,  ihe  symptoms  oniilh 
recur  with  iocrea9e<l  iotensity,  and  lead  to  a  fatal  terminatico- 

§  738.  Treaimeni. — In  the  large  majority  of  cas«  rery  litik 
can  be  done  by  treatment,  but  even  in  these  onpromiijlf 
cues  curative  efforts  !*hould  not  be  abandoned.  In  the 
atages  of  cerebral  tumours  the  symptoms  are  generally  tbcoe 
irritation  and  of  local  cnngention,  and  those  must  be  treated 
eold  to  the  head,  purgatives,  and  occosioaally  by  tbe  na»] 
Hying  bliHtcra. 

The  cephalalgia  may  be  combated  by  ice  to  the  head.  aoAl 
no  relief  bo  tifiordeJ.  uarcotics  arc  to  be  cautiously  itaorted  to, 
Subcutaneous  iDJectiona  of  morphia  will  bo  fotind  tbe 
useful  and  reliable  remedy,  altbough  small  doaet  of  boIUd 
have  occasionally  been  attended  with  benefit.    The  chl 
ammonium  may  ooeasionally  be  fi>uud  useful. 

When  conruUiona  are  a  prominent  Bymptom,  doses  of  fi 
liatf  n  draehm  to  a  drachm  of  tbe  bromide  of  polaasium  may 
useful. 


THE  NATUBE  OF  THB  LESION. 


M7 


With  the  view  of  promottug  absorptiou  of  the  morbid  growth, 
iodide  of  potafisiiiin  has  been  administered  in  large  close^i  and 
with  appareat  beaefii.  FormiiiUs  liair-dracbm  doses  may  be 
given  to  bi^iu  with,  aud  iucrcasud  uutil  a  dracbm  is  taken 
three  times  a  day,  OT  courtic  if  there  be  evidence  of  syphilis, 
energetic  anti-«yphilitic  treatment  by  means  of  mercury  aod 
iodide  of  potassium  is  iudicat(.-d. 


CUAFTER  TL 


(IT.)     SPECIAL     f^NSIDKRATlON     OF     FOCAL     DISl 
ACCOBDISG  TO   THE    LOCALISATION  OF  THE  LESK 


L    AFFKCTI0N8   OF   THE    PEDUNCUl.AR    FIBRES    AND 
INTEHNAL   CAl'St'LH 

a.  AgtiAwm  of  the  PymmidtU  Tract. 
{L)    Hzmruou. 

§  739.  Hehiflegia  coniisu  of  pamlysis  of  oae-lulf  of 
body,  although  many  of  the  muaclea  aie  either  not  implicated  or 
ouly  letnporarilj  weakeoeil  Tlie  paralyBu  tB,  as  a  rule,  Uraiud 
to  the  arm,  leg,  and  part  of  the  face. 

Id  facial  paraly^s  of  cerebral  origiu  Uie  clieek  on  tbe  bSbcUiI 
side  looks  Hat.  the  corresponding  naao-lahial  foM  i-i  obliterated, 
the  upper  lip  in  less  arched,  and  the  angle  of  the  moutli  i* 
lowered  on  the  affected  side,  the  diatortioD  becoming  more 
marked  when  tbe  facial  musclcH  of  tho  healthy  side  contract 
PonUysisof  the  orbicularis  oria  ioterferes  with  tbe  prononciatioii 
of  Ibo  hibiobi  aud  with  aucb  actions  as  whistling  and  blowinj 
out  a  candle  The  patient  can  frown  aa  usual,  raise  bts  ey- 
brow  and  eyelid  and  close  his  eye  on  the  paralysed  almo<t  M 
w«ll  as  OQ  the  b&Bltby  side,  but  is  unable  to  perform  a  uni- 
lateral  action  like  winking  on  the  affected  side.  The  hicui 
paralysis  begins  usually  to  disappear  in  a  few  weeks,  ajid  khom- 
times  in  a  few  days,  while  it  may  persist  for  niontba  Ttw 
muscles  cbie6y  affected  in  facial  paralysis  of  cerebral  origia 
are  the  buceioator,  orbicularis  oris,  and  the  straight  mosdw 
which  pass  to  tbe  angle  of  tbe  mouth  and  to  the  noae  on  tin 
paralysed  side;  while  the  ooci pi tu-fron talis,  corrugator  super- 


(dUi,  oad  orbicularix  oouli  remain  almost  eotirel;  unaiTected. 
lo  facial  paralysis  of  pcripberal  origin  all  the  miucles  supplied 
by  tlie  fanal  nerve  below  tlie  lesion  are  etiually  paralysed. 

Tb«  hTpoplogsal  nerve  is  afTecLed  in  most  ca&es  of  apoplexy, 
as  showa  by  a  coruin  degree  of  difficulty  in  executing  the 
movemeuts  of  the  tongue.  On  protrusion  its  point  deviates 
more  or  less  to  the  paralysed  side,  the  ba&e  being  dragged 
farther  forwards  ou  the  healthy  side.  The  affection  of  the 
tragus,  as  a  rule,  disappears  in  a  short  time,  but  is  occosioually 
pcnoanent. 

Some  observers  state  that  the  mueclea  of  the  trunk  arft  uo- 
aficctcd  in  bomipiegia,  but  the  inspiratory  muscles  undoubtedly 
act  less  freely  oo  the  paralysed  side  for  the  fint  few  days  io 
Mirere  casesi 

|iL}    Hu(iit?A»M. 

§  740.  The  spasms  which  occur  in  conneclioD  with  focal 
cerebral  lesions  are  of  three  kinds :  (a)  Tonic,  (t>)  combintd 
tonic  and  td<mic,  and  (o)  donic  ep<t»ms. 

(a)  TonU  Spoimi.—Thtt  tonic  contractions  which  occur  to 
oonnectioo  with  focal  It-itons  of  the  brain  may  he  divided  into 
two  clamcfl :  (i.)  Ettrly  and  (ii.)  late  rigidity. 

(L)  Kitriif  liigUiUy. — The  contractions  which  occur  in  early 
rigidity  may  be  snhdivided  into  thoee  which  immediately  ac- 
company the  lucmorrbage,  and  those  which  occur  a  few  days 
after  the  attack.  The  contractious  of  the  first  kind  aro 
probably  produced  by  irritation  of  the  fibres  of  the  pyramidal 
tract,  occasioned  either  by  rupture  or  partial  injury.  The 
second  form  of  early  rigidity  appears  in  the  paralysed  parts  a 
few  days  after  the  occurronco  of  ba-morrbage,  and  during  the 
time  itittammatory  changes  are  taking  place  in  the  tisitues  Rur- 
rouoding  the  clot.  The^e  contractions,  tbetcforo.  are  probably 
•ian  the  result  of  irritation  of  the  fibres  of  the  pyramidal 
ttad  Barly  rigidity  may  be  so  slight  ns  only  to  be  manifest 
when  passive  movement  of  the  paralysed  extremity  is  made. 
When  the  ann  is  tleied,  for  instance,  if  an  attempt  be  made  to 
itraighten  it,  the  biceps  offers  re»iHtaiice  to  the  movement; 
while  at  other  timeii  resistance  is  offered  to  flexion  by  con- 
traction  of  tbo  triceps. 


no 


FOCAL  OISBiaES,  ACCOBDINQ  TO 


Thfl  rifcidity  may  sometimea  be  limited  to  the  liiigers,  «U1« 
at  otlier  times  the  arm  is  drawn  to  the  side  of  the  chea^  tkc 
elbow  and  wrist  are  Bnnly  bent,  the  fiugcrs  are  flexcid  upon  tfat 
palm,  and  all  attempts  to  extend  the  limb  increnso  the  ooo- 
tractioDH,  and  cause  pain  an  vrell  as  some  amoiiot  of  tremor  or 
slight  clonic  spasm.  The  resistance  yielda  oocafliooally  undor 
steady  pressure.  This  form  of  rigidity  may  affect  the  leg  m 
well  as  the  arm,  and  then  the  tbigh  becomes  flexed  on  tbe 
trunk,  and  the  leg  on  the  thigh,  so  that  the  heel  is  brougbt  up 
to  tbe  buttoclc.  Karly  rigidity  generally  disappears  mod,  bol 
may  peniist  for  wocks  or  months.  The  affixted  muscle*  do 
not  iindorgo  atrophy,  their  faradic  and  reflex  excitability  ll 
increased,  and  they  become  completely  relaxed  during  sleep, 
altbongb  the  spasm  recure  imm(>diatoly  on  tho  patient  atraking. 
The  appearance  of  early  rigidity  diminishes  tbe  chances  of  tb« 
patient's  recovery,  and  whi>n  it  continues  for  a  lon^;  time  cbaagos 
take  place  in  the  musclos,  tendons,  and  joiota  of  tbe  affected 
extremities, which  utlimately  leave  them  permanently  contracted 
and  usetesfl. 

(it)  Late  Rigidity. — This  form  of  contracture  is  caused  by 
descending  degeneration  of  tbe  fibres  of  the  pyramidal  tiad, 
and  corresponds  in  its  essential  character  to  the  spasmodic 
rigidity  of  primAry  lateral  scleroua.  Its  most  cbamclenittc 
feature  is  the  ex^ger&tion  of  the  tendinous  and  periosteal 
rcHexea  When  the  lower  extremity  ia  affected  tbe  patellar- 
reflex  is  in  excess,  and  onklc'Clonus  is  readily  elicited,  aod 
corretponding  phenomena  may  bo  obtoioGd  in  tbe  upper  ex- 
tremity when  it  becomes  the  subject  of  contracture.  When 
the  lotui  of  Toluntniy  power  is  complete,  the  rigidity  is  more  « 
leu  constant,  although  it  is  in  most  cases  diminished  daring 
sleep  and  increased  during  voluntary  efforts  and  Hmotioael 
diaturbancea 

The  attitudes  assumed  by  the  limbs  AffE<cted  witb  Ula 
rigidity  differ  conniderably  in  different  oases,  but  on  the  wbak 
they  conform  to  tho  mio  observed  in  almost  all  spasmofc 
affections,  namely,  that  flexion  predominates  in  tbe  upper,  and 
extension  in  tbe  lower  extremity.  In  tbe  most  uraol  attitude 
of  tbe  upper  extremity  tbe  arm  is  drawn  towards  tbe  tnink  by 
cootraciion  of  the  pectoralis  miijor.    Tbe  forearm  is  aeim-6exed 


*".<■ 


THR  UJCALISATIOS  OF  THK  LCSIOlf. 


571 


tbe  ftrm  aod  pranated,  the  hand  is  slightly  flexed  on  the 
ino,  oud  tbfl  6ngera  are  closed,  la  8omc  Casos  tb«  forearm, 
Btead  of  being  semi-flexed  and  pronated,  is  &eiui-fl«xed  and 
ipioated.  In  a  few  rare  coses  tlie  forearra  is  extended  upon 
le  ana,  and  then  tbe  forearm  may  either  be  in  a  8tat«  nf 
Bopinatioo  or  pronation  (Charcot).  Probably  the  most  frequent 
attitude  of  the  Imrd  is  that  in  wbinh  the  finger*  ore  ex- 
tended At  the  Tnetscarpo-phalaogeal  aud  Sejced  at  the  phalangeal 
jointB  (Gowera).  The  inferior  extremity  is,  as  a  rale,  main- 
tained in  a  state  of  rigid  extcnaion,  the  foot  being  In  the  pori- 
IjoD  of  talipes  equino-vanis.  In  some  few  caiteB  flexion  pre- 
doniinatea  over  extennion  in  the  lower  extremity,  and  then  the 
thigh  bectrnies  flexed  on  the  trunk,  and  the  legs  on  the  thigh. 
fo  thai  tbe  heel  touches  the  Imttock,  Li  the«e  caaea  the  con- 
tracture is  apt  to  extend  to  tbe  opposite  extremity,  and  then 
ttalion  and  locomotion  are  impoaaiblc.  In  some  cases  the  con- 
tracture extends  to  the  inferior  mHacIcs  of  the  face.  The  c»n- 
tncture  ia  at  6r«t  transitory,  and  only  manifested  when  the 
patient  laughs  or  cries,  but  after  a  time  it  becomvn  permn-uent. 
Tbe  at:glo  of  tbe  mouth  on  the  affected  side  is  then  elovatcdt 
ic  na.«o-lahial  fold  is  increased  in  depth,  aud  even  the  eye  of 
the  corresponding  side  may  be  iimnller  than  the  healthy  eye 
(Plate  VI..  2.  3,  and  4), 

After  a  time,  however,  the  nmscles  may  undergo  progressive 
atropliy,  and  the  contrncturea  almost  entirely  dinappear,  although 
the  bone«  and  ligaments  having  become  adapted  to  tbe  form  in 
which  the  limb  haa  so  long  been  maintained  tbe  deformity 
p«nti«t8.  Iq  these  cases  it  is  probable  that  the  descending 
degeneration  of  the  lateml  column  of  the  spinal  cord  baa  ex- 
tended to  the  ganglion  cells  of  the  anterior  grey  homn.  The 
Bmselea  which  do  not  suffer  at  all,  or  suffer  least,  from  tate 
rigidity  are  those  that  are  bilaterally  aKRodated  in  their  nctions, 
while  those  acting  independently  of  tbe  corresponding  muscles  of 
tbe  other  side  arc  most  nfiectcd.  In  accordance  with  this  mle,  the 
tnusele^  of  tbe  trunk  remain  unaffected,  and  the  muscles  of  the 
tower  extremity  are  less  fre<iuenlly  and  less  profoundly  affected 
than  tboKe  of  the  upper ;  the  i^uperior  muscles  of  the  face 
generally  escape,  while  tbe  inferior  facial  muscles  are  occasion- 
lly  attacked.   The  rigidity,  however,  is  not  always  so  fixed  and 


572 


FOCAL   DISEASES,   ACCOBUINO  tO 


unvarying  aa  that  just  described.  It  may  never  become  fiiU| 
establUbed,  or  after  having  become  estabtisbed  may  aodergok 
coiisiderublf  amount  of  improvement  Whcu  tbc  rigidity  bu 
ocrcr  been  fully  eatabliithcd,  it  may  be  ob^it-rvvd  that  the  teuaion 
becomes  less  when  the  limb  is  warm  and  greater  wboo  it  it 
cold  ;  that  itcun  bu  diminished  by  gently  nibbioK  the  muade*; 
and  that  it  disappears  almost,  if  not  cnttroly,  during  aleep.  Oft 
the  other  band,  the  rigidity  is  increased  during  roluDtary  effon* 
to  more  the  limb,  this  effect  being  more  marked  vih<M  th« 
patient  is  under  obserpation. 

AlLbougb  rij;i<lity  may  have  become  fully  cstabtiabed,  at  the 
end  of  i^omc  months  it  grodaally  dimtDisboa  tu  aucb  a  degnw 
that  Bri»saiid  propoHex  to  uall  the  condition  latent  contractoie,] 
The  patiRDt  may  perform  nil  the  simple  movements  of  the  Ui 
and  probably  with  undimioislied  power,  but  whenever  bis  att 
tiou  is  spfcially  directed  to  the  movements,  as  when  be  wlshe*' 
to  perform  any  manual  operation  Te<niirittg  a  little  dt-xlerity, 
the  muscles  iustantly  become  rigid,  the  fingen  aro  Buxcd  on 
the  palm,  and  the  deformity  which  was  present  during  th« 
period  of  Sxed  cootracture  reappears.     It  amy  also  bv  shunu^ 
that  the  tendon  reflexes  continue  ezf^erated,  although 
muscular  tension  has  in  great  part  disappeared.     It  is  not 
ascertaiued  whether  the  di^ppearaoce  of  the  muscular  tensioa' 
is  due  to  a  corresponding  repair  of  the  fibres  of  the  injurw) 
pyramidal  tract  on  the  opposite  side,  or  to  the  establishment 
of  QOff  coanectioos  with  the  cortex  of  the  braio  on  the  aibi 
side  through  commissurnl  6bres  in  the  oord. 

[b)  Combined  Tonus  and  Clonic  Spasms. — ^The  cases  j 
described,  in  nltJch  a  slight  degree  of  muscular  tension 
raanontly  present  in  the  affected  extremity  is  aamxdated  with 
marked  »ipasm  ou  a  voluntary  effort  being  made  to  more  the 
limb,  form  a  fitting  traosition  to  those  ciuieii  in  which  a  fixed 

tonic  contraction  of  some  of  the  muscles  is  associated  with , 

clonic  contractions  of  others.    In  the  combined  tonic  and  clooi^^f 
varieties  of  post-hemlplegic  motor  disorders,  the  muscular  cou*^^ 
tractions  are  at  first  entirely  like  tboee  irbkh  ocoar  in  lale 
rigidity,  bub  after  a   tJmc  some    of   the  muscles  implicated 
become  tbe  subjects  of  clonic  spasm. 

Va-rietiea. — The  combined  tonic  and  clonic  b|Muuiu  of  beui- 


TBE  LOCALISATION   OP  TOE   LESION. 


673 


plegio  liinbs  ooanHt  of  the  following  Tarietiea  : — (L)  IntermitteDC 
tremor,  and  (ii)  Choreiform  movements. 

(i.)  Jtiler-mittenl  Tmmor. — The  most  uaunl  form  of  tremor 
obserred  in  lieioiplegic  limbs  currespouds  with  that  which  U 
observed  in  spastic  xpliml  paralysis.  The  tendoa  reflexes  are 
exAggerateJ,  and  the  tremor  is  induced  when  the  inuscIcH  aro 
pot  upon  the  stretch  by  nay  nttempt  at  voluntary  movement 
or  otherwise.  This  kitid  of  tremor  is  therefore  eimilar  to  that 
described  as  "spinal  uptlcp»j"  in  hit«ral  Bclcrosis  of  the  Hpinal 
cord,  and,  like  the  latter,  it  is  aasuciated  with  descending 
BcleroeU  of  the  pyramidal  tract.  The  tremor  is,  like  that  of 
multiple  sclerosis,  absent  during  repose. 

Tho  mu»cles  of  hemiplegie  Uraba  are  liable  to  be  afiect«d 
with  tibrill&ry  contractions  similar  to  thos«  which  occur  in 
progressive  niiuciilnr  atrophy  nod  amyotrophic  lateral  ncEerosis. 
It  is  probable  that  muscular  atrophy  is  always  associated  with 
these  conlractioQii  in  hemiplegia,  and  that  the  descending 
changes  of  the  pyramidal  tract  have  eztcndod  to  the  gaugliun 
cells  of  the  anterior  grey  bonis  of  the  cord. 

(ii.)  Cftorei/orm  Movements. — Clonic  choreiform  spaama  of 
the  extremities  may  eitb»r  pTec«de  or  fulluw  an  attack  or  hemi- 
plegia, the  former  being  ntimed  i*re-kennyilcgic,  and  the  latter 
p09t- hemiplegie  chorea  (Weir  Mitchell,  Charcot).  In  pre- 
hemipicj/ie  dtorea  thv.  patient  complains  of  a  feeling  of  numb- 
ness and  feebleness  of  the  extremities  of  one  aide,  his  gait 
becomes  hesitating  and  irrf^gular,  and  the  upper  estremity  of 
the  affected  side  is  attnked  by  choreifnrm  movenient.'*.  These 
symptoms  may  continue  for  some  days,  when  complete  hemi- 
plegia, UKually  Ofwociated  with  hcminnaisthesia,  is  either  aud- 
deoly  or  gradually  e.stablished.  Post-hemipleffic  chorea  occurs 
in  part  iaily  but  never  in  completely  paralysed  lirnb^,  aud  usually 
appears  simnltaneoiiHly  with  a  matkeil  diminution  of  the  para- 
lytic symptoms  The  clonic  spasms  as  a  rule  beconae  gradually 
established  M  mol*r  power  rclams,  although  they  sometimes 
supervene  suddenly,  and  appear  to  bo  nomotimcs  induced  by  a 
strenuous  voluntary  ett'ort  on  the  part  of  tlie  patient  to  move 
the  paralysed  limb.  Clonic  spasms  occur  more  frequently  tu 
the  arm  than  in  the  log.  and  when  they  exist  in  both  they  are 
more  severe  in  the  former,  while  if  the  leg  bo  exclusively  affected 


ar4 


FOCXL  DISEASES,  ACCURUINO  TO 


lUc  arut  U  usually  oompleu-iy  paralj26(L  The  miucle*  of 
face  are  sometimes  affected  by  tbose  epaaios,  causing  variout 
di»iortioDB,  wbtcb  becomo  greatly  iDcr«a»ed  whoa  tba  paiieot 
Isugbis  or  crien. 

The  uiuvtitueDU  affected  by  cboreiforia  Bpasm  in  the  appv 
extremity  aro,  in  ilecreasing  onler  of  troiuency,  the  special 
movuiUtiuUi  of  tbe  Ongers  aud  lUuiub,  tlexiou  and  extetmion 
the  wrist,  protialioQ  atid  supiuation  of  the  fureiuin,  oxUioaii 
aud  fluxion  at  tbe  elbow,  and  uioveraents  at  tbe  fehoulder-joint 
Tbu  itit«3iUEisui  &m  particular/  lii^le  to  be  afflicted  by  cliorei 
form  spasm,  and  cuusequenlly  tbe  movemeDtfl  loost  fiMjueotly 
observed  coDsist  of  varying  degreii'S  of  flexiuu  aud  extensioo  al 
the  metacarpo-pbaUngeai  articulatiooa,  lusoctatetl  rea^kectiTel; 
wLlb  extenaioti  uud  llcxion  at  tbepbalangeal  articulatiooti.  Ti 
tnoremcula  inducud  by  these  spasniB  are  of  wider  nuge  tban 
tliose  of  licmipK^ic  tTemor,  resembling  lu  tbts  rtwpoct  the 
inoveuieutb  of  cUoroa.  Tbey  arc  disurdurly  aud  tncgulsr,  sod 
way  or  may  nob  continue  during  ootflpliite  rcpvue;  tliey 
during  slocp,  and  become  macb  aggravnted  during  velUBtary 
efforts  to  perform  a  dcfiaito  morement  witb  tbe  affected  Urn 
Kucb  a»  tbat  of  raising  a  glass  of  water  to  the  moulb.  WJi 
tbe  lower  extremity  la  affected,  tbe  whole  body  may  be  tl 
into  a  Htau^  of  agitaiioo  during  loconiution. 

Two  forms  of  po^-ftemijjtejfie  eko}'ea  may  be  distiDguiabed: 
(a)  the  post-be  111  iplegic  ctiorea  of  adults ;  and  (fi)  the  apantie 
heniiplegic  of  infaucy.  The  spastic  beniiplegia  of  ioCuioy  may 
coiuist  of  a  purely  tonic  spasm  of  tbe  miuclea  without  any 
adtnixluru  of  clonic  spasms,  »lcbougb  the  choreiibnn  variety  i« 
probably  tbe  more  common. 

(a)  foat-kemiplegic  Cfuyroa  of  AduU^.—^Thvi  poiit-bemiplegic 
oborca  of  adults  aud  tbe  cocrospoudiug  aflvclion  uf  infancy  differ 
in  varioua  waya  la  U)e  lortner  the  history  of  the  caae  t^ow* 
that  tbe  attack  of  beiuiplegia  which  preceded  the  appeanuicc 
of  tbe  clooic  spasms  occurred  during  adult  life,  or  at  any 
Lot  in  early  mfancy.  The  attack  of  hemiplegia  may  have 
aionally  become  gradually  eslablinhud  wbeu  due  to  the 
growth  of  a  tuiiiuur,  but  as  a  nile  it  has  come  on  suddenly  with 
apoplectic  symptoms.  An  examioatiou  of  the  patieot  ii^y 
reveal  valvuhir  disease  of  tbe  heart,  or  there  may  be  &  hi 


k 


ho** 
raoc*      J 

dioipfl 


TOE  LOCALISATION  OF  TUB  LESIOEf. 


575 


Djury  to  the  bead.    The  po8t>b«miplegic  ciiorea  of  adults, 

apart  from  tlie  liUtotj,  differs  from  tbal  of  iufaocjr  in  the  co- 

existeDce  of  tiemianx^thesia  in  the  former  and  its  absence  in 

the  latter.    The  aoKsthesta  extends  over  the  lateral  half  of  the 

body ;  and  all  fornii!  of  suusibtlity,  including  ibe  special  bl-udcs. 

are  more  or  lei-s  affected.    Three  distinct  cues  uf  the  poat- 

bemiple^tc  vborea  of  adults  have  come  under  my  own  obeer- 

vation.     All  the  patients  were  cum|>arativc-ly  young  uieu,  tlieir 

I  agea  rangtug  troca  2o  to  SS  years.    The  attack  of  bemiple^ia, 

which  bad  preceded  the  cboreifonn  movements,  occurred  ia 

each  several  years  previously  to  tuy  seeing  them.     Two  of  the 

patieota  presented   evideuco  of  alight  sienosis  of  the  mitral 

valro,  and  io  the  third  iho  apoplectic  attack  bad  bcea  induced 

by  a  fail  ou  tbo  head.     The  attitude  assumed  by  the  affected 

lann  was  vory  similar  in  the  three  ca.scR.     There  was  mnrked 

itouic  spasm  of  the  posterior  third  of  the  deltoid  in  all  of  tliom, 

IRQ  tbat  the  elbow  was  abducted  from  the  trunk  to  the  extent  of 

about  two  and  a  half  inches,  while  it  was  also  drawn  backwnrda 

ICMiaidenibly  behind  the  poaterior  plaim  of  tb«  body.    The  fure- 

aim  was  slightly  tiexed  on  the  arm  and  strongly  prunated,  the 

iband  was  slightly  flex«d  oa  the  forearm,  whili.'  the  fingers  were 

kept  in  coustaui  muveEiiunl  by  clonic  spaxmsof  the  iuteroKnei 

muscles.     There  was  also  a  certain  degree  of  spasmodic  pro* 

natioD  and  supiuatioa  uf  the  forearm  aad  flexion  and  ext«uaioa 

of  ibe  band  iu  all;  while  in  one,  irn^gular  jerking  movcincnta 

of  the  forearm,  hand,  and  fingera  occurred  when  the  patient. 

attempted  to  grasp  any  object  with  the  paralysed  baud.     A 

marked  feature  presented  by  theae  cases  na&  the  fact  that  each 

palivUt  carried  the  affected  hand  in  tht;  out  pocket  of  his  coat^ 

in  order  to  arrest  its  disorderly  movomcntiL     In  tbia  positioa 

the  upper  arm  wa»  diroctdd  dowuwards,  outwarda,  aad  back- 

watdH  from  the  abouUler,  the  elbow  being  considerably  remuvfrd 

from  the  trunk  and  behind  its  posterior  pliine,  ibe  forenrni  waa 

aligbtJy  bent  on  the  arm,  and  the  back  of  tlie  baad  waa  preased 

«U>sdy  agaiuKt  the  hip. 

In  (h«  three  patients  referred  to  the  tactile  sensibility  of  the 
palm  and  fiogera  of  the  affected  bnud  was  remarkably  delScienL 
When  the  patient  was  asked  to  close  his  baud  on  a  coin  placed 

closed,  he  could  oot  sav  wbethar  he 


pall 


eyes 


57« 


FOCU.  DISEASES,  ACCOBOINQ  TO 


bad  or  bud  not  the  coio  id  bis  grasp ;  ftud  wbeo  Uie  aaa  v«i 
vrilbdmwu  before  tbo  closure  of  the  fingers,  it  waa  amtuiag  to 
obMrve  Ilia  puzzled  eiprcs«ioa  oa  op«Dijig  his  oyee  and  bud 
when  b«  found  the  Utter  empty.  Tbe  patients  could  be  pricked 
with  a  pin  over  bair  the  face,  trunk,  and  over  extretDitiei  on 
tbe  affected  side  aJmo^t  without  pain.  In  one  of  these  euas 
all  forniB  uf  cutaoeou»  sensibilily,  aud  the  muscitliir  eensa,  w«r» 
Jimiaished  over  half  of  the  body  on  the  afiected  side,  the  seims 
of  taste  aaJ  smcU  were  aliio  diminished  oa  the  corresponding 
side,  but  the  xentfes  of  hearing  and  night  wens  not  afTected  to 
an  appreciable  exteol. 

(fi)  Spuxlk  HemipUgia  of  Infancy. — In  the  spastic  hemi- 
plegia of  infancy  the  lesion  wbicb  determines  the  paralysu 
occurs  duriug  birib,  or  in  early  infancy.  The  paraljra* 
appeant  sometimes  to  have  become  e-stabtished  before  Inrth. 
but  cases  of  this  kind  ore  cxceptionaL  It  is,  butrever,  not 
uncommoD  to  ascertain,  on  iniiuiry  from  the  parents,  that  tL« 
patient  who  is  affected  with  tbo  spastic  bcmiptogia  of  infancy 
suffered  from  repeated  oonvuUioiks  accompanied  by  nncoo- 
sciousncss  for  the  first  two  or  three  days  after  birtb,  altlioagb 
It  may  not  he  observed  that  tbe  child  is  paralysed  on  one  half  of 
tbe  body  tUl  some  time  subsequently.  In  the  majority  of  th«ss 
patientR,  however,  the  onset  of  the  disease  dates  from  the  age 
of  two  to  three  months  to  that  of  four  or  6ve  years.  Tbe  neit 
usual  history  is  that  after  an  illue.'»  of  iudefmiUf  character  ei- 
tending  over  a  few  days,  or  without  any  warning,  the  child  hst 
been  taken  witti  coovuUions.  Theae  convulsions,  as  a  rule,  have 
reairred  repeatedly  for  some  hours  ordays,  the  child  remaining  in 
thetneauiiineinastateofuncouiKiousuess.  In  many  cases  this  u 
the  only  history  which  can  be  obtained,  but  where  the  pare«u 
are  intelligent  it  may  be  ascertained  that  the  convulsioiit 
were  limited  to  the  aide  vS  the  body  which  had  subsequenUf 
become  paralysed.  Many  infants  doubtless  die  during  lliotc 
convulsions  or  a  few  days  after,  but  in  the  caaes  whidi 
survive  it  is  soon  observed  that  one  half  of  tbe  body  is 
paralysed.  l*he  hemiplegia  in  these  cases  pursues  tbe  ususl 
course,  contractures  become  established,  and  choreiform  move- 
meats  may  or  miiy  not  make  tbcir  appearvice  during  partisl 
recovery,  but  wbc-u  once  these  movemeats  appear  Ibey  mnaiB 


THB  LOUALISATIOS   OF  THB   LESIOM. 


577 


permanent.  So  far,  then,  these  cases  present  cotUinf;  peculiar 
except  tbat  tlie  disease  da.t'CS  from  childbood,  that  it  i»  usUureU 
in  by  coDvulsioDS  aod  profdund  unconsciousness,  and  that  the 
motor  pyaralyais  is  Dot  accorapaaied  by  bi;niLaD»stliesi£L 

In  the  spastic  heraipU^ia  of  childhood,  however,  it  is  soon 
observed  that  th«  inteltoct  of  tlio  patient,  however  bright  the 
child  may  have  been  previous  to  the  attaclcs  of  convulsions 
which  RiArkod  (be  onset  of  the  disease,  has  become  markedly 
defsctira.  ThiH  fonu  of  hemiplegia  is,  indeed,  Dearly  always 
associated  with  »)nie  degree  of  idiocy. 

Another  marked  peculiarity  of  the  affection  is  that  at  a  oer- 
tain  age  Uit*  hemiplegia  becomes  amociated  with  epilepsy.  The 
epileptic  attacks  generally  begin  when  the  patient  is  from  seveo 
to  ftfleea  years  of  age,  aud  at  first  axe  usually  limited  to  the 
paralysed  aide  of  the  ijody,  and  may  nut  be  attended  by  decided 
lofls  of  cooflcioiisness.  In  the  case  of  a  well-developed  ^rl  four- 
teen years  of  age.  under  my  care,  sutfering  from  the  spastic 
hemiplegia  of  childhood,  the  epileptic  attacks  began  when  she 
was  eight  years  of  a^e.  The  right  half  of  the  body  was 
pBnily8ii.-d,  the  arm  being  more  paralysed  than  thu  leg,  botJi 
limbs  were  »omewh&t  rigid,  but  oeitber  oiaoifiested  any  cborei- 
fona  movements.  The  epileptic  attack  always  began  by  move- 
meota  of  the  paralysed  arm ;  these  soon  extended  to  the  muscles 
of  the  mouth  on  tbe  name  side,  and  then  to  the  paralysed  leg. 
In  most  attAcks  this  patient  became  unconscious  for  a  few 
moments,  and  thon  got  up  and  walked  about  as  if  nothing 
bad  happened.  In  some,  however,  thu  couvuHons  were 
limited  to  the  paralysed  arm,  with  probably  a  slight  exten- 
BioQ  of  them  to  the  angle  of  tho  mouth,  but  ibe  lug  remained 
free,  and  there  was  do  loss  of  conHciousnesa  The  patient  was 
once  reported  by  the  ourse  to  bavo  walked  across  the  ward 
during  an  attack,  holding  down  the  convulsed  and  paralysed 
ana  with  the  opposite  band.  In  old-established  cases  the  coo- 
vuUions  may  iKOome  general,  but  it  may  bo  observed  that  they 
retain  a  unilateral  character  at  the  commence m>(-nt  of  the  attack, 
and  the  patient  usually  describes  a  unilateral  aura. 

Tbo  uura  is  often  described  as  a  sensation  begioning  in  the 
paral)-sed  hand,  and  ascending  along  the  arm  to  tho  shoulder 
and  b«ad,  when  unconflciousuess  supervened.     At  other  times 
LL 


678 


FOCAL   DISEASES,   ACCORDIKQ  TO 


tbe  MDS&tion  begins  in  the  paralysed  leg.  and  aaomds  soeci*' 
sively  to  the  arm  and  bead.  In  several  caues  under  ibo  cue  of 
Mr.  Biirdic.  wliich  I  examined  rec«ntljr  is  CmmpattllWorkboBK. 
three  of  which  arc  rt-pnist'Dted  in  FUUe  VI.,  Fig«.  2,  3.  and  ♦.  tli« 
patients  could  not  give  aoj  account  of  on  aim;  uud  so  far  u  I 
could  judge  from  the  account  given  by  their  attcudauL^,  the  aiO' 
vulsioDS  did  not  aaautnc  a  unilateral  character,  lu  all  tboM 
caaea  marked  idiocy  was  pr«£eat,  eo  that  the  presence  of  &u  auia 
could  not  bo  determined  from  the  inability  of  the  patiebti  i* 
describe  it  In  one  ciuto  of  tlic  kind,  with  chorctfonn  more- 
meotfl  of  the  paralysed  baud,  svaX,  to  me  by  Mr.  CullingWDTth, 
the  patient  had  au  epitepiic  attaclc  once  while  I  was  oxamitufif 
her.  I  could  not  ohsen'e  that  the  convulsions  auumed  a  pro* 
nounced  uuilaterul  character  at  any  time  durbg  tbe  attack.  Oa 
cross-examining  her  with  respect  to  the  aura,  sfao  poaitiTfllj' 
deLted  that  she  bad  biid  any  waruing  whatever  of  impeailiBC 
attacks;  but  after  a  limv  bhu  volunteered  the  i)lst«iDeDt, 
"  When  the  iitD  began  Hint  I  u»ed  to  have  a  cre«piDg  fevting 
in  the  li-g.  which  came  up  to  tbe  arm,"  at  tbe  ssime  lioM 
pointing  Bucceeeively  to  the  paralysed  leg  and  arm. 

These  patients  also  present  other  phenomena  which  an 
worthy  of  notice,  the  most  remarkablo  of  which  is  an  armt 
of  dcvelupmeiit  of  the  paralyacd  limbe,  generally  impUcatiog 
the  corresponding  side  of  the  face.  The  circumference  of  ibe 
paralysed  extremities  ia  aaually  less  than  that  of  correspotii^H 
part4  of  the  opposite  limbs,  although  not  always  aa  Whei^P 
limb  is  subject  to  violent  choreiform  movemeDts,  tbe  mutckf 
may  become  hypertrophied  so  that  its  circumference  exceedl 
that  of  the  corresponding  healthy  extremity.  Hut  even  nodv 
thetie  circumetiiDCL's  it  may  be  found  that  the  circamf«ro&e«o( 
the  holies  on  the  affected  side  i«  less  than  that  of  the  eoasd 
side,  and  that  the  enlargement  ia  limited  to  the  musclea  Eacfc 
of  the  long  bones  of  the  affected  extremities  may  be  from  ^ia. 
to  lin.  shorter  than  tbe  correspooding  bonea  of  the  aiKMied 
aide,  and  even  the  clavicle  of  tbe  paralysed  side  may  be  frun 
^in.  to  Jiu.  aborlvr  tbou  the  opposite  clavida  The  diminutioa 
of  size  of  tialf  the  face  may  extend  to  all  tbe  featnics^  iodo* 
diRg  the  eyebrows,  eyelids,  half  of  the  nose,  tbe  cheek,  and  half 
the  luouth. 


TRB  LOCALISATION   OF  THR  LRSION. 


070 


Spaiims. — The  post-hemiplcfjip  motor  disordere, 
t  of  clonic  epaeius  unncconipanied  by  tonic  con- 
tractions  of  the  muscles,  are  (i.)  continuous  or  remittent  t^pmor, 
(ii.)  choreiform  roovemeniB  (athetoaift),  and  (iii.)  jerking  move- 
meiitK  on  voluotar;  effort  (lieiniataxia). 

(L)  Gmtinuou^  or  RemlUent  Tremor. — 'ITie  tremor  which 
li(ts  already  been  described  as  occurring  in  liemiplcgic  Hmba 
waa  associated  with  increased  miisculur  tension,  cxcbhs  of  tlie 
tcodoD  reflexes,  and  only  occurred  when  a  voluntary  movement 
of  the  limb  waa  made.  In  the  form  of  tremor  about  to  be 
described,  mtiscular  tension,  if  present  rn  excefls  at  nil,  is  not  a 
prominent  feature  of  the  case,  the  tctidou  reflexes  are  not 
exai^geratcd,  the  tremor  is  continuouu  ut  least  during  waking 
hours,  and  instead  of  being  exno;gerikted  it  may  be  dimiitiebed 
or  arrested  by  a  Toiuutarj'  cffwrL  Wo  have  seen  that  the  first 
form  of  tremor  is  like  that  which  as  observed  in  sclerosis  in 
patehee;  while  the  second  form  ia  iu  all  essentkl  particulars 
like  ihe  tremors  of  paralysis  agitans.  A  case  of  the  Utter  kind 
has  been  described  by  Grassct.  The  tremors,  which  continued 
daring  reposOj  wore  accompanied  by  sensations  of  heat  like 
thoM  eompiaineU  of  by  patienta  eufiering  from  paralysis  agitanx. 
A  cow  is  described  by  Leyden  in  which  tremors  occurred  in  the 
right  arm,  niomeatarily  arrested  by  a  voluntary  eflfort,  while 
there  was  complcto  absence  of  any  paralysis  or  cuutrActures  and 
of  HiwoTy  disturbances.  Around  sarcumatowt  tumour  was  found 
in  4ho  left  optic  thalamus.  By  the  courtesy  of  Dr.  Leech,  I 
had  an  opportunity  of  tthowiug  to  the  members  of  the  British 
Medical Anocialion  at  thu  Manchester  meeting,  acase  in  which 
one-half  of  tho  body  presented  all  the  charactoristJcA  of  a 
moderately  advanced  pamlysis  agitans.  The  tremors  extended 
to  the  right  foot^  leg,  ami  one-half  of  the  trunk;  while  tho  atti- 
tude of  the  forearm,  fingers,  and  thumb  was  quite  characteristic 
The  Bymptoma  supervened  nine  months  previously,  and  were 
praoaded  by  a  slight  attack  of  confusion,  not  amounting  to  un- 
oonscioosDess,  followed  by  alight  paresis  of  the  right  side  of  tho 
body. 

(iL)  Atket^ns. — An  affection  has  been  described  by  Ham- 
nond  under  the  name  of  athetosia,  in  which  the  patient  w 
unable  to  ronintain  the  fingers  or  toes  in  fixed  positioa».    The 


«H> 


POCAL  DISEAttES,  ACCUKOINO  TO 


flogere  aad  toes  in  thia  affoctioa  aro  mainlaiiied  ia  oOQUnooQa 
filow  muvemcDi,  and  u-re  mmie  to  assume  various  diatortwJ 
positiCDS.  Xli&sd  moTOtncnU  are  not  alwaja  iimit«d  to  tibc 
tiQjjera  and  toes,  but  extend  to  tbe  band  aud  foot,  and  oecauoa- 
ally  cvt'D  to  the  tnusclofl  of  the  oeck  aud  face.  Ho  mattw 
weakaestf  baa  been  recogniMd,  tbo  movementa  are  ooly  Ui  a  sligtit 
extent  under  tb«  coulrot  of  iho  will,  they  unuiillj  peraistdunag 
ftlo«p,  and  nre  not  nccompatiie^l  by  cuutructure&  Cae«8  of  th* 
aflectioa  have  beeo  described  by  Allbutc,  Currie  Ritcbie,  Fiilior 
(BoBton,  U.S.),  Qairdaer,  aud  others,  while  Claye  Shaw  and 
Oreschreld  bare  dnwn  attentioD  to  ihe  aoulagous  condiliuo 
somolimes  ub«erred  m  the  limbs  of  imbecile  cbildivn.  OalowBl 
has  written  a  viiluablc  mouograpli  of  the  wliolo  subject 

The  appearance  of  the  clonic  aposm  ia  in  almost  ail  caaet 
preceded  by  a  disiinct  attack  of  hemiplegia,  and  wbui  do 
decided  paralysis  can  be  ascertained  to  hav«  been  preaeat  Uie 
biatory  of  the  cose  idiows  that  the  paUeot  baa  iofTercd  fmn 
attack  of  couvulaioDs  and  uoooaecioitsueaa. 

HemiansMtbeala  is  described  aa  being  pKMmt  on  the  affi 
Bide  in  some  of  the  reported  cases,  while  a  certain  degree 
numboees  of  the  same  side  is  froqiicntly  mentioned.  Id  aeoa- 
8)dorable  number  of  cases  the  condition  of  senubitity  U  not 
mentioned,  and  probably  no  specinJ  attenttoii  was  directed  le 
tlie  point 

Tbo  afTected  extremity  UHualty  prcBDOts  vatx>-mutor  disturb- 
ances. It  is  red  or  livid,  moist,  and  colder  than  the  oorw* 
spending  extremity. 

The  oCTucted  baud  or  foot  i«  also  freqaently  atmphttd; 
although  the  muscles  which  are  affected  by  Lbe  sp&»in  may 
undergo  a  certain  amount  of  hypertrophy.  The  electric  eoB> 
tractility  of  the  affected  muscles  raries  in  different  caaea,  being 
HOmetimes  uoirnal.  at  other  timca  enfeebled  or  iDcrcaacd. 

Oulmout  huA  ubsorvcrl  an  unusual  degree  of  relaxaUoa  of 
ligaments  and  joints  of  the  affected  extremitiea 

A  biiaieml  cUhitoaie  haa  been  described  by  Oulmonl. 
does  not  differ  essentially  from  the  unilateral  affc-ction,  OZ' 
that  the  muscles  of  the  face  appear  to  be  more  liable  to  be  m- 
plicated  to  a  greater  extent  in  the  former.  The  bilateral  aff«- 
tioo  is  genemlly  associated  with  idiocy,  but  may  oocar  wiUwut 


THE  LOCALISATION  OF  THE  LESION. 


KSI 


tiiis  oomplicatioti.  Tt  is  not.  according  to  Oiilmotit,  prcceiled 
hf  apoplexy  or  bciniplc^a.  and  ie  unaccompaniod  bj  sensory 
dUturbaaoe!). 

(iii)  Bemiataaia. — A  case  has  been  deKribed,  by  Dr.  Gowere 
ID  which  there  was  groat  iuoo-ordiDation  of  the  right  arm 
during  voluntary  raovement,  while  there  was  comploto  absence 
of  pormaaODt  rigidity  aod  spontaneous  spasm.  The  patient 
bod  saffored  from  a  slight  attack  of  apoplexy  followed  by  hotni- 
pleg'ia  ay^ar  and  a  half  before  he  came  under  observation,  but 
the  parmlyiiis  had  disappeared,  a  slight  weaknesa  of  the  arm, 
I^  and  faoe  alone  romnining.  The  ntnzic  niovcnientg  of  the 
arm  became  exaggerated  ou  the  eyes  beiug  closed.  Tuctile 
sensibility  was  diminished  in  the  right  arm,  hut  Hensihility  to 
pain  wax  normal.  In  a  somewhat  Mtnilar  caite  recorded  by  the 
Bune  obseiver  the  autopsy  rwealed  "a  puckered  cicatrix" 
passing  through  the  left  thalamus  from  the  one  side  to  the  other. 
A  case  in  whicli  ataxic  movements  occurred  in  the  right  hand  is 
also  described  by  Qraasei.  The  p-iticnt  had  a  series  of  apoplectic 
attacks  followed  by  hemiplegia  and  a  certain  embarrnRsmpnt  of 
Bpeecb.  The  ataxic  moTcmeDts  were  limited  1o  the  rigljt  arm, 
iho  paraljais  being  more  marked  in  the  face  and  arm  than  in 
the  leg.  At  the  autopsy  three  centres  of  softening  were  found 
in  the  left  heouiiphcre.  The  6rst  occupied  the  region  of  tli« 
leoticulO'Striatc  artery ;  the  second  woe  in  the  optic  thalamus 
eioae  to  itf*  ventricular  border;  and  the  third  was  found  in  the 
thalamus  clos«  to  the  posterior  portion  of  the  internal  capsule. 


5^7-11.  The  HemipUffie  Wtill\ — When  the  mnsclea  of  the 
paralyaed  lower  extremity  have  acquired  n  certain  dogroo  of 
rigidity,  the  patient  is  able  to  walk  by  the  aid  of  a  stick,  even 
if  the  voluntary  paralysis  of  the  affected  side  remain  complete. 
"Hlb  patient  leans  towanis  the  healthy  aide,  but  is  prevented 
from  fatUng  over  to  that  side  by  the  suppoK  of  the  stick  ;  the 
pelvis  and  hip-joint  of  the  paralysed  (tide  arc  elevated  by 
oootractioD  of  the  abductors  of  the  opposite  thigh,  so  that  the 
weight  ia  taken  off  the  paralysed  extremity.  When  the 
paralysed  lower  extremity,  say  the  right  leg,  is  the  active  one, 
the  lioe  of  gravity  i.-^  carried  over  to  a  sliglit  extent  to  that 
side;  but  instead  uf  reuchiug  the  centre  of  the  paralysed  fool, 


rOClI.  DISEASES,  ACOORDISO  TO 

it  ronuUDs  mlJw&y  betweeo  it  aod  the  end  of  the  stick,  io  that 
the  vreigbt  of  tlio  body  its  maintaiued  partly  by  tbo  pudyMMl 
lower  extremity  aud  partly  by  the  bealtliy  arm  tbrougb  tb* 
fttiek.  The  hciUthy  or  left  lower  extremity  is  now  quickly 
moved  forwards  a,  step,  an  umuual  degree  of  flexion  of  the  tbigb 
upoa  the  body  tAkiQg  place  in  order  to  aroid  tbn  oecenity  of 
carryiog  the  line  of  gravity  too  far  to  the  paralysed  side  The 
loft  Ivg  now  becomeii  active,  and  the  paralysed  ODO  mast  b» 
moved  forwards.  The  maDoer  in  which  this  toovomcot  is  exe- 
cuted depends  upon  the  degree  of  paraly^s  and  of  muaeolu' 
rigidity  present  If  the  pjiralysis  be  almost  cotDi>lete  and  the 
rigidity  not  great,  the  extremity  is  partly  swung  and  partly 
dragged  round  mainly  by  the  oontnctiuu  of  the  inward  roiaton 
of  the  healthy  limb.  Contractioa  of  tbcve  mntclea  causes  tbt 
pelvis  to  rotate  forwardti  on  tbu  b  ijvjoint  of  tbe  beallhy  nde.  aud 
consequently  the  oppoiiite  hip-joint,  drawing  ailer  it  the  paia- 
lyacd  leg,  is  moved  forwards.  Thia  forward  movemeot  is  aided 
by  a  further  elevation  of  the  right  Lip-joint  caused  by  coatnfr- 
tion  of  tbe  abductors  of  the  opposite  thigh,  and  sometimeAby 
a  uligbl  backward  ioclinatioa  of  the  tmuk  by  means  of  which 
the  distance  between  the  p.>iab8  of  origin  and  insertion  of  the 
flexors  of  the  thigh  on  tbe  body  is  increased. 

If  n  high  degree  of  contracture  with  talipoa  equiniu  be  pr<- 
Bo&t,  tbe  paralysed  lower  extremity  is  moved  forwards  much  is 
the  same  manner  as  has  already  been  described  in  tbs  case  of 
primary  lateral  sclerosis.  Wbeu  once  the  weight  of  tbe  body 
is  taken  off  tbe  paralysed  extremity  tbe  heel  becomes  elevaleil. 
and  the  toe  during  the  forward  movement,  wbicb  lakes  plac*  in 
a  semicircular  manner,  makes  a  obaractdristic  scraping  noise. 

If  tremors  or  choreoid  movements  be  present  io  tbe  paralysed 
lower  extremity,  tbe  bemiplegic  walk  may  become  modilied  io 
sucb  numerous  ways  as  to  render  it  imposuble  to  comprise  the 
different  varietieswhicb  may  be  presented  in  a  single  description 

b.  Affections  of  ike  Sensory  Peduncular  7'raet  and 
Optic  Sadialicna  of  Qratioltt, 
HmiABxaTBuiA. 
§  74-2. — lu  ccrebml  bemianatsthesia  the  affeclioD  derslopa 
suddenly  after  an  attack  of  apoplexy,  or  gradually  as  Um  ihuU. 


TOE  LOCAUSATrOU  OV  TEE  LESION. 


6SS 


for  iasUoce,  of  the  progressive  growth  of  a  tumour.  The 
seofibiLity  is  diminUhed  over  tlie  whole  of  one-half  of  the 
body,  face,  and  extremities,  iucliiding  the  accessible  raticouB 
membraaea  an  well  aq  the  skin.  The  abolition  of  sensation 
is  sometimes  incomplete,  and  then  cutaneous  anal;:;c8ia  or 
tlienuo-aao'Mbi'iiia  may  be  preucut,  white  tactik'  sensibility 
remains  unaffected.  At  other  times  the  anjeathesia  of  the  ftkio 
and  mucous  membraaui  is  complete,  aod  even  muscular  ecii- 
stbility  and  miucnlar  neoao  are  abulitihud.  The  patient,  for 
instance,  doea  not  feel  deep  pressure,  strong  contraction  of  the 
muficles  may  be  produced  by  the  faradic  curieut  without 
causiuj;  pain,  and  when  his  eyca  arc  closed  he  is  unable  to 
describe  the  poaition  ia  which  the  affected  extremities  may  be 
placed  by  pAaaive  movements,  nnd  ia  not  aware  when  hit) 
attempted  voluntary  movements  are  forcibly  prevented.  The 
patient  can  walk  without  difficulty  whoa  kiii^  oyca  are  clofted, 
but  by  slight  pressure  upon  the  nHe(!t«il  s.\<\a  he  may  be  easily 
iodooed  to  walk  iu  a  circle  while  uuder  the  impression  that  he 
is  walking  in  a  straight  line. 

One-half  of  the  mucous  membrane  of  the  tongue,  mouth, 
•Jid  veil  of  the  palate,  and  the  conjunctiva  of  the  same  side. 
are  inHensittvc,  but  the  cornea  retains  its  seni^ibility. 

The  affected  side  ia  colder,  and  the  prick  of  a  pin  does  not 
bleed  »o  readily  as  on  the  opposite  half  of  the  body. 

The  cutaneous  reflex  actions  may  be  abolished  on  the  side 
affected,  while  the  deep  reflexes  are  retained. 

The  aerWM  of  taaU  and  smell  are  both  abolished  on  tho 
affected  side. 

Tbe  M7t«a  of  Iiearinfj  is  also  diminisbed,  and  in  some  cases 
there  may  be  complete  unilateral  deafness. 

Tbe  dense  of  alyht  is  impaired  but  not  abolinhcd,  but  favmi- 
opia  has  not  been  observed  when  tbe  lesion  is  limited  to  the 
internal  capsule.  The  acut«iieS8  of  vision  may  be  tested  in 
the  nsual  manner  by  Snellen's  scale.  There  is  also  concentric 
TGStnctioQ  of  the  field  of  vision,  and  ^he  perception  of  certain 
ooUtire  may  entirely  cease  (dyscbromatopsia). 


§  74^3.  Afoi'trid  Anatomy  and  Phyitiolcgxf. — It  is  impossible 
to  separate  lesions  of  Iho  internal  capsule  and  crusta  from 


5» 


FOCAL   DISEASES,   ACCORDniQ   TO 


tbow  of  the  ganglia  bj  whi*^  tbey  are  sorrotinded.  Since  tin 
days  of  Willis  aod  Uorgafroi  up  to  a  fev  yean  ago,  paralyna  o( 
on&<hair  of  the  body  has  be«n  aiuwciated  with  diBoiuw  of  ttii 
corpus  striatum.  This  doctrine  iiad  lodeed  received  a  ibodt 
apwatctti  of  t  wenty  years  ago,  from  the  observatioDii  of  Tiirck. 
who  showed  tliat  hemtaoiestbesia  of  the  oppoKile  side  of  lhi> 
body  might  result  frotn  disease  situated  in  the  poalerioi  part 
of  the  lenticular  nucleus.  It  was  also  auggcitod  by  Meynert 
and  Broadbetit  that  Bome  of  the  Rbrefi  of  the  crust*  puwd 
upwards  bo  reach  the  cortex  of  the  brain  without  Ueiog  io  aaj 
way  connected  with  the  baaal  ganglia;  and  CharcoU  with  bi* 
usual  readioess  and  skill  in  utiUsmg  the  detaiU  of  aoatotnical 
Tveoarch  for  clioical  purposes,  suggostoO,  aod  &oon  proved  by 
observation  and  aoalyeis  of  caBes,  that  both  hemiptegia  and 
hemiaaiesthesia  are  caused  by  injury  of  the  direct  fibrbs  wbic 
lio  between  the  basal  ganglia,  and  not  by  lesiona  of  tlio  ganglj 
themflelirea.  We  have  already  seen  that  the  5brea  of 
posterior  third  of  the  posterior  eegmeot  of  the  iotornal  capsult 
ore  sensory  ;  tbiit  those  of  it«  middle  third  oonaoct  the  oi«clia- 
niftinH  in  the  cortex  of  the  brain  and  spinal  cord  which  regiila(«_ 
the  ftuidameotal  actionn ;  that  thoxe  of  the  anterior  third  of  i 
posterior  division  connect  the  mechanisms  wbicb  regulate 
ipecialised  aclions ;  and  that  those  in  the  knee  and  tlie  aotef 
segment  of  the  capsule  conaect  the  tnechaaiams  which  regulate 
the  must  spLcialibed  ai:tions.  Spi^nkiug  broadly,  it  may  U-  Miitl 
that  the  fibVca  of  the  middle  third  of  the  posterior  twgment  of 
the  capsule  are  coucemed  in  regulating  the  actions  of  the  tntnk, 
lowt-r  L-xtreniitics,  and  probably  the  gcnt-ral  actions  of  the  npper 
exlremities  ;  that  the  fibres  of  the  anterior  Uurd  of  the  poatcnot 
acfcaent  are  concerned  in  regulating  the  more  spoctal  moro- 
ments  of  the  hand  aa  an  organ  of  prehension,  and  probably 
the  movements  of  rotation  of  the  head  and  neck,  dobg 
the  a-isooiated  ocular  roovementa ;  and  that  tho  fibrei  of 
knee  of  the  capsule  and  tbo  adjoining  purt  of  the  ant 
segmeut  of  the  capsule  are  concerned  in  tho  regiilatioo  of 
movemcnta  of  facial  expresttion,  articulation,  and  the  mo 
special  movements  of  the  band,  as  those  of  writing. 

Of  all  the  artoriea  of  the  brain  the  leuticulo-ilrinte  Jirtm 
is,  according  toCbarcot,  the  one  which  la  rooet  liable  tti  rupture 


THE  LOCALIRATtOS  OF  TAB  LESION. 


086 


lie«,  as  WQ  have  seen,  between  the  exlfiruftl  capsule 
aod  the  external  surface  of  the  lliin)  division  of  the  lenticular 
nucleuit.  WbcD  this  vessel  ruptures,  if  the  haemorrhage  bo 
small,  it  may  lodge  between  the  external  capsule  and  the  lenti- 
cuUr  nucleus,  and  give  rise  to  no  symptomii  (Cliarcot).  The 
vend,  howerer.  being  a  comparatively  lar^e  one,  the  haamor- 
rfaage.  as  a  nite,  exbemU  beyond  tliene  limitsi,  Tt  is  sometimea 
directed  upwards  between  tbe  exl^rnal  capsule  and  the  lenll- 
cnlar  nucleus,  and  may  then  cxtcud  fur  a  coDtdderable  distance 
into  the  ceotmm  ovale.  Under  thettc  circumstances  the  Sbrt-s 
of  the  ioberual  capsule  become  ruptured  at  their  point  of  emer- 
gence from  between  the  basal  gunj^lia  where  tlioy  form  the  foot 
of  the  corona  radiata.  Ufemorrh^eo  in  this  fiitiiaiion  may 
exteosive  u  to  extend  upwards  to  the  auumits  of  the 

Fia  S49. 


^CU- 


^v. 


'-> 


V 


c?. 


Tk>,  S12  (M™Hfl>?.l  fmm  Cliuroli.  Vmitnf  Stefion  t.j  thi  Brain  «  litt!4  htJii7i4  Uit 
K»rt  of  tA<  JttUrnal  Captutt.  *howinit  the  rSeclK  i>f  miaurf  of  ih«  l«iiti«ul»- 
MrlMo  wteiT.  yO.  llFitil,  Bud  .VC',  Trul  of  the  oiuj*t«  nucUtif;  Ch, 
OUmbw;  A'r.,  I.rfinlicTilBr  nil c lei] I ;  /K,  Intomftl  Cftpanto;  Cl»,  ('It-Wtrvm; 
1,  Tha  mmt  tr«>|ii«'iit  ij>m1U>'i1j  in  wliioli  t)w  Wnliculo-Rlrintn  arliry  U  ru^tuiwd ; 
r,  1*,  1**.  Ptuyi«i»i»*  Tjteiuiuu  ■>!  ttin  luuuiorrlittjc"  inqJucing  comiin— iob  md 
ruptur*  of  ibe  fibres  of  the  pyraRtidal  ttstel  (.hn  mi p login) ;  2,  PrimkTj  footMin 
lln  Imnal  e»Faul« ;  V,  f,  r,  SuoMaKvo  exMmmon  of  ili«  clot. 


«8t! 


FOCAL  DISEASES,  ACCOftDINO  TO 


aac«adiDg  froatA)  and  parietal  convolutioos,  wbile  the  cortm  of 
the  Isiaad  of  RcU  is  ooinpressu<l  b;  tlie  clot,  but  the  extefoal 
CApftiilo  is  rarely  ruptured.  At  other  timos  the  hfemorrbags 
U  directed  innards  llirougli  tlie  grey  matter  of  the  leoUeuUr 
nucleus;  and  if  it  b«  large,  it  must  impinge  apon  and  rip- 
ture  the  fiWos  of  the  tuternal  capsule,  and  when  tbeie  fibm 
give  way  the  limmorrbage  may  make  its  way  into  the  latenl 
ventricles,  tlien  through  the  foramen  of  Monroe  into  the  third. 
and  through  the  aqueduct  ofSylvius  into  the  fourth  ventricle. 
If  the  hjemorrhagR  remain  limited  to  the  space  between  the 
exteraal  capsule  and  lenticular  uiicleas,  it  pnxluces  no  symplotni 
during  Hfe;  but  when  it  makes  itn  way  into  the  eubsiance  of 
tbo  lenticular  nucleiiB,  or  into  the  centrum  ovale  above  the 
nucleus,  the  fibres  of  Uio  pyramidal  tract  are  compreesod,  aod 
hemiplegia  of  the  opposite  side  of  the  body  resulta.  If  the 
6bres  of  tbo  pyramidal  tract,  however,  remain  intact,  the 
patient  will  rccovor  more  or  less  completely  from  the  paraljna 
A  case  which  came  under  my  observation  several  years  ago  wai 
that  of  an  old  man  who  died  a  few  hours  after  being  knocked 
down  by  a  cab  when  crossing  a  street  The  left  leoticular 
nucleus  woa  completely  destroyed,  and  its  usual  pnaition  wu 
occupied  by  a  cyst  contRiniog  serous  fluid.  No  good  history  of 
the  case  was  procurable,  but  be  was  not  supposed  to  be  sufTerbg 
at  the  time  of  the  injury  from  any  form  of  paralysis.  A  (till 
more  striking  case  will  be  snbHefiuentlydescribed,  in  wbidi  both 
lenticular  nuclei  were  converted  into  cysts,  the  symptoms  daring 
lifti  being  thuae  of  bulbar  paralysis  without  any  evideoce  of 
paralysis  of  the  extremities.  When  the  hiemorrhnge  rc-iuua* 
limited  to  the  lenucular  nucleus,  not  only  does  the  patient  uUi- 
matoly  recover  the  full  uae  of  his  limbs,  but  the  ajtoplectic 
symptoms  duriug  the  attack  are  slight.  The  patient  oocaplaiaf 
of  giddiness,  there  may  b«  vomiting,  and  confusion  of  ideas, 
but  ho  doee  not  lose  eoosciousncsa,  or  tbo  los.^  i«  transitory 
When,  however,  some  or  all  of  the  fibres  of  the  internal  cap- 
bule  rupture,  the  larger  size  of  the  clot  praduees  a  mnrv  pn>- 
found  immediate  efiect,  while  injury  to  the  6bre8  of  the  pyn- 
raidal  tract  gives  rise  to  a  paralysis  which  rcmaiua  perinanitDL 
The  degree  and  extent  of  the  paralysin  will,  of  ootine,  depend 
upon  the  extent  of  the  injury  done  to  the  motor  tract.    It  t* 


THB  LOCALiaATlON  OF  TH£  LBSIOH. 


687 


probable  that  tliB  first  form  of  early  rigidity  occur*  dunog  bbe 
time  the  fibres  of  tlie  tract  are  Wag  stretcbed  or  ruptured  by 
tke  hipmorrhagc;  llie  second  form  of  curly  rigidity  is  again 
probably  caused  by  irritatioo  of  tbeae  fibres,  caused  by  ioflam- 
nuktury  cbaagcs  ia  tbe  tiasuea  Kurrouoding  tbe  clot;  while  late 
rigidity  is  caused  either  directly  or  indirectly  by  doscendiog 
degeneration  of  the  ruptured  fibrea  But  if  tbe  ba^morrbago 
toake  ibt  way  cither  between  tbe  asccndiiig  longitudioal  fibres 
of  tbe  corona  radiala,  ao  that  a  large  clot  fc^rms  io  tbe  centrum 
ovale,  or  if  it  rupture  into  the  lateral  ventricle,  profound  s^-nip- 
toms  of  coma  iuporveue,  aad  tbe  patient  dice  id  a  Rhort  time. 

We  have  seen  that  tbe  comparatively  unyielding  wall  formed 
by  tbo  external  capsule  directs  bteniorrhnge  from  the  tonticuto- 
stciate  artery  iuwarda,  and  oonsequently  the  full  force  of  th« 
blcK>d  will  impinge  ugainat  tbo  internal  capBule  at  a  point  a  little 
behind  ita  knee,  or  at  the  point  whoro  embryological  considera- 


Fid.  sia 


tta.  943.  Btritmtal  Stettoa  <^  thi  Batat  Gambia  anil  InUmat  CapMnlt  i»  an 
trntrya  a/  nuu  mamA*.  ~.VC.  CwdkU  DBOlciWi  TH,  (i^lK  thklmmiua;  iM, 
UamI  of  Kril ;  JI,  It  It  SteemA  maA  tlilrH  miriniKiLi  •>(  thr  Ipnticultr  ouelcriu ; 
fw,  T1iitr«  r  paduncuUr  Inot:  F.  yuutlanieuUil.  uul  f.  Miavd  portlnn,  uid 
f,  Qv/deaiat*  fMcdmliw  o(  the  prrMinirUI  tract;  i:,  Aatcriot  M>;iD«'nt  <£  ibe 


588 


roC&L   DISEASRS,   JlCCORDIHO  TO 


tions  bad  led  us  to  believe  tboM  libn»  to  pus,  which  c 
witb  each  otbcr  tb«  ucrvous  raecbanisms  in  tb«  coTt«x  aod  sptual 
cord  tbat  regulate  tbo  movonacnt)  of  the  buid.    In  bsnumbig* 
Trora  tbix  tkrHry,  therefore,  the  upper  extremitv  is  more  puml^s^^ 
than  cither  the  lower  extremity  or  face.  Rtipture  of  tho  aoten^H 
branchtta  of  the  artery  may  injure  the  anterior  segment  of  ihf 
capsule  to  a  greater  exleDt   Ihau  the  postt<rior  aegmeot,  aii4^ 
then  fncinl  paralvHia  predominateti.     The  fibres  which  O0DiltM^| 
those  impressions  from  the  cortex  which  cause  rotation  of  th*^ 
head  aud  eyes  to  the  oppomte  side  probably  abio  pan  in  the 
anterior  thinl  of  the  poAterior  segment  of  the  internal  capnil^ 
nod  oD  the  side  of  the  capsule  which  adjoint  the  IrnticuUi 
tiuclcuH,  and  they  alao  muot  be  ruptured  hy  a  moderatcly-Mznl 

Fio.  S44. 


Cm 


Fu.  »4<M<>dtfloa  fnraiCbveot).    Vtrtlett  SMbmyf  Urn  Bmbttmaln^mml 

Ptttfriar  Pari  of  t^  InltrmU  (\xpmile,  tliinriiiK  tfc«  vBvoto  ct  mMOfW  «l 
Imtlcivlo-optio  sit«ry(heiuUkieMl)aaBX— JVC,  /TC.  Tail  of  ItM  eMMMta  i 
XL,  I.^mticulM'  naclpoji:  TU,  Otitic  tlMlMatUi  da,  GlHntniiD:  1,  L 
fo0UJi  iu  tbe  ponUhor  port  of  lb*  «xWrakl  c»|i«n1«  <hpniM>Brtk*i«> ;  V,  I'.  1 
i*r(i(|tcMvB  cxtHniiiiTi  of  th«  priinary  foeueaudiiff  eenfmHlDOflr  i~ 
at  tbe  lotenutl  cat*u]«  ;   2,  Prmutj  loam  in  tke  InMaN  nimb 
thaua)  i  7!,  S",  S'  ',  iiac«f*R<r«  «xlaifiiM>  of  ll»  (<«ua. 


THE  LOCALISATION  OF  THE  LESION. 


589 


tuemorrbage  of  the  leoticulo-atriate  artery,  but  tbo  conjugate 
denatioQ  which  results  is  as  usual  oaly  a  transitory  symptom 
<§  90}.  Hjvmorrhogo  of  tb«  lenticulo-optic  sirtory  is  aIbo  directed 
inwards  against  tbe  fibres  of  tbe  internal  capsule  by  the  uo- 
yieldiDg  wiills  of  the  oxtornnl  capsiiJc,  and  its  greatest  force 
inipioges  agaiast  the  posterior  half  of  tbe  posterior  segment  of 
tbe  capsule.  It  is  evident,  ther«fure,  tbat  buemorrbngB  from 
ibis  vessel  will  tend  to  injure  the  sensory  peduncular  iiliros  and 
the  fibres  of  the  fundameutal  mechaDisin^  but  inasmucb  as  the 
muscles  of  tbe  trunk  are  bilaterally  a»sociat[>(I,  tbe  paraly^iH 
rasttltiDg  from  injury  of  tbe  latter  ii\yres  will  be  more  marked 
iu  tbe  leg  titan  in  any  other  pHrt  of  tbe  body.  An  analysis  of 
clinical  records  had  led  Dr.  HiiglirmgH-JackHuti  long  ago  to  con- 
clude tbat  the  form  of  bemiplegia  in  whicb  the  leg  in  more 
profoundly  aifected  tbau  tbv  arm  is  gcucrxlly  associated  witb 
bemiauai.'stbvAiiL  Titu  Hbres  uf  Gmtiulut  aro  not  usually  otfucted 
in  biemorrhoge  from  tbe  opto-etriate  artery,  and  consequently 
tbe  special  senses  are  nut  always  implicated  in  tbe  onieslhesia. 

Tbe  anterior  segment  of  tbe  internal  capsule  is  frequently 
mjured  by  lesions  of  tbe  bead  of  tbe  exudate  nucleus,  tbe 
rwulting  bcmiptcgin  of  tbe  opposite  side  being  tbus  more 
marked  in  tbe  face  tban  arm,  and  in  tbe  arm  than  leg,  while 
M«usibiltly  is  seUloin  affected. 

Cases  are  recorded  of  lesions  of  old  date  having  been  found 
at  tbe  auloptty  without  paralytic  symptoms  bavtng  been  preae nl 
duriog  life  (Nothnagel,  Snmt),  In  a  case  of  this  kind  recently 
described  by  Uonoggcr  there  were  no  df^cendlng  cbaiigvs  ob- 
•enred  in  the  cruHta,  medulla  oblongata,  or  spimil  cord,  although 
the  fibres  of  tlie  middle  third  of  the  poHterlor  segment  of  the 
internal  capiiiil);  in  the  left  lieinitipbtsrH  appear  to  have  been  iu 
great  part  destroyed. 

llje  iutemal  capsule  may  be  injured  by  lesions  of  the  optic 
thalamus.  Himnarrbogu  from  the  poistorior  iuteruul  optic  artery, 
if  small,  does  nob  appear  to  give  rise  to  any  deBnite  symptoms, 
and  certainly  not  to  permanent  paralysis.  A  large  baemoirbage 
from  the  vcosol  generally  makes  its  way  iutu  the  carity  of  the 
veutriole,  and  death  results  in  a  Hbort  time.  Lesions  in  the 
region  of  distribution  of  tbe  posterior  external  optic  artery  are 
bable  to  implicate  the  fibres  of  the  external  aud   posterior 


590 


FOCAL  DISEASES,  ACCOBDiyO  TO 


extremity  of  tUe  crusta  and  Llieir  contionatioai  thioi^  the 
iDlemal  cnpoiile.  The  path  of  least  reaUlaoce  to  the  pungv 
of  hibmorrbage  frum  the  vessel  appears  to  bo  upwanls  uii] 
inw&nls;  iLiid  as  tliv  internal  capsale  lies  below  and  to  the 
outsidu  of  the  thalamus,  lU  fibres  are  ncrer  injitre^l  to  the 
name  extent  bj  ha'morrbageB  from  this  vcvmcI  a»  tbey  are  m 
those  which  take  place  into  tbe  lenticular  nacleuB.  Hemi- 
plegia is,  ttiervfore,  not  a  protniDcot  feature  of  lesiooa  of  t]ie 
optic  thalamus,  aod  wheo  it  orcuts  it  ia  seldom  complete.  Tlic 
Sdosor;  peduncular  fibres,  and  the  optic  radiations  of  Qratiol* 
are  rery  liable  t«  be  injured  by  lesions  in  the  region  of 
tributioa  of  the  posterior  external  optic  artery,  and 
queutiy  complete  hemianicsthesia  with  implication  of  tti* ' 
special  scn8iO-s  'm  a  frequent  symptom.  When  tbe  lesion  oocun 
in  the  pulvinar,  ibe  external  gouiculalo  body  isapt  to  be  tmpH 
catad,  and  then  bilateral  hemianopsia  of  tbe  opposite 
results.  VHiea  the  lesion  is  situated  more  anteriorly  clan ' 
the  internal  capsule,  the  Bbres  of  tbe  pyramidal  tract  sufi«r  in* 
jury,  and  hemiplegia  results.  Tbe  hemiplcigia  is  usually  tuatf 
ciatcd  with  a  certain  degree  of  bemianKStbeaia,  and  after  ■ 
time  choreiform  niovemeats  are  apt  to  become  established  in 
the  paralysed  limbit.  In  six  casus  of  post-bemiplegic  cbom 
collected  by  liaymond.  in  which  a  post-mortem  examioatuia 
was  obtaiucU,  tbe  lesion  was  situated  in  every  instanoe  lo  the 
pofilerior  part  of  the  optic  thalamus,  and  involvctl  the  tibros  of 
the  internal  capsule;  aod  in  two  cases  of  pre-hemiplegic  chor^^ 
reported  by  hira,  tbo  lesion  was  situated  in  tbe  same  localism 
In  a  case  of  pre-bemiplegic  chorea  roport«d  since  then  bj 
Qrasset,  eeveral  lesions  were  found  in  different  regions  of  tbe 
benaisphcrcs,  but  one  of  these  occupied  tbe  external  margin  «i 
tbe  optic  thalamus  clo«o  to  tbo  iuternal  capsule. 

The  lesions  which  bare  been  found  to  give  rise  most  freq  iieot 
to  hcmicboren  arc  yellow  cicatrices,  the  reinojos  of  old  bipmc 
rbages,  or  softening  from  occlusion  of  tbe  posterior  exl 
optic  arterji-,  although  choreiform  movementa  have  occaaic 
been  observed  during  the  growth  of  tumours  in  ibis 
It  is  evident,  therefore,  that  tbe  symptoms  depend,  hoc  upon 
the  nature  of  tbe  lesion,  but  on  its  localisation.     The  aympConis 
do  Dot  appear  to  depend  upon  lesion  of  the  opti 


THK  LOCALISATION   OF  THB  LESION. 


S91 


itself,  inaamucb  as  they  are  udvor  present,  unless  some  of  the 
fibres  of  the  aen-sory^pedancular  and  pyramidal  tracts  are 
injured,  nor  does  it  even  appear  to  ha  ciiiised  by  injury  of  the 
sensor;  fibres,  since  heiniaciBi^chesia  witii  bilateral  hemianopsia 
may  be  present  witbotit  heitt^  asnociat^d  with  cboreirorii]  itiove- 
[Ddnt&  It  would  seem,  Uierefore,  that  injury  to  some  of  the 
fibres  which  lie  in  front  of  the  senHory  peduncular  tract  is  the 
cause  of  hemicliorea.  That  iwme  of  the  dhtas  of  the  pyramidal 
tract  are  always  injured  in  these  ernes  can  scarcely  be  doubted, 
ioBsmuch  as  the  clonic  are  always  aAsociutud  with  tonic  spasms, 
aod  exaggeration  of  the  tendon  reflexes,  the  latter  symptoms 
being  tboso  which  ore  atwaye  associated  with  disease  of  the 
pyraoiidikl  tract  Two  probable  vxptaiiBtioue  of  the  clonic 
qManu  present  in  these  cases  suggest  themsel?oi4  to  my  mind. 
The  first  is  that  Obres  coDcectiug  the  cerebnitn  with  the  cere- 
belluni  are  injured  by  these  losions,  so  that  the  normal  propor- 
tion between  the  outgoing  discharges  vrbich  regulate  the  tonic 
(cerebellar)  and  the  clonic  (cerebral)  actions  of  the  body  is  lost. 
The  Recond  is  that  tho  injured  fibres  all  belong  to  the  pyramidal 
tract,  and  that  those  which  sutftir  most  are  related  to  the  more 
fundamental  and  not  to  the  more  special  fiiuctioas,  as  in  disease 
of  the  lenticular  nucleus.  W*o  have  seen  that  the  more  funda- 
mental actions  are  regulated  from  the  convolutions  uear  the 
longitudinal  fissure,  white  the  more  special  movements  are 
r^ulated  from  the  convolutions  bordering  the  Sylvian  fissure  ; 
and  it  is  therefore  manifest  that  the  fibres  which  descend  in 
the  corona  radiata  from  the  former  will  pass  along  the  optic 
thalamus  side  of  the  internal  capsule,  while  those  which  descend 
irom  the  Utter  will  pass  on  Ibu  aide  of  the  capsule  next  the 
lenticular  nucleus.  The  eficcis  produced  by  dtistructtve  pro- 
oewM  in  any  structure  whatever  must  differ  greatly  according 
M  the  foundations  or  the  lau-«t-fonned  portions  are  the  fiist  to 
be  injured.  It  appears  to  me,  therefore,  that  partial  injury 
done  to  the  fundamental  motor  mechanism  while  the  accee- 
»ory  one  is  left  unaffected  would  be  very  likely  to  rausie  tho 
pbonomenu  of  hemichoroa.  In  such  aa  event  the  usual  toutc 
contractions  and  exaggerated  tendon  rcHexes  would  result  from 
injury  of  tho  pyramidal  tract,  while  the  apparatus  »f  the  more 
voluntary  and  special  actions,  although  still  uninjured,  would 


592 


FOCAL  DISBASBS,  ACCOBDINO   TO 


act  io  an  irregular  maoaer  owing  to  tU«  da[nag«  done  to  t)u 
tuodamenlal  apparatus. 

The  t&tiona  founit  in  cases  of  anilaler»i  atbetoeu^  al 
uot  always  Htrictly  liinittid  to  the  region  of  the  posterior  exle 
opUc  arUary,  bave  often  been  io  it«  viciaity.    In  three  cuet 
of  athetosis  observed  by  Charcot  tlie  lesion  wu  8ituat«d  to  tb* 
posterior  extremity  of  the  optic  tbalanius  in  one,  tho  poAtu 
part  of  tbe  caudate  nucleua  in  a  second,  and  the  most  puat< 
part  of  the  corona  radiata  in  a  third.     Tbe  lesions  of  all 
caa^s  were  »iluat4xl  lu  aucb  poutious  that  tbe  aame  syatam 
fibres  which  are  implicated  in  post-hemiplegic  chorea  woold 
be  likely  to  suffer  damage,  and  conaeqiieatlj  atbetosta  mint 
generolly  be  regarded  as  a  minor  degree  of   poat-bemiplcgk 
cliorea.    In  a  case  observed  by  Landouzy  an  old  focua  of  nAcD* 
ing  watt  found  in  the  portion  of  tbo  lenticular  niicleu*  whicb 
adjoins  tbe  internal  capsule      In  anolber.  observed  by  Gnauc^H 
tbeco-uxiatenceofsensory  diJtlurbuuceain  tbe  region  of  dtKlnbtf^^ 
lion  of  tbe  fifth  nerve  on  the  side  oppusito  to  tbo  apoMmaiiiic 
iiiovemeots  rendered  it  probable  that  the  lesioD  was  situated 
in  the  tn1«ral  half  of  tho  pons.     It  i»,  tbereforo,  probafala  tbal 
the  Idston  in  athetosis  may  occupy  dilf«rcnC  positions  in  tbt 
vicinity  of  tbe  pyratnidaL  tract     The  posiiiou  nccitpied  by  tin 
li-^ion  in  till  casea  rendered  it  probable  ihnl  tbo  tibrea  of  tlw 
pyramidal  tract   are   never   completely   ruptured,  and  cuoia- 
([uently  there  are  no  descending  cfa&ageit  iu  (he  curd  aud  an 
muscular  rigidity  during  life.     The  fibres  of  tho  tntcl  are,  huw^ 
ever,  likely  to  have  suffered  partial  injury  by  being  iuvolv«d 
a  cicatrix  or  other  men-bid  change,  and  tbe  impulses  which 
through  them  liecume  cooseq^ueutly  irregular. 

Dirtci  Cerebi-al  Paralysit. — Although  the  paralyni  of  ibt 
extremities  Ja  usually  situated  on  the  side  of  ibe  body  oppootU 
tbe  It^iou  iu  tbo  hraiu,  it  is  occastonully  situated  on  tfac  bum 
side,  aud  is  then  called  direct  paralysis.  The  moat  rcaantiable 
supposition  in  these  casee  ia  that  the  p3rnunidal  tracts  do 
not  decussuto  as  uaual  in  tbe  medulla  oblongata.  The  uiual 
method  of  crossing  is  that  from  ifl  to  97  p«r  cent  of  tbe  Stms 
oriMS  over  to  the  lateral  ooluiun  of  the  opposite  side  of  tho  co 
while  from  9  to  3  per  cent  pass  downvarda  in  tbo  colntnnt 
TUrcfa  of  tbe  same  side,     flechsig,  however,  has  ohoira 


TBI  LOCALISATION  OP  THE  LESIOy. 


£93 


e  proportion  of  fibres  which  decustsate  is  veiy  variable,  and 

c  has  even  found  tbat  it  occaMunally  fails  altogether.     It  ia, 

therefore,  probable  tbat  the  decuBHaTion  may  fail  in  cases  of 

direct  paralysis,  although  thin    htui  not  yut  huea  proved  by 

ilisaeclioo. 

The  leaioDs  observed  in  the  Bptuitlc  hemiplegia  of  childhood 
icarcely  belong  U>  the  category  at  present  under  coDsideratioe, 
inasmuch  as  Ihey  primarily  icYolve  the  cortux  of  the  brain, 
while  the  internal  capsule  is  only  secondarily  implicated.  In 
ioEuitile  hemiplegia  tbo  lesion  is  situated  in  the  convolutions 
of  tiie  motor  area  of  the  cortex.  The  primary  lesion,  consisting 
probably  of  a  local  encephalitis  sometimes  following  an  in- 
lory,  local  aofteoiag,  or  haemorrhage,  gives  rise  to  extensive 
Roondary  changes.  In  iwme  ca»c.t  a  large  loes  of  substaace  has 
been  vbaervod,  causing  various  deformities  of  tlio  skull  when  it 
Kcors  in  early  life,  or  leading  to  hydrocephalus  in  order  to  fill 
Dp  the  vacsntspace.  At  other  timM  a  puckered  cicatrix  may  be 
(ouod  at  the  seat  i^  the  primary  lesion,  while  the  hemisphere 
haa  undergone  a  diffused  consecutive  atrophy.  The  fibres  of 
the  pyramidal  tract  in  connection  with  the  diaeaaed  focus 
Undergo  descending  degeneration,  and  to  it  the  spastic  con- 
dition of  the  paralyiKt]  extremities  in  either  directly  or  in- 
directly due,  Bilateral  athetosis  appears  also  to  be  due  to 
partial  atrophy  of  the  motor  area  of  the  cortex,  l>oth  bemi- 
•pheres  l>eing  probably  inplicated.  The  considerations  which 
favour  this  opinion  arc  tbat  the  affection  is  either  coageuilal  or 
becomes  establielied  in  early  infancy,  that  it  It  associated  with 
•ome  degree  of  imbecility  or  idiocy,  and  that  there  are  no  sen* 
sory  dtaturbauces. 


HH 


S9« 


CHAPTER   VII. 


(II.)  SPECIAL  OONSIDEEIATIOK  OF  FOCAL  DISEASE^ 
ACCORDING  TO  THE  LOOALISATrON  OF  THE  LE8I0K 
(CosrmciD). 


S.  COBTICAL  LESIONS. 

a.  leaiona  in  the  Area  of  the  ittdiiU  Cerebral  Artery. 

(L)  McMtoarABici  uto  Ununau.  CovTiiuiom. 

§  714.  IftoiTATivB  leaioDS  of  tbe  cortex  are  cluncicriaed  b; 
uoitnteml  coavulsiona  or  moDoepaBiDS.  Lwioiu  of  wiou  kwb 
may  cause  irritatioo  of  tbe  cortex,  tbe  mo»t  common  of  thee 
being  localised  meuiogo-enoeplialitifl,  tuWrclo,  s^philtuc  fftm- 
mata  and  othor  tumours,  cicatricM  of  wounds  and  spicuU  of 
bone,  and  of  tiiesa  tbe  sypb'iUtic  are  b;  far  the  moit  frequmt 
lenons.  The  UwiuM  id  the  immediate  Dcighbuurbood  tk  tlw 
main  focus  of  dissaae  are  mAintaiued  in  a  state  of  irritntioo.  and 
are  coasequeoUj  supplied  by  an  usually  large  quaotity  of  Uooi 
Tfaoganglionceltnof  tbegrey  sulMtanoeabscMrb  an  undue  supfily 
of  nutriment,  so  that  they  discharge  tbemselves  in  a  sudden  ami 
exploaivu  mauusr  (Hughtin^-JackMu).  But  ve  have  aliMiiy 
iteea  that  exploatre  dlecharges  of  nervous  eue^y  aro  followed  hj 
e&baustiou  aud  consequent  paraJyids  of  the  muftcloa  imi^icatcd 
>n  the  connilsion,  and  accordingly  unilateral  oonvalaioDS  an 
often  followed  by  temporary  paralysis  of  tbe  convulacd  bnhi 
It  must  be  remembered  that  an  irritative  lesion  Is  frequeaUr 
a«Jtociated  with  a  destroyhig  one.  A  syphilitic  guoitaa,  fv 
instance,  destroys  the  portion  of  the  cortex  in  which  it  if 
situated,  while  it  maintains  tbe  surrounding  tissues  in  a  state  o' 
irritation.  It  is  not,  therefore,  unusual  to  find  a  certain  dugn* 
of  permaueDt  paralysis  associated  with  unilateral  oouvnlsioBa 


FOCAL  DISBASEa 


505 


Umtat«rm]  convulsions  vera  first  distioguisbsd  cliDically  and 
their  varieties  accurately  described  by  Bravais,  although  he  did 
not  reoogniie  their  pathological  oignilicance.  Similar  ohservo- 
ttoos  were  made  by  Bright  aud  Wilke,  who  Hurmised  thai 
tbeM  convuUioiifl  were  duo  to  local  diBeose.  The  pathology 
irf  theae  spasmodic  affections  was  firet  clearly  recognised  by 
HaghliDgs-JocksoQ,  and  it  was  in  explanation  of  theae  convuU 
nocu  that  he  finit  suggested  the  idea  of  the  existence  of  motor 
KBtres  in  the  cortex,  an  idea  which  has  been  8o  fruitful  to 
Jiafcliology. 

In  BOine  caaea  the  spasm  is  limited  to  one  limb  or  to  th« 
aide  of  the  head  (monospasm);  in  other  caacs  it  be^os  lo  one 
limb  fprotospana),  and  extends  to  the  other  or  lo  the  head,  to 
the  half  of  the  body,  or  the  couvulsions  may  become  bilateral 
Mtd  generalised.  Another  characteristic  of  theso  codvuIsiodb  is 
that  they  are  either  not  atteuilcd  by  loss  of  consciousoesa  or 
the  coQvuIsiou  begins  before  the  patient  becomes  uncoosciouB, 
so  tbat  be  is  afterwards  able  to  describe  a  motor  aura. 

g  7*5.  VarUtles.—The  following  are  the  clinical  varieties 
of  unilateral  convulsiocui : — 

(n^  Ownil  MonotjKum  or  proUapatm,  iii  which  the  spasms  are  either 
limited  to  the  19;,  or  b«gia  in  it,  the  Ana  being  next  attacked  «ud  the  f&CA 
ImC 

(t)  SnuAiat  mo>wtpatm  or  prototpam,  in  wtuoh  th«  spasm«  an  either 
United  to  the  arm,  or  begin  ia  the  arm,  the  face  being  next  implicated  nnd 
tbeleglwt. 

(e)  FiMcial  monotpatn  or  prototpaKn,  in  which  the  itpaMmH  ure  either 
liaitw)  to  the  sid*  of  the  fiwe  or  begin  iu  the  faoe,  ihi  um  being  uext 
Implicated  umI  the  leg  Ivrt 

(a)  Cnirai  Jfom^iprum  or  Pivlotpa«ni.—T}nm  are  not  maajr  Qnoo[«- 
plicatad  comm  on  reoonl  in  which  the  MpMm«  were  limited  to  the' leg,  or 
iDTanaUy  begiVR  in  the  left  aad  in  whJoh  a  pojrt<miMtem  eiitmin&tioa  wae 
obtUDod.  Fcrricr  quotea  a  oaac  recorded  hy  Broo  of  crural  moDospasm 
oaueed  by  injury  to  the  left  side  of  the  nlcull,  which  wm  cured  hj 
trr[ihitiiDg,  but  the  exact  {HxritiGQ  on  the  brain  is  uot  mouUDoed. 
Chareot  aad  Pitras  qoote  a  case  from  Orieeinger  of  fraqnentl^  recurnug 
i^aam  of  the  leg  and  arm.  Kumnoua  cf  aticcrci  were  found  in  the  brain, 
the  laf^BHt  of  which  occupied  the  au|>«rior  part  of  the  asuending  parietal 
ooaro>1utjo<i  of  the  op[M)nite  aitle.  Sevaral  amall  qyats  were  found  on  the 
frontal  anil  parietal  surlaoe  of  the  aame  hemisphere.  HughllDge-Jactnon 
raportA  a  cave  iii  whid  the  fits  were  ofteu  liuiitvd  to  the  leg,  and  alwaja 
bsgao  then.    The  leg  beoame  gradually  weaker  after  oach  attadc,  ati4 


596 


FOCAL  PI3IUSES,  ICCOit&lKO  TO 


&nal\y  lecamf  poroinneiilly  ponlraod.  A  tumosr  «rw  found  «t  ttw  nffv 
uii)  [(osUirlor  port  or  ttiit  tuft  fh>ntal  lolw,  about  t<n>  iiiohe«  in  diuneUr,  ci> 
t«odiuj{  Iroin  tbo  po«t«rittr  ostremittM  of  tbe  finit  wid  iwcoiid  £rontal  o» 
vclutiona  b&cVvnnl«  to  th«  (i«Hire  of  Rolaiido.  Id  airottMr  omo  neatU 
by  the  Muo  author,  tbe  goorulainui  bogaa  in  titv  lo(V  gnat  lof,  hkI  «in 
aft«ii  liiuiUiI  to  tliii  left  le^.  A  Hy^ihiUtio  Imioti  inu  fouod  aX  tlw  Vffm 
ptri  of  th«  AMendlDg  pari«tikloi>UT«Iuti>>a4nil  t)v«r««T«nilof  tbe  •<)JM«a 
couvolutiooa  of  the  parietal  lobule.  BouraeviU*  dcMribea  k  cua  of  U* 
hemlplegin  of  inrnucy,  iu  which  tbe  oourulwooa  begu  by  treown  ui 
MviUihing  ID  the  loTt  or  ponlyaed  leg.    Tba  cortex  of  tba  ri^t  bnmuphw 


x; 


mu  found  litropbied  in  front  of  tba  fiiMare  of  RoUndo  in  th*  MtiMCicr 
half  of  the  asceiidins  fh>ntal,  the  pooterior  extremltjes  of  tbe  flnt  mi 
•MODd  liraata)  {Fij.  i-lSj,  and  the  whole  esteat  of  the  pmMbtral  lotafe 
(b)  Brachiai  JTiniMpiuin  or  Protoapatm. — Sevanl  men  w*  nooidrili 
which  the  »pum  is  either  limLU>d  to  or  begiue  in  tixi  Rrm.  IiuCwaMi 
of  Ibia  kind  have  been  recurdoii  by  l>r  Hn^ngii  JookNti.  In  Lbeoa 
of  one  nuta  who  mffered  from  repeated  oonvuleiooK  limit*d  to  the  rigU 
arm  with  eubeequent  [wralyida,  »  nodule  wm  fuaod  aituated  at  lU 
jKuUirior  extremity  of  tbe  first  frontal  oouvotution  of  the  left  bembphim 
la  another  cam,  iu  wbtoh  the  spoaios  were  almoat  auuilBr  to  Ihoas  iiliiiil 
in  the  last  oiae,  a  nodule  wm  found  aftuatod  at  the  porterior  utmnity  «l 
the  brat  Eroalal  ooDvolution  where  it  joioit  the  aaoeoding  froutat  IV 
•poeo  Iu  this  ease  began  ta  the  shoulder  aud  went  dawn  tbe  ana,  cow 
tfity,  Dr.  J^mIcoou  tbinka,  to  the  nanai  order.  In  a  third  caao  tbe  n— n 
invariably  bagau  io  tbe  left  thumb,  ntxd  a  tumour  of  tbe  stxe  of  a  baanlmal 
WM  fouDd  under  the  grey  matter  at  tlie  |»9teriur  cxtmaity  of  the  IhM 
frontal  ociiiviiluti<iii  of  tbo  right  hemLR|>hci«.  In  a  fourth  caM  Iba  ifaw* 
began  in  tbe  right  arm,  and  oooaatoaallj  lit  the  right  aide  of  tbe  taM,  mi 
the  |)ati«DtbadMuifered  friim  a  tmniitnry  iflai  V  nf  Irft  Tiaoiii^^ia  Intk* 
left  hemtapbere  adheeion  waa  (bond  betwaon  tbe  dun  inater  aoJ  the  hiata. 
orer  "  the  lower  part  of  tbe  ancending  frontal  and  OKendlog  (Mrietal  ooa- 
mlutlooa,  to  a  trifling  extent  to  the  Under  put  of  tlw  third  frontal  Uti 


TUB  i/x:aus4tios  of  the  lesion. 


597 


:  of  the  conndntionH  of  the  upper  wall  of  the  fissure  of  SyhniiH 
liad  tbt  uceaHiiig  p>n«Ul."  In  tbe  riKtil  hemisphem,  the  slit  oppoeite 
I  puniym,  a  Dun  was  toand  behind  tbe  figure  <>r  RoUndn,  lint  han 

b«MiDf  upon  our  ps«*eut  Bubjout.  In  a  fiflb  civra  tonipiorsry  right 
iup]egia aupervflDttJ  «ft«r n  imilntornl  eua  vuinion,  CoiivuIstobs  rocurred 
HMLtMlly,  Wgiuning  in  the  littlo  Giigor  nf  tho  right  hand,  occasionally 
tbe  right  sid«  of  th?  face,  and  alwavs  folloned  hy  slow  and  hesitating 
leob.  A  avphilitic  tumour  of  couBiderablu  aixa  wiu  fouud  iu  the  ci>rt«x 
■at  tbejuoctioQ  of  tbe  frontal  and  parietal  lobea,  surrounded  hy  no  aren 
•ofUning  ia  the  poaltrivr  tjitrutuitida  of  tbu  (routal,  ascoudiu);  frontal 
1  uoandiog  [wrietal  oouvolutiona,  and  jtartly  of  the  Island  of  Reil.  A 
B  of  partial  •.■]>tl«)Hiv  U  imported  l>,v  Bidlct  mid  LidetHtut:  tn  u-hivh  th« 
WHS  bagHD  iu  tbe  rifbt  liand.  ParoHin  nf  tb<;  riglit  una  niijiervirimt,  the 
hi  aide  of  tlw  fiuo  and  toiiguo  bciug  also  implioalvd  to  a  sligbt  dogrov 
the  caM  (QOgTMaed.  Some  d«grw  of  embarrannunit  of  speech  was  ahm 
MOt  b«fon  <IiMth.  At  ihf  autopay  throe  umaJl  hydatid  cy»t«  wan 
od  in  tbe  oorlex  of  tbe  left  hemuphere,  one  beiuff  aituated  about  the 
Idle  of  tbe  uccoding  firontal  oonrolutiuii,  the  seooud  at  the  juActiou  of 

middle  aud  lower  thinbi  of  ttie  aitceiidiiig  imietal  oonvolution,  and  tbe 
rd  at  tbe  poat*rior  vxtn-mity  of  tbe  »<MKiiid  frootol  oouvolutiou. 
A  case  of  brachial  prototpaam,  caused  by  ayphititic  diiWMe,  faA<i  been 
aided  by  Dr.  DrMchfold,  in  wbicb  I  oondactwl  tbe  poet-uortem  examt- 
loEi,  confirming  the  diaguoaia  made  by  Dr.  Dresebfsid  daring  life.  The 
Ida  began  "  by  sudden  cleucbing  of  the  fiat,  f!«xiu(;  of  the  wrist,  ftod 

Pio.  246. 


MtioD  of  tbe  foreami  of  tbe  left  aide,  the  corresponding  angle  of  the 
)tb  being  at  Ibo  aenM  time  drawn  down  vardo.  This  sudden  Ionic  spasm 
•d  tbreersnl  aeconds,  and  was  then  followed  by  a  few  clonic  Hpaama  of 
•ante  extremity  stidaxlight  treinorof  the  arm,  the  patient  being  at  the 
)•  tiineaigitated  and  pale,  Imt  perfectly  ovnsoiouD."  Tbednra  tuaterwoa 
)d  edberent  to  tbe  brain  on  the  right  aide  over  the  greater  part  of  tbe 
■oding  parietal  eonvolution  and  tbe  Mipra-marginal  lobule  </^'^.  346). 


S98 


POCAL  DISEASES,  ACCORDtNO  TO 


Tbo  cu«  of  a  buy,  threa  montlis  old,  la  raport«J  bj  Mr.  CulUnfwartli,  lAa 
dowioped  eenbnil  sjrmptoiDB  BotaairfaAt  suddonl;  nearly  four  mantMaafc- 
■oquantl;  to  aa  iiuury  to  his  hc«l.  Tho  Hyiaplonw  bogaa  bj  wrrMmlat 
and  dtsvatinn  of  torapunturv.  A  r««  houn  Ut«r  It  vm  oh—  vmJ  tlui  tk» 
left  arm  and  Land  won  flexed  ood  rigid,  and  Ibis  wan  aooa  toOMnl  \f 
liODJu^te  deviation  at  Iho  «;« to  tbo  right  Tba  dant  mater  waa  feol 
t,liii:k«ii«d  and  adberoDt  to  tba  boDo  ovbt  a  miaQ  ana  of  tb«  rigltt  baai- 
s^here  immediatfllj  to  the  right  of  tba  loDgttiidinal  flanira.  Tba  brIk 
undcrlyitix  the  edhediuiis  was  roddeDod  aud  aoftoooJ,  ilia  aancoad  part 
involving  the  upp«r  poriioa  of  the  aaoendiug  broatal  oaavolutioa.  A  la^ 
of  piui  woo  found  orer  the  vhota  aurfaoe  of  both  bemiapbana  and  tht 
groatar  porUou  o{  the  oarebeUain. 

Cbaroot  aad  Ltfpiao  daaoriba  a  oaao  of  partial  epikfjay  begiDtiiof  la  tfat 
left  arm  in  which  aftOT  doath  a  hnmorrhagio  focoa  waa  foaud  situalad  is 
tb«  poatorior  part  of  tb«  firat  rlghb  ftvatal  oouvotutioo.  lit  a&otliar  caai 
of  partial  eptlapsj  be^^DDing  in  the  left  arm,  dowribed  by  the  ■»• 
authon,  au  old  focua  of  aufUoing  waa  foiiod  batwaeo  tbe  fint  and  atotai 
frontal  coavolationa  of  the  right  hamiaphen  wbera  tbajr  adjoia  Ibt 
asoeadiug  Qrontal  oonvolutton ;  while  in  another  cum  described  bf  Iksa, 
the  GonTDbdoua  began  In  the  right  arm,  and  a  «n*ll  fucua  of  diaaaaa  wai 
found  in  tho  supcriipr  port  of  the  Moondiug  parietal  ooav>olitlioQ  of  tbe  liA 
beDiiitpliere.  A  caa«  i«  deaoribad  by  Qliclcy,  in  which  tbe  oonTobdMa 
began  in  the  loft  arm,  bob  aaWqnently  i  oTohrwl  tlie  left  half  of  tbe  body : 
a  glioma  waa  found  whiob  had  daativ>y»d  the  two  asoeiiding  Deatrml  onoto- 

lutintiaaad  tbe  paracentral  lobule  on  IboH^ht  wdo.     Slahot  report*  a  eaat 

of  partial  con  vulaioua  beginning  in  the  Aiigen  of  the  left  hand,  in  whld^^f 
taberovloiis  mass  wm  i>b««rr«d  imbodded  in  th«  aabataooe  of  the  rfPi 
aeoeudiug  frontal  ooiiroltition  in  itM  middle  thlnL  Berger  reiiorta  the  am 
of  a  woman  who  auffofed  from  conTuLniooa  of  tiie  right  arm  villi  aohe^ 
quent  woaknoaa  of  the  aame,  tho  conruIidoDa  after  a  tine  bmana  genatal 
and  tbo  right  arm  waa  oomplotely  paraljaed,  while  there  woa  weakaaH  at 
tho  miuclea  of  tho  leg  and  fiaoe.  A  aarooma  gmwiog  from  the  dun 
mater  had  penatrutad  into  the  cortex  of  tbe  bnin  ovar  tba  left  aauaadiag 
frontal  oonralutioD,  opponitc  tho  posterior  extremity  of  tbe  seoond  Aenlal 
convolution.  Burraai  describes  a  case  of  partial  epilepsy  of  the  left  an 
fullawed  by  iiarvsis,  and  at  butt  by  comiilete  paralyabj  a  tuborcalma  maa 
van  fonnd  in  the  fiaanre  of  ILolondo. 

(c)  Facial  Monotpatm  or  /'rolo^pam.— Tbe  oaee  of  a  Freodi  aoUkrii 
described  by  Hitng,  who,  two  months  after  a  bullet  wound  on  tbe  ifgjA 
atde  of  the  head,  auflered  from  olonio  apauna  followed  by  paralyas  of  thi 
left  nde  of  the  Eace  and  toogoe.  An  absoaaa  wt*  found  in  tbe  oortas  d 
tbe  righb  hemisphere  situated  in  the  Uiferior  part  of  tbe  aaomiUDg  boM 
on  a  level  with  the  third  froutal  oonvolution. 

Weniher  reportti  a  cane  iu  which  there  were  coavulsiaoa  of  lb*  Bwalfl 
of  tbe  fMe,  naolc,  roreorm,  and  of  the  sxtensore  and  6axocm  of  tba  ftngn^ 
all  OQ  tbe  right  aide.    The  leaoa  wm  aitealed  in  tbe  oortes  of  the  liA 


TBB  LQCAJASkTlQH  QF  TllE  LESION. 


599 


beiiiiapbtra  in  tho  ioforiar  psrt  of  ths  anoGodmg  frontal  ooarolutioii  naar 
Uw  flmm  of  Sjtvtufl. 

Tbo  OM  of  a  W41IMU1  m  doacribed  by  Dr.  BtwDwell,  who,  «fi«r  «  cnmial 
injur]'  received  9oo»  yeua  [nevioiul;,  bogiui  to  luiv«  rigbt-sidod  caiivut- 
aoDa.  Tii0  couTulsioiu  alvrajs  begsa  id  tii«  right  pUtjumii,  ildiI  won 
Bflap  almoat  autiNljr  ooufinud  to  ihii  muw]*.  A  H^iiculuiu  of  boLo  wax 
i  projootiu);  from  tbo  iuccr  table  of  tbe  ekull,  and  causing  a  liiaited 
I  of  tbc  iufshor  inuigin  of  the  ascandiag  pariotal  ouuToliition  {F^. 
1}- 

Tra.  347. 


Ki 


S<«li)[iau]ler  ileacribM  a  outf  of  epil«ptifonu  eoDTqlMons  of  tiu  right 
half  of  the  fuce.  foUowDii  after  a  time  hy  facial  iianlyttiN.  At  a  scioe- 
whatUtvr  peri  Oil  tha  right  anubecacae  ooovulned,  uij  aTttirwanU  pandjood. 
A  Mrooraatotia  tutiiLPur  was  foODd  ia  the  anuutlicig  iiKrietal  couTglutioUi 
which  prababl;  began  to  grow  at  ita  lower  oxtrftmity  and  progneaod 
ii|iwanb. 

ThoH  mm  toad  to  abow  that  oonvulBioim,  oithor  limitod  to  or  begin- 
niog  ill  Che  face,  ar»  oaiweil  by  a  lefiioD  situatod  io  the  inferior  part  of  the 
MoeadiBg  frontal  and  parietal  oonrolutioua,  the  portion  wliiuh  adljoiutt  tlio 
Gamm  of  Sjlvioa 


(iL)  CoanoAL  PAULTiin  xvu  Mnstopuui^ 

§  746.  It  18  DOW  well  establisbcd  that  destructire  tcsiona  of 
tbc  oortvjt  of  ttiu  liraia  caunc  pcrmanunt  paralyaos.  Defltrojing 
leaioos  of  the  motor  area  of  tbe  cortex  may  be  diTided  into  (1) 
General  UsUma,  extcnJing  over  tUo  greater  part  of  tlie  ajea ; 
add  (t)  Partud  or  localised  Unions,  Uraited  to  email  portions 
of  ii(Femer). 

(t)  Qeneral  orExlensim  Lesions  ( Hemiple^oi). — Kxteasire 


602 


FOCAL  DIS&ISBS,  ACCOBDUIQ  TO 


of  tlitt  iwuceiktral  lubtite,  Kiipttriorlf  aai)  txittntilj  by  tfa*  grey  i 
uf  ths  oMMudiag  frraUl  atul  parietal  ooDwluUoofl ;  iii  front  it  •riaaJri 
to  tha  pne^sentral  flsnira,  aud  behind  to  tba  {toBtsiur  border  of  tbe  aiotiiid- 
iuK  jMirietal  cuuvolutiou ;  vthUa  it  wks  ae|)ttrat«<l  iafenorljr  from  ttte  coqwa 
sCrJKtum  by  a  Uy«r  nf  wliiUi  subituic*  Ice.  in  thiekiM«a. 

Dr.  HuigroH  Atkios  Ifks  rscordnd  ft  com  of  right  bonuplagis  due  to 
eiulxiliitin,  iit  wliich,  iu  adtlittou  to  ■  patoh  of  aofl«iiiiig  at  tbo  Inmr 
oxti^mity  of  tlio  UKWudtog  puivtal  warolutioa  {Fig.  251),  then  «»  » 

Fro.  *>l. 


/ 


Uiaan  of  Koftoning  two  inehM  ia  4lUnMt«r  in  the  oaatruin  oraU,  BXtwd 
Troui  tt  ^Kiiat  2|  iucIiM  bcliind  the  Apoi  uf  the  loft  froutul  lube  to  >  potoft 
3|'  Itiche*  outward  to  tba  opu  of  the  occipital  loba.  Th«  baul  g^^ 
were  noraiaL 


(2)  Partial  or  Loocdiaed  Leauma  of  tht  Molor  Arta  of  thi 
Cortar — Mono^egia. 

{a)  Oural  Ma»opt«gia.—Xha  neordod  cu«a  of  diaosM  of  Uu  oofta  in 

which  tho  pondynEa  waa  liuiit«il  to  the  leg  are  uot  namflroua.  A  tuifidnt 
iiuiulmr  are  reported  to  reod^r  the  existoooe  of  a  ocrtioal  eentra  for  iki 
regulation  uf  the  laOTomMtta  uf  tho  lover  extremity  moro  thao  profaabki 
even  fruiii  i-Iiulcal  aviduuiM  alone  ami  in  thaabuooe  of  the  mntwetahnnili 
(trouf  nlT'Tdud  b/  ciimrimeitt  on  aiiiuuK 

Liillliir  <l<u«chbwi  tho  cow  uf  a  Daulah  corporal,  vbo  «a«  iitmdc  hj 
a  buUot  at  tbo  saporior  aad  posterior  utrsmity  of  the  left  parietal  boae, 
atom  to  tho  sagittal  aature.  The  ri^ht  lag  ma  tminediately  poralyaed,  tai 
(h«  right  arm  oa  the  eereuth  day  after  tbe  M«idoaL  On  tr^phiaim, 
reooTary  took  pUoe.  the  arm  bfliii;;  first  mtored  aDd  tbao  tlie  leg.  la 
utotber  MM  reported  by  the  aame  author,  firactore  of  tho  summit  of  lk« 
right  parietal  bon«  waa  follomd  by  paralyaia  of  tb«  left  leg. 

Tbe  oaae  of  a  woman,  af;ed  Tft  yean,  ie  reportad  by  Oiidia,  in  wbidi 
tliera  wu  iMnlyaifl  with  oootractitraa  and  aneii  of  dBTetopamil  i 


TUB  LOCALISATION!  OP  TUil  LBSlUN. 


t}03 


right  lower  •xinmitiea,  (latiiig  ftomthv  ag«of  Diaosnd  a  balfyoara,  itud 
Mlowing  a  bU.  At  the  autopsy  the  luedian  part&  of  the  superioi  Burf^« 
of  Um  hemiapbenM  irorv  TuuNd  to  (>reMat  a  nuoarkabls  a^vutaotr^.  Th» 
poAetrior  extremity  of  the  Ant  froatal  aud  auporlor  extrcoiitr  of  thu 
MMndiag  frontal  coavoluliou  were  reowTkably  ati\>pbi<>d  on  thu  l«ft 
httuiapben,  whiU  thfl  cornwiiuudipj  puts  of  th«  right  hamiitijlieni  worti 
uomul  and  of  comparativoty  largo  aim.  Th«  miporior  iwrtioaa  of  thu 
uottmliii;;  pariotal  cmi volutions  van  atrophied  aa  both  siden,  although 
the  atrophy  in  the  loft  hemwphere  wiw  more  prouotmood  th»ii  iu  tlm 
right.  The  anterior  oitrocuity  of  the  nuperior  parietal  lohulo  was  alu) 
iDVoIrad  in  th«  atrophy  ou  tho  loft  aido  {f^'j.  Sbi). 

Fio.  35?. 


>F 


/. 


Dr.  Haddoo,  of  Maticheator,  rooordu  a  cam  in  which  paralyai«  remaiued 
biuited  to  th»  left  loi;  fur  &vo  months,  but  after  a  timo  the  left  arm  also 
becaiDV  pamtysed.  After  death  a  tumour  three  inohea  in  diaiuet^r  waa 
IVMiiid  coonoctod  with  the  dura  mater,  altiiato)  to  the  right  of  the  luitklle 
)lcM^  CotapreaaiDg  the  siibjaoeat  httirtisphero,  and  dnttmying  the  upper  cx- 
tnmitias  of  the  aooeading  frDDtuI  and  parietal  coiivo1utiou»,  an  xieM  as 
the  paat«ro>pati«ta1  and  paracentral  lobule*  {Fi^  Sfiil  and  S&4).  Tho  caite 
of  a  maoi  bL  40  years,  is  reported  by  Dr.  Fcrrior.  in  which  thu  nytuptoiiiH 
of  gauend  tubeKuloala  war*  eomplicnted  by  motiopUigia  of  thv  kft  lower 
axircraity.  The  panlyaia  was  itrictly  limitod  for  four  dayn  to  thu  loft  log, 
but  eabaeqiuatly  ext«Dded  to  the  left  ortu.  The  patient  died  a  month 
■ubtunantly  to  the  appearaooa  of  the  paralytic  aymptoms,  aod  at  the 


9m 


FOCAL  DISEASES,  ACCORDtNO  TO 


left  ettremitioii  in  which  a  fociw  of  sofUning  wm  tvaoA,  oat  in  tba  i 
tmt  in  the  coiitrum  ovalo,  ituinod>at«ly  beoaath  ths  pastvrior  ezfendai^ 
of  the  ftnt  fVoutft]  convotutioo  (/"i^.  ibt,  h),  md  wctatiding 
aiid«rtiMtli  the  auiierior  iiu-tetal  lol>ule. 

{6}  Braehial  MontfpUgtA. — A  cue  of  pftnljnia  of  the  left  «na  ta 
wrilMd  by  Piurrut  iu  whkb  s  oeatre  of  aafteniug  wm  rouuil  iu  the  i 
of  the  right  heiniii(tlivru  at  the  pniiit  where  the  aeoond  fruate]  Joins  lW 

FMkSST. 


/J 


aeoending  froiitAl  canvotiition  (/Tjr- 2d7J.  Boycr  rocords  b  can  id  ' 
ata  and  leg  beouno  middetily  {Mndyiwd,  tha  parelysui  of  the  arm  i 
roautiiiog  permaneut.  Doellt  took  phce  Qve  years  aubseqaeutlj  to  titie 
attack,  and  a  patch  of  atroph;  vaa  fouiid  on  the  right  beniiaphen  io  thi 
aaeendEng  froutal  and  parietal  GODTtdutioaa,  with  an  ext«Dmoa  cl  iha 
]eaiOD  to  the  tempont-spbeDoidal  lobe. 

A  oaae  of  iiaralynitt  of  the  right  bant)  and  arm  ie  nport«U  bj  Riagraar 
AtlciiiJt  Ht)iH>rveDiu];  a  few  days  before  death  io  a  patient  mfCMiig  ftnnt 
gvuttrul  i>anil}PBii9.  The  wirtex  waa  aofUned  la  the  middle  «f  the  aaondini 
frautal  and  parietal  BouTolationR,  the  laaton  alao  exteiidiug  baolnraida 
abng  the  anterior  edge  of  the  eapra-margioal  gjrnia  •■  abowo  ia  Fig.  U& 

Vjo,  2J8. 


V 


TEB  LOCALISATION  OF  THB  LBSIOK, 


607 


Deokbne  faM  collected  n  liu*ge  niimlier  of  camm  of  briicbl£l  monoplegis, 
bat  it  vDold  oocup;  too  much  spDoo  to  quote  loon  easM  ftt  ptemot. 

It  maj  b«  obaorved  in  pasaing  that  the  ceutral  convolutioiu  of  tbo  oppo- 
■it*  houiapbon  bare  boou  rauiid  atrophied  in  cams  of  )ong-«t«iding 
ampatatioti  (dmc^uet,  Boyer).  The  results  obtRined  have  not,  hawDWcr, 
been  Jtny  dc^ito.  Dr.  (lOirera  found  iit  a  cane  of  congenital  abamce  of 
tha  left  band  the  middle  partof  theaac«ndliig  [jnrietal  coDTolutions  in  th« 
ri^it  faemi»)ihere  diatiiictlj  amaller  thaii  tha  vomwpoudtQg  convolutione 
in  the  left,  and  a  itoniAwhat  similar  cneii  ha*  l>«»o  newdod  hy  Biuitiaa. 

(</J  Brachio-fadal  Mvnopltjia. — Paralfoin  of  tbc  face  and  arm  are  aot 
aneommooly  nMoclnted.  Whvii  the  Ivft  ImmiHphuro  in  thit  mat  of  the 
lanoD,  thoM  caaw  are  uauollir  anAociatc]  with  opbtun^  Diculafoj  record* 
a  oaaa  of  paraljmiH  of  th«  fiic«  and  arm  in  which  the  autoiw^  nTcaled  a 
btentocrbagtc  focus,  tbo  eiM  of  a  out,  situated  iu  the  aeocitding  frontal  con- 
volution oa  a  line  nith  the  third  frontal  convolution.  Troisier  m«utionB  a 
CMC  of  paralysis  of  the  arm  and  fiux  ia  vrbicb  iubjrvulor  groualatimi* 
aad  ooagastioQ  were  fuuud  immediately 
poaterior  to  tb«  third  Iroiitul  tourolu- 
tion.  Laadouiy  danribea  a  rawe  of  slight  fp^ 
paraljna  <4  tbt>  inferior  facial  muaclvs  aod  of 
tha  arm  caused  by  a  ii|mt  of  tubercular 
aMaisgitia  oecvpying  tb«  inforinr  {tart  nt 
the  flMure  of  Rolando,  and  the  inferior  balf 
of  tbfl  two  aaeendiog  coDTolutioua.  Pitrcs 
qnotM  flrom  Anton  Frey  a  caae  iu  vrliich  thcirw 
was  panaia  of  tbo  left  arm  and  at  tbi:  loft 
ad*  of  tbe  faca;  the  antopsy  showed  a  focus 
of  sofUtiing  in  tb*  m«duUary  dbros  at  tbo 
junction  of  th«  middle  frontal  with  the 
Moaoding  frontal  coQTolutioDa  {Fig.  2b9}. 

(t)  Fadat  Monoptt^ia. — Facial  paraly«tM  of  cerebral  origin  Kit  gflijorally 
conplicatad  by  apbasia  or  patalysla  of  the  area,  but  a  fon  uucomplicutcj 
OUM  of  facial  paratyala  from  ilijManeii  of  the  cortex  have  been  obeervcd. 


rio.  IStL 


Fia.  aeo. 


BB  70CXL  D1SE1A£ES,  ACXXIBDIKO  TO 

CtukTOot  and  Pitns  il«wrilM  *  ou«  of  ftpO[»lajC7  fgUuirail  by  UR 
(tle^a  Rtid  rittidit;  uf  Uie  liinljM.  The  rigiditf  dis^lpe■Iwd  &ftflr  &tin»aod 
tbi>  p»riklysi4  becfuao  limitod  U>  iUc  lowor  focUl  iaa»«loa  Au  «it«itatvc 
ariM  of  softouiDS  woa  founi  in  th.o  o:>rti3X  of  tba  right  tHiiaia|>bar«,  iavtr^b| 
tbd  third  frocitAl,  tho  Iawsf  oxtnxnttiM  of  th«  kHMiidiitg  rraoLtl  taii 
IJitrieUl  coavolnlioua,  &iid  «  Urge  aitout  of  tbe  pamlsl  uul  tampon- 
«|iheDoidAl  lobes  of  th«  iftl&nd  of  UdU  {Fiff.  880).  Although  Ui»  cortaed 
Imiouii)  tbkiicaaewaa«i>eKteiiuve,itwiUbe»eeDth&tdUeMeof  tbatnfcnur 
oxttxiraitics  of  tho  uoendiag  coQvolntiotu  wu  tho  iuportuit  loMoo  n  br 
M  tho  motor  otm  ia  oouooraed.  Uitog  roUtov  the  cuo  of  a  aoUicr  who 
reOMVad  a  bullot-vound  on  tb«  right  ode  of  tho  howl  and  boeuao  dfoebd 
two  moDtho  Buboequeittly  with  clonic  aiMums  iu  tbe  loft  side  of  the  flwa, 
folknrod  b;  par4);«u  of  choM  mu^cloo  aod  of  tho  laA  half  of  11m  toagw. 
Aftor  death  an  nbMaoa  ma  fouikd  iu  tbe  anaadlng  firontal  ooDToliiliiM 
betwtieu  tlie  pne-oeatrkl  Bman  and  tho  flaBOfo  otRoUodo^  i 
tit  tho  neat  «f  iiijur^r  [Fit/.  £81). 


Flo.  901. 


A  cane  uf  loft  hemi{>)egu  b  reported  b;  Dr.  Oowen  in  which  \ 
rooororj  tm>k  plttce,  nilh  tho  exception  of  uMrkod  paralyna  of  tbe  iuleriar' 
bciil  uiiiaubM.  At  the  auUtpa;  a  tawaorrlugic  extraTuatioa  ww  faoMt 
ia  and  boDMth  tbe  upper  half  of  tbe  pr«-oeutnI  aulooa  which  h«d  ftmmt 
into  tbe  Hubatanoe  of  the  adjoining  O0DToliitioivi,coadding  of  Ui«  jioatokr 
Mtremitjos  of  tho  middle  tad  wp«rior  frootal  and  oonvupooding  part  of 
the  asoendiiig  front*!  of  the  right  hemtspbere.  A  large  nomber  of  eaai 
might  be  cited  in  which  right  faciU  pualyna  eziated,  aoociaJed  whi 
BphasiA,  Hud  ill  wbtcb  the  leaiou  nu  aituated  at  tike  juoctloD  of  the  tUrd 
fMDtal  with  the  oMendii^  fh^mlal  convolutioa  of  the  left  hamiaphira.  1^ 
c«M  of  a  woman,  aged  71  jreara,  b  repotted  by  Ballet,  who  bad  aalight 
attackofaiKipUxywitboatlamorooDaoioiuiMM.  The  peraaneBt  ityapletiw 
ootupBtod  of  paraljelsoftbo  left  half  uf  the  faoeuid  of  tlu>tougiM>>  Tbtn 
WW  alto  aliglit  fL-eblonoM  of  tba  left  upper  axtmnitioe,  but  tl»  lower  wm 
uuaffe«tod.  Thare  wen  an  mtaofy  diaturbaooas.    TowuUa  tba  ev«ill|g  ef 


Ii8  ume  A»j  the  head  xnd  n«ck  bccaiua  deviated  to  the  right  and  tbe 
[xxralj'sio  or  Uw  kft  anil  iMfcaine  luoni  inwked,  Peftth  took  place  from 
comit  four  dajrs  •ubwu.iueiitljr  to  tb«  Wgtnuirig  <jf  the  attnclc,  and  at  the 
•utrtpo^  a  hnmorrbagid  foctui,  af  tite  *ixa  »T  a  l&rgo  iiul,  waa  found  in 
tha  inferior  lurt  of  ttm  txcvDiliug  fmnUl  wnvolutbn  (F>if.  SSi).  The  lu- 
ftfior  froiitAl  and  inf«Hr>r  parietal  faHoioiili  of  the  whtU  ttwue  were  iwrliallT 
datiujcit,  but  tbc  Uvm!  ganglia  were  normal. 


Fio.  an 


(/}  (hiUaltmt  (kulo-wolor  Mtmitphgia. — It  ha«  ftlroady  be«n  luciiUaned 
that  ooujufate  deviation  of  the  cyea  aod  rotatinn  nf  the  dead  and  neck  an 
fnquant  Byni[)taiii)t  both  of  ooiiriikioiiM  and  of  hemiplsgia,  and  that  the 
4«viatioo  iu  the  r-irmor  in  direoted  aira;^  &»<>■■  si>d  ui  the  latter  buwnnlii 
itw  hnoutpherv  in  whish  tho  lusinti  is  xiLiiaLeil.  In  the  bniiri  at  Hm 
MOitkey,  Pcrrier  looiUws  a  cuiitre  {/%,  33i,  Li]  iii  the  poateridr  i»tr«iuit]r 
of  tbe  second  frontal  aztmuity,  irriUtiuii  of  whtch  caiiMO*  ulevatioii  gf  Um 
•yetitlsy  dilatation  of  tbe  pu|>ile,  oonjugnta  deriAtian  of  the  eyva,  and 
tfimia;  of  the  h««d  to  the  o|i[)OMt«  vide;  while,  au  the  other  baud, 
extaanre  oioveaifntt  of  the  a;r«balU,  along  with  awockted  morement*  of 
khs  head  and  iitcIc.  rMtilt  from  irrjt*Uon  of  the  aupra-tiiargiiial  and 
aogalar  gj-ri  CMiy.  232,  13, 130. 

A  CAM  U  repfirted  b;  Cboupiie  vhioh  appeum  to  shov  that  the  centre 
for  the  prodoetioa  of  conjugate  deviation  of  the  eyee  and  rotation  of  the 
head  and  neoV  ia  aitiiated  in  tbe  poeterior  extremity  of  th«  socoad  frontal 
ooBvolittion.  Th»  etee  m  quoted  hy  Landouay  «a«  that  of  a  ymng 
atui,  19  yean  of  age,  vrho  praoeated  tbe  ordinary  Hyinptonu  of  tubuniuUr 
raeobigltia,  tb»  moot  atrileing  being  a  rotation  of  tbe  head  and  eyos  to  the 
ngbt  without  say  other  paralyila.  Aft«r  death  a  auperflcial  Ticiif  of 
diwm,  of  tbe  siaa  of  a  frauu  piece,  w».t  found  on  tho  piutterior  •Mtrvtnity 
of  tbe  middle  frontal  o>inv(>hiti<iti  in  thti  left  liuiaitjihttra.  Othur  loiiun-'i 
ware  bniid  in  the  superior  i^nd  Uteml  part  nf  the  sphenoidal  lobe  of  the 
ri^t  betnlaphere.  Laudoiuy  thinlct  that  Lhu  deriation  of  thn  oyus  was 
oauwd  by  an  irritatiro  lainAa  of  thn  jtmiterior  oxtnimity  of  the  aecoud 
fruutal  uuurnlutioa,  but  it  muat  bo  romomlwrcd  that  the  Ukuou  m  1}h& 
NN 


610 


FOCU.  DISEASES,  ACOOBOIKO  TO 


8U|H)rior  [inrt  nf  Iho  sfiliciioidA]  loba  wu  cIom  to  tfa«  u>gnW  cfroa,  u4  H 
is  probalflu  tlutt  Iho  deviation  was  due  to  B  deatro^iug  Imiun  ia  Uils  Uik 

Thtt  OOM  nf  a  child,  ogml  fivs  mitiittia,  b  DM-Mtiuimd  by  F«fri«r,  on  tk 
wttboritf  of  Dr.  CmtoII,  of  Nom  Vorlc,  in  wiiicb  *  tnwturo  of  tba  •fcnU 
wiK  jirrxluovd  by  s  fall.  WIioii  Dr.  Ctirrull  saw  Um  pxUotit.  IIm  bmi  «■ 
rotutod  tottw  ngbt,  its  ningo  of  motioa  Odtct  cstcadinif  to  ihe  brft  rf 
tba  middle  line ;  th«  eyos,  wbuii  at  rest,  mro  UitdmI  tu  th«  ri^bt,  bnt  ooidl 
bo  Toluntartly  movod  nluwit  to  tbo  utddl*  lino;  pupiU,  |«orb«pi^aMb 
diUtfld,  but  reepoDsiva  to  ligbt :  upper  lidn  Diovat«d.  then  wmi  •  tnotof 
in  the  rigbt  parieUl  ngion,  and  a  limMir  fraotiire  oould  be  d*t«ol*J  n  Ik* 
parietal  bone,  about  midway  b«t<reaii  the  miiwdoiu  and  mgittil  intaii^ 
and  totcTMctiag  &  vortical  line  drava  upwanla  frata  tbe  auditor;  na«lat 
Tbo  poaitioQ  of  th«  ftacturu  wii«,  as  pwuted  oob  by  Fcnirr,  snch  ■§  ixi%k 
coiucid«  nith  injury  nf  tho  poatcrior  cstntnity  of  ttis  Mooctd  frixital  oi*- 
roliitiw,  tho  lesion  baiug  doubtloaa  of  a  piaralytic  nature.  It  mnat,  ha9- 
mar,  be  a^lmitt^d  tfaat  thaee  two  caMM  are  tiot  of  themMlvaa  auAoioit  tt 
prove  tho  oxiateooe  of  a  txatrt  for  tbe  rotation  of  tbo  «yea  aituated  » !!■ 
middlH  fiTttit4d  courolutioD. 

Strong  ovidouoe  biu  iadixd  boon  rovootly  brougbt  forward  by  Qaot 
to  Bfaow  that  wliea  conjugate  deriation  of  Om  eyea  ia  csoasd  by  Aiamtd 
the  oortex,  tbe  leaion  ia  situated  iu  tho  supra-taarKiuaJ  aiul  angular  ga. 
He  roports  a  case  of  left  heiaiplegU  with  conjugate  deviation  dincladu 
tbo  right>  ia  which  the  lesion  couBioted  of  diMHse  of  tb«  pit  eotutt  uf  lb 
right  hvminpheie  (A'l^.  263).     LiouviUa  describes  a  eaM  of  right  uoilawri 

l-'io.  303. 


^\ 


\: 


eoavubiona  ia  which  tbe  bead  wai  strongly  turned  towank  lb*  ri^ 
Tba  leaion,  which  oonaiated  of  tubcvculor  maoiagitia.  waa  ajtoalad  « 
both  aldw  of  the  borixoaUl  limb  of  tbo  flamra  of  Sylriua  oa  tht  W 
bemiaphero. 

Sei^u  report*  a  east)  of  IcA  boniptcsia  with  contracture  of  tbe  mgrib 
of  th«  right  aide  (probably  parsljns  of  tbe  araactea  of  the  letl  aide)  irf  tb 
iwok.    The  Uhoq  ootiuKled  of  a  mvuiago-euoephalitia  iu  tba  ri^bt  mii^ 


TIIE  LOCAUSATEOK  OF  TBB  LESION. 


611 


lobe  lit  the  level  or  tbe  miperior  piu-L  of  tli«  fieaure  of  Bylviuii.  Cliaroot 
uiA  rttew  mention  a  c«ao  r«|kort«(]  by  Sarat,  iti  ivhioh  thcro  iriw  right 
'hemiplegia,  «rhi}e  iho  hewl  ami  aycn  wore  deviated  to  tbo  left.  A  focua 
of  MOlUitiing  wttM  fouii<l  situulud  ujioii  thts  [Utriota,!  \aht>,  not  qtiit«  reacbiag 
tbe  Mooodiag  firoDtal  oonroluttoD  in  front,  bouudcd  poatcriorly  and  in- 
teiori/  hy  the  pnrtarior  Ditraiaily  of  the  parallel  gsnura,  and  pnaaiag 
hejoDil  tbe  interparietal  Assoni  eupcriorly,  but  uot  quite  reaching  t*)  Ihc 
gmt  lougitudiual  fissure.  Theu  cases,  %ltho\i£h  man;'  more  might  ho 
atUed,  irill  BolUce  to  efaow  tbo  imvortance,  witL  regard  bo  conjujiiate 
devtttion  ot  the  eyea,  of  the  aouvoluliooa  wliioh  border  tba  posttirior 
•xtremitios  of  the  Sylvian  uxd  pnrnllcl  ^dsiitch. 

Many  oesM  m  reoonlad  iu  wUiuh  conjugate  deviation  of  the  nyeti  wnM 
ooiUNcl  by  cUMaaa  of  tlw  centrum  omlv,  and  in  theoe  tbo  Icaion  vom,  ta  a 
lille^  KbuiLt*!  butwveii  tlio  iiitvniul  (.--nii^ulv  and  tlie  RU|)rit- marginal  and 
Ufolar  gyti  Pnjvoat  raporta  ■  cum  «f  rt)(ht  beouplogiA  with  rotation 
of  tbe  head  and  eyes  to  the  left.  A  hmmorrhagic  focus  «a«  found  in  tht 
posterior  part  of  the  pari«tal  lobe  of  tbe  loft  bvuiinptiora.  iu  another  can 
K[ioit«d  by  the  mm*  author  right  hemiplegia,  with  rotation  of  tba  head 
wd  eyw  to  the  UFt,  was  OAWwd  by  a  sarcoma,  of  the  eiio  of  a  pigeoa'e 
Bgg.  aituated  iu  tbe  centrum  ovale  Itahind  the  fissure  of  Rolaudo.  and 
tlODg  the  longitadiual  fiaoun^ 

It  Houtd  appear  that  diaease  in  the  neighbourhood  of  the  angular  gynie 
lad  nipnt-murgiuftl  lobule  produce*  at  tiioM  paralyau  of  the  levator  pol- 
nbm  eujierionM  of  the  upimnite  eido,  without  the  uther  muHclw  eu[>plied 
mj  the  third  nerve  being  implicated  (Landousy). 

LrMiODS  may  occur  in  the  cortex  of  the  brain  in  the  area  of  disthhution 
it  the  middle  oenbral  art«ry  without  Iwiug  atteuduii  hy  pamlyain,    Boyer 

JDtaiuM  that  there  tint  two  "  neutral  "  xoiieH  iu  Ute  area,  the  one  <iccu- 
the  ouperivr  pariutal  lobtilv,  and  tbe  other  tbe  autcnor  part  of  the 
leu*  aud  a  part  of  tbo  gynw  foruicatuH.  A  ea-se  is  Te|iurt«d  by  Dr. 
iogroae  Atkiua,  in  wbtoh  there  was  a,  euperticiol  CTMiion  of  the  cortex  on 
poatero- parietal  lobule  of  tbe  left  bemiaphent  without  motor  disturb- 
hticc  having  benti  pfc4ent  diiriiig  life.  I  nniild  nuggent  that  the  iioutrAl 
toiras  of  Boyor  arc  aMociatcd  vrith  coutrifugul  fibres  oomicctiug  tb«  cortex 
if  the  brain  with  the  cerebellum.  Other  caaos  are  recorded  in  nhioh  the 
Eortical  motor  centre  of  the  leg  wan  found  dLsooeed  at  the  autopsy,  yet  in 
■rhicfa  the  leg  on  the  opponite  tdde  either  had  never  been  ikoralyBed  or  had 
reoorered.  It  i.<t  imibable tbiit  in  such  OMOtthe  movements  of  both  lower 
Utremitiea  wvre  rogaUted  from  one  hemisphere,  the  one  on  the  aide 
ftppoaiw  tbo  loaiOQ  receiving  its  impulsue  through  oorauiitwura]  fibres  in 
tbe  epiual  cord. 

The  motor  area  of  the  cortex  maybe  comproased  by  very  Urge  tumours 
Iriibout  paralyms  being  produced.  In  the  Fathological  Museum  of  the 
wsna  ColbKe  there  \n  a  |iTti|nratit)ti,  proentcd  by  Mr.  Windsor  in  1877. 

S  aarenrnktciua  tumour,  nl)nnt  the  »iM  of  the  closed  fist,  which  grow 
dura  mater  over  tbe  vertex,  and  near  to  tbe  faU  cerebri.     Tbe 


61 S 


FOCAL  DISEASES,  AOCOBDIAQ  TO 


ODdwI^lng  bemispbcra  wm  oompreawd  and  flsttMMri,  th»  matorirNtf 
tbo  oorUx  b«iug  involred,  Imt  Um  psti«iil  had  iw  |>ttral/tk  •7n94(H 
(luring  life.  T«ro  ouoa  of  a  more  or  l<ma  slmUmr  Idad  ium  ban  rmo^ 
HcNcribccI  b;  PitNM. 

Snuory  /KuurimKiu. — It  bM  bMn  nwioUiiwd  bjr  Tripier  that  lain 
of  the  cortioal  motor  are«  of  tho  brain  «n  aonttitDcs  aUcoMly 
liemiaiiieatlieaia  lu  well  aa  p^ralj-aia  of  tbe  oppoait*  aide  of  the  hatj, 
t*ctiU  oeuaibititjr  being  vpucinUjr  affuct4Hl.  Ho  ftclduOM  id  &Taar<f  tt 
opiition  soma  exiwriineiital  vrideiioe,  wid  repocta  of  nem  clttiital  owi 
in  which  more  or  le«s  of  bomipilftgia  «M  a«aei«tMl  with  h»wiiaMrth«M, 
thu  Imioii  in  h11  nf  them  b«iiig  foand  UmiM  to  tha  mot<r  tnaof  tt> 
corUx  of  tha  hemixfihon  ojtpoaita  to  th«  aida  tfK>ct*d.  But  bat 
iuin«tbraia  mi  fmiiiciitly  rcmilU  from  functknil  disturbanoM  U  At 
hrkiii  thnt  it  wntitd  be  Hnmnnhat  hanniotu  to  ooDclnde  froui  Umm  am 
alono  tbat  thv  Iimjou  of  tbe  motor  area  of  the  cuftoz  ira*  lb«  caaae  of  Ito 
baa  of  sensibility,  Ser«ral  cmm  are  collactod  bj  Nolhiiagal  to  Afm 
that  ilimiiiutioii  of  the  muscular  asnaa  is  not  anfrMjueuttf 
ivitb  motor  pAr&ly>>t«  ftv>m  oorlioal  diaeuie.  He  tlUDka  tfa«t  tba 
dtiritn!*!  of  thu  iniitKiilar  nenoe  lie  Doar  to,  althoujfh  thery  ar«  dm 
with,  the  motor  ceiitrea. 

V'aao-macor  and  trophic  (tutwixMCM,  conidiiiiiK  of  alerali^a  of  thi 
tam|)*r(ttura  of  thn  par&lyaed  limbs  and  scat*  bvd-anra,  bara  htm 
obaerred  iu  caset  of  <litieaM3  of  th«  cortex  of  tbe  faniii,  but  they  da  nA 
posMaa  atiy  value  as  localising  qrmptoou. 


(iii.)  ArrKCTt9Ss  or  Sraaca  no*  OoanuL  Vui 

§  717.  Tlie  disorilers  u{  speecli  whidi  aru  liable  lo  occur  ti 
cortical  dUeaae  ouuatitule  one  of  the  most  complicated  prableiBft 
of  ueurology;  and  before  prucveding  further,  it  is  deainhle  U 
limit  our  subject  so  as  to  separate  disorders  of  speech  dut  U 
disease  of  the  cortex  of  tlie  braio  from  other  affectiooa  at  kba 
nervoua  s^tom  tbat  may  resemble  tbcm.  Laoguago.  taken  il 
its  widest  aenae,  consists  of  tbe  varioua  means  by  whicb  auimiii 
indicate  mental  states  to  one  another.  Uirntiil  status  nuy  be, 
as  we  bave  eeen,  divided  into  feelings,  cognitioos,  aud  rolilMK 
In  one  sense  laiigua^  may  be  aaid  very  ofleo,  if  not  always,  tB 
indicate  volitions ;  but  inasmuch  as  votitioiu  ant  pcactkmUy 
always  determined  by  what  are  called  motives,  or  in  other  vrofdt 
by  the  feelings  and  coalitions,  tbe  language  of  rolitioas  mcfgai 
itself  into  tbat  of  the  other  two  mental  statM.  Langaii^  najr 
therefore  bo  divided  into  that  of  the  feebogs  or  mnotiomd 
language,  and  that  of  the  cognitions  or  tn/eUwtiusI  tangwigt 
vetpeeelL 


THC  LOCALISATION  OF  THE  LESION. 


613 


it  the  iliviiuoD  between  tlie  language  of  ihe  emotioaa  aad 
is   by   DO  means  clear  and   trencbaiit.      When  a  mao 
deliirers  an  oration,  for  imtauce,  only  a  fimall  part  of  what  he 
utten  in  speech.     All  the  varintlonR  of  tr>uc,  the  melodious 
'  voice,  tbo  graces  of  attitude  and  gesture,  tlie  cUarm  of  elegant 
and  rfaythmical  language,  and  tlie  thousand  other  ways  by  which 
la  great  orator  knows  how  to  sway  and  inSuence  his  audit^'nce, 
belong  to  emotional  and  not  to  inluilc-ctual  laDgtiage.    Similar 
!  remarks  apply  to  written  language.     The  pleasure  we  derive 
from  looking  at  a  clearly-printed  volume,  and  e.specially  from 
looking   at   an    illuintnatc-d  text,   the    pic-aiiure  dcrivLtl   from 
looking  at  a  vell-eiccuteil  picture  rather  than  at  a  diagram, 
Itbe  methods,  as  accent,    italics,  and    notes  of   exclamation, 
jl^wbicb  inScctioQ  and  emphasis  and  wonder  are  indicated; 
'  tbe  rhythm  of  metrical  language,  and  the  diction  and  imageiy 
of  poetry  belouii;  to  emotional  language.     The   languages  of 
1  emotional  and  of  iutvllcclual  gesture  arc  also  by  no  means  readily 
ifl^Mmted.    The  gestures  of  those  who  retain  the  full  use  of 
•  spoken  and  written  language  are  in  great  part  indicative  of  the 
feolings,  but  that  gesture  can  be  made  snbsortfiont  to  intel- 
lectual expression  is  shown  by  the  importance  it  asDumes  in  the 
intellectual  training  of  the  deaf  and  dumb. 

Loo^Hge  is  the  iusti-umeot  of  the  social  state,  and  that  it 

may  be  the  means  of  intercommunicatiim  between  animals  it 

posMSses  to  each  a.  sttbjective  and  an  objective  value,  or  fulfils 

an  impressive  and  expre$»ive  function.     Each  individual  of  a 

social  community.  In  order  to  become  an  effective  member,  must 

I  be  able  to  feel  or  comprehend  the  mental  states  of  the  others 

I  from  watching  their  gestures  and   listening  to  their  various 

'  rocoliaations,  and  must  also  be  able  by  his  gestures  and  vocalisa- 

tioQS  to  render  his  own  mental  states  tutelligibte  to  the  others 

The  sUfbjectivf,  or  impreaitive  function  of  language,  or  rather 
of  speech,  with  which  we  are  here  more  immediately  concerned, 
may  be  subdivided  into  receptive  and  regulative  functions. 

The  receptivn  departmeut  is  represented  structurally  by  tbc 
various  peripheral  bcnse-organs  and  the  centripetal  fibres,  or  cells 
and  fibrefl,  which  conduct  impreasions  made  upon  the  former  to 
the  cortex.  Complete  lo&sof  speech  from  disease  of  the  receptive 
ratus  ia  unknown. 


t(U 


FOCAL  DISICASES,   AOCORDIKO   TO 


The  vocal  speech  of  a  persoo  horn  blind  i%  almost  eotinlf 
unaffected  either  in  ils  subjective  oi  objectirc  aspecUk  'U* 
tilt!  patient  may,  by  the  devioe  of  rataed  letters,  be  twigbt  l» 
uiidcrslaud  written  Inusuage.  The  deaf  inutc  i»  taught  bulk  D 
anderatand  and  to  give  cxprc»tiiou  to  ft  coinpticatvd  KpeMlibf 
gesture  ;  and  ia  recent  times  8u«h  patients  have  been  tAtij^toi 
use  ibeir  vociU  orjiraus  for  expreseiou  iu  speech,  wbtle  lb«]r« 
made  to  uaderataud  the  vocal  speech  of  othen  br  dotelf  uIkJ 
nerving  the  muvemenls  of  the  muscles  of  articulation. 

Tlie  remiirkitlilG  cute  of  Lttum  Briilici^tiutn,  wlio  btsctnte  hlind  mI  i 
in  hi^  iwcfwd  yunr,  whiU  hnr  fwiute  of  antell  and  IakU  wm*  i 
ilclit'iprit,  xliowA  li»w  luuob  cucfid  tntning  iniiy  do  in  iWslApinH  bncoip 
taui  fhoti){ht  l,hn>iigh  tbn  aenae  of  touch.     Thi»  girl  «raa  taught  bjr  Dr. 
Hdwc,  of  Bi)«bni,  who  affixed  nii  n  tiunibcr  of  ronunvii  ubjocta  bMi is 
which  ch>f  niuiio  archo  lutidit  wn»  trtittvn  ui  raiMd  ehanetcra.    After  i^ 
hnd  listnit  to  iimodate  cnch  IaIkI  with  it»  object^  a  Dmnher  at  «r|anb 
UbdH  wvre  put  in  lii^r  fuuiil,  and  ttho  vu  thun  eneomgail  ta  plais  mA 
label  on  its  oom»iu»dins  object    After  n  time  the  a^wmta  lettan  ««t 
plncwl  ill  hur  luunl,  anil  she  was  then  taught  to  put  tlioiu  Icgrttwr  (q  M  li 
form  the  u.imi^  irf  commuu  objects.    ' '  V\f  to  this,"  my»  Dr.  Knwv,  *  tb 
pinoenilin);  vnn  only  a  tuechaDtoU  one,  and  the  roiiilt  wan  abont  ■■  pmX 
wt  if  one  hoi  taught  &  number  of  triek»  to  n  clever  do^    The  ivrr  MA 
hail  lint  tliern  in  nitito  aatonishmont,  and  patMDtly  imjtat«4  avuTtbinf 
that  niM  porTomiGd  bcforo  her.   But  now  the  matter  oeeniMl  to  dawn  htkh 
)ii>r  in  iU  tniu  light.  liOTundcrstatKUngbeguttoewrotae  itaalf,  alw ootiiad 
that  she  uow  poaaaaaed  Uie  raeaiuflf  amngjii)c  fi^r  hvmil  gqrrataJa  ot  ■av' 
tiling  that  lay  before  her  mind,  and  of  ahowii^  this  to  anaitbar  ndal; 
jiumMlintely  her  counU-niuio;  Iwamcd  with  hiiuitn  nmina;  afaeomUai 
longer  be  Domiond  to  a  iwrrut  or  dog ;  th«  imaorta]  iBl«Ucct  nuw  anal 
greedily  upon  this  now  bond  of  imion  with  other  intAltecta  t   I  uunU  atami 
point  out  the  moment  at  which  this  truth  dawned  upon  htr  aad  puuial 
Uxht  over  her  whole  tuoc" 

The  Btnictural  counterpart  of  the  reguiative  function  conasb 
of  tluit  part  of  the  cortex  of  the  brun  in  which  the  centriprtal 
impulses  are  reduced  to  such  order  lu  it  neccesar^  to 
them  the  ooTTeUtives  of  the  cognitionH.  Now.  tbe  oognitic 
as  we  have  seen,  express  the  relations  between  our  feelingly  i 
all  cojgoitions  must  be  expreuied  by  propoititiona.  Tbe  mod*! 
expression  may  not  always  assume  a  distinct  proporitioKol  film. 
but  it  must  at  least  possess  a  propositional  value  if  it  oonwy 
disiioct  knowledge.  If  I  repent  the  won!  "orange"  in  the 
heariog  of  auotberj  it  may,  or  may  not,  convey  to  him  distil 


TBS  LOCALISATION  OF  THE  LESION. 


615 


but  if  any  information' be  imparted,  the  word 
must  convey  to  the  lisleoer  the  idea  tliat  tbe  object  nameil 
"oraDge"  belongs  to  a  clajts  of  objects  already  known  to  him 
noder  tKat  name,  and  the  word  in  this  sense  possesses  the  value 
of  a  distUict  proposition.  If  the  liotener  hm  never  had  any 
experience  of  the  object  named  "orangp,"  it  in  clear  that  the 
nlteraoce  of  the  name  will  convey  no  meaning;  hut  if  he  has 
had  expericuce  of  other  fruits  and  of  colours,  dLstinctiDronnation 
ma.y  bo  conveyed  to  him  with  rngani  to  the  object  by  saying 
"an  oraoj^  ia  a  yellow  fruit."  The  listener  will  be  able  to 
aasociate  the  general  propt^rtios  of  fruit  and  a  dintioct  colour 
with  the  word  in  future,  but  the  iDformution  has  been  im- 
parted  by  meana  of  a  formal  proposition.  The  activity  of  the 
regulative  cortical  centres  of  speech  have  for  their  functional 
correlative  the  arrangement  of  the  preventative  and  represen- 
tative cognitions  into  the  form  of  distiQct  mental  propositions. 

The  objective  or  expresftive  function  of  speech  may  be  sub- 
divided into  emitaive  and  cxecuitm  departments. 

The  emimve  dopartmont  is  represented  fltmcturally  by  that 
ot^oisAtioQ  in  the  cortex  of  the  hrain  in  which  the  regulative 
trapul«^  arc  finally  co-ordinated  before  being  conducted  to  the 
erecotive  department. 

The  txeeutive  department  is  repreaeuted  structurally  by 
groups  of  nerve  celU  in  the  central  grey  tube,  and  hy  the 
ten  and  miincles  concerned  in  vocalisation,  articulation, 
le  manual  operations  of  writing,  and  various  geatur^K.    Coto- 

ttft  Ion  of  speech  from  disease  in  the  executive  structure 
moat  unuKual.     The   patient,    for   instance,   may   lone  hi-q 

lice  ia  different  diseases  of  the  larynx,  but  he  can  still  arti- 
culate; he  may  lose  both  voice  and  articulation  in  bulbar 
paralysis,  but  ia  generally  able  to  make  known  his  wants  in 
writing,  and  when  unable  to  write  from  want  of  previous 
education  be  cau  make  his  ordiuary  wonts  known  by  gesture. 

Oor  further  remarks  must  be  liraitod  to  the  derangcmcnta  of 
speech  caused  by  disease  of  the  cortex  of  the  brain.  Theae 
eoDsist  of  disorders  of  the  regulative  department  of  the  im- 
preaaive  function,  and  of  the  emissive  department  of  the 
oxprcMivc  function;  and  aa  the  latter  ts  probably  the  Btmpter 
of  thotwo.  we  shall  deal  with  it  first. 


FOCAL  DISBAaSS,  ACOOftDltta  TO 


§  748.  (a)  Loa*  m-  Impairment  0/  Uu  A^tMi'iv  < 

o/the  Expr^iunve /nciUltf  of  Hpuek  while  the  Impramn 
factdty  w  ututfecUd.     (AUkueic  Apkaaia — JyrupAia— 

Amimitt.) 

In  cases  of  tliis  kind  Uic  patioat  is  uD&ble  to  ODmmuiiieaU 
bia  tboughta  bj  words  or  by  writiD^,  wbU«  bis  iDtclloctual  pu- 
tomtmo  is  impaired.  Hb  cad  ofteo  utter  words,  bat  tbew  nu;  inA 
poasew  an;  iatellcctual  value  ;  in  tbe  words  of  Vt.  Hugbltog*-^ 
Jackson  the  patieat  is  spf^ehie^  but  not  tR>rcU«w.     Tho  wordifl 
wbicb  the  patient  can  ultcr.  as  a  rule,  coniioue  the  Bain«  in  th?  ~ 
same  patient — "  recurring  utlcrancea."      Or  tbe  pativnl  may 
under  excttemerit  swear,  or  even  utter  a  pbra&e  appropriaU  tji 
the  surrounding  circutnatance,  sucb  as  "Oood-byc,"   when 
friend  is  leaving.     It  will  be  readily  seen  that  the  "  nci 
utterances"  sncb  m  "  Yen"  or  "  No,"  wliich  are  repofttod  cm  aEj 
oooaaons  whether  appropriate  or  not,  do  not  pone«  any  iotel' 
lectual  value,  white  of  the  occasional  ntterancea  •wearii:^  it  a' 
purely  emotional  expression,  and  even  tbe  phraae  "Cknd'bre* 
must  bu  regarded  as  cxpresung  a  stAte  of  mental  regret  rmther 
than  a  purely  intellectual  appreciation  of  the  surrounding  coodi- 
tiona     In  sumo  cases,  in  additlou  to  thu  usual  recurring  atler- 
anoes  of  "  Yea  "  and  "  No,"  the  patient  repeola  sach  pbraaes  ■■ 
"Conieoatonie"fJackson).or"I  want  prolcctioD^CPMECt).   Tbe 
man  whose  recurring  utterance  was  "Come  on  to  me"  was  a  rail-. 
way  signalman,  and  liad  been  taken  ill  on  the  rails  in  front  of  I 
box,  while  thu  man  who  could  only  say  "  I  want  pralection" 
his  U-ft  cerebral  licmisphere  injured  in  a  brawl    Dr.  Hagbtings- 
jMkaon  makee  tbe  very  probable  supposition  that  to  thsM 
cases  the  recurring  utterance  constitntod  the  last  words  spoltto 
or  which  were  in  a  state  of  mental  preparaUoo  for  utteraaw 
when  the  damage  occurred  to  the  brain.     It  is  not  improbabte 
that  words  uttered   or  about  to  bo  ottered  <luring  a  porind 
of   great   excitement    might    leave    permanent    traces    wbtdi 
would  render  them  liable  to  be  Hubsequenlly  uttered  ax  into- 
jectional  phrases  during  emotional  stat«sL    That  all  these  words 
and  phrases  must  be  regarded  as  expressive  of  «motional  ratkw^ 
than  intellectual  atates  is  shown  by  the  fact  that  the  patient  i^^ 
frequently   unable  to  repeat  his  favourite  oath  on  hii  fonnala 


¥ 


THB  IOCALI8A.TI0K  OF  TUE  LE8I0N.  617 


of  Ieav&4akiiig,  or  perbaps  "  Yea"  or  "  No"  vhen  asked  to  do 
so  (Btoiadbetit). 

The  patieot,  oo  the  other  hand,  underatanils  al!  that  is  said 
to  hiiD,  &ijd  retnembera  what  is  read  to  him  or  what  be 
roads  himselC  His  articulatory  actions  are  well  performed,  aod 
duriu;;  uutio^  aad  swallowing  his  vocal  or>;An8  act  oormally, 
sod  he  may  siog,  laiigh.  8mile,  aod  frowo  as  usual.  Uo  will 
point  to  obJecM  naioed  and  rcco^uise  drawiogB  of  tbctn,  pro- 
rid^  they  woro  knowo  to  him  before  bi«  illnem.  He  is  able 
to  play  at  cards  and  other  gnmes,  and  rocogtuMs  haadwritiug. 
The  few  word*  which  the  patient  can  um,  aa  yes  or  do,  may  bo 
uttarod  with  nich  rariations  of  tone  aod  gcsturo  aa  to  indicate 
whoa  he  ia  angry  or  joyful.  His  use  of  words  is,  in  accordance 
with  Mr.  Herbert  Spencer's  theory,  moro  akin  to  song  than  to 
speech,  aad  boloogu  rather  to  emotional  thao  to  intcllectuat 
language. 

So  far  we  have  coonidered  the  casoa  of  those  patienu  who  are 
oomptotely  deprired  of  the  power  of  expre8aing  intellectuiU 
laogoage  while  retaining  the  power  of  understanding  it^  but  we 
must  DOW  turn  our  atteutiuu  to  those  lesser  grades  of  ataxic 
aphasia  in  which  the  patient  hUII  retains  the  use  of  a  few  words 
or  phrases  of  real  speech  value.  We  have  seen  that  most 
apfaasics  uae  words  in  au  iotorjcctional  sense,  and  nhen  excited 
oaths  or  pbraaes  as  "  Ood  bless  me "  may  be  uttered,  hut 
these  also  most  be  regarded  lu  compound  interjections  and  as 
purely  iodicatire  of  emotional  conditions.  Besides  the  intcgeo-  * 
lk»i*l  use  of  wonis  and  phrases,  the  patient  may  occasionally 
utter  a  word  or  phrase  whi<:b  is  evidently  equivalent  to  a 
distinct  proposition.  He  may,  for  instanco,  retain  the  full 
oso  of  tho  words  "  yes"  and  "  oo,"  and  even  when  he  uses  "  no" 
to  expreiB  assent  as  well  as  dissent,  he  may  lie  able  by  the 
aid  of  pantomime  to  indieato  in  which  sense  he  intends  the 
word  to  be  understood.  Dr.  Hugh  lings- Jackson  mentions  the 
CBue  of  a  woman  who  could  only  utter  the  phrara  "  Yea,  but 
jroa  know."  who  was  odc«  hoiird  to  say  "  Take  caro  I"  when  a 
child  waa  la  danger  of  fulling,  but  could  not  repeat  the  phrase 
when  asked  to  da  It  cannot  be  denied  that  this  utterance 
possoBses  an  intellectual  element,  luasmuch  as  it  is  an  appro- 
jiriate  admonition  to  a  person  in  danger  of  falling.     It  must, 


618 


FOOit.  D1SSASB8,  AOCORDrKO   TO 


however,  be  remembered  that  tbe  ptinue,  although 
to  tbe  occasion,  was  uttered  under  circumslaucee  calculated  lo 
induce  alarm  and  excitement,  and  the  same  vordii  hat)  prohMj 
been  frequently  repeated  under  similar  drcumstanoea  lo  Uk 
slighter  defects  of  speech  tbe  |>atient  can  talk,  but  iiseB  a  maii 
kindred  in  it«  meaning  with  the  one  intended,  as  "  word- 
powder"  for  "  cough -medicine,"  or  in  ita  HMind,  as  "  panud"  br 
"  cafltor-oil"  (Jackgon). 

(b)  Lom  or  Tmpaimneni  of  ihe  Regviaiiw  deptvrtmni  •/ 
Uu  Imprtsgive  facuUif  of  Spettk,  wkUe  tJu  Sxprmm 
u  eiiher  wnaffeded  or  only  teoondariit/  impUcaUL 
(Amnesic  Aphana.) 

(I)  Lots  of  Memory  of  S'ameo  or  itToUfw. — In  many  ohm 
of  loss  of  memory  for  words  tbe  uame*  of  thiogit  are  for]{otl«P, 
vbile  the  memory  for  datM,  events,  and  the  relaliooi  betvM 
these  may  remain  good.  Dr.  Broadbeot  mentions  the  foOflvisi 
case: — An  old  gentleman,  after  very  slight  right  bemiple^ 
could  give  long  answers  flueoUy,  and  volunteer  statemeali,  •» 
long  AS  the  phrase  did  not  contain  a  noun. 

"  Oh,  ycM  ;  ]  am  much  b«tt«r  th&a  when  yon  iMt  mw  ma*    - 1  dal 

be  73  on  the  three — four ,"  whoa  be  confiued  hitnaelf  in  trrins  U  tbi 

tb«  wArd  DecomWr.    I[«  could  oat  noma  a  hAn<t  when  told  to  4?  m,  htf 
iu  bis  effort  Aomcthmg  like  a  leg  was  once  hard.    Tbia  gatlonaX^ 
■uemnrj  of  bats,  oraute,  dotm,  aud  fitoM  ia  rtrj  sood. 

The  patient  ttt  oftea  eDa1>led  to  supply  the  want  of 
by  a  paraphrase,  as  in  the  foUoviog  case,  quoted  by  K( 
from  Bergmann  : — 

"  A  hiud,  40  ywtn  at  age,  was  uooofwctoux  fn-  four  wosha  eft*  > 
aevero  it^ur;  of  the  head ;  ho  pa^ained  hia  racuUacUon  of  thLnp  mJ 
|>laixe,  hut  hu*  luvmotj  for  naow*  wa»  |o«t.  Tbe  noun*  hud  ib»)iyMnri 
lioQi  bia  Tooabalnrr,  but  be  still  bad  eomound  of  th«  rarba.  A  {vir  rf 
adasora  he  ealleil  ilut  with  wlikfa  one  cuta ;  tiw  wiodaw,  that  IhiM^ 
which  one  sees,  through  which  the  ructtn  ia  QlummattnJ.  &<,■.  B*  hal 
fotgotteu  uioxt  of  bia  aon|t»  ukI  prayers.     He  roournnd  sutiaMinHtti/.' 

Sometimes  the  initial  coDsonaota  of  words  are  lefi  oot  <i 
words  in  speaking  aad  writing  (Scblosioger),  while  in  «  «•■" 
recorded  by  Grares  the  sight  of  persons  and  objects  ntf^F 
suggastcd  the  initial  consonaQts  of  their  namef,  thi 


THE  LOCALISATION  or  THE  LEStOK. 


619 


iMknie  not  being  recalled  until  the  corros|X)Ddmg  writtea  word 
met  tlie  eye. 

"  A  niAn,  tS  j-GATB  of  nge,  nlbrr  nn  apojilectic  ntUck,  lost  hia  metiioty 
for  rrofcr  DnuKM  mn)  subftantlrea  in  general,  with  Uie  eiception  of 
tkir  &r«t  latl«rK,  Although  the  ponrer  of  K]ioech  wiui  not  ini[iair(Hl  in 
otber  mqjccts.  n<?  {ircpanxl  for  himitrif  mi  iiljilijilx^t.itvilly  iimmKisl 
dJetMtutfi^  oT the  KvitKUtntivM  iwiuinyl  iii  hii>  home  intcTwnmc,  luid  wlicn- 
«ver  it  beisuue  nvocmary  for  him  to  use  a  iioan  he  iiiuiicdint«1y  looked  it 
rat  ID  hi*  divtioiuuy.  When  ho  wiiihi^il  to  say  'Con,'  he  Inokid  iind«r  C. 
As  loug  as  he  kept  his  eye  ujxiii  the  Kxittoti  naiim,  he  could  pronounoo  it, 
Int  M  aiiiitKtiit  aftorwards  he  was  uuatilij  to  do  ao." 

(2)  1-M.hUit]/  to  Express  the  Relation*  between  Things. — Tu 
Another  form  of  aniDeeic  aphusla  tlie  nnnaes  of  persons  and 
thiogH  are  more  or  less  remembered,  but  the  memory  of  words 
indicative  of  relAtions  and  attributes  ia  ifcpaired. 

In  the  «ute  of  a  Miniowliitt  (■jwijtlkjiUiii  iliHiinlwr  «>f  jutomli  iDentioiied 
by  Ur,  Broadbcnt  the  ]vtti<Mit  c-Jiild  only  say ;  "  BK-ther,  t.wther— New 
Vnrk — Ameriia,  two  l>mtluT>«  in  Ann-ri'.M — I'-tt^-r,"  Ttii.'<  |Nitiutit.  «a«, 
thwelorv,  abl«  to  rrcuill  ttic  timiKsi  of  the  jM-^nuiii.t  linil  plmin  iiitcmlml,  hut 
(MuM  [tot  I'xpnwt  tho  rt'lutious  bctwoea  tbeni  no  oa  to  uoEinlruct  a  setitenoe. 

(3)  In  another  disoider  of  tbe  receptive  faculty  of  spQCCb  the 
pAtient  ia  unable  to  name  any  object  which  he  soea,  or  to  raad 
a  t\a%\t!  letter,  although  ho  may  convcwc  fluently  and  write 
eoiTOClly  (word-biindnees — word-deaf  new).  A  cxsc  related  by 
Dr.  Broadbcnt  is  a  remarkable  example  of  this  affection. 

An  tnteUigeDt  inaii,  69  yastr*  of  nge,  nftor  an  actito  ct!i«>>ral  attaolc, 
fcrt  com|>lpt«ily  the  j^owar  to  Tva4  jiriuted  vr  written  wonli".  His  wiui 
•fan  aiuible  to  recall  the  name  of  tho  nin*t  fiuuiliar  object  prmented 
to  him.  Thia  lunn  could,  howeror,  oohvitbc  anontly,  hia  vooftbukry  wm 
bagG,  aud  his  worda  well  diotieu  and  arrau^I,  ulthou^  he  ocounonally 
(argot  the  [iJuniM  of  ntrcftw,  pcraons,  and  thingK.  U«  ccidd  &lw>WTit« 
mnty  and  oenrectly  Imtli  Trom  dictation  and  spoutaowouxly.  He  died  from 
an  vEtenaivB  faamorrhogit  into  tho  loft  t4inii>onil  loho,  with  rupture  into 
the  kit«»al  ventricln.  Two  foci  of  soft«tm]g  of  old«r  dnte  were  obaerved, 
one  bdn^  altUAtfrd  in  the  t^mporo-spbcnoirlnJ  lo1>«  liencath  the  |KiatGiaor 
end  <]i  the  pauuUol  solcua,  and  the  other  higher  up  uiKlrrl.niii;  thr  »iiK<ilur 
gfTMS|  and  botvMn  it  and  the  point  whore  tho  doMending  horn  of  the 
ventricle  in  pnn  oft 

(4)  In  a  fourth  form  of  amneaic  apbasia  the  patient  appa* 
rently  fails  to  comprehend  wntteu  orBpokcu  language,  and  seems 

aoonacious  that  hia  speech,  which  consists  of  mere  Jargon, 


6S0 


FOCAL   DISKISES,   ACX'OBt>lNO  TO 


is  uaiatolHgible  to  atliars.    The  following  brief  abatrooU  of  ti 
cases  deacribed  by  Dr.  ^xiadbeat  are  good  exsmples  of 
oondttion : — 

A  man,  ftg«d  00  jwa,  wha  tikd  prwvioml^  bMn  »  good  Ulkir 
gTMt  iwuier,  suRWreiil,  after  •  fit  of  nomo  Idud.  from  a  paaultar  dhetMt  4 
S[>e«ch,  {>&r«!iU  of  th«  rij{ht  sicU  of  the  tmao  hut  do  bemiplagi*.  HU  ipMcfa 
wa-t  a  m«n)  iiMi-liciiUt«  Jaisoo.  Wheo  aslnd  *  questtou  bs  mmld  wha  ■ 
brief  roplj  aa  if  ha  undantood  wid  uwmrad ;  tin  moduUtioa  oT  lb 
roioii  and  the  acapbaaia  wars  parfacil;  uaturml,  and  GOiT«i()oudad  with  ttr 
factal  ezprasnoa  and  gesturaa,  but,  as  a  rulo,  thara  was  not  tba  lanl  Mta- 
blaui^  to  wanh  tn  wbat  he  aaid.  His  rapliM  mre  ofton  ao  aoiUUa  hi  Ingth 
aud  emphuM  ttuit  it  might  faare  beea  suppoaed  that  ti«  had  ewnpubwidl 
tho  queetioD.  WhoD,  hovDvor,  ho  wm  boM  lo  Aa  tayihia^  it  was  mob  Ikit 
ha^kl  not  undorsttuid  tbu  aiinpttrnt  phnMu.  Haaatupln  b«]  oncc  or tvin 
whou  rcquirad  to  do  ao,  but  na  thia  ira«  not  madv  a  t««t  qa— two  tbM 
woulH  beotheritidicatioiAof  what  wiu<iruitod,andfaa«aa«itraRH>1jtBBdy 
in fiODtprehouding ingns.  Wbon  told  to giw  bia  baud  ha  iuTarMbljr  |iat«al 
tfaa  tongue.  A  letter  addrMutad  lo  hioi  at  tba  hoapiUl  bajng  banded  lo  hia, 
bo  took  it,  appeared  to  rwwl  the  oam*  aud  addnea,  aad  put  it  down  apfak 
Not  ftttampttiig  to  open  ii,a  piece  orpa|ier  having  "  Qtve  ma  jmorbaod* 
wrilteu  upvii  it  wan  baiiil«d  to  him.  Ue  took  it,  hold  it  ao  aa  to  giat  a  fati 
li][lit  oil  it,  Mid  thtiri  huviiii!  ApjiiUiHitlj'  raad  it  laiil  it  acid*  arithovi  l^eb^ 
his  baud,  though  asked  to  do  ao  bj*  word  of  mouth  aa  wall  ae  in  Tinting. 

Ttio  [iAtii*iit  diud  Hi>iii«what  auddenlf,  and  at  the  autopey  a  laigfl  Ibooa 
of  «oA«aJag  n-aa  fouaH  to  tba  kft  bauuapbore,  liiuited  to  ita  poatanor  half 
Part  of  the  cuprn'iuargitial  lobula  was  jreUaw  in  colour.  abniDkM  ta 
rolunte,  and  iH>rt.  Tbi«  oonditioo  attattdod  aptnrda  ajtd  bavlc^mnk  la 
vrithin  aliout  half  aa  inch  of  the  loagitudioal  llsmn  jnat  in  frool  of  the 
o(t«rnat  pamto-occipiul  &aaore,  ioTolvin^  tbarefore,  tba  poatero-pahetal 
lobula  The  morbid  change  implicsted  the  aii|[ular  Kfrua,  and  naat^ 
raacbed  the  occipital  lob^ ;  tbe  adjacent  puria  of  tba  tuinn  i  i  hiIwiumM 
lobe,  the  poatorior  end  of  tbe  infro-aiarginaL.  and  panlUil  )[^  wm  aol^ 
but  not  waated  or  di«ooloiired  on  tba  aurfaoe. 

The  aiTectiou  of  speech  in  the  following  cuwt  reported  hf 
Br.  Droadbeut  is  inoro  complicated  than  that  ia  tbe  a 
described. 

The  piticDt  was  a  waU-aduo»ted  and  inttfUiKKiit  jroun);  man,  wbo  I 
eootmctixl  nyphilifl  eight  jwara  previoua  ta  the  dato  of  tba  report. 
a  fortnight  b«fon  bia  admisMon  isto  St.  Marj'a  Hoapitol  ha  waa  ■■■A^^iy 
aalitd  wiUi  hemiplegia  and  loan  of  aiweeb.  Ha  appeand  to  uinliieliiiil 
all  that  wat  eaid  to  him,  but  (,-ould  not  lUMwar  quaatioaa  at  fint^  mfUfiff^ 
after  a  few  weeka  bo  impgroirod  av  much  at  bo  be  abia  lo  rrply  to  qpa^tkwm 
»qairiiig  briefMidBimplansmn.    Ha  waa,  bowavnr,  luaUa  |o  ftre j 


THE  IX)CAUKATION   0¥  TUB  LKSION. 


6S1 


iiActod  aoMuat  of  luiTthing  raquiriiig  more  tlun  n  few  vurdM.  H  is  nivtboH 
of  comotiug  an  «mMMo«»  aUtomout  yriacb  had  bovo  DMd«  that  Iw  nokv 

fma  slevp  pftnljWIand  speechle»  was  m  Mlows:   "No — oveuiitg, 

aing— put  down  my  cigar,  smottiug,  Huxjkiitg  not  ■.  qnartAr  of  an  ln^up — 
all  tt  OQCe  " — iDdicaUng  by  gesturea  the  Iom  of  pon<<r  io  the  limW  tuid 
kddtng— *  Couldn't  spMlc"  U«  lost  at  firat  all  kiii>w]»<ige  of  iiumb«r8,imd 
could  DOC  ull  iiotr  mauy  3  and  i  mado ;  hut  i<y  prnctioe  h«  could  iu  a  few 
wmId*  multiply  by  3  and  3  up  to  IS. 

Whui  a  table,  glH»,  itiluUtid,  Mid  vi»l«tH  wem  jmiiited  out  to  hiiu,  be 
«M  unabU  to  iiatua  tb«ca,  nor  c«ul<I  bo  n«iiia  hia  glovM,  bat,  or  a  pan. 
U«  tiaiued,  howvver,  mmeobjectfl,  Mncb  m  bis  hand  and  th«  fira.  II«  peniaed 
hia  t)«ini[>apttr  regularly,  and  with  nil  th«  marlu  of  itit«Iligont  iiitor«»t. 
He  undentood  it  also,  for  be  went  to  the  aister  in  a  atate  of  great  excite- 
iMnt  to  tall  ber  of  tho  failure  of  a  finn  with  which  b«  bad  businMa  rala- 
ttODB,  oanyiug  the  {wper  in  tiia  baud,  aiid  paiiititiK  out  tbe  aiitiounceinent ; 
WhI  ba  could  alvaya  find  a  giirvii  paragrft)ib,  wliuii  oaked  to  do  ao  aa  a  t«at. 
Wboii,  howerer,  he  wa»  aalced  t<>  rend  aluml,  tbu  re-iuU  wim  ^ihWrinb.  The 
bUowtng  paaaage  ivm  aeleeted  :— "  Vou  rtmy  recoire  a  report  from  other 
•OUJCCH  of  a  Kuppoaed  attack  o»  a  Britinh  Oon»ul-Oi'ii«rAl.  Tba  aflW, 
bowerer,  u  uttarly  uuvortby  of  connidomtiao.  No  oulrago  wan  ovrvn 
iotecMled,  aiid  tbo  report  waa  duo  to  minrvprwrntation  of  tbo  focbf.  Tba 
Oimm,  lino  ID  oij-aiii  working  projiorly.'"  It  n-oa  rvnil  alitwly,  aud  iti  a 
Jerky  nuuiuer,  aa  i»early  aa  it  could  \te  tulceu  downi  tbua  : — "  Bo  aur  wiajea 
DM  veoemetit  aji  ri|iay  fro  friu  fonenient  mx  K  aooonce  ooz  (o?.  tio  Saphiaa  A 
tbea  frackkd  gmtlij  coiiollied.  Thia  iifTAiau  eb  nb  Otuit  nh  unrly  uf  ot>»Mi- 
qiunees.  Uee  andoa  ral  ah  ea  m  ontoin  ah  tbM  enepol  K  oh  doc  a  nb 
inaneqnencs  oh  ooa  fos.  Tbo  Mnnuil  lotin  A  puff  pifl  mim  corron  povoty." 
It  ma  avidentty  an  aRVirt  to  read  aloud,  requiring  close  atteutioo,  aud  be 
nad  aeriouvly  ai>d  ntcadily,  apparenlty  uucoii«ciou«  «f  tbo  absurdity  of  hia 
■ttarapeea,  till  iiitgrniptwl by  Imgbter,  which  it  waaimpDB<iiUetor^atraiD, 
ID  vhich  be  usually  joined.  He  won  never  abb  to  give  the  aiiiiplent 
writtsu  aiiaw«r  to  a  qneatioa,  or  to  write  from  dictation,  but  be  aignod  hia 
navka  quite  well,  and  wrot«  duwu  thu  uamea  of  IiIh  Ifrotburu,  but  with  the 
initial  only  of  the  CThriatiim  uame,  tliu  Miirnatne  in  full. 

Wbeu  aaked  to  copy  aM.nit«tice,  he  wrote  tho  short  words  quickly,  and 
Iti  a  good  baud  ;  but  a  long  word  ho  took  tlown  utowly,  lett«r  by  letter, 
iu  large  aoboolboy  ofaoracten,  uaually  accurutoly,  but,  an  bt»  wrote  oach 
Itttar,  be  naoiad  )t  sluud,  attd  aluagt  vrontfly. 

§  749.  jUarhid  Anatomy. — So  Tar  as  ia  known  of  the  morbid 

rktoiny  of  cortical  diHrdcrs  of  sp^ccli  may  be  eumm<Hl  up  in 
few  words.  A  cotnparitiou  of  a  large  number  of  observattonB 
ahowi  that  the  leBion  in  aUixic  aphasia  is  situated  lO  the 
posterior  portion  of  the  tliird  Trontal  convotution  and  tbe  ad- 
joiuiug  porliuo  of  tbe  Island  of  Rett  of  tbu  left  bemispb«re.   to 


632 


FOCJLL  DISEASES,  ACCOBDIICO  TO 


exceptional  cases  the  disesse  of  tite  third  froutol  oooTolatM 
has  been  found  in  the  ri^ht  instead  of  tbe  left  hcmiitpiifre.  &ih) 
in  these  thu  aphasia  was  ussociated.  with  left  hemiplegia  liuna; 
life;  the  patients  were  in  moat  cases  known  to  be  left  tioocJed 
lo  other  caaos  of  right  hemiplegia,  but  wiUioui  aphiuia, 
posterior  extremil;  of  tho  third  left  frontal  convolatioa 
beeo  found  disorganised  after  death,  and  in  such  com*  alu  i 
patients  were  left-handed. 

The  portion  of  ttie  ascending  frontal   eoovoliitieii  wd 
adjoins  the  Islaod  of   Reil   is  often  involved    in  iho 
Tbe  leeion  generally  consists  of  ooolnHion — either  by  oe 
or  syphilitic  tbrombosig — of  the  left  nitddlo  corehral  arlAry,  irf' 
at  least  of  tbe  branch  which  suppUcit  Bruca'a  couvoluttoo. 

Id  amnemc  aphasia,  on  the  other  hand,  the  lesioo  is  in  tke 
area  of  distribution  of  the  posterior  and  terminal  briAcbM  of 
the  left  middle  cerebral  artery,  and  tbe  region  of  mfteiiiiig 
comprises  tbe  supra-marginal  and  postero- parietal  lobales,^ 
angular  gyrus  (visual  ceutm),  tbe  posterior  part  of  tbe  infir*- 
margiaal  convolutioa  (acoustic  centre)  and  the  cooTolatloo* 
bouuJing  tbe  parallel  aud  collateral  lis^urea  (Broadbeol). 

Lt'Hiuns  that  damage  tbe  fibres  of  the  corpus  -^'l"!™^ 
wbich  connect  the  (bird  frontal  coorolutioDs  of  the  two  udei. 
aud  those  which  connect  tbe  tbird  left  froutut  convolutions  witli 
the  iaternal  capsule,  produce, as  baa  been  pointed  out  by  Broad- 
bent,  as  pcrmaueDt  an  afiectioD  of  speccb  as  dcsinictioB  ti 
Hroca's  oonvoliitioD  itself. 

Fio.  S64.  ^  ""*"■  ^°^  ^  fMn*  wboM  caa*  m 

nport*d  by  Pitru,  niServd  tram  right  htm- 
pisgia,    with    ombuTMnnwut,    and    6atOf 
coinpl«t«loMor^««ch.    At  till  •ut«ip^,tMi 
V  ■         Bmatl  pakchflB  of  yellow  aoAeDing  wtn  iaaU 

\  tj  bi  tht  oort«x  oftbs  Isfl  hflou|)lMn,aiic  \ma% 
^^  ntuatflil  upoD  tb«  snpvnor  parwUl  labqfa,  mA 
th«  otbor  upoD  ths  lobul«  of  Uia  pU^tmit. 
Vo  cliuigeB  were  vbaerved  u  the  tUid  ftooUl 
eonvolntioii,  Iwt  a  Isrp  (bcua  of  aefttBlag 
was  obocmd  in  tho  ceutram  evala,  vhkk 
axtMkded  anteriorly  to  tht  part  audariylaf 
tbo  poeterior  astroni^  of  tha  third  frwilal 
oouvolutiou,  sod  posteriorly  bajoiHl  Um  fm- 
tenor  ostninity  of  Iho  optic  thalaipiia  (j^ 


THE  LOCALISATION  OF  THE  LESION. 


62S 


f750.  Morhid  Phyaioloiji/.^Vi'heti  tlie  structure  of  the  cor- 
tex at  t!ie  posterior  exuemitji'  of  the  third  left  frontal  convolu- 
tion is  thoroughly  disorgunuiecl,  the  expretnive  faculty  of  speech 
is  armteil  at  its  ongiD.  The  patient  can  untltrstaod  everything 
ifaat  i«  said  to  him,  he  can  think  and  probably  clothe  hia  ideas 
in  Buitable  aubjccurc  language,  but  tbe  objective  or  expressive 
jOHt  of  speech  is  entirely  lost.  He  can  tiudertitaiid  the  thoughts 
^pitbers.  but  cauuot  communicate  hia  thougbta  to otbers either 
'  by  apokcn  or  wril4«u  langui^c  or  by  gesture.  Moat  aphasics 
present  apparpot  exceptions  to  this  rule,  ioasraucb  as  tbe 
majonty  of  themarenuttiuitetleatitutoof  the  power  of  utteriag 
worda  but,  as  pointed  out  by  Dr.  iIughliDg»-Jackiioa,a  patieDt 
may  be  completely  speechless  though  sot  entirely  wordlesa. 
Tbe  words  that  aphasie  patients  u«c  are  recurring  uttcranefla 
like  "Ves"  and  **^o,''  which  are  repented  on  all  oceasicns, 
whether  appropriate  or  not.  The  patients  have  only  an  inter* 
jectional  and  not  a  cognitional  uao  of  tbcHc  wonla,  and  they 
must  be  regarded  as  part,  not  of  intellectual,  but  of  emotional 
langnage.  The  patient  may  be  able  to  swear,  oaths  being  part 
of  emotional  language.  Dr.  Uughliugs-Jacksou  thinks  that 
as  actions  become  more  and  more  automatic  they  tend  to 
become  organised  in  the  right  as  well  as  iu  the  left  hemisphere, 
and  he  believes  that  the  recurring  utterances  and  phrases  used 
by  aphnsics  are  those  which  had  become  automatic  either 
previous  to  or  during  the  attack,  and  consequently  organised  in 
ibe  right  hemisphere.  The  wonls  which  become  automatic 
.are  those  like  "Yes"  and  "No,'  which  have  been  frequently 
rspcotcd  iu  the  experience  of  the  individual,  and  words  of 
tbe  character  of  OAths,  which,  although  they  may  not  neces- 
sajily  have  been  frequently  used  by  ihu  paiienl,  have  been 
oaod  under  circumstances  of  excitement  and  are  exprcssivo  of 
eatoUODol  slates.  In  those  case^  in  which  the  patient  can 
ropMt  words  in  tbe  form  of  a  proposition,  such  as  the  man 
meatioaed  by  Pa^et,  who  was  injured  in  a  braiwl,  and  who 
could  only  say  "I  want  protection,"  it  is  thought  probable  by 
Dr.  UughlingWuckson  that  the  patient  was  about  to  repeat 
the  words  at  the  motnent  of  injury.  He  thinks,  therefore,  that 
these  words  hod  become  automatic  in  him  by  being  repeated 
'circumstanced  uf  great  excitement.    But  whatever  may  be 


es4 


FOCAL   DrSRASES,   ACOORDINH   tit 


the  explaoation  of  the  reciirretioe  of  stich  phnMS,  it  is  nbriow 
that  ttitij  posjtias  uo  valuo  oe  a.  form  of  intatlectual  exprenoi, 
iunamuch  ns  they  are  repeate-1  withoTit  any  refereaoe  to  tkvr 
appropriateoeiM  to  surroiindlng  ciicumsuacea. 

But  what  ezplauattoa  cad  be  given  of  tlie  fact  that  tlw  <■» 
plex  muMciilar  inovorncnts  which  serve  for  )Dt«ll«ctuiLJ  cxpnttim 
are  orgaikised  in  one  hemisphere  odIjt  ?  Accepting  the  cnwd 
conneclion  of  the  huinixphurea  of  Lbti  brain  with  the  luovW 
of  the  trunk  and  Iimb«  as  a  fact,  there  ran  be  oo  ditii  ''' 
In  uuderstaDtling  why  in  rjght -banded  people  Iht;  more  ifxcw 
muHCulur  adjustments  of  the  hatid  should  be  urganiaed  la  tkt 
left  bemiaphare.  It  Beoms  strango.  howoTer,  Ibat  tho  tntiacilu 
movcmeota  coDcerned  in  articulation  Ahouhl  fulluw  tb«  wk 
rule  It  must  at  least  be  admittid  that  it  would  bd  an  Moooof 
of  force  if  the  muscles  of  the  two  udea  concerned  'a 
articulation  were  regulated  from  one  hemispbcre,  and  U  ii 
also  probable  that  a  greater  prAcioioD  in  the  execution  «( 
tbeoe  raovcmenls  is  obtained  by  a  uoilateral  ori^isaiioD.  It 
iR  likewise  somewhat  difficult  to  understnnd  why  in  left-handed 
peaplo  both  the  atructural  correlatives  of  the  more  special  mev*- 
meats  of  tbe  hand  and  of  the  articulator^  moTemeoLt  of  ^loka 
language  are  found  together  in  the  right  bemiapbere.  Bet 
whatever  may  be  the  explanation,  there  is  abuudant  dinicil 
eridence  that  such  is  tbe  case. 

If  then  ataxic  aphasia  be  caused  by  a  destmying  laioo  «l 
tbe  cmit^ive  organisation  of  speech,  it  might  be  auppoacd  thai 
simple  aeroranoe  of  the  cortical  organiaation  frum  tiie  cxecutin 
organisation  would  produce  the  same  effecL     In  otber  woctk 
it  may  be  supposed  that  disease  of  the  Gbrt-a  of  the  pyranuda) 
tract,  which  cuouect  the  posterior  extremity  of  tbv  third  frootil 
ooDirolatioD  and  the  nerve  nuclei  in  the  medulla,  would  pradue* 
the  same  effect  as  disease  of  the  oortex  itsell     When  a  cmd- 
mander-in-cbief,  for  inatanoe,  sends  orders  to  a  geoent}  of 
division  to  execute  a  particular  movement,  the  hitter  canoe' 
obey  the  order  unless  tbe   lino  of  eommunicattoti   botewss 
the  two  be  kept  open,  no  matter  how  effective  may  (m  t^ 
orgaoisAtion  of  tbe  emissive  dopartment  of  intelligence  al  Jti 
ceatial  end.     But  it  bo  happens  in  war  that  when  tbedinei 
line  of  oommuaication  is  cut  off,  an  indirect  one  may  I 


THK   LOCALISATION  OF  TUB   LESION. 


625 


And  sometbiDg  of  tbia  nature  occure  in  spbasia 

by  disease  of  the  pyramidal  tract     We  liave  already 

x  the  fibres  of  the  kooe  of  tho  iotcrnal  cnpsulo  coDoect 

frontal  coovolulion  aud  the  nuclei  of  artictilalion  in 

idutla,  and  when  these  art!  interrupted  oa  the  left  side, 

pent  sufTtirs  from  temporary  loss  of  speech.     Bui,  aa  Has 

pointed  out  by  Dr.  Broadbent.  th«  patteDt  under  these 

LSlaucus  tnalces  a  good   and   moderately  rapid   recovery. 

||>UaatioQ  given  by  Dr.  Broadbent  of  this  rapid  recovery 

alUioogb  the  diroct  liue  of  cummunicatioQ  between  the 

a  organisation  and  the  executive  ia  cut  ofT,  an  indirect 

readily  established. 

tuiial  course   in    for    the    mewiage    to    be    conducted 

^rds  by  the  fibres  of  the  left  pyramiilal  tract  and  to 

rer  in  the  medulla  to  the  auclei  of  articulatioa  of  the 

9  ode,  and  then  through  commissural  fibres  to  tho  nuclei 

larae  gido.     But  when  this  chaonel  is  tnterruptaJ  the 

is  sent  from  the  left  third  frontal  convolution  through 

of  the  corpuK  callosum  to  the  corresponding  convolu- 

i«  right  8tde.  and  from  the  latter  through  the  right 

al  tract  to  the  nuclei  of  articulation  of  the  opposite  stde^ 

igh  commissural  fibres  to  the  nuclei  of  the  aamo  side 

Iq  tbis  way  the  organisation  in  the  third  left  frontal 

itjon  can,  after  a  time,  be  utilised,  but  during  the  time 

in  opening  the  new  channels  of  communication  ths 

suffers  from  greater  or  leaser  degrees  of  diaturbauces  of 

Uut,  as  has  been  pointed  out  by  Broadbent,  when  the 

the  pyr&midai  tract  ia  ooonectioo  with  the  hemisphere 

'a  Bbrcti  of  the  corpus  callosnm  which  connect  the  third 

i  convolutions  of  the  two  sides  are  both  interrupted  by  a 

Ik  the  centrum  ovale,  the  afiuctiou  of  lipouch  in  as  peniui- 

I  if  the  third  frontal  convolution  itself  were  completely 

Bised. 

tb,  in  its  objective  or  oxprcseive  aspect,  oootist*  of 
ip«cial  and  complex  movements,  and  the  question  arises, 
t  oases  of  aphasia  not  associated  with  paralysis  of  the 
of  articulation  1  The  reply  is  that  although  there  is 
inJysis  of  the  separate  actions  of  the  muscles  of  arti- 
,  yet  there  is  a  paralysis  of  the  combinatioos  of  octioo 
o 


626 


FOCAL   DISSASBS,  ACCORUI.SO  70 


which  are  Decestarj  for  the  produclton  of  apeech.  Tfaal  ■tur 
aplmsia  ia  of  a  paralytic  aature  m»y  be  sbowa  in  seviual  asn. 
The  third  left  frontHi  convolution,  for  initance,  u  Kituated  bw 
the  ceulrea  for  the  reguUtion  of  the  movemeDts  of  the  iBferiv 
fttcifti  luuacles  aud  of  the  muscles  of  one-half  of  the  tooguft  m 
tliat  the  apliuaia  cau9C<l  bjr  disuuHi  of  Broca's  cuuirotutioiMu 
afisociated  with  uailatemi  facial  and  lio^al  paralyuc  oven  to  (ix 
slighter  coses  iu  which  complete  hemiplegia  ii  not  prodMli 
But  stiU  more  cogent  evidence  in  favour  of  ttiis  view  uu;  be 
derived  from  cosesof  bilateral  diseases  of  the  heinLspberet,afl«(t- 
iug  either  the  third  frontal  coovolutiont  or  the  tract*  of  tibni 
which  connect  tbe«e  with  the  nuclei  io  the  medulla,  and  a 
which  there  is  not  only  paralysis  of  the  special  hutalau  of  tbt 
gODerul  ruovoments  of  articulaUoo  (anarthria).  For  the  tattt^ 
ingexample  of  this  uffection  I  am  indebted  to  l>r.  ImtA,  «In 
kindly  transferred  the  case  to  me  ten  dayn  befurv  the  patiMit 
died.  The  notes  of  the  case  were  taken  by  !ilr.  GoniflO.  wba 
the  patieut  was  under  the  care  of  Dr.  Leecli,  and  by  Ht. 
Liickman  after  he  came  under  my  care. 

JuM^b  C ,  aged  40  fears,  waa  adnittteil   under  the  OH 

Leech,  November  IDtb,  18^0.  The  [xui«iit  was  bmhh;  until  ab« 
inoutha  ago,  when  ba  begao  to  Gonijilaiu  tif  headacEw,  uBuallr  tHattmi 
tb«  t»tlt|i)es  anil  occa«on»]Iy  in  tli«  tnuk  of  tiie  licntt  It  vna  alaa  »I«uib1 
alfgat  this  tiiuc  thut  bin  tq>cc«li  wm  "  tbidc,^  Init  tto  otbcr  twtalilc  spaf- 
tonia  vnav  obeamd.  four  and  a  half  uootlw  afo  ba  firiQ  o>tt  td  bid  Am 
or  four  times  ibfl  Miae  tught,aactwaa  uoaUo  to  got  in  again  until  mmIiI 
hji  his  wifo  anil  win.  From  tbnt  time  up  to  tbe  |ge»ent  hi*  ■|<a>^ 
appeared  to  have  bvoomo  toon  aud  man  unintelligible,  while  hm  am- 
plained  of  geoenl  weafcnww,  tmt  thera  wu  no  distioot  ponl^ais  of  aajd 
tb«  ttxtrvniitice. 

I'rtstnu  Cviteiition.— The  patient  in  emadatwl  and  CmUc,  m  that  kc 
«oou  tiros  on  attetnptiot  t«  walk,  but  there  ta  uv  poralrns  •A  the  eiln^ 
McA.  There  is  coiwidentble  Icmh  or  £nciiil  tvpemiaa,  uhI  the  |himiI 
(Mtiiiivt  ootu|veiaa  hU  IJ]pe  or  whincla,  but  con  Uow  out  a  mmD*  *iA 
tolerable  bctUty.  Hi!  uui  {Nrriu-ude  bia  tongue,  but  caminnt  cuH  tb 
tip  itp  toWMiis  tuA  DOM,  or  roU  it  up  Ut«ndlf  ao  a«  ti>  ivtulAr  tt  taMtf 
HU  ^Mocb  ia  aluuHA  nuint«Ui|[ibIe,  aud  gnal  attention  b  wiui— 17  ■ 
order  to  unilenrtaad  th«  few  wwds  )u>  is  ablo  to  utt«r.  Ue  «an  piuuMn> 
the  neparate  ootuononts  with  tolerable  distinctnoM,  but  AixU  dtAodti 
with  tlu  kbtalt  and  d«titals  tho  letter*  (s,rf, /,/,«,»,#,(,  a  *.««^' 
giving  Itim  the  gmit*»t  difficulty.  Foud  ooUMta  between  Ua  UMb.  ri«l 
aalin  ouUouta  iu  bin  n»utb,  whioh  iuu  to  be  oonMaatlf  wipftl  aw*;.  >^ 


TOE  LOCALISATIOS  OF  TQ£  LESIOlf. 


027 


oT  ileglutitioa  In  [ai|inir«].      Uia  artorics  oro  athoromAtoiu, 
t  other  iinportant  gencrnl  afinptoiuB  ore  ^ivH«tiU 

TSar.  Stt.     H«  hiw  oompluueii  of  |)aiii  for  thv  bat  Cbw  tlajw  orer  the 

.  ro({ioD.    Tlw  aano  reiiortH  that  be  ban  bocn  nUgbtlj  tlvlirJMis  «i 

i  for  thv  last  ttiw  daje,  that  he  ffit  out  of  li»it  xevnni]  tttunt  ,Vra(teniajf , 

1  that  on  ooB  occaaioQ  bo  fell  dovm  anil  hail  lo  be  luxdntnl  JuU)  bed. 

ring  this  ftttack  bo  is  rv]KNrt««l  to  havit  tiorn  oi»iKi:i<>tu«,  1>ut  tiiN  !<{i««ch 

I  gmtl;  uSectvd,  luid  tbm  wu  souv  d'Cgroc  of  paral)-Bii)  of  buth  the 
■  extraoiitieH.    Thero  is  at  preseut  ui>  tlistioct  Ims  of  power  in  vither 
Itgi  iX  th*  uias,  but  hia  ainwdi  in  utoK  umiit«lligiblv  Uuui  at  taiy 
i  aiiioB  his  admissioo. 

Hue  1.  The  [»titiut  in  iiuw  sutt'ering  TrDm  (litLrrhaiO,  and  tliere  are 
burked  UuctiintioQS  of  the  t««apcmturo  cimo.  The  uvabt  it)  somewhat 
|«iulul<iiM,  itltbuimih  Dot  ilistorted,  and  ite  nflei  vxcitHkility  iniiiiuSuliilwil 
Wht  Gmmm  aiul  epigl»tti»  cau  b«  «uuuiueJ  with  Iho  poiut  of  the  tiitgev 
jrritbotit  [troToldng  ■  oough,  while  tb«  (ntieut  exhibibi  a  rcmiirknlili;  t4>lur' 
iweo  to  larjrngoaoopu  exaiiiituU.iou.  TLu  voca]  cords  move  nomuilljr  diirinf; 
hqiiimtioii  and  pbotmtioa. 

.  Doc,  ID.  SiDGo  last  ropurt  the  iliarrhcEa  bait  pnnv))  iiitractablu  to  traat- 
(uaQt,  and  the  [JOtieul  is  much  fccblfir,  the  tfim|>cmtar<!  enrvc  priMtcinta 
parked  vanatiuus  in  the  cuurac  of  twcDty -four  huura, being utuooiijcator- 
m  below  97*  F.,  and  al  midiuRht  105' F.  During  the  yrBrioua  thirt««i 
li^  (Ik  tcmperntuic  vnriwl  fmni  bc-tweeij  1JG0°  F.  and  ItlBT.  in  llie 
JBumiog  to  bctwMD  lul-VF.  aad  lU3-i°F.  iii  the  eveuiog.  The  Bp«ecli 
biB  boeo  for  sooie  daja  quite  uaintelligiblt-.  Tlie  juatienl  now  bemau: 
padoaUy  comatoeo,  and  died  id  the  eveuiug. 

Tha  fMwt-iuiirbsiii  exaiaiitatidii  wiui  oundnotwl  by  Dr.  A.  H.  Voimg 
ta^onty-fuur  hoiuH  after  di^utb.  Tho  arachDoid  over  the  niit«rior  port  of 
^  oonvEiity  of  t)iv  brain  was  o[Kujtiv,  niid  tho  flubamchnoid  ttasiw 
bdaiDBtous,  but  tho  moaibnuiw  vam  healthy  ]K»ft«riorly  aud  orcr  the 
MML  Each  cwrvlind  humisphera  prewnted  a  tuiiglo  well-defiDed  tystic 
lavitj,  Miutaiuiug  cIikU'  stiaw-ooluured  tluiil,  ami  iiC4Jui>yiiig  tbo  {j^witiDiu 
tl  tlie  leutic^ilar  ou^lai.  Id  the  left  heuiitiihiire  Utu  IciiLioidor  uut'luiia  wa^ 
|tiD(jly  RiiUoud  by  the  cyst,  but  iit  tho  rii(bt  thu  cavity  wnn  mniniJuntbly 
kigtf  tluui  tht!  area  of  Lliii  ituclutiH,  vitviidiiig  tLuUirinrly  nliglitly  lit-y<Dnj 
^a  aatcrior  ostremity  of  thv  oaudatv  ciucloun,  and  iMmtcriorly  t»  th«  wuU  of 

EdsMBodiDg  honi  of  ttio  lateral  v*9iitricl<>,  nUhoiigh  it  did  nut  omiunu- 
M  with  tbe  latter.  The  olauatnuu.  aiid  iat«irual  eapeulo  uu-  cod)  aide 
a  imafieotad.  The  venCricles  oontainod  a  slight  uoem  of  fiuid.  Thv 
hrteriM  al  the  baao  of  the  brain  went  atlkeiviiuatuus.  The  niuoous  tuctn- 
\)nue  uf  tht!  tectum  anti  deaoendiug  ocili>u  vas  iMver»i  by  deep  ulcem,  with 
Itackiuied  lunrgins. 

UJorvao»pi«  ajuuniiiatiau  showed  that  th«  norvc  nuicUi  in  the  tuL-dulla 
Wen  healthy,  and  no  deaoeodiog  ehangea  could  be  detected  in  the  pyra- 
.  tniele  iu  auy  iMrt  of  their  ooursc 


628 


FOCAL  DISUSB5}.  ACOOnDINO  TO 


Dr.  Barlow  was  probfibly  the  fine  to  draw  alt«atioo  (otk 
fact  that  leKioDs,  Hrmmetxically  sitiutcd  id  tbe  hemiqikNt 
may   produce   symptomB   closely   simulating   thitac  of  buHar 
pomlyais.     A  'boy,  nged   10  yeara.  aafferiog  from  aortic  diMK 
had  aa  attack  uf  riglit  beaiiplegia  with  aphasia,  frora  vbtdi  bt 
made  a  good  recovery.     Four  months  aubaequently  b*  bail  M 
attack  of  left  hemiplegia  with  aphaaia,  aa  well  aa  paralyBiaf 
the  musclM  of  articulatioQ,  thoae  coDcemed  iu  the  firrt  actrf 
deglulttioD,  and  of  the  tnusclcs  of  roasticalioo.     At  ifae  aoti^ 
evidence  of  an  embolus  was  fouod  in  both  Sylvian  aruii« 
I'hc  obliteration  of  the  veasel  on  each  side  was  aa8ociat<d  wilk 
a  focus  of  softening,  about  the  sizo  of  &  nhitling,  and  nlmlai 
in  the  inferior  part  of  the  ascendiDg  frfiotal  coDvolulJoa.  uiJ 
the  posterior  cxlrcmiUes  of  the  second  aod  thin)  fmntal  obb- 
volutiona     Soou  afterwards   au    important  paper  was  ouiiri- 
buted  by  Lupine  on  this  subject.      Id   the  caae  ohmvad  t^ 
this  author  the  RymptomN  were  more  or  leaa  «imUar  lo  tlune 
juKt  described  in  the  caae  of  Joseph  C— v  ^*it  io  the  fafiDW 
the  difficulty  of  deglutition  was  moro  marked   than  id  ih 
latter.     At   the   autopsy  a  diaeaaed  focut  was  fouiul  in  «ch 
hemisphere,  involving  the  external   capsule   and   the  moibI 
and    third    divisioDs    of    the    lenticular   nucleua.    while   tfal 
ID  the  right  heminphere  exteodeil  to  the  convolutiooa  of  Ui* 
Island  ot  Reil  and  the  posterior  extremitjr  of  the  third  Eruttl 
convolution.    ADOtbi>r  case  of  the  some  kiod  is  quoied  tf 
Lupine  from  Oulmont. 

Ldpino  alao  rcfera  to  a  case  reported  many  yw*  ago  If 
Haffixa,  in  which  anarthna  was  caused  by  a  unilatenl  l«Mi 
of  the  braiu,  th«  dinease  being  aituated  in  the  corpus  atrtatuB 
of  the  right  hemiaphere.  Another  case  in  reported  by  KirdniffiB 
which  bulbar  sympiomii  were  caused  bya  diaooBsd  focus  ntoaitd 
in  the  right  beminphere,  the  left  being  healthy.  The  caaai  in 
which  the  lesion  was  unilateral  appear  to  show  that  the  geosn' 
or  more  automatic  movements  of  bilaterally  associated  mmelr* 
are  often  rt^ulated  atmoat  entirely  from  the  right  bomtspbm*' 
the  brain.  Coses  of  this  kind  suggest  the  question  aa  to  wbetltt 
tbs  bulbar  symptoms  were  caused  directly  by  the  t«soo  of  ^ 
lenticular  nucleus  or  indirectly  by  implicatjoo  of  the  Sbntif 
the  ku«e  of  the  iobemal  capsule.     In  the  caae  obaervi 


THE  LOCALISATION  OF  THE  LKSIOS". 


629 


the  most  careful  microscnpical  examituttion  of  the  crasta,  pons, 
anterior  pynmidis  of  the  medulla,  and  spinal  cord  failed  to 
detect  any  di^sceudiug  changes  hi  the  pjpra.uiid&l  tracts.  The 
cysta  in  the  hemispheres  were,  however,  very  much  distended 
with  6uid,  o-nd  it  is  quite  protmble  thnt  a  certain  amount  of 
prenure  wa^  thus  exercised  upon  the  fibres  of  the  internal 
caprale,  Riifficient  to  partially  tntemipt  conduction  through 
them,  without  heiug  sufficiuut  to  cause  secondary  degeueralion. 
This  qaestioD  muHt,  therefore,  be  left  for  future  observations  to 
determine. 

The  mechanism  by  which  the  differcut  forms  of  amnesic 
apUania  is  pnxluced  ia  much  more  difficult  to  comprehend  than 
that  of  the  ataxic  variety.  In  order  to  facilitate  the  compre* 
Iienuoa  of  the  variuuij  forms  of  aphasia,  several  authors  buve 
OHirtructed  dia^ramn  to  repreaent  bypotheticalty  the  nervoua 
mechaaism  concerned  iu  speech.  The  beat  of  these  are  the 
diii£fr«ju8  of  Kuwsiuaal  and  of  Broadbeut,  aud  although  uot 
Mtirely  agreeing  with  either  of  them,  we  Rbalt  avail  omrsolves 
of  ifae  din^mit  of  the  Utter.  Dr.  Broadbent  nets  out  in  bis 
explanation  with  the  proposition  "  tbal  all  muscular  movements 
are  performed  under  the  direction  of  a  '  guiding  sensation.' "  It 
would  have  been  better  if  he  had  said  under  the  guidance  of 
"centripetal  impubes"  instead  of  "sensation,"  inasmuch  as 
muscular  movemeuta  take  place  in  the  entire  absence  of  sensa- 
tioQ.  If.  for  example,  the  palm  of  the  hand  of  a  person  asleep 
be  tickled,  the  hand  closes  under  the  guidance  of  centripetal 
impulses,  hut  indepetideutly  of  Heumliuu,  the  action  in  this 
case  being  reflex.  But  when  the  individual  is  awake  the  oat- 
going  portion  of  the  reflex  arc  can  be  utilised  by  the  cortex  of 
the  brain,  and  theu  voluntary  clwurc  of  the  hand  takes  plaoa 
The  nuclei  of  the  motor  fibnw  of  the  pcriphurul  ncrrcs  in  the 
BpiDjkl  cord  are,  therefore,  subservient  both  to  centripetal  ira- 
pulaes  coming  from  the  periphery,  and  to  centrifugal  impuLsea 
comiog  from  the  cortex  of  the  brain.  But  the  centrifugal  im- 
|H|1*M  from  the  cortex  are  initiated  and  controlled  by  ceutri petal 
tmputflee  coming  towantB  the  cortex  from  tbe  periphery.  It 
tbiu  appcftTH  that  each  movement  is  represented  in  the  anterior 
grey  hums  of  the  coni  by  a  group  of  connected  cells,  and  that 
this  group  may  be  called  into  activity  by  centripetal  impulses 


630 


FOCAL   DtSCASIS,  ACOOEDUtO  TO 


coming  from  the  periphery  to  the  same  level  of  the  cord,  cttpjr 
ceotrifugal  impulsoa  from  a  higher  nerve  centre,  or,  in  Di 
Broodbent's  words,  "a  motor  cell-group  ia  formed  imdeiUe 
guidanoo  of  n  soosory  celUgronp  on  the  same  level,  nod.  wIm^ 
formed,  is  made  use  of  by  a  higher  ccnlre." 

The  "  motor  cell-group"  in  the  case  of  speech,  which  for  I 
sake  of  coaveuieDce  Dr.  Broatlbent  cslU  a  vfordrgroup. 
combine  into  orderly  action  the  thoracic  mmicles  in  order  in 
obtain  an  expiratory  current  of  air.  the  laryngeal  mnsclM  fiir 
pbonation.  and  the  mnscles  of  the  lips  and  tongue  foruttetdi- 
uon.  I  shall  fuUow  Dr.  Broodbeot  iu  placing  the  vord*gnBp 
in  the  corpun  Btrintum,  although  in  my  opinion  it  wonld  Inn 
been  better  had  he  discarded  this  gangttun  from  tfaeeiplttar 
lion  and  merely  Kpokon  oi  the  cortex  and  mcdnlla  ohlooj^ta. 
which  aie  connected  with  one  another  by  ntraight  fibres 

When  the  cella  of  the  word-group  are  called  into  actieB bf 
centripetal  impulses  on  the  umc  lord,  the  action  ia  reflex,  ai 
the  resulting  contraction  would  «imply  represent  a  complicated 
muscular  adjustment  without  any  reference  to  intellectual  u- 
preasion,  nnd  it  is  only  when  it8  actirity  is  oTokcd  from  the  cortei 
that  tho  raorement  becomes  Bubaervient  to  speech.  The  oortial 
outlet  for  speech  is  situated  in  the  third  left  frontal  coDToltUki^ 
while  the  cortical  guiding  sonKory  centre  for  spoken  laoguagvil 
situated  in  the  superior  temporo-sphenodial  conrolutioD(auditai7 
centre).  In  accordance  with  the  annexed  diagram,  lenon  of  & 
the  speech  centre,  wilt  cause  ataxic  aphasia,  and  letitMi  of  A,  tlw 

auditory  perceptive  centre,  or  i' 
at.  the  6hrcs  which  connect  tbt 
inleU  and  outlets,  wilt  cause  dif- 
ferent forma  of  "  misUkee  ia 
SPLtCH  I  wonla"  A  hypothetical  expUu- 
tion  is  thus  afforded  for  thn* 
disorders  of  speech.  In  leMm  ft 
S  the  *  way  out"  for  all  the  mn»- 
eular  adjastments  concenwd  ia 
intaltectual  expreamon  is  d^ 
stroy«l  ■  in  leaion  uf  a  i^  tlu 
Una  of  communication  betwew 
the  guiding  aeuaory  centre  and 


Fia  2CS. 


.  Aunronv 


OJ  -^cs 


THE  LOCALISATiOK  OF  THE  LESION. 


6^1 


ibe  motor  oailet  is  damaged,  aod  miBtakea  in  words  recognisable 
by  tbe  patient  occur ;  wbile  in  lesion  ot  the  eenaory  centre  A, 
mtstaketi  in  vords  occur,  of  wbicb  the  speaker  remains  un- 
cooacioua. 

[  But  in  intetlectu&l  eipression  still  higher  centres  are  en- 
[gaged,  and  diseases  of  these  produce  various  complicated 
'dtsordere  of  epeccb.  "Tbo  fonnation  of  an  idea  of  any  ex- 
ternal object,"  says  Dr.  Broadbeut,  "is  the  combination  of  the 
evidence  restpteting  it  received  tlirough  all  tbc  senses;  for  the 
Mnptoyment  of  this  idea  in  intellectual  operations  it  must  be 
lOBSOCtated  with  and  aynibolised  by  a  name.  The  structui&l 
arrangement  corresponding  to  this  process  I  have  supposed  to 
coQsist  in  the  convei^ence  from  all  the  '  perceptive  centres'  of 
tracts  of  fibres  to  a  convututional  area  (not  identified),  which 
.m&jr  be  called  the  'idea  centre'  or  'naming  centre.'  This  will 
be  ou  the  senmij,  afTereut,  or  upward  side  of  the  nervous 
lyMem;  its  correlative  motor  centre  will  be  the  propOHitianining 
centre,  in  which  names  or  nouns  are  set  in  a  framework  of  other 
words  for  outward  vxprusaion,  and  in  which  a  proposition  is 
Irealised  in  coosciousness  or  mentully  rehearsed.  If  we  arc  to 
Ihave  a  seat  of  the  faculty  of  language,  it  would  be  here  ratber 
than  in  the  third  left  frontal  convnlation,  with  which,  however, 
it  may  possibly  be  in  close  proximity.  E.^presaing  tliis  by  a 
oiagram.  we  have  V,  A,  and  T,  the  viaual  (augulur  gyrus,  Ferrier), 
lauditoiy  (infra- marginal  Sylvian 
gyms},  and  tactual  (unciuate 
\gynu),  perceptive  centres  send- 
ing converging  tracts  of  fibres. 
|V n,  an,  ( n.  to  N,  tho  '  naming 
;centre.'  Here  the  perceptions 
.from  V  and  T  (smell  and  taste 
are  omtlled  for  the  sake  of  sim- 
plicity) are  combined  into  an 
iUlea,  which  idea  la  symbolised  by 
the  name  reaching  N  through  A- 
which  has  always,  in  the  expe- 
irieoce  of  the  individual,  been 
jaModated  with  the  object.  Pis 
propositioDi^ng   centre    in 


Fig.  266. 


6U 


FOCAL  DISEASES,  AOCOftOOtO  TO 


which  the  phrase  is  formed,  ita  lelatioDa  with  N  uiii  S  iMiig 
Bufficiently  deiur." 

According  to  this  scheme  leuon  of  the  uuniDg  cmtre  X ' 
would  cause  looa  of  the  memory  of  nameB  <h-  nouoa,  Innif 
the  pntieob  able  to  exfinsw  himself  imperfectljr  In  wonU  iiMb- 
c&tive  of  relatioDS  and  attributes. 

LeaioD  of  F,  the  propositiooisiog  centre,  would  ruidartlH 
patient  uaable  to  construct  a  sentence  although  retaiittAg  Ibt 
use  of  names.  This  condition  is  illuatr&Kd  by  tb«  patient  vbo 
could  say  "  brother,  brother — New  York — America — two  bfr^ 
tilers — America — brother," 

Lesion  of  vn,  the  channel  oF  communicfttion  betw«ra 
Tifiual  perceptive  centre  V  and  tKe  namiog  centre  N, 
explain  cases  of  word-blindness;  white  cases  in  which  the  lenna 
is  situated  in  the  auditory  perceptive  centre  A,  or  ita  line  of 
communication  (an)  with  the  naming  centre,  would 
cases  of  word-deafness. 

When  the  leHioD  involves  more  than  one  of  the 
centres  or  their  lines  of  communication  with  the  nainitigi 
it  is  manifest  that  complica.ted  disorders  of  speech  will  aciM. 
difficult  to  analyse  into  their  aeparate  factors.  What  has  fast 
been  said  with  regard  to  spoken  speech  may  be  czteudeil  M 
writtuo  speech  and  intellectual  pantomime,  inasmuch  as  all 
forms  of  intellectual  expression  are  osaally  involved  io  tki 
disorder. 

1  have  so  far  endeavoured  to  give  a  saocinct  aoccaot  <( 
Dr.  Broadbent's  theory  of  aphasia,  while  making  use*  as  mvA 
as  positiblo  of  his  own  words.  It  would  be  companUiTsly  Hi; 
to  criticise  this  acheiuc,  but  not  so  easy  to  coostroct  a  belter.  I 
(io  not,  for  instanco,  liko  Dr.  Bnxidbeot's  ate  of  the  fkttm, 
"perceptive  oentrc."  If  I  look  at  a  patch  of  yellow  cokmr 
before  me  and  perceive  that  it  is  cauwd  by  what  I  koow  m  la 
"  orftoge,"  it  i«  because  along  with  a  vivid  sensation  of  colonr  I 
feel  a  faint  revival  of  tactual,  gustatory,  and  other  ■anaatioM 
previously  experienced  in  conjunction  with  a  similar  nnmtiM 
of  colour.  If  I  stretch  out  my  hand  and  find  that  the  fiual 
tactual  sensation  I  feel  along  with  the  visual  seosatioo  osnaM 
be  converted  into  a  vivid  sensatioa,  ]  call  the  pat^  W 
colour,  not  ao  orange,  but  an  illusion,  and  I  begia  to  tbok 


THE  LOCALISATIOK  OF  THE  LESIOH.  688 

thai  015  senses  bare  played  me  false.  The  pfa3raical  coire* 
lative  of  a  percepUon  must,  therefore,  be  oxcitatioD  of  a 
portion  of  tbe  cortex  of  the  brain  in  which  all  the  sensory 
ioleU  arc  rarioasly  combiDc<l.  and  would,  therefore,  correspond 
in  the  diagTBm  to  Dr.  Broadhcut's  naining  cootre,  wbilu  his 
perceptive  abould  be  described  as  sensory  centres.  On  tbe 
other  band,  I  see  no  good  gruunde  for  postulating  tbe  exigence 
of  a  Darning  as  distinct  from  a  perceptive  centre. 

The  process  of  namiug  demands  a  large  increase  in  tbe  size 
of  the  porcepttre  centre,  but  not  tbe  existence  of  a  sepanitc 
centre.  Suppose,  for  iostance,  again,  tbat  I  have  an  ocular 
peioeptioa  of  an  orange,  tbe  prcseutativc  clement  in  tbe  cog- 
nition is  a  vivid  feeling  of  a  yellow  colour,  and  the  repre- 
■entative  elements  faint  revivntn  of  previously  experienced 
feelings  of  touch  and  taste.  I  now  close  my  eye  and  hear  the 
word  "  OT&oge"  spukeu,  thu  souud  of  tb^  word  forma  the  prcsen- 
tative  element  of  tbe  cognition  arouHi-d.  whila  tbt-  repreeeiitative 
■IsowDt  as  before  consists  of  faint  rovivals  of  toucb  and  taste, 
and  of  sight  aUo  now.  The  process  of  naming  is.  therefore,  a 
methwl  by  means  of  which  artificial  symbols  are  linked  on  to 
groups  of  previously  experienced  feelings,  and  although  the 
exercine  of  this  function  demaadH  a  great  extension  and  com- 
plication on  the  perceptive  centre  of  aaimaU,  yet  it  does  not 
demand  the  formation  of  a  st^parate  ceutre  for  its  exercise. 
Agoin,  I  hardly  tbiuk  that  Dr.  Broadbcnt  has  shown  KufBcient 
grounds  for  assuming  the  existence  of  a  distinct  propositionidng 
ccDtre,  but  I  i>refer  not  lo  enter  upon  a  criticism  of  tlm  portion 
of  bis  schume. 


b.  Letwwt  in.  the  Area  of  DiMrUnUwn  of  the  Po^erior 
Cerebral  ArUrif. 
Tbe  posteriOT  cerebral  artery  supplies,  as  we  have  already 
saeOf  tbe  temporo-epho&oidal  and  occtpital  lobe«,  with  tbe  ex* 
oeptioti  of  the  supenor  tempro-fiphenoidal  convolution,  which 
receives  branches  from  the  Sylvian  artery.  The  experiments 
of  Ferrier  auU  othere  appear  to  show  that  tho  functions  of 
tb«  cortex  of  tbeae  lobet  ore  purely  Ronsory,  aud  that  it  is 
directly  connected  with  centripetal  fibres,  and  only  indirectly 
with  oeatrifugal  fibres  through  tbe  cortex  of  tbe  parietal  lobes. 


«M 


FOOU.  DISEASBS.   AOCORDIXO  TO 


Ducase  of  the  cort4x  of  the  t«mpoTO-8pbeDoidal  and  oed; 
lobes,  however,  does  not  gWe  rise  to  looLlised  motor  dutnrbiM 
and,  ooDtrary  to  what  the  resultu  of  experiments  oo  aoiioili 
would  lead  us  to  i>xpect,  dtittinet  sensory  dinorden  mre 
wanting.     lieatons  of  theae  lobea  are,  as  a  rule,  UU«nL 

Lmant  of  tkt  Ocaipital  Zo&«.— P«rrior  qwAm  *  «Mt  npOfM 
VftuttiAt  of  jelloir  )!oft«Diiis  of  th«  right  oocipiUl  lob*  aad  of  tba  UrtBHt 
kHp«ot  of  tho  luft  lobd  (quadriUtenJ  l<>l>al«).  Th*r*wuo«itb«rdi«Mriwi( 
mottoD  nor  wimatinD,  and,  with  the  exception  of  coondenbla  IteWadt, 
there  were  no  symptonu  of  m  c«reln»l  (iffection.     Pitra*  rvpcttBAew 
ill  which  no  uIkiomm,  ths  siu  of  ■  bHlinnl-liall,  furnwd  in  tl»  partfltDr- 
inferior  aspect  of  th«  bmiQ.     Tboro  wcrw  do  MOWtrjr  or  motor  dlporJn 
DMntal  ohtuwDMH  being  the  only  indication  of  &  oarabvsl  Moo.    Is  i 
«iu>o  whioh  camo  to  tha  post-mortou  tnHlo,  «rlwn  I  wm  pttlhologiat  1ft  tk* 
Uanohoater  RnyiJ  riidrmiirjr,  a  tnuitutic  abao«a^  about  tba  ttii  «f  * 
hea^  egg,  occupiod  tbo  ri^ht  occipital  loHo,  do-Arnyiog  o«*ri]r  tbt  «Wt 
of  fta  whitit  Mibiitanoe.     Dr.  Drmohfald.  who  Mv  thaiwUeakdarioKlifci 
aaanrod  mo  that,  with  ths  exoeptioo  of  t4iaporarr  hypwithaia  «f  ttt 
left  Bide  of  the  body,   there  wm  DO  diaorcter  of  the  powil  or  ^"^ 
Miuea.    Th«  (latient  solfenvl  from  doliriun  and  gaoeml  eoavoIrieiMi.  b* 
these  aymptomo  were  jirobahly  due  to  tho  pnnnKo  of  mantiagiti^  abb 
had  apivMl  ovar  the  oooipital  and  parietal  lob«a  of  both  hamMpbam 
Ikfany  aimilar  c*«m  an  recorded  (Oull,  Etodnotlat,  Pltrm).     Ifwc4  neak 
a  caie  of  cootuaion  of  the  right  occipital  lobe,  followed  b;  effiuMO  Me  At 
membranwi  and  aoRentng  of  tha  oortax.  without  anjr  MIU017  nr  tntiv 
diaordem. 

In  a  case  reported  bjr  Seatjtf  there  was  an  abaoen  in  aaeb  qeri|iMii 
lobe,  hut  III)  Hennory  didtuibanoea  ware  preaeot  darn;  Ufa.  dwat 
baa  ebaemd  outaneona  formication  and  othar  panaatbada  io  com  rf 
aoRening  of  the  occipital  lol«fi,  while  UugUuiip-JaehMB  aod  DaalMi 
believe  that  disease  of  the  porterlor  lobes  ie  mora  frvqaantlj  aaoddil 
with  mental  dflranfEeneat  than  diaease  of  ether  pMta  of  tbe  Inia 
Hnghlinga-Jackaoo  also  thinlcs  that  discbargiug  lesioaa  of  the  ri^ 
oooipital  lobe  are  more  apt  to  give  riw  to  ookxmd  vinioo  ani  iMw 
ocul&r  apectra  than  diaeaso  of  the  left  lobe.  Farrier  q«o4aa  tb 
following  oaae  from  Abereroubie.  A  boy  aoAfed  from  an  ii^jmy  ^ 
the  head  eanring  depreaaion  of  a  ooneidecable  portioB  of  the  rifU 
parietal  bon«,  the  depreaaed  poction  Ixin^  forced  tbnmgh  the  dan  aMV, 
and  driven  inwanl*  upon  the  brain.  He  had  [Mraljaia  of  tha  left  «b 
and  anuuimfti*  of  the  left  ay«.  On  the  depnaaad  portion  being  leniaiiil 
the  pamlyniH  was  greatly  diminiahiyl,  and  the  eye  recovered  a  Bueildwrt* 
degree  of  riaion.  On  the  third  day  after  tbe  operation,  the  woond  ia  Of 
dura  mater  wsb  inflamed,  with  oooiidetsbk  twBiAurtioa«  and  liwnedlatdy 
the  left  leg  aod  arm  beeame  paialyeed,  tiu  pua^jife  bilag  pwcaWIg] 


THE  LOCAtlSATION  OF  THE  LESION. 


635 


ootivnlnons,  uid  Uw  leFt  eye  agun  bectnio  anuiurfttio.  He  had  A«qiteat 
fiutiTuItiuiui  iif  the  rtfloctod  DXtromitaos  for  serural  days,  the  right  side  not 
being  in  tho  loast  aS«et«cl,  whan,  auppurattoa  h&Tiog  takoii  |)la<!«,  att  the 
^mptooLi  subeiilad.  It  in  very  ymhiAAn  that  the  ddpruHioii  of  tUo  skull 
ia  Ihk  OBw  had  extandod  bej-^nd  the  rantor  area  cj"  the  c«rti.<!K  Ut  the 
ugolar  gyros,  aiul  oompremioQ  of  the  latt«r  would  i>mbabl7  snfficv  tp 
■xplaia  the  taiuporB>y  MuaiirotUH  of  th«  »])|>cu(ite  eyn. 

It  has  beao  stated  by  Bantiao  that  vision  in  ayA  to  be  impaired  on  tho 
«de  of  the  motor  paroljrsiH  in  caam  of  thniraboms  of  the  iioHt«rior  oercbnl 
«rtei7.  Flinituvr  has  observed  uiiilatoral  affootions  of  Mgbt  in  casm  of 
getwcal  paraljTKia  of  the  Lckgane  iu  whii^ii  the  occipital  lobM  were  speclAlly 
inrolrod  Id  th*  diasase.  A  tnix«t  important  case  iii  this  oonnoctioo  haa 
hsMi  Tvportwl  by  Oljpno,  iu  which  the  patient  becu-me  sudduiilir  ftod 
oompl«t«ljr  bltud,  and  in  which  a  dot  wait  fuiind  occluding  Uiu  posterior 
oHvbntl  artvry  of  the  left  aide,  oatuiing  eit«naive  Boftening  of  tlie  left 
occipit*!  aiid  temporo-ttpUcDoidal  lobes,  Iu  the  caue  of  irord-bliudnesft 
ot— ryd  bj  Broadbent,  ai]<]  which  «-i»  have  already  reported  in  full,  tho 
toportant  lemon  was  fuuud  iu  tb«  r«giou  of  the  angular  gf  nui  and  supm- 
mar^ual  loliale  (AV^.  267). 

Via.  267. 


Several  caws  are  mentioiiiMl  bj  Nothiiajtnl  in  which  dinettMi  of  the  occi- 
pital lobe  vaa  aiaoeiatod  with  bilateral  hemiiina|titii%,  htit  in  i»o«t  of  thMO 

:  ooea  tho  diooaM  of  the  heiiiifl{>hurt:  vrnt  ikvuiciittail  with  an  nffoctioD  of 
the  aptio  thilftiniuL  Rat  the  aztemal  goniciilftt«  hndy,  in  which  the  optic 
tnMt  tflnoinatoB,  la  no  liable  to  be  implicatod  in  losiooa  of  the  nptio 
ihai&moi  that  no  oaae  in  which  the  thalciniuii  m  ext«naiTo!y  involved 

^  akng  mtb  the  occipital  tobe  poaaeaaos  anj  value  for  the  deterTalnii.ttoii  of 
llua  qoMtioo.  Eran  larife  tumouis  of  the  occipital  lobe  which  might 
injofs  the  exLen^al  genictiljite  body  by  compronsi^o  do  not  nffnrd  trunt- 

,  vortbjr  ©vidBnce-     In  a  case  de«orib*d  by  Pooley,  there  wae  poreaiH  of 

I  tbe  fishi  half  of  the  U-dy,  diminiahed  aeosibilitj  of  Iha  right  ana, 
,a  ■faaridy'deaued  right-eided  bemianopaiaof  both  eyeo.    A  tiiinour 


886 


TOCAL  DISEASES,   ACCORDDiO   TO 


was  foniid  in  tbe  left  oocipiUl  k>bo ;  but,  ia  kdditiaa,  tiw  hft 
thalunus    and  tbe    aorroundiii;   cerebnl    mibsUnM    wan   oocofMrff 
softened.      An(>tlier  oam  is  deeciibed  bj  HiracfaWqti  la  ubiob  IWi 
were    aiibiuia,    rigbt-tldfld    hemtporeBU,    and    rigfat-sidcd    hentiuMfriL 
A  tuinniir  vu  fouud  ia  iho  left  «<«i|jit«l  lobe,  samnuMled  b;  teltmti 
tjjwiic,  wbiclt  oit4i»<lu(I  to  the  ofitic  tlimlMsua.    It  ta  dUSouh  te  on^ 
stuul  how  the  oiteniKl  geokulitte  hvAj  Mold  eaaftpe  'btHag  iJwtwti  k 
each  ti  case.    Wwnicto  repowtit »  can  in  whieh  tbe  ejinptoiDa  eorafetalrf 
aphui^agrapbia,iilezia,andrigfat-aH]odb«tiuaoot)«ia.  Esteoatn eoftcniif 
wu  fouDd  ia  the  caaveiitf  of  tho  Isft  h«mifpbevi.    Tbe  ana  of  ■afteciif 
moh«d  poateriorlj  3  cm.  behioil  su  ideal  lit>o  drawo  rerticaU;  downev^ 
ftom  the  parietO'^OGtpIUl  flsura ;  euperiorly,  it  was  limited  by  the  biBi' 
parietal  soleua;  aot*riarl]r,  it  exteuded  to  tbe  asoeudiii)cp«ri«ta]ea)Te- 
tution  above  the  Sylvian  Aiuiare.and  involved thesoperior  loiddle teopw- 
Bph«uoi<]&l  coDvolutioDH  below  it.  Tbe  aoft«ntng  pettetrated  into  tbe  wbik 
substance  till  it  Twwhed  tbe  ependfoia  of  the  poaterinr  b«Tn  of  tbe  kiml 
rentriclft.    Tho  loft  corpita  itriatatn— both  the  caudate  and  lealieiAv 
DDolei — was  softeaod :  but  the  optic  thalamtui,  tbe  genioulala  bod j,  te 
oorpora  ^ludrigeimna,  and  tbe  optie  tracta  wen  nonnal     Batinpfta 
mentioDs   a  oane  obaerved  hy  Jaoobaon   and  Jaffa,  in    which  tbe  kit 
halves  •^^  tW  fieM«  of  vimoo  b«<«in«  sndd^nly  to«t    Tha  affoetioa  of  ii|^ 
continued  unchaniteil  until  death,  which  occurred  afowmotitba  later  ftw 
Borti«  regargitation.    An  apoploctit  oyst,  tboat  the  mat  of  a  wabutl,  ew 
found  in  the  aubatanoe  of  tbe  rifflit  occt[ritaI  lobe,  and  a  small  bnotf- 
rhagie  fooua  to  tbe  contro  of  tbe  riglit  optic  tfanlamna.    Kothnagel  leporti 
a  CMe  of  left  brachial  monoplegia,  witb  right-aided  faemlanopaia  tit  baft 
«jml    Th(<  aiitoitsy  revenlod  caroinot&A  ef  the  paoeraaa,  witb  mooniuf 
deposits  in  tbu  liver  and  atomach.  The  right  bemisphera  ^weBtaJjaPtw 
softening  of  the  middle  third  of  the  ascending  frontal  and  parietal  eiB- 
voIutioDB,  which  penetrated  deeply  into  the  undiirlring  whit«  aafariMO 
and  into  thf  superior  parietal  lobule.     About  tbe  mm  of  a  faaaal^nl  4 
tbe  ooQToIuUauH  on  csicb  fiido  of  the  intrnparietal  Boloua  wm  of  a  gnr 
yellow  colour,  while  the  softening  ext«uded  in  tbs  nndari^iagwhiia  snl^ 
aitanoo  down  \a  tho  wall  of  the  deaoending  bom  of  tbe  laUnd  natrii)» 
The  third  oeoipital  oonvolution  of  the  right  bemiirphera  waa  alae  anftaoil 
A  ipot  of  rod  eottenlng,  about  tbe  eias  of  a  haael-nutt  was  obMrrad  is  ft* 
right  optic  thalamua.    In  the  left  benuaphete  the  posterior  utrsBit;  ^ 
tbe  second  frout«l  conrdlution,  alpug  witb  a  small  part  of  tba  a4*^i^ 
portioa  of  tbe  aaeending  (Vontal  ooDVolution,  was  aoftMwd.     Aaolhv 
mmH  foeus  of  aofteoiag  was  (bond  in  tbe  anterior  paK  of  tbe  mtfmlM 
parietal  lobala,  while  the  whole  cortax  of  tbe  oedpiital  lofaa  maa  i  iiiinal 
into  a  avfteuod  mooa  of  a  dirty  jraUow  colour.    No  ebaagH  wore  nbwrreJ 
in  tbe  optio  nervM  or  tacttc     Siiftening  was  obesrtud  io  Iba  iabner  |M* 
of  the  ««rvical  onhtfgomiHit  of  the  epiaol  oord. 

Of  the  CAMS  just  mentioned  of  ilJiwiain  of  tbe  oodpit*!  lobai^  aanoittiJ 
with  bemiauopeia,  oa|f  oM  or  two  poasese  real  valuew 


P«<ilqr^i 


THE  LOCAUSAnON  OP  THE  LESION". 


687 


I  tluJaiuuii  mkI  stimnitiding  ccrcliral  HubatAuoe  is  liescribed  as 
beinjf  eitenairdj  •oftened,  ajid  it  U  diffionlt  to  undorstaDd  haw  the 
esUini«l  gcDicutftta  bodjr  could  dwnpe  uinlur  auub  circiininUnuoii.  In 
HiiMhlMr^a  cMm,  ttui  aofWiiing  which  miriMuikded  a  tumour  iti  Ibe  ooci- 
Cital  k>faM  «xt«odnl  M&u'ulli0u[)tio  thaLuuus;  iuid,agaiii,  tbo  tist«TiiiO 
|«deu]ttCs body  would  bo  vwy  Liable  to  b«  dwejuacl.  Wvrmulce'H  case  is, 
aa  Um  othor  b^nd,  toon  oouTimans,  bub  ovou  in  it  tbu  curinin  sthotum  is 
nMntioued  bb  botng  aoftaued.  It  w  Dot  contvinlwl  Ibat  ttLO  luirtuiiiug 
of  tbo  corpus  itriatiua  alouo  would  ocoouDt  for  tbo  bmuiouupaift ;  but 
it  iDUBt  be  mnembenHl  that  the  surcitigle  of  tha  0EHitl«t«  iiucleua 
pan**  ia  doac  pruxiiuitj  to  the  ojit^ru&l  gomouUtit  body.  It  u, 
bamtmr,  meatioaiid  specially  thai  the  geuic(il»t«  bodim*  wen:  huxltby 
Jb  this  CAW,  «o  (but  it  uiuet  be  ht^ld  to  favour  tho  idoa  ttiftt  huiuiftuopeiA 
BHJ  be  CftiMed  bj  diw5aae  of  the  occipiul  lube.  Baunigart«u'a  case  also 
point*  to  Uio  saoio  coQclu>)ii>B,  for  nltbougb  a  hmniorrha^c  (ocuawu 
found  in  the  oeotre  of  the  right  optic  tbaUiutui,  yut  its  amall  him  and  the 
poaitioo  it  occupied  noden  it  imjjrobable  that  thla  waa  the  cause  of  the 
hamiaiioiicda.  Nolhnasel's  ca«e  ia  not  above  auaiiiciou.  Tbe  red  npot  in 
lite  thalamut  i>«>bably  oocunod,  an  tho  author  suvn'tts,  during  tho  Uat 
•ItgM  of  life,  and  could  not,  tborsfore,  have  cawwd  tlm  heinUu()[>«ia ;  but 
the  ledMW  obMrred  were  so  estetisire  and  complicat«d  that  it  would  not 
be  aifs  to  attach  much  iniportaii>c«  to  the  case.  Of  tho  casce  juat  de- 
Bsribed,  thoM  of  Wemioke  and  BAumgiuten,  and  in  a  leea  degreo  that  of 
Nothnagi!!,  are  the  onljr  oatm  to  which  miy  iiii[iurtouce  need  be  altiichcd 
aa  indieatiug  that  biLat«nU  becainpopMin  rany  riaiult  from  dLaeaati  »f  one  of 
the  occipital  lobes,  but  these  cabbs  can  ouly  b«  rvgardod  Ba  B&brding  a 
pranimptiora  in  favour  of  this  Ai>ini»n.  It  in  nght  to  odd  that  Ballouanl, 
who  has  written  aii  admirable  mouograpb  ou  the  aubjeot  of  homiauoiwia 
fpom  ceraLiral  di»ea»e,  beliorox  that  tj^ii;ai  biliiWruI  hemiaiioptiia  may  be 
oaosed  b;  diaeaae  in  the  [lanterior  ^Mrt  of  tbe  hemisphere  a  abort  diMtauoe 
behind  the  radiationii  of  Gratiolet'it  fihrea.  Ttua  questioB  must,  th«Mfar», 
bs  leli  for  futuro  oberrrations  to  ilvtttnnine. 

£«ti0iu  />/  tAd  T«mporo-*f}htixaidiii  /^fx.— Leaii^Ds  of  the  tt^mporo- 
•pbenotdal  lobe  an;  oftco  latent  as  roganls  ajnnptouut.  Ciiarcot  and 
Pitne  i»|iort  a  caae  wbicii  pTMOut«d  no  aeiuorj  or  motor  disturbanoM 
daring  life,  but  in  which  jreltow  softening  waa  found  after  death  iii  the 
cortex  of  the  right  bemuphere.  The  di»oa>wd  anui  occupied  the  posterior 
half  of  the  lalaud  of  Reil,  the  [Kviterior  half  of  the  second  and  tbini  teni* 
pefO^htiDoidal  coDvoIutiona,  and  the  lower  two-thirds  of  tbe  luferior 
perietfll  lobule.  Ferrier  i>U«ch  th«  umUtory  ceutre  iu  thti  first  miA 
■eeeod  tainporo-cpheooida]  eonvulutiona,  but  there  is  no  eaae  on  record 
in  which  disoaae  of  tbo  cortex  of  the  bralii  baa  gir»n  riue  to  dcafucogb 
Tbt  KHSOD  of  this  is  that  hearing  ii  bilaterfilly  a>wociate<l,  and  mu  long  aa 
one  heous^eni  is  unafiecteJ  the  auditoi;  nonso  remains  unimpaired  or 
only  slightly  v»akeued.  The  couditioo  already  tk-Jwritwd  us  wordHleiifnesa  , 
aworer,  naeociated  with  discAiw  of  tbo  first  and  u  portion  of  Um 


688 


VOCAL  DmSASBS,   ACOOSDING  TU 


aecond  temporo-aplienoidal  coDVolutioD.  lokcaseof  tbhi  kiodtvporUjIi; 
WeruMlie  tlwra  «m  »on«i)iog  from  thmnboaiv  of  thd  fiiat  mad  m  Ivy*  pr 
tioo  of  tb«  Mcond  MmpuroMpboDoldAl  oonrolntioa  of  lbs  l«ft  haBt^tat 

Fio.  30& 


l\ 


V 


7 


-<  ^ 


Fia.  sssi 


(/y^.  S68).     Dr.  Sbuttleirortb  nporto  &  caae  of  aiicroecplulia  ii 
ill  nhich  bearisg  wu  dull  during  tifo,  and  »t  Um>  «Qt^Mjr  rmimmltol  i 
cinicy  of  Ui«  occi[)iUl  aiid  t«iiit>un>4pliflDoi(Ul  lotm  was  fuund. 

Ttio  OMv  of  a  wouuui,  mgtA  1U  ymaty 
u  d«Mrib«l  hy  ritraa,  in  vhkfa  imlt 
o«ouirtd  k  f*<r  boun  aA«r  wi  ftfnf^ 
ticatuck.  AlUiough  tbanwMtlBHd 
c<i|n|it(t«  hiiwtrf  TnntriniinDMn  tna  ikf 
tint,  tbers  «m  ti<>  juralTria  of  u;  iT 
Um  timtM^  inMomcb  m  «Q  of  Ika 
wan  inoradon  ^riii|r  nfrnin[ljr  [iliiibd 
TboK  «rM  »o  iwUtivii  of  Uw  bo^  tr 
ilcTiaUoii  or  the  eje«.  tnit  Uia  left  pjJ 
WM  nort  diUted  Uiu  tba  lij^L  Al 
the  Buto[Mf  a  reoouL  hMoioRtMCB  vw 
found  ooeupyiog  Ibo  wbola  uf  Um  wIom 
mbatwMa  of  ib«  •phsnottUl  IoIm  '  Fi§. 
980}.   TbflbaaalgauslJawvraUtlt 

Ferrior  fouuJ  tlut  d«*tnicUaa  of  I 
n<Ai'<ni/t(M  corpMi  Jminomw  ca 
of  amell  ou  tbo  mnu  dtk,  wbi 
A4mMIIUMlA«(M  ft<MB  fiiiinw  irf  Ik' 
imtarior  Slim  of  Uu  i>t»tmrim  m^ 
UMot  of  the  intMDiJ  cajMuIa  Um  I)m 
uf  btuell  ia  (mi  tb«  aide  oppoti(«  tha  Iwiou.  Aa  alnadjr  deachtjvd.  iW 
otfaobor;  nvm,-!)  hu  two  roots,  oiM  of  wliloh  ptMM  dirvotly  to  the  «il»cuk« 
Kgiao  of  Um  aaaM  wdo,  wkita  Um  oUior  cr»Mn  oror  tu  tbe  0|)pc«lu  haw- 


THE  LOCAUSATION  OF  THE  LESION. 


639 


I  bhnnijth  the  atterioroomoiliiuiraof  th«  thini  vontricle.     It  u  uoC, 
ir^  pnbable  that  uuilataral  cortical  due«ae  will  caiuo  oampl«t« 
tfitwroift  uf  oDo  nootriL 

TIm  aiioamw  of  tba  op|)OHit«  noKtril,  th«  reault  of  dUesM)  at  the  [Kwt«- 
rior  fibres  of  the  iuteruol  vapeulo,  is  couswl  i>artly  by  the  loao  of  common 
•maUiuD  iu  th»  dom,  troo  wrcmum  of  the  fifth  nurve  (rem  tho  (xirt«x, 
pkI  partly  by  dcatnictioa  of  tha  flbraa  of  tho  iutonial  root  of  tba 
DttKlacy  Mrro.  LoM  of  staeU,  eitho*  atooe  or  aasociatwl  with  dimi- 
nabOQ  of  umXo,  not  unlraqueuUy  inulta  from  btoira  ou  tha  occiput  or 
ractex  of  tlw  head.  Dr.  U'j!«  hw  deacrib«d  several  oawa  of  this  Idad, 
tad  hi  tbiulu  th«t  tha  tiyiapUtiu  u  due  to  iujury  of  tho  olfactory  uerv«s, 
Dulbo,  or  tracts  by  counteratroko.  Wbeu  the  occiput  raceim  a  blotr, 
the  »)eaU,  l>«iug  «U«ti<;,  may  jiuld  without  frauturv,  and  tbv  whole  of  tho 
Mnbs^l  mass  a  tboii  thruat  fonvarda  ag^iust  iL«  anterior  wall  Tbe 
MAjioro-itphMioidal  lobe  must  bu  th«  lini.  to  impi&ge  sgainflt  the  wiiigs 
}t  tba  sphBQoid  bou«,  aud  the  furwitrd  movemeat  of  thia  lobe  ia  auddecdy 
orested,  while  tb<i  upper  part  of  the  <wrebmm  is  allowed  to  move  forworda 
inltl  ibis  arreated  by  the  frouul  bono.  It  ia  evidoiit  that  Uiu  aiiddeu 
inwt  of  Ibe  temporo-tfpli«noidAl  lobo  muitt  toud  to  ru^'turv  th<;  r(x>t«  <i 
h»  (rifaotory  tnct.  The  forward  luuveuieiit  of  the  up^r  portiou  of  the 
crelruiu  will  aUo  tend  to  carry  with  it  tho  olfactory  bulbo,  aiid  tliuato 
Qptura  tho  olfactory  uttrvM  as  thoy  i>a88  vertically  tUruugh  tlin  cribrifonn 
ilat*  of  tha  ethmoid  boot, 

A.  cava  of  abaOMs  of  the  t«mporo-spheuaidal  lobs  la  n»port«d  by  Dr. 

UyuD,  in  which  tha  moat  promiueut  Byoi^itom  was  oomploto  aiin«daia. 

The  ejtmptoma  oQuaiat«d  of  soiaea  in,  oiul  partial  deafneaa  uf  tho  loft  car, 

Aiblf  opia  aud  dr»ohfOQiato|»iA  of  the  left  eye,  neuralgic  paiue  over  the 

Maponl  regiou  aud  alj.ivo  th«  left  oar,  the  acalp  Iwiug  ewolleu  over  those 

Igiooa,  a  crop  of  her|jo«  ou  tho  left  ala  aui,  parana  of  the  left  maasetar, 

bgbt   facial  paralynta  of  the  left  side  of  thu  budy,  loan  iif  tante  over 

he  left  bAlf  of  tho  toagoa,  ptoaia  of  left  eyelid  with  contraction  of  the 

uptl  OD  ihat  aide,  double  optic  ueiiritii,  complotc  aitoamia.  and  qatui 

jatatical  attacka.     At  the  poat  mortem  a  ciruuinwnlintl  iiImccxh,  >tKiut 

iro  iijcboa  iu  luugth,  was  fouud  aituated  ia  the  aotcriar  port  of  tlii;  drat 

Kn|)an-8pheaoidal  coavolutiou,  aud  extending  tnwarda  aud  dowtiwarda 

nranla  the  base  uf  thu  bniiu.     With  tba  exceptiou  of  the  aaosmia,  the 

■ftH^g  Byiaptomn  iu  this  coae  were  caosed  byoompreaaiau  of  tho  orauial 

arvea  at  tho  baw  of  the  brjiiii  iu  tho  aiituriur  Timjm  of  tbo  nkull.      Dr. 

ijjiti  appean  to  tbink  that  the  lom  of  smell  was  oaiued  by  implioatioD 

r  the  cortical  oeiitrei  but  it  ia  more  likely  to  have  boeu  caused  by  com- 

FMaioa  of  tha  external  root  of  the  olfactury  tract  of  the  samq  aide  at  ita 

not  of  oiitmuoo  tuto  tho  L(iin|)onKaphoiio<ida]  loljo  aud  of  the  fibn* 

htch  cnMN  III  tho  auturiar  comuiiiuiiira  of  the  third  vuutriolu. 

Farrier  localiaea  the  cautre  of  taotile  MtisiU!ity  iu  the  bippocampflt 
igtou,  but  unilateral  Isaioua  of  tbo  hippucauipal  iwurolutioua  are  not 
lUwn  to  ^irodiicv  auaiathaaia.     Iu  the  c^aaaa  uf  diseaie  of  tha  iphenoldal 


«D 


rOCAL   DISEASES,  ACOORDIBtO  TO 


lobe,  io  which  thoro  waa  looa  of  taotila  aenaibilit/,  tha  latler  wi 
[>rob*blj  etaaed  hf  dJMiwft  of  Ui«  Mtwot^  Gbro»  of  the  iotcrual  onfaak 
The  tilppocumpUii  ia  lfei]ue])Uy  (bund  atrophied  la  B|il)cplk>i  (iUjuOi 
but  the  leaioQ  haa  not  as  yet  b««n  ooaneeted  with  any  ti{Ma^  aymptea. 


e.  Lmona  in  the  Area  of  Dietribution  of  the  Antaitr 

Cerd/ral  AHery. 
LcsiuDii  ill  the  pnc-frontol  rvgiou  uf  the  hemispbeiv  Hrewd 
to  be  latent,  although  it  wotild  be  more  correct  to  aay  thu  l^ 
<lo  uot  give  rise  to  muDtrcst  aeosor/  or  motor  disturbaooai 

Oa«  of  th»  tDovt  nioulcabla  ouu  on  moofd  of  ti\juT7  to  Um  tmM 
lobo  IB  thkt  kiiown  ua  tba  Araoricui  crowbar  nue,  doacribod  ta  6»Htii  tj 
Forrier.     Ad  iron  tttr,  3fl«  7in.  ]oag  ind  l^n.  ia  (liAioetor,  uid  Mi|tdB| 
13jlb«.,  propcUoii  witb  it»  |Miut«d  vud  fir»t  by  fto  oxplowoa  which  ooeaoil 
duriug  bUatdng,  eut«T«d  at  the  left  ftngle  of  th«  patwnt's  jaw,  «ad  {aad 
thtuufh  th«  tu})  of  lib  boad,  near  the  ugitt«l  auturs  in  th«  frotalil  n^ 
The  [iHliecil  wa~  f»r  «  mouieut  hIuiiuoiI,  but  Ui  au  huur  aft«rwv\l«  he  «■ 
ablo  tv  naU  up  ft  lo»g  flight  vf  atairs,  atw)  giro  the  sarpwa  «o  iaUUi|iU) 
accuunt  of  bi»  ii^ury.     Ho  reoowrDd,  after  {iiutncted  aii9i>ri»g,  aotl  iind 
upffordx  of  twelvo  yoara  Afterward*.     But  altbougb  the  11^107  bed  Mt 
left  peruutneut  traoea  in  the  form  of  jMraljrrii  or  asDeorj  dlaturinA 
UlU  mau'a  diepoeitbii  aud  character  wore  ubaerred  to  ta«T«  iud«fpat» 
■arioiifl  change.      Dr.  ILirluw,  wbu  rv[>urt«  tbe  caae,  eaya  ;    **  Hia  is- 
|>loy«ni,  who  rogorJcol  hiia  M  the  mo«t  efficient  foirioeo  iu  Utedr  ^Kfif 
previous  to  hia  injury,  cotuidered  the  change  in  bin  uiin<l  au  marked iM 
they  could  not  give  him  bin  place  ^aiu.   Ho  is  fttful,  imvereut,  tt»de]|tii| 
at  times  iu  the  groSMet  prarauity  (which  wan  trac  prmriouely  bvi  coiCilt 
raaoiftetlng  but  tittle  defereooe  to  hit  fUlowa,  Inpttieatof  MrtnMW 
a>lvice  when  it  conflict*  with  hitt  deoinM,  at  tiraee  pcrtinoomiMly  obrtWit 
yet  QApriciotu  and  racillftting,  deruiag  many  plana  of  future  openUM^ 
wbioh  are  no  aooiKw  arraugod  than  tbey  ant  abaiMloned  in  torn  fbr  othn 
appearing  mors  feasible.    A  child  in  hit  intellectQal  eapacltjr  and  miai- 
feetatiofts,  he  has  the  animal  paaaiona  of  a  eirong  mau."    Smamom 
casee  might  be  cited  of  jnjurien  aiid  UeanoiiMi  rf 
tbe  froutal  loU»  fniui  guu&hut  wouitda  and  etttf 
aeoidaota  without  any   rery  naaif^  pw  lawial 
aymptoma  being  prodnoed  ;  but  tbe  rwailw  ia  R- 
ferred  for  the  delaUa  of  aueh  eaaw  to  worita  Itti 
tboee  of  Perner,  Onueet,  Notbo^el,  PUrot.  mi 
Boyer,  which  arv  apaaially  darotod  ta  Ibe  anlfMl  d 
oerebnil  Ic-coliastioo.    Senntl  oaeee  of  iqlwydf  M 
fKuttal  lobee  without  aen»u*7  or  mtAor  attettM  *■ 
oollactedby  Fitrea.     Ia  a oaee  reported  byClvtfl 


Fie.Srik 


and  i^tna^  a 


after  eating  a  \Mrga  1% 


THE  LOCALISATIOM   OF  THK  LKSIOK. 


6-tl 


ait,  mffertd  from  rapeatod  Tomitiog,  anA  di«d  two  dftja  nabM- 
qoeotlj.  Tbcro  was  no  tnux  of  paratysia  of  tho  fooo  or  upper  «x- 
nwmitUH ;  uid  nlthough  tfa«n  ms  parmiasot  ooatmeton  of  the  loww 
ciiivmitin,  tlua  was  miiSdooti;  uooonted  for  by  lookl  dinawo  of  tho 
MBkbo  Dcrvaa,  and  tb9  tambar  auUrgament  of  tha  ounL  In  tbo<  rlgbt 
hiiiaphTP,  imroadifltely  subjaoeut  to  tiio  anterior  extnmity  of  tb«  aoconcl 
fKKitalGoDirolntioii,a  baimorrfaagic  foouaof  tbe  sze  of  a  tiut  wm  fouiul. 

PitTM  d«schb«a  aoTeral  caMH  of  abwxca  of  tkc  aut«rior  lobo  of  the 
lifaiD,  ia  wliKfa  there  waa  entire  abaeoce  t>(  paial/tfc  HymptoruB  duriag 
lifc.  In  a  oaM  cf  »bec«tMt  of  IIjo  aut«rior  lobe  of  Utti  ritjht  heuiispbere 
nqwmoiug  upou  ii^tuy  to  the  orbit,  which  came  under  ay  obaervatiou, 
iuB  patient  laj  for  about  teu  daja  iu  a  itoouiclout  ooudittoo,  but  without 
laaifeatUV  anj  |>aralyi(ut.  Two  dajra  befora  death  liligfil  twitching  waa 
■l»erv«d  iu  the  taft  fooial  mu«vlo»,  which,  ui  tho  counw  o(  aome  bouia, 
iiteoded  to  th«  arux.  Two  il»yn  aftor  the  twitchiug  umveinenta  began  the 
ha  patieut  had  a  general  oouvulaioti,  be«amo  oomatoae,  and  diM  aoon 
iWwanln.  An  abeoeaa  about  the  bjm  of  a  heu'a  egg  vriui  fouod  iu  the 
lUtanor  oxtremitjr  of  th*  right  hemiaphere.  Tbo  motor  ityiaptoma  which 
mwgTWwd  bobrv  death  in  this  case  were  doubtleaii  due  to  an  oxteoaioa 
t  aooaphalitis  aioood  the  primary  focus,  and  were  not,  therebn>  direotly 
uued  by  the  praeeocc  of  the  abnciMw. 

In   another  e&w,  which   cuae  ooder   my  ohaervatian,  the   patient 

%j  tar  a   periud  uf  tdii  daya  in  n  aomnoloiit  oonditioii,  but  without 

faMDting  any  paralyaia  cf  »i»a«atjon  or  motion.     When  loudly  naked  a 

Matiofi,  thv  patient  looked  up  and  gave  an  intvlligout  aimwor,  but  luuiM' 

lately  KlaiuKnl  into  tlio  aamo  aomiiolent  oouditinti.    Ho  iIimI  coioataae, 

ad  ai  the  autopny  a  tucmorriiagio  focus  about  the  eixo  of  a  pigeon's  ogg 

■a  found  in  tha  autarJor  extramity  of  the  centrum  ovale  of  the  luft 

mOKfimn.      Cgugonital   dc&cioucy  of  the  frontal   loboa  is   frequently 

Mtmd  in  idiocy.     Tbu  ttyiupUiius  which    characterised    the  c-mwb  of 

wmM»  of  the  prw-£rontal  rugiouA  that  camo  under  ray  own  obwrvatiou 

aiV  nwiital  1or|>iiiity  and,  towardb  the  tenuitiatioo,  Horanuteiicy,  &Otu 

bieb  th»  pkltt-iut  could  uuly  tra  Iviupuranly  uruivwd,   aud  which  gta- 

2Sily  iovreaWHl  to  coma      iJr.    Crichtou   liniwno  liim  il.mwu  alt«titlon 

I  Um  lact  that  during  the  oarl/  Mtogc  of  genoml  paralysis  of  tho  iuaaae, 

Imo  Uw  CDiiTolatioua  of  the  frontal  lobe  are  particularly  apt  to  nmiiireHt 

^nantiTv  ohaugoe,  the  charaotariatio  aymptoaui  couaial  of  "general 

ItlaaBDeea  and  uont^adiiiiewt  of  mind,  with  impairuieot  of  attontion, 

Umaliag  with  u/wMy  and  dnuvinfu."    Tumoura  of  tho  frontal  loboi 

Itiob  apnng  from  or  reach  thair  inforior  aurfacoa  may  by  oomprwa- 

B  Uie  tuirrDe  which  paas  along  tbo  base  of  the  skull  givtt  rise  to 

fectiooa  of  the  seusea  of  smell  and  sight,  ssuiwry  disturbancoB  in  the 

jfoo  of  diatributiua  of  the  hfth  nerve,  ur  paralyms  of  the  uerroa  which 

iM  along  the  wall  of  the  cavernous  aiuuH  ;  but  caaee  of  tliia  kiwi  will 

sabMquouUy  cooaidcicd.     Focal  lenioua  of  the  ^nu-fcontol  may  alao 

ndiug  baclcwarda  to  the  frontaL  region*  occanionally  d)]t49TUiue 


642 


FOCAL  DISEASES. 


irnta>tivo  or  {inrtiljrtiG  iielurbaDOM,  tho  riubcIm  of  the  foca  and  suck  t 
tlrat  implioated,  then  thoM  of  the  nm,  ukI  Ukms  of  Uw  lag  bst 
lasioiw  of  th«  |>rw-fro]ital  region  are  attended  by  active  deHriuiOi  or  i 
miBionB,icis  pmlwble  thattbe  prinuuy  foouau  mirrMUidedbjraiacntf 
leu  ilifToatnl  eiioephalitia,  or  at  leut  by  a  aoue  of  tiaeae  in  a  klala  ol  m- 
tatiou,  which  exteads  to  the  oortoz  of  the  nurtov  ana.  The  chandsMjt 
featurea  of  leuoiia  in  tlie  ime-frtmtal  repoa  cf  the  cort'jx  an  aflbnUd  ^ 
the  peycbical  diatiirbaDOas,  oonriitlag  of  demeDliA,  a|^tbj,  and  Koa* 
lency.  '^^'beD  oodtuImodb  we  pnsetit,  they  are  not  preceded  by  m  im, 
aud  the  ftpatmodic  {tbenonisiia  ore  of  dhurt  duration,  while  the  atiged 
iiiiwD»ibility  ia  oouiparutivelj  prolongeil. 


CHAPTER    Vra. 


(11.)  SPECIAL  COKSIDKRATIOX  OF  FOCAL  DISEASES, 
AOCORDINO  JO  THB  LOCALISATION  OF  THE  LESION 
(OonaoiD). 


1    LESIONS  OP  THE  BASAL    GANOLtA.   EXTERNAL   rAPSUT-R, 

AND    CLAUSTRUM. 

LcsioNS  of  the  basal  gauglia  have  alreatly  been  considered 
iDftgcnerol  tnnnncr  aloag  with  the  ntTectioos  of  the  internal 
capsule,  and  little  retnaiQ^  but  to  gkow  tLat  tbo8«>  liniiteJ  to 
die  ganglia  tbemHelveo  do  not  give  rue  to  decided  nymptoins 
during  life,  or  at  least  that  these  HymptomB  are  not  of  ao 
eoduring  character. 

(a)  Le9ion«  of  tke  Lenticular  Tfucleua. 

§  721.  Several  cases  are  now  on  record  in  which  tho  tcntioular 
nucleus  bad  been  fuuDd  at  the  autopsy  couvcrted  iulo  a  cytt, 
coQtaining  soroiis  fluid,  but  in  which  paralysis  of  the  opposite 
aide  of  the  body  hail  been  completely  absent  duriug  life  (Lupine, 
Qiarcot,  Notlinagel),  When  a  history  of  the  symptoms  can  be 
obtained  it  is  found  that  the  patient  had  some  months  or  yeara 
previouily  suffered  from  an  attack  of  apoplexy,  followed  by 
temporary  hemiplegia  The  patient,  however,  makefi  a  good 
recovery,  aud  the  cerebral  attack  from  which  he  ftuQered  may 
be  complotolj  forgotten,  so  that  tho  lesion  of  tbo  lenticular 
DQcleus  is  revealed  quite  unexpectedly  at  the  autopsy,  A 
woman,  aged  57  years,  su^Ttiring  from  tnfm  iUtrs<ilis,  w&s  umler 
the  observatioQ  uf  Notbnogcl  for  nix  months  before  her  death, 
during  which  tirae  she  had  do  cerebral  symptoms,  yet  a  diseased 
focus  WM  found  in  the  posterior  and  inferior  angle  of  the  right 
Uaticular  nucleus. 


644 


VOCAL  DISEASBS,  ACCOBDINO  TO 


In   the  case  of  pseudo-1>ulbar  poralyus  lUread;  clescribat' 
which  came  under  my  own  obeervation,  both  l«aticulv  iiiiela 
were  converted  ioto  cy%t»,  and  yet  there  was  do  panljsia  of  tlw 
extremitieK  duriug  life. 

Tumours  of  the   lenticular  uucleuf  generally  give  rin  U 
hemiplfgia  of  the  oppontite  side,  the  pgualysta  being  aoautim 
prvcvdtxl  by  spasmodic  coutraclions.     Speech  waa  affected  lo 
six  out  of  sixteen  caaes  of  tumours  of  tfae  lenticular  nndm 
collected  bjr  Ladame,  but  the  aizc  of  the  tumours  in  some  d 
these  C8fle6  precluded  the  idea  that  they  cuuld   hare  ban 
limited  to  tho  area  of  tbe  lenticular  nucloua     In  two  cwi 
there  was  difliailty  of  articiiUtioQ,  in  three  alowneei  of  ipMck. 
aud  in  oue  ouly  aphasia.     The  difficulty  of  articulatioo  pnK 
bably  depended  upon  compression  of  tlie  gcDictiUt«  tract  of  tW 
internal  capsule,  the  aphsuia  upon  nnultaneous  compruaioB  of 
the  geniculate  fibres  and  those  of  Ibe  corpus  callosum  wkki 
connect  the  posterior  extremities  of  tbe  third  fronial  cobtoIo- 
tiona  with  one  ariotbor,  while  the  alowiiess  of  speech  taigbt 
either  be  a  symptom  of  general  compreseioD  of  the  bruia  or«f 
special  compression  of  the  Island  of  Reil  and  tho  postefki 
extremity  of  the  third  frontal  oontoIutioD.    A  largo  tumour 
the  lenticular  nucleus  might  compress  the  optic  tracts  sit 
at  iu  oriijin  in  the  external  geniculate  nucleus,  br  an  it 
round  tho  eras  cerebri,  and  tliou  bilateml  hemiauopiHia  of 
opposite   Bido    would    be    presents     Tnmoant,  however,  whifl 
remain  limited  to  the  lenticular  nucleus  do  not  give 
decided  paralysia. 

Hie  cue  cf  a  vouau,  aged  30  yeua,  ui  dncfibnl  l>y  Furatmr,  lo  i 
two  ^nuunim  of  cblocal  luul  been  ^wa  w  a  bj^^uurtic  on  maxmA 
^iitirpcml  IUIUU&,  awl  wbd  miDitv*!  fniiii  iiyui|>tui]w  of  eldom]  pDMaii 
Slit-  IumI  rDjMatml  rigifn,  bmriug  of  tho  tctui-cntuxg  of  tbo  bml;,  pilfi^ 
tioii,  luxl  ueuta  indema  uf  tbu  luugs.  For  lome  da/a  «be  eain|UAUKiJ  •< 
genccnl  wtakmwi,  while  oo  «rytIieiuaUiiu>  iiru|>iiuu  apinand  urer  th« 
hodjr,  and  a  bed-«oiv  iir«r  Ibi'  aovrum.  PiuiuuMJuia  iiow  tngmnmmd,iKi 
the  j>at)«D(  died  aovuii  alujn  alier  tho  ailiuiuitttnlkia  cif  tbe  cUaaL  il 
the  auU){M^-,  bmidoH  thv  tiwinl  iti^in  uf  pDcimionut,  A  tclau^MlBlie  i 
WA«  fuuuJ  (i;,*miiu;tnciU1y  pbwed  «i  cacli  atd«,  koA  ooevppa^  iba  : 
of  Ui«  miiltUe  aud  intcrml  diviaioaa  of  tbe  toutioular  pooled  Ifaa 
diviaioQ  being  trtn  ou  balh  Hwlea 

Fbrstncr  aacribe*  tbe  feeling  of  general  feeUeiMH,  of  wkiti 


THE  LOCAL1SA.T10K  OF  TUE  LBSION. 


645 


the  patient  complained,  lo  the  toxic  aclion  of  the  cbloral ;  and 
evea  supposiag  (Uat  this  fcciiug  was  u  bilateral  hemiparesis 
caus«d  b;  tbti  tumours,  it  must  bo  r«men)bered  that  the  syinp- 
torn  only  appeared  a  week  before  death ;  besides  it  is  probable, 
from  the  position  of  the  tumourti,  that  (be  fibres  of  Iho  internal 
capsale  suffored  a  certain  aiiiouDt  of  injury.  A  somewhat 
similar  case  is  deacribed  by  RoodoU 

A  man,  a^^  30  yvan,  iwEuplaiaed  of  paius  iu  the  neck  and  head,  ami 
nf  a  fMliof  of  vealcnen  of  the  extrvinitieA,  hut  wns  able  to  walk  abiiut. 
At  no  tiow  did  the  case  preee&t  any  pamlyaia,  voutrocturvei  ot  neaiiorj 
diatarbaacaB.  Dcsbb  occiured  wimevhat  Middeiily;  anil  at  the  autopcj 
iwo  lumoiin  were  found,  unoh  being  about  the  aize  of  ft  Wjfe  haxol-niit, 
nod  ftymmetncntlj  placol  i»  the  hcmixiihi'rai.  A  traiuiTcrHe  vertical 
MDcbon  ihowed  that  each  tutuour  occujiiod  tho  {inaition  nf  the  IcnticiilAr 
oacleua;  the  Qbre«  of  the  hit^tnuLl  c^miilu  wen-  ociijii>r«^!*wiI  luiil  inwhocl 
inwaids,  wlule  thA  corebntl  sulwtAiioc  mw  sofUiiwI  to  the  cxti^nt  of  thn» 
(»  ftiar  nun  in  thickncm  ou  thu  citenial  BurfivctJ*  (if  tlif  tiimimrs.  Thr 
tumoiin  were  donee  nnd  vhit«,  though  their  [loriphnnU  zon«M  worp 
faseuLu-. 

A  cnse  of  sypbilomn  of  the  brain  has  been  obsen'cd  by 
ScfaUtz,  and  one  of  tubercular  tumour  by  Bramwell,  in  each  of 
which  the  tumour  occupied  the  position  of  almost  the  whole  of 
the  lenticular  nucleus  of  the  left  side,  and  in  neither  were 
there  symptoms  of  a  locatiiied  cerebral  affection.  It  may, 
there/ore,  be  laid  down,  as  a  geDeral  rule,  that  acute  le»ionH 
limited  to  the  lenticular  nucleus  gtre  rise  to  a  transitory  hemi* 
plegia  of  the  opposite  side,  while  ibis  symptom  may  be  entirely 
{kbaent  in  chronic  stationary  lesions  and  slow-growing  tumours. 

^P  (&)  Lwiona  of  tJte  Caitdate  Ntictewt. 

§  752.  Lesions  of  the  caudate  nucleus  do  not,  any  more  than 
those  of  the  lenticular  nucleus,  give  Hbo  to  permanent  symp- 
toms during  life,  unless  the  iutornnl  capsule  bo  implicated. 
Small  cyHtic  cavities  and  foci  of  softening  ore  frequently  found 
in  the  caudate  nucleus  at  a  poKt-mortem  examination,  in  the 
■iHeDOSofall  bistory  of  c«Tcbral  symptoms  during  life.  Other 
caaea  are  reported  in  which  a  slight  hemiplegia  bad  occurred 
during  life,  followed  by  a  speedy  recovery,  and  in  which  a  focal 
lesion  was  subsequently  fotmj  in  the  caudate  nucleus. 

Hi    following   ca»e   observed    by    myself  illustrateB    the 


e4(t 


FOCAL  DI8BASES,  ACOOBDINO  TO 


symptoms  wliicli  may  be  present  duriug   Ui«  growtli 
tumour  of  Uie  c&udato  nucleus. 

Samusl  Holmes,  wt  7  ywn,  prvMnted  biuuelf  as  an  nut>patJaDt  il  tb 
&autlierD  IIonpKal,  MonchcotcT,  uti  Jkdiuu?  MU),  1676. 

T)i»  following  liiiitory  wiui  cliaitad  from  the  mothor: — Hv  wn*  tU^ 
iatoUigonti  «ad  huolthy  hoy  untQ  about  15  inantlMi  ago,  trkcn  lie  Ml  bat 
II  wbII,  5  foot  high.    Souo  nAvrvords  bs  eataplAined  of  ajiiM«at  hadiifaL 
cliioflj-  ooQimod  to  the  Rndicad.    Tbe  iop  titibe  head  wm  m  ■■•IN 
tbst  OQialniig  his  hair  caumd  him  madi  jnia.     H«  mulcl  tint  tcnqi  ^; 
hiB  legs,  eepedoUy,  were  coiutantl;  tooviog,  aod  at  totiai  titow  Iw  «m  • 
the  habit  of  laiooldng  the  t«ble  with  bis  right  luuid,  u  tf  from  ignwtitta 
About  nioo  months  a^  tbe  moUwr  noticed  that  lua  uunitb  w  ^c''^ 
"  ctooIchI,"  and  that  bia  l«ft  nnn  huug  helpteHly  by  his  Me.   Tb«  timmm 
vaa  tvriatvU  au  that  thv  |ialin  of  tlw  hand  wiui  duvctvd  uutvranb  ai«l  tb 
tLiuiib  iackviinbi,  his  fiiijivra  wen  Wnt,  but  abe  tUiiiln  bia  thonk  u 
fint  WW*  held  rtnught  and  drawn  awaj  frum  tbe  Kttgon.    AAr  ■» 
w«d»,  howovKT,  tht?  thiuub  btKune  bent  inivanb  under  tlwiwlin-fiian. 
and  sho  had  Ut  pare  the  nail  of  tli«  thumb  fitequcntly  to  pivveut  tt- 
the  akia  of  tii«  outaide  of  the  middle  finder.     lie  now  bugao  tn  limj  u^ 
left  foot  in  waUduff,  and  the  foKann  vm  fiTiidually  drawn  np  txUnd  ki* 
Inh'Ic.  instead  of  hanging,  us  at  flnit,  I>y  hi*  aide. 

Th«  Diotber  had  had  ttini.'  ot  a  &un3f ,  so  miacmngM  uti  tto  al91-b<CT 
children.  OnecJulddiedftamixinvubdaiuduringbastlungi  awoondeUUi 
■  iriw  was  weakly  from  birth,  died  At  the  Age  of  three  moaths  i  ami  a  liw^ibltf 
liaa  Huflered  for  the  loMt  two  yean  from  white  awelling  of  the  knoo. 

On  prtwcnting  hiauwlf  ot  the  hoefatal  he  waa  a  wvU-niailc  and  f■lt^ 
developed  boy  for  bia  jmra.  Hu  head  waa  hrge,  lut  Wi>II-i*iipurliMiid; 
foca  rrniud  nnH  plump,  althoi^  pallid ;  hia  inctBor  t«eth  wen  Rgvlar,  ki* 
noma  woa  wcU  fonaed,  tlte  muscular  ajntetn  was  well  derdoped,  and  th■^ 
vea  abuodanoa  of  aabcntaneoiu  fot  There  waa  nay  K-cU-niaHcad  M 
faotol  paralyns,  so  that  the  left  oonier  of  the  mouth  could  uol  bo  nond 
Both  e^  eoiild  be  dowd ;  the  pnpila  were  laige,  equal,  Moaitle*  te  Q^ 
luid  there  waa  no  aflboUon  of  Uio  iqvdul  aeiiBea.  The  left  elbmr  waa  bfl 
a  tittle  behind  the  body,  and  i  inehM  tnm  the  aide ;  the  ienmrm  wm  k«l 
at  right  ati^ce  to  the  nrni,  and  drawn  iMbind  tbe  tniak ;  the  hand  «> 
Btrongly  pronated ;  tbe  thumb  was  adiluoted,  and  the  twoond  phalMi 
flcsed,  ao  that  the  )>o«nt  ceated  ogainat  tbe  eewnd  jihalniis  of  the  mUA 
tiuger.  The  Hrst  [dudonges  uf  the  fingeni  were  eiliuidod  awl  In  a  Iiik 
with  the  nwtuoiirpal  booei.  and  thn  acoood  and  thipl  plulsiiif  vm 
flexed.  A  ootuidiinble  Amonut  of  oniBOular  rigidity  wsh  ndond  « 
aU«uipting  peeeiTe  motion  at  the  elUnr  and  wnst  jotsta.  By  a  nto' 
Ury  effiHi  h«  ooold  miee  bia  elbow  to  neariy  the  level  of  Iha  ahenUg, 
and  then  bring  tbe  upper  ana  alowly  fisrwoids;  but  be  ooaU  nrtlla 
extend  the  roPmnn,  pn^uce  aupjnation,  nor  extend  the  itifgen.  Tb*  ^ 
legdngged  duriuji  wiUkint^  but  tbete  waa  tM  muecukr  rigidity,  SDiil 


TnC  LOCALISATION    OF  TflE  LBSIOK, 


647 


tile  tnovduetits  «f  the  t«g  cmild  be  wpantcly  performed.  The  el«ctt^>- 
cQtaoeoils  iemrihility  of  the  left  half  of  the  hoAy  wa§  Iiicrensed,  especinlly 
nver  the  bnvk  of  the  left  hiuiJ,  un^  tiia  l«ffc  hiilf  of  the  face  aiMJ  siile  of  the 
hewL  The  iill)thtiHt  touch  of  the  aldn  ovw  the  vertex  nf  tim  heaii  to  the 
left  of  the  middto  Hw  oauMd  the  |)fttieiit  to  wioee,  and  the  eutaueons 
KfMihilitjr  to  pala  wm  iaoreoaeil  owr  the  left  half  of  the  Uxly  genemllj'. 
Th«  other  orguui  Appeared  to  be  healthy,  uul  there  wiut  na  klhiitnui  or 
aogBT  in  the  arine.  He  ma  ordered  four  fftaiua  of  iodide  of  (lottmtiiii 
tbiwi  tuitc*  «  Any ;  hiit,  ut  no  itnixnvcme^nt  took  pljMC,  hi)  wait  ndmittol 
tnbo  the  hospital  u(i  February  £!HJi. 

M«i«b  10th,  1877. — He  wa«  ordered,  on  tulniiwiion,  fiftoun  luiiiiuw  of 
the  BjTUp  of  the  iodide  of  iitai,  to  bo  token  three  timeo  a.  day,  and  thu 
4^lj  ■ppUcntioc  «f  ft  wvAh  eoiintnnt  eumtiit  t»  tho  immlywid  tn  iukIcn  nnd 
■trwiBU.  After  two  ^ipIiostioiM  of  tli«  coiurtniit  cunmt  he  could  extend 
bn  fiogwH  to  a  ali^t  extvtit,  and  in  n  few  duyH  he  wm  nhle  t«  nuB(>  ha 
hand  to  Uie  back  of  his  htW.  It  wm  obscri-cd,  hoirerur,  that  the  tnoet 
inarked  impravement  tixik  ploou  »t.  thu  ithoiitdvr-jritat ;  and  that  im|m)ve- 
ment  in  th«  mo^-ctacote  of  the  forearm  lud  hand  woo  only  to  a  slight 
mtant.  Thia  inprovement  was  of  short  duiatiou,  oDd  he  now  looks 
decidaUy  warse  th&u  on  admianoD.  The  pallor  of  tiw  Caoo  in  maoh 
tnemaed;  his  appetite  hu  failed;  the  pulse  is  110,  veak  and  irregular; 
tuA  tbe  otuse  eaye  that  he  has  becoKie  very  stupid.  Ord«t\>l  to  be  kept 
in  hed,  milk  diet  and  &  uline  mixtiiic: 

March  tbtli. — Since  laat  rejMrt  he  hoe  p;ot  tAeadily  wofse,  haa  romited 
fmqtuintly,  and  UMlay  haa  been  aeixed  with  general  coavuUioDa.  The 
vonrulsioDs  Avqiwntly  recurred  dorinf;  the  nest  two  days,  coDaoiousoeea 
nut  being  reoiteml  in  the  iitterrab,  and  he  dictl  early  (in  March  2laL. 

^■fi'o  (VT^t<«rM,  twelve  hoiini  after  death.— On  opening  the  aleaH,  the 
coiiroluttonnof  lliehndit  pretiuiiod  a  flHttenul  iuulaini}ireModappeMr«Lnoa, 
And  obont  2  ouncM  of  fluid  escaped  during  rcmavnL  The  hmin  weighed 
61  ounovtL  On  nlicing  tlw  hraiii  to  a  level  with  the  oor[>uti  callosum  tho 
upper  Kurfiuie  of  a  tunieur  wnfieipoaed,  which  wiutitltuatoil  in  tho  centrum 
onln  of  the  right  hutaiephcm,  tnuuixlifttoly  to  thu  right  of  the  corpiin 
oilleciini  and  at  tbe  junction  of  th«  aiilnrior  nnd  middle  lobea.  On  o]wiuq^ 
the  lateral  rentriclea,  thia  tumour  vaa  felt  a«  a  hanl  nodule,  slightly  pro- 
jecting into  the  right  Ut«ml  ventride,  and  ocoupyiug  the  positiaD  of 
the  aauiLtte  uucleua  nnd  anl47lor  portion  of  tlie  optic  thalaniiiH,  and  only 
«ov«red  by  the  c|ietulyiuA  of  tbe  veutricl&  The  tumour  mcoauied  three* 
qnartcn  of  on  inch  in  the  tmnnvcmu  lutd  aii  inch  in  tlie  iuiturc»-puaterior 
and  Vdrtical  iliaiiiirtuni  twjiaetivnly,  ao  that  not  only  the  cniidato  nuclonN 
lukd  lUilcnor  iwrtiun  of  the  optio  tb&liuiiua,  but  idoo  the  anterior  two-thinla 
of  the  inu.-rnHl  cn|»ulv  aitd  tb*  notorior  portion  ot  the  lenticular  nutsleua 
wore  duatrT>)-cd  by  it 

The  growth  was  pretty  shandy  defined  from  Ui«  aurroundhig  twain- 
tiaiuo,  aod  on  wction  it  prceented  on  outer  greyi  aoroowfaat  vaacular  cortex, 
■bout  two  lines  tluck.  and  a  oeutml  oorv  of  a  yellow  colour,  aiid  a{4)anatly 
dastitut*  of  aoy  structure. 


648 


FOCAL   DIBK1SS8,  AOXIRDISO  TO 


MJooeiaopic  oiomUifttioii  shmrad  tbAt  the  gnj  railax  t4  ihn  loans 
vomuHtM  of  giant  ooUo,  codi  aunuuiM)«l  by  Ijrupboid  ooOtitaUdUtei 
fibhUntod  teticulum. 

Th«  nsitit  long  was  gIomI/  anQiemtt  to  tbe  dHcst  mil  aai  to  lb 
diaphragm.  TbK  liitig  itwlT  woa  ooiigmtwl,  liut  ««-U7  |nrtiMi  <if  U  ted 
ID  irater.  No  tuberoleB  oor  cheaj  gUuda  wen:  diMuvcnd,  and  lb  •te 
afgatw  were  bealchjr. 


Fm  «7MPi«a  FlMhiiK).  JbriMriof  JteriM  a/i*«»a(>«^«Cl4M«lMi 
or  a^.  U«  F^U  (i^  Mm  «  «  «MUMJbal  tMMT  IiTCf  UUa  UU  i«t  M^.  -  r.  r 
nL TeniMro-apbeBoUal,  km)  O.OccIplUl  bibci:  Ok Opcreohiai :  / 
Bnii  a<.  CUutetim;  /"■  Thud  boaul  «m«olatiaa  ;  n.  t>i.«i« 
JVC.  Caudat* nncloua :  JtrcT,  Tail  of  euidftU  Bvcfau  ;  /^A'.  I^oiirtUar  DDOtM*: 
/.  //.  ///.  [^^t,  ■tcrqitl.  Mil  Iblrd  itirlaUiM  of  Uw  toattcoUr  auclMu:  JJC 
ExUnul  eapwln  ;  V£',  Pnatvrinr  (li»  i-aon,  tF,  AaAvtiar  Avimiat,,  mmd  JT,  Ka« 
c4  th*  InMrnal  cajiciili) :  aA./iA,  Anterior  aftd  poaMiorkanMnqMlitalralMi 
lalcnl  TfMridfa  -  iw.  Kara  <■/  Ui«  cMpiM  o^lisniB ;  qt,  Spbnina ;  »^  mU* 
•Muniwim ;  /,  rontU ;  W,  StpUin  IsciduB ;  «,  Ctna  Awwifc 


TRB  LOCALISATION  OF  THS  LEBIOH. 


649 


lie  tumonr  io  thin  csme  appeared  to  liard  comm«ne«d  growiDg 
B  tJie  caiulate  nucleus  (ft^,  271,  AC),  although  it  ultimiitely 
exteoded  to  the  autcrior  half  of  the  leoticutar  Ducleos  (Fi^, 
S7I,  /^')>  and  completely  destroyed  the  arit«rit«  negmeDt  of  Uic 
rmemal  capsule  iPig.  271.  IK').  The  most  remarkable  feature 
ibout  the  Bympioms  waa  that  the  face  was  more  poxalyscd  than 
Ike  onu,  and  the  arm  than  the  leg,  this  being  the  order  in 
irhich  the  paralysis  might  be  expected  to  appear,  provided  pres- 
ntie  was  exerted  ou  tbo  iuboraul  capsule  from  before  back- 
varda.  The  hypftrsstbeda  of  the  head  was  probably  caused 
ly  irritatiuQ  of  the  poeterior  fibres  of  the  internal  capsule. 

(c)  Lmiohs  o/  the  Optie  Tttalamus. 

§  7o3.  The  ledons  of  the  optic  thalamus  by  which  the  Bbres 
if  the  iotermil  capsule  sufier  damage  have  already  been  ooo- 

red.  Acute  lesions  of  the  thaUntus  except  those  of  small 
are  UBQctat«d  with  more  or  tees  paralysis  of  the  opposite 
ide  of  tbo  body,  but  uoleas  the  lesioa  be  large  the  paralysis 
I  only  temporaTj,  aod  it  it  probable  that  when  pcrmaneDt 
aralysis  results  the  fibres  of  the  pyramidal  tract  are  alwaya 
tjured.  Lesiooa  of  the  tbolamuH  iire  also  frequently  osao- 
ated  with  heiniann«tbc«ia,  but  the  sensory  phenomcDa  are 
t  BGtarly  alt  casea  caused  hy  injury  of  the  sensory  peduucular 
act  in  it«  ascent  through  the  ioteroal  capsule,  and  of  the 
lUc  ladiatioDB  of  OnitioleL 

Lesious  of  the  optic  thalamus  are  frequently  associated  with 
lateial  hemianopsia  of  the  side  opposite  the  lesion.  When 
e  leeioD  of  the  thalamus  is  of  the  nature  of  ha;iDorThage  or 
fteniog.  the  hemianopina  in  probably  caused  by  implication  of 
Aaxtenial  geoiculate  body  iu  the  diseased  focus;  but  when 
■lesion  is  a  tumour  of  the  thalamni),  ttm  defect  of  sight  is 
EtD  the  result  of  pressure  on  the  optic  tract  as  it  winds  round 
cerebri, 

(rf)  Leffi&ns  of  £/«  Corpora  Quadrigemina. 
8  754.  Tontoura  of  the  corpora  quailrigemina  arc  of  rare 
■rrttDca     Out  of  the  331  cases  of  iDtracrnnial  tumour  col- 
wd  by  Ladame  only  two  were  situated  in  the  corpora  quod- 
Severul  caaea  of  discuse  of  these  ganglia  have  been 


650 


FOCAL  DISBABKS,   ACOOBDISO  TO 


recorded  since,  but  in  tbe  majoritjr  of  them,  tlta  teaoa  IimM 
boon  strtctlj  Hmiteii  to  these  txHties.  Tlie  more  luual  Sfmfiaat 
of  i««ioD  of  Ibe  corpora  quftdrigemina  arc  dbtarbuKU  if 
muRculnr  co-onUnatioa,  tlisordera  of  tbe  inovetDeota  of  tW«^ 
balls  and  iris,  and  ilefectx  of  viiIod. 

The  Jisturbaoces  of  muscular  oo-ordioatioo  conaiit  of  Mip 
gering  and   difficulty  of   maiDLaiiiiag  tbe  erect  poatnia,  the 
symptoRiB   being  gimiUr   to   those  caused  hj  diwue  of  tht 
poduuclos  of  tbo  corebelluin.     Aud,  iadoed.  wbeo  the  MtM- 
mical   n?Iati»Dft   between   tbe   corpora   quodrigemina  aid  1)m 
superior  peduncles  of  the  cerebellum  are  coDBidered.  it  becaoa 
doubtful  whether  these  motor  disturbaQCes  ought  not  to  bi 
attributLil  to  implication  of  tbo  latter.     Tbe  dutotbaMOl  B 
tbo  ocular  movementa  are  generallj  caiued  iiy  panljM  «f 
individual  bnuicbe«  of  the  oculo-motor  oerree ;  and  Nothsigil 
thinks  that  those  disorders  arc  moro  Uttelj  to  oocor  wfaw  tb 
posterior  pair  of  ganglia  are  diseased.    The  FOtino-pnpUlin 
reflex  is  aUo  abolisbed.     No  deSnite  statemeot  oou  be  ati> 
with  regard  to  tbo  state  of  the  pupils.    When  tbo  anterior  pik 
are  affected,  kliDdneK  is  apt  to  supervene  at  an  earljr  pmol 
of  tlio  affection,  and  often  precedes  the  development  of  oflit 
neuritis  in  eaaen  of  tumour.     In  two  cases  of  tumour  of  tl» 
cerebetluin  which  1  observed,  and  in  which  tbe  corpora  ifttdO' 
gemina  were   secondarily  implicated,  blindnem  was  an  ssfy 
symptom,  and  was  complete  in  both  cases  lieTore  tbe  moxhImj 
atrophy  of  the  discs  had  advanced  far,  although  not  bdontb* 
appearance  of  douUe  optic  oenritUL 

(«)  Ltaums  of  the  Olausirum  and  External  Cap^uU. 

§  755.  A  case  is  described  by  Brault  and  BeunnaDn  of  a  «a 
aged  71  yearn,  who  a  few  weeks  after  on  injury  had  an  Mpt' 
plectic  attack.  On  the  fotlowing  day  there  was  bIowmh  ^ 
spct-cb,  and  ponUysU  of  the  right  half  of  the  body  including  iki 
face.  Three  days  after  the  attack  speech  was  still  slow,  but  tht 
fadal  paralysis  hod  disappeared,  and  the  p&ralysds  of  Um  itnm- 
tics  was  much  improved,  while  every  symptom  of  the  atudi  M 
disappeared  six  days  from  ita  ODsot  A  few  days  snbs«i|wadf 
the  patieuL  died  from  causes  unooQoected  with  tlia  MfOfin^ 
attack,  and  the  left  claustram  and  external  cnpsuts  wot  foM^ 


THB  LOCAUaATIOK  OP  TBK  LESION.  651 

completely  destroyed  tiy  a  hiL>morrlmgic  focus,  3  cc.  long,  2}  cc. 
io  depth,  aod  only  S — 3  mm.  broad.  Ttie  hemiplegia  ia  this 
case  was  doubtless  caused  by  a  temporary  slight  pre»iiire  on 
the  fibres  of  the  internal  capsule,  while  the  afpHClioo  of  speech 
was  occasioned  probably  by  pressure  on  tho  Island  of  Reil, 
but  none  of  the  eymptoms  could  be  attributed  to  the  destruc- 
tion of  the  clauatnim  and  external  capsule  thomsclvos. 

{f)  Leauma  of  the  Base  of  tlie  SkulL 
().|   AmcuoK  VoMM  or  mi  Rkvul. 

§  756.  Records  of  legions  limited  to  the  anterior  fos!ui>  of  the 
4kull  are  not  numerous.  Disturbances  of  smell  are  not  unfre- 
queutly  present  in  chronic  baial  meningitis,  but  the  lesion  almost 
Always  extends  beyond  the  auterior  fouot,  and  gives  rise  to  com- 
plications. The  symptoms  caused  by  tumour  iu  this  region  are 
muiable,  hut  the  most  tmRtworthy  i.-:  afforded  by  compreitsion 
of  the  olfactory  bulbs  or  tracts.  Several  coses  of  tumour  in  this 
r^oQ  have  been  collected  by  Longet,  of  which  the  followlug 
is  an  eiample: — 

^^^  A  woman,  axed  5tf  yiHinit  buffered  frviu  ruaiinvnt  attoolcs  uf  duxitiiasi, 
BtftlUitpi  uf  frrniiicntiiin,  iukI  iiumtwes*  of  the  loft  half  ot  tbo  tuDo.  AtUir  » 
^■ritxl  uf  four  ycnn  bIio  b<-j,'aii  to  stiffcr  from  cpilcgiiiform  <»n\-iilinoii», 
but  enjuyvil  ga-ul  tinilth  tti  tho  iiit«r%-:vU.  A  vmr  l»t«r  the  ]Kttiont  «x[i«- 
rioooed  a  peculiu:  disordM*  of  amcll,  wUgh  etc  coold  wit  occiunUtlr 
ifaicrilift,  immodifit«ly  before  eocb  attack  of  dizzinesa,  and  tluA  last  was 
followed  by  mi  •pileptifvnu  attack.  MUir  tbc  cxpirotlou  of  oiuither 
jcor  ths  diflordBT  of  smell  biul  beoune  Imui  troublcAouo  miil  liii&lly  diaap- 
ftaatol  iMadaclM,  low  of  icteLli((euoe,  oud  oumi.  At  the  nutopsf  a,  can- 
peanxL  The  terminal  syniptoms  coaniHtdil  of  ittLa<elui  of  iterare  dicdncaa, 
Mtotu  liUDOur  tbe  sixv  of  a  duok'a  ugg  w«m  found  iti  tbu  aiitvrior  lobe  of 
Uie  left  hetai«plier«.  lying  on  the  dura  mat«r  of  tli«  tiiitfirior  ftMaa,  and 
citending  fnm  the  lamina  oribrosv  ta  the  olfoetory  roots.  The  left 
oUaaUiry  tract  m»  o(jiiii>U:h^1>-  dtstrojed. 

(H.)  LwKHtn  or  thi  Uiodu  Fussx  or  tiik  Skuli.. 
§  7.^7.  Diseases  situated  in  the  middle  fossa?  of  the  skull  are 
liable  Co  implicate  mauy  important  iitructurea  as  the  olfactory 
nerves,  the  optic  commuisure  and  tract,  an  well  as  the  third, 
fourth,  fifth,  sixth,  seTenth,  and  eighth  nerves.  It  will  thus  be 
•eeit  that  lesions  of  this  fossa  must  give  rise  to  very  compH- 


U&4 


FOCAL   mSEASBB.  AOCOBDIKO   TO 


to  Blill  more  definite  symptomii.  The  symptoms  in  the  &illo«iig 
case,  uQii«r  the  care  of  Dr.  Drcscbreld,  deserro  to  be  oonputJ 
with  those  of  the  caw  which  haia  juat  been  described. 

A  Toaa,  ngod  40  ytan,  mSercd  for  toax  timr  from  ■yiu|*fni  td  tm- 
limldbease.  For  •oouiWMtlu  Mora  bis  d«aUi  his  ajmiptiniiawmUarias 
of  the  rigbt  ^y«  mUi  atnff^iy  uf  fcho  iUm,  pkaw,  JnuaolMltt;  of  IIm  itML 
nnd  [ni«l;tio  exopbthjOmo*  of  Um  right  ejtf  oftw  *  titoo  ■Hnifit-fKBljB 
opbthalmia  of  tbc  Homc,  tight  Cftcial  pnwopalgia,  optic  Deuritii  tHAitt. 
with  UviDjioml  hpmiaiiojHuoftbvMtvyaiani)  polj^uim.  The  pnt-molA 
vith  o(iuiliict4Kl  by  aiyaell.  I  round  a  nucomalous  tumour  I)iag  <k*  *• 
the  right  optkt  fotaioen,  aiul  oompKmiiis  tfaH  ofitic  vwrm ;  it  sttnM 
tuctcwiurds  over  the  carenwiu  aiuua,  miiI  oouijineBMl  «11  ttw  wt^to  l*ti| 
iu  it«  vnUa,  and  likewiue  the  right  0|itiG  tmct  (/V|^  S?^  ■*  6^. 

Most  of  the  symptoma  in  this  case  were  so  defiDite  that  tin 
HcurCL-Iy  require  a  word  of  explaualion-  The  bliDdoeM  at  tbi 
rigiit  eye  and  atrophy  of  tlie  disc  wure  caunt-d  by  the  iDJurj  d 
the  oplic  nerre  at  its  poiat  of  eotiance  ioCo  the  optic  fotmiscs. 
the  temporal  hcmiunop«ia  of  thu  left  eye  by  comprcaMOD  ^f  Um 
light  optic  tract,  the  optic  neuritia  of  that  eye  in»  the  tuotj 
form  indic&tire  of  the  presenoo  of  an  tntncnnial  tiiuMi, 
while  the  paralysis  of  all  the  ocaUr  miucles  wms  emmtA  kf 
compresiitoD  of  the  third,  foarch,  and  sixth  Qerrca  as  Hmj  jim 
along  the  wnl)  of  the  careroous  sious.  The  polyuria  prtMrt 
ID  this  case  is  Dot  an  unfrc^uent  symptom  of  tumoun  ia  lb* 
neighbourhood  of  the  pituitary  body,  and  glycosuria  U  worn*- 
timcB  observed  in  such  cases. 

Aneurum  of  the  intenutl  mrtAid  artery  at  the  tiaae  of  lb 
skull  doeit  Dot  appear  to  give  rise  to  any  chamcieriatic  synptoBt 
and  auscultatiou  of  the  cranium  has  not  proved  of  mncbMniefc 
Besides  a  constantly  recurring  and  dutrcaaing  beadocti^  tb( 
moi%  lunial  symptoms  of  aneurism  of  the  internal  carotid  st  th* 
base  of  the  skull  are  Qtiilateral  or  bilateral  disturbosew  ^ 
vision  from  compression  uf  the  optic  tract  or  nerve,  spasms  torn 
followed  by  parolyais  of  the  ocular  muscles,  hypenotbesii^  tsrf 
neuralgia,  followed  by  aoKsthesia  in  the  region  of  dtstribatica 
of  the  fifth  nerve  and  great  mental  disturbances.  Faralysiiif 
the  extremities  of  the  opposite  side  may  occasioiuUIy  uocur  fna 
compreraion  of  the  pyramidal  tract  on  its  way  through  Uw 
crusu. 


THE  LOCitlSATION  OP  THE  LESION. 


«55 


,on))a^  into  the  vcntricleis  is  followed  bj  <Ieep 
tna,  and  the  majority  of  patients  die  io  the  course  of  the  first 
•eC0D<l  daj;  althougb  occasionally  they  may  live  for  several 
yt,  Hfcraorrhago  into  the  latc-ml  vcatricl««  coostitutos  tb« 
yority  of  Ihoee  cases  which  have  been  called  mgravescent 
Opiexy,  but  some  of  these  are  cauoed  by  a  large  hsimoirhage 
■4>  the  centnim  ovale,  or  on  to  the  surface  of  the  brain 
m  tbe  burstJDg  of  an  aneurisn).  Wheu  rupture  iuto  the 
er&l  veotrtcle  takes  place  the  corpus  calloBum  am)  fornix 
come    partially  deHtroyed,  and  the  hemorrhage  makes  its 

tinto  the  third  ventricle  aiid  into  tlie  lateral  ventricle  of 
)pposil;e  side,  and  passcH  through  the  aqueduct  of  Sylvius 
e  fourth  vectricla    The  first  stage  of  biemorrhage  into  the 
ride  may  coosisb  of  ordinary  hemiplegia,  commencing  with 
3plectifonn,  epileptifonn,  or  simple  mode  of  onset.    lo- 
tbe  simple  mode  of  onset  in  not  an  udukuuI  one,  eince 
lorrhage  frequently  begina  in  the  head  of  tho  caudate 
;leus,  lenticular  nucleus,  or  optic  tiialamus,  and  the  primary 
toma  produced  are  not  well  marked.  But  whonovcr  the  braiu 
is  ruptured,  so  that  blood  ie  poured  in  considerable 
tity  ioto  the  lateral  ventricle,  a  severe  apoplectic  attack 
,  cbaractprtscd  by  profound  comn,  general  paralysis  of  the 
,  and  dilated  pupils.     Tlio  rectal  temperature  sinks  several 
and  remains  depresHed  for  tuaveral  hours;  but  if  a  fatal 
do  not  speedily  occur  the  initial  depression  is  followed 
,  rapid  riie,  which  continues,  in  cases  about  to  prove  fatal, 
le  death  of  the  patient.     Haemorrhage  into  the  lateral  vea- 
11  freqaently  attended  with  a  spasmodic  contraction  of 
ctremitiea  of  tho  opposite  itidc,  which  may  be  either  tem- 
or  persist  until  dealb. 


(It.)  Tviiovui  n  rni  imaiiMcitiiooD  or  tdii  Firt'iTAVT  Bonr. 

759.  Tumours  of  the  pituitary  body  are  usually  uf  large 
,  They  pro<ince  comprefision  of  the  anterior  perforated 
,  the  olfactory  tnKts,  optic  commi&sures  and  roots  of  the 
norvvs,  the  corpora  albicantia,  the  posterior  perforated 
and  when  tbe  tumour  ia  large  the  pons  and  pedunclee  of 


6o8 


FOCAL   DISKUBS,  ACCORDINO   TO 


the  cerebellum  may  be  pressed  upon  aud  flatteoed  Tli«j  ou; 
also  encroach  upon  the  cavemous  siooses  aod  spheaoidal  fmura 
and  the  aerves  wliich  pnas  through  them,  while  the  rent 
arc  nub  uufi-ciiucQlIy  distorted  or  obliterated.  Ttieae 
are  al»o  verj  liable  to  caUH  aoftfituog  of  the  biutduq 
cerebral  tissue,  which  may  extend  to  the  basal  gaogli«  or 
ooatrum  ovate. 

Periodical  headache,  usually  situated  io  the  frontal  aoij 
poral  regions  and  extending  forwarda  to  one  of  tbe  eyeballt  i 
Hupra-orlnluJ  region,  is  one  of  the  earlieat^rntptoma  of  Uisuor 
in  the  neighbourhood  of  the  pituitary  body.  BliodoeM  ocrun 
at  an  early  period  of  the  growth  of  thene  tumour*,  owing  ti 
their  proximity  to  the  optic  commissure.  It  is  itaportsat  ts 
Temember  that  pressure  oo  tlie  optic  commissure  or  nerrca  cao^ 
secondary  atrophy  of  the  discs  without  being  preceded  by  tW 
"  choked  diua" 

There  may  alao  be  unilateral  or  bilateral  anoBmia  di 
injui^-  of  Uic  oll'ftctory  tracta.     When  the  tumour 
pressure  on  the  ciivcrnous  stnuace,  iucoiuplete  or  oomplrte 
lysis  of  the  motor  Dervee  of  the  eye  auperreiiea  oo  oaa  er 
aides. 

Disorders  of  cutaneous  sensibility  are  rare  and  geaerally| 
a  transitory  nature.    If  the  tumour  be  large,  one  or  idoc«| 
the  broQchca  of  the  fifth  nerve  on  one  or  both  aidee  is 
irritated  and  then  compressed.     When  a  large  taoMwr 
presses  the  cerebral  peduaclee  and  interpeduncular  ffpAO^ 
modic  contractions  of  the  muscles  of  the  oxtremittei^  fo 
by  hemiplegia  or  paraplegia,  may  superveua 

Two  other  interesting  symptoms  are  SDmetimea 
with  turaouni  to  the  vicinity  of  the  pituitary  body,  the  one 
sccumulation  of  fat  in  the  subcutaneous  tissue,  and  the 
diabutei*.     Id  a  case  reported  by  Molir.  as  quoted  by 
the  patient,  who  ftubse<iuently  died  ^m  tumour  of  the 
body,  bad  become  very  fat  before  death  ;  aud  in  a  i 
the  care  of  Dr.  Simpson,  in  which  the  symptoms, 
mainly  of  paroxysmal  headaches  and  bliDduess,  with 
white  atrophy  of  both  diaos,  pointed  to  the  praseoae  of  a  tac 
iu  this  DL'i^Lbuurhood,  the  patient  became  veij  fiu  afUr 
illD€M.     During  her  residence  at  the  Maachester  Royal  Ir 


THE  LOCAIISATIOH  OF  THB  LESION. 


AS9 


Brmai?  she  was  pasatng  a  considoialile  quantity  of  pale  urine, 
being  ouly  tOOl  in  specific  gravity.  In  a  case  of  tumour  of 
the  pituitarj-  body  reported  by  Rosenthal  the  patient  voided 
from  SIbs.  to  lOlbe.  daily,  the  specitic  gravity  was  from  1038 
to  I04U,  and  the  urine  contained  a  larf^e  quantity  of  sugar. 
Roeentbal  coojoctures  that  in  cases  of  this  kiad  the  grey  matter 
lining  tlie  (bird  ventricle  is  first  irritated,  and  that  the  irrita- 
tioD  Lravelii  along  tlie  aqueduct  of  Sylvius  to  the  tloor  of  the 
fourth  ventricle. 

Tbe  following  case  is  &  good  example  of  the  symptoms  caused 
bj  tumours  in  the  ncigbbourbood  of  the  pituitary  body,  and 
poesnsM  a  melancholy  interest,  inasmuch  as  a  respected 
member  of  the  uiedical  profession  was  tbe  victim  of  tbe 
Oiseaso; — 

Mj.  R ,  about  3t  yeara  of  age,  conaiiltwl  me  nn  May  10t}i,  1878.1. 

Be  bad  •niflvnd  Tor  some  tima  from  ftequently  rectirring  attockBoffoint- 
OMa"  aad  a  peculiar  dcfuut  uf  I'Jiiiut).  Hu  in  ii  tnll,  dork  luati,  at  bcoltli; 
apinBAUoe,  tbare  isaslightdfjinimiuu  in  thorigblCroiital  bone,  caused  by 
a  Mow  RCeivMl  in  childhood,  but  be  does  not  appeur  bo  buw  Bu9vr«d  tmy 
inamnaieDai  ttvm'it  During  tboFmiiUngRtla(in,UDD  urwblch  I  liad  aii 
•ppotiuoity  of  observing,  tbcro  i»  pallor  of  the  faco,  tlic  pul»e  beuta  from 
IX)  to  140  in  the  minute,  aiid  the  [Hiti«nt  looks  agitat«<cl,  hut  thuru  iit  iiu 
loBB  of  cvDscionaueaa,  Tliu  Jurntiuti  of  tlie  attack  is  mdy  about  Imlf  a 
mtantr.  On  aiamming  hb  eywigiit  lie  is  fnmid  to  be  auffm-iiig  Crom  doubli) 
taa(«ial  iMtuiauopaut,  tlie  iniivr  bidvw  of  tbi;  rcUuw  hvia^  blind.  Th« 
opUo  discs  are  ix-rfocllv  MiiriuiiJ,  Hi»  opiiitDU  buitijf  uonflnned  hy  Mr. 
WlDdMr. 

Felwuaiy  7,  1879.  Thrj^iiiundHymptomiiujiitinuouiK'hnii^,  but  the 
UoUds  albat^kn  an;  uuw  nccom[)aiu«]  by  temporary  1o«  of  ooiuttiouauem. 
The  [jntieQt  in  now  Mind  oo  the  right  »ye,  wliilt!  th«ro  is  htnipond  hemi- 
AuopsLa  of  tbe  left.  Dr.  Little,  who  jDAdc  on  ophthnlxaoacoiiic  uxauiiuuttuii, 
npOTla  wliita  ntr:^>hy  of  the  rij^bt  and  iuoipient  ntmjihy  of  tbe  left 
oplio  diM.  The  urtim  in  aliuiid&iit,  pale,  and  of  low  spccJiio  gravity,  but 
I  doM  BM  oaDtaiu  olbuiutin  ur  sii^or.  TIjb  only  {MycbiiHil  diHtiirlianoe  ub- 
I  merwgd  wu  a.  uarkwl  ami  uui  uuuulunJ  beodency  Ut  brood  over  his  o«-u 
fralingw  oad  syxaptoiuK 

The  diagnosis  in  this  case  presented  no  great  difficulty.  It 
vai  manifest  that  a  tumour  at  the  ba^e  of  the  skull  was  grow- 
ing in  such  a  way  as  to  compress  tbe  centre  of  the  chiaamu  ai 
first,  and  that  it  subsequently  extended  to  the  right  so  as  to 
have  compressed  tlie  rijrbt  optic  nerve.    I  saw  the  patient  two 


iraqoonuT'  ounug  a  vwitw  4N 
nttuck»  tbi:  aixwni.'t  vcrc  marc  \tmnmiznxd  nn  the  left  Umd  oa  tlH 
sidt\  l)(iring  ih^t  aight  tlia  pntiont  lay  in  a  wmi-ficsaalOH  cod 
but  he  gnuluatly  rcguined  coiucioaaDea*  on  the  fbUcnring  i»J^ 
now  noticed  thut  th«  loft  tads  of  Um  face  waa  pundyiwd,  and 
tmo  sniDc  dcgmj  of  |iaresiii  of  the  left  extrGmitim. 

AiigUHtSO.    Since  bA  report  the  pntiont  racoveml  th* 
liulx.  oud,  olthmigh  be  !ua  HulTeivJ  from  occBaouiiJ  att 
he  has  walked  about  th«  garden  as  usual    This  ■wniog,  1 
bad  oaotlicr  eptle|itirorm  seiziiro. 

Septomber  It).    Sinoe  Inat  leixnt  the  patient  hoM  hpea  dix 
iraUdng  about  tlie  j[».rdui,  btit  nfWr  |«rtalciii|c  of  lub  imuaI 
morniiig  be  beoaoic  ttouiewhat  HuiMonl^  InwnxiUc,  ukl  ilicd 
uight.     Uiit  tompcratitrc  iimuctliatcly  bdvre  death  wmm  108*  F.| 

At  th(!  iMMt-mortoui  euuuiiMtioa  ttui  atmbnuwR  of  tto  : 
oODvexltj  wuTv  Tuuiid  oormaL  Tba  iaaa  taUc  cf  Uia  aktiU  «■ 
ouUcr  were  noniutl  nl  thv  t^olat  uorrMpoDding  to  tb*  «it«fi»l  dn 
uf  Ibe  right  &outaI  bone^  Tlw  wbataiioe  of  Uw  bmia  waa  obatm 
bulged  betveeo  the  fttiiita)  and  parietal  luhiw  in  the  nght  hmi 
0»  lenuvnng  the  brun  a  lobuhtMl  tumour  wa»  obww«i]  Ijius  1 
Mde  of  the  o|>tio  o(iniuii»tini ;  the  right  optic  nerre  tnu  uumj 
but  the  left  tutrvo  oMnipiod  its  uaual  poeiUon,  and  did  twt 
alU-nd.  The  luuiour  Hpntiig  from  that  ponion  of  tlie  dura 
cover*  tlie  Kxly  and  basilar  prooeae  of  tbc  niJK-ixnd  Icoc,  the  li> 
bone  U'iiig  eroded  by  the  giowtli.  The  orbiuil  mirfiuv  of  the 
lobe  of  the  right  hemiflpli«R!  prenottMl  u  ile«|)  uuavation  cw(nil| 
to  the  jinijeetiijtt  of  llii;  tuiiiuiir,  aiid  the  iwnnna  timiee  Ui  the 
of  the  gionth  Wire  Koiiwwfaat  eoftetMd.  Tlte  tumour  was  luultilo 
and  of  the  colour  of  lifcT. 


6Cl 


CHAPTER    IX. 


(IL)  SPECUL  CONSIDERATION  OF  FOCAL  DISEASES, 
AOCORUINO  nx»  THE  LOCALISATION  OF  TJIE  LESION 
(Coimvcso). 


i.    LESIONS  LOOALISKD    IN   THE  STRPCTURES  SITUATED 
BBLOW   THE  TENTORfOM. 

ti.  Le^urua  in  tha  Pons  ami  Pe*l\incU»  of  tiu  0/«&rum. 
(I)  Lmam  vt  tbk  Pokb. 

§  760.  Ilamuyrrhage  into  Ae  Pon$. — If  llie  brpraorrhage  be 
of  large  size,  prolbuDiJ  apoplexy,  wUb  flapping  of  the  clieekx 
during  expinttion,  iuseosibililj  of  tbe  conjimctivte,  aod  stroDgljr 
oaDtractuil  pupils  h  prtxiuced.  If  tbe  batmorrbage  extend 
apwanli  to  the  grey  matter  beneath  the  aqueduct  of  Sylvius, 
the  ociilar  muscles  may  be  paralysed,  and  the  pupils  dilated 
and  fixed.  DeiLlh  occasionally  takes  place  io  a  few  mlnutet; 
or  iu  a  few  hours,  altbough  life  may  be  pnilooged  fur  a  day 
or  two.  Bursting  of  the  hemorrhage  into  the  fourth  ven- 
tricle is  geacrally  attended  by  convulaions,  although  convul- 
siona  may  occasiooolly  occur  indcpondcBlly  of  this  accident  If 
Uie  patient  recover  from  tbe  shock  of  a  central  haemorrhage 
into  the  pons,  consoiousncaa  is  gradually  regained,  but  it  is 
found  that  all  the  extrcmittca  ore  paralysed,  while  culaneous 
ieosibtlity  may  be  more  or  less  impaired.  Double  facial  poralytis 
involving  the  musclos  of  the  eyelids,  as  well  as  tboM  of  tbe 
mouth,  may  be  presont,  both  sides  of  the  tongue  are  also  para- 
lysed, while  the  patient  experiences  difficulty  in  deglutition, 
there  13  a  copious  flow  of  saliva  from  the  paralysed  side  of  the 

I  mouth,  and  the  power  of  articulation  \»  impaired. 
If  the  lesion  bo  situnted  in  the  lower  part  of  the  lateral  half 
of  the  pons,  the  Rymptoms  m.iy  present  the  appt^antuces  cfaarac- 
toistic  of  what  Gubler  bats  called  alternate  kemijpUgia.    Th«;ro 


662 


FOCAL   DISEASES,   AOCOBnmO  TO 


FlO.  S7ft. 


S—\ 


V.5 


\^ 


is  well  marketl  facial  panUysia  on  Uie  siJc  of  the  Imioo.  aad 
more  or  lean  comploto  motor  and  Musory  paral^rEU  of  tUe  lim 
OD  the  oppoaite  side.  M 

If  tlie  upper  put  &f  th«  ui 
fa&lf  of  tlie  pons  be  the  seat  of  il 
losioD,  th«  buul  pwolysu  b  ob  d 
aatno  sido  as  the  ptnUyvU  of  tbe<i 
tremitiei.  !□  order  to  anouDt  fi 
tbc&c  phcnomoaa  it  is  noBf  ifjl 
assume  that  the  fibres  of  the  fjn 
raidal  tract,  whicli  connect  the  eotu 
of  tho  oppoette  hemisphere  with  tl 
Ducleus  of  the  facia]  Derre  in  ll 
upper  part  of  the  medulla,  croMon 
about  the  middle  of  the  poaa.rifl 
preseated  in  the  annexed  fignnH 
Coojugaie  deviation  of  th«  9Jt 
with  rotattoD  of  the  head  and  oee 
is  a  symptom  of  paralTsia  of  tl 
pona,  but  the  rule  willi  rcg 
the  direction  in  which  the 
taken  place  is  tho  coQvetw 
whicli  applies  to  lenona  of  the  ImM 
apberee.  When  the  leaioD  is  aituM 
in  tho  boQURpbcres,  the  ImmJ  M 
eyoa  are  turned  towards  tbe  afcM 
limbs  duriDg  oo&vuUioDS,  and  towaidft  the  side  of  the  UiiM  I 
paralysis ;  but  in  lesions  of  one  lateral  half  of  the>  pons  d 
head  is  turned  iownrds  tho  side  of  the  Icsioo,  if  the 
conTuUcd.  and  towards  tho  affiled  limbs  when 
paralytied  (Grasset). 

Early  rijjidity  of  the  muscles  of  the  paraljrsed  exi 
the  masticatory  muscles,  and  those  of  the  oeck,  is  often  i 
ID  lesions  of  the  pons. 

Disturbances  of  oiitaneous  miribility  aie  frequeDtly  i 
in  lesions  of  tbe  poos,  wbiob  become  mure  prafouod  aad 
as  the  lc«ioQ  approaches  the  upper  or  anterior  end  dC  ll 
near  tbe  crusLa.     The  setisoiy  disturbiuicea  gencrallj 
of  aoicsLbesia,  although  uoilateral  hypeneatheeia 


Fni.  375  (From  NoUuuvtl). 
£,  Left. 

rt.  iiiiikt. 

p.    PcMH. 

HP,  D«otMwatio  pjTKiiidtua. 
S,  Ntrr«libmMrth««ittMni- 

F,  FibiMiIutiunl  for  tbe  facial 

nerve. 
X,  Ijerian  in  tlic  uiipcr  pkrt  of 

)f,  t<«u»n  ID  til*  1i)ir«r  put  i4 
tiM  puna. 


ii 


THE  LOCALIE^TiON   OF  THE  LESION,  66S 

rionalljr  been  obwrvftl,  and  either  condition  may  be  accom- 
panied  by  painful  sensationi^  iti  the  limbs,  or  b^'  a  subjective 
feellDg  of  cotdaess,  evea  when  the  temperature  of  the  part  U 
higher  than  nattiml.  Tmplication  of  the  fifth  nerve  gives  rise 
10  aou'Sthcaia,  bypem-stbe«ia,  panf^tkesia-,  or  puinful  seuaatioDK 
ID  the  r^OD  of  distrihution  of  the  norve,  as  welt  oa  to  partial 
tmpaimteDt  tyr  perversion  of  ta«te  on  the  side  of  the  lesion.  The 
nusticatorj  miisclca  arc  often  weakoiicd  or  compluttily  paralysed 
00  Ute  side  of  the  teaion.  Acute  lesionn  of  the  pona  arc  gCDC- 
rally  attended  bj  hyperpjrexia,  aod  the  urioe  is  ofteti  abuadaot 
acd  tii&y  contain  lugar  or  albumen.  These  syrapt^RiB  are 
caused  by  irritation  of  the  grey  matter  on  the  floor  of  the 
foarth  ventricle. 

Three  caws  bavo  recently  been  described  by  Erb,  in  which, 
judging  from  the  symptoms,  the  primary  lesion  was  aitualed 
in  the  nerve  oaclei  of  the  pons  and  medulla  oblongata.  The 
afTection  began  with  pains  in  the  head  and  neck,  and  attained 
iiafull  development  in  the  cotime  of  a  few  montlis.  The  chief 
•yroptoma  consisted  of  ptosis,  paresis,  often  associated  with 
atrophy,  of  the  iifuscles  of  mastication,  tongue,  and  back  of 
the  oeck.  There  was  also  weakne-ss  of  the  muscles  supplied 
by  the  superior  branches  of  the  facial  nerve,  associated  with 
phenomena  of  irritation  in  them,  such  »s  slight  clonic  spasms ; 
but  the  muscles  supplied  by  the  inferior  brauchex  were  un- 
aBectod.  In  one  case,  the  movements  of  the  eyeballs  were 
deficient,  but  in  the  other  two  they  were  normal.  Difficulty  of 
deglutitiou  was  present  in  two  of  thcao  cases;  buzzing  iu  the 
cara,  and  an  abnormal  galvanic  reaction  of  tile  loft  acoustic 
nerre,  were  observed  also  in  two  cases;  while  great  weakness 
of  the  extremities  ia  mcnttoQcd  as  having  been  present  in  two, 
and  slight  weakness  of  the  arms  in  the  rcoinining  cose. 

One  of  these  coses  terminated  fatally,  but  a  post-mortem 
examination  was  not  obta-ined.  Putting  aside  tlie  weaknes<i  of 
the  extremities,  which  wna  probably  caused  by  implication  of 
the  pyramidal  tracts,  the  other  ftymptoms  were  evidently  due 
to  dineaso  of  the  nerve  nuclei  of  the  pons  and  medulla  obton* 
gata,  or  of  the  fibres  of  the  cranial  nerves  in  their  passage 
through  theiie  structures.  It  is  iDteresting  to  observe  that  the 
bulbar  nuclei  or  cranial  nerves  imjJicated  in  tliese  cases  are 


0C4 


FOCAL  UlSIUSiU,  AOCOBDINO  TO 


those  that  regulate  the  actiooe  of  muscles  which  are  freqoeattf 
ossociateJ  io  their  aclious.  The  aMOciatioD  of  the  actioai  of 
these  musclea  is  better  observed  io  animals  than  in  maiL  Let 
UH  Muppuse  that  a  Jo^,  for  iustaoco,  in  lying  in  repoie,  wii^  bit 
eyea  closed,  luni  that  a  rabbit  or  other  aoimal  upon  mhicbk 
preys  nulies  paat  to  his  left.  The  noise  nuule  by  the  paauog 
object  is  conducted]  to  the  brain  of  the  dog  maioty  tfaroiigli  t^ 
left  ear.  aad  iDHtatitly  bis  eyelids  open,  the  eyeballn  «»il  lU 
bead  are  rotated  to  the  left,  the  mouth  opens  ao  as  to  prepan 
far  closure  of  it  upon  the  prey,  and  the  toagne  is  atao  ready  far 
protrusion.  It  would  appear  that  aotne  of  the  muscles  suppbd 
by  bnuidiM  of  the  cervical  plexus  were  affootsd  io  tt:«se  tmm 
as  well  as  those  supplied  by  the  spinal  acceasory  oerre.  I  vooU 
suggest  it  OS  probable  that  the/oNricu/us  rotundiu^  the  faa^ 
tioos  of  which  are  not  at  preseot  Icdowd,  is  the  tnediutn  of  ismv 
elation  between  the  mecliaotsm  iu  the  upper  eod  of  tbt  pos 
and  crura  cerebri  which  regulates  the  moTomeDts  of  the  >^ 
balls,  and  tfae  mechauifim  io  the  medulla  oblougata  and  upptf 
end  of  the  spinal  cord  which  regulates  the  movemeiiU  of  ths 
neck  aod  bead. 

Tumours  of  the  Pons.— A  aluw-gruwiog  tumour  ntay  b* 
situated  in  the  centre  of  the  pons,  and  attain  Uie  siie  ol  a 
bazel-Dut,  without  giving  rise  to  any  symptonu. 

Aa  in  other  intracranial  tumours,  headache  is  a  fiiii|Ml 
symptom  of  tumour  io  this  regioo.  The  headscbe  is  mmtiiam 
frontal,  sometimes  occipital,  and  at  other  times  gensul  sal 
deep-seated,  but  it  does  oot  afford  any  indication  of  the  ^Ibm 
lion  of  the  growth.  < 

Uotor  disturbances  constitute  the  most  characteristic 
of  tumours  of  the  pons.  General  CDUvulsions  which  are 
onfrcqueotly  caused  by  lesions  like  haemorrbago,  which  cam 
suddenly,  are  very  rare  in  tumours,  and  probably  Mdt 
appear  eicept  towards  the  last  few  days  of  life  or  whM  iW 
ntfcction  is  complicated  by  meoingitis;  Even  loctA  wptam^ 
the  muscles  of  the  extremities  are  rare  in  tumour,  inasavdiv 
the  fibres  of  the  pyramidal  tract  are  slowly  subjerted  to  ]M^ 
sure  without  previous  irritation.  Paralysis  is,  tborefors,  hvbt 
the  most  important  motor  symptom  obserred  in  tumour  af  tkt 
puus.     When  the  tumour  is  situated  in  one  lateral  half  of  tb 


THK  LOCJlLISATJOH  Of  THE  LESION. 


«66 


poD«,  «8peciftll7  in  iti  posterior  half,  the  paralyHin  aaaiimes  the 
form  ofaUerTMt^  hemiplf*p<t.  Wheo,  for  inslanco,  a  tumour  is 
Htliuted  in  the  righthalf  of  the  poiuoQ  a  level  with  tbaDUcleua 


Iti^ 


JlVll 


■^x 


>ivi 


TV 


■•T 


Fia.  arn  '^tixUSfdfroBBrb).  Tranncrtc  Staia»  vf  if^  Pon*  on  a  Itni  tnlA  dt 
Alfloixiu  and  Axiaf  Jbob,  /rum  «  ttiiK  <nMilA4<m4>fy«— Tha  rig!bl  Wf  r«p*«- 
maU  >  HCtiaa  umU  k  litUa  bwur  tLan  tb*  Infi.^  P,  fyrmmUM  tnol ;  o. 

-        -       ■  "       1  of  ilio 


.  poitlon  of  (ba  prrantidal  tntel ;  Tr  ftnd  TV,  ttMurena  fibrr*  i 
nNw;  w,  >up«r>orolivKrTbod]r;  off  anil /•/«,  BoUri'irui'J  iKigtrrinriiuclvi  of  lh» 
burml  (column  t«p«etiv«lr.  reimeaantici;  the  nucleuii  of  tha  fkcul  nerve  ;  ktii, 
KN>i«r  iti*  (*cialB«r««:  TI*.  nuden*  ol  thuaixlh  n«rT«  :  iivi,  root  of  theaixtli 
Mm  i  ^,  iMMDiUoK  root  vf  itu  tri|t«ui>uu«.  it.  The  iutviiiol  <liviaion  <it  Um 
padnBclfaf  III* m^beltun  «t  it  piiaw  fromihe  (^riiWlliim  -.  /,.  [HMUrJor  long!- 
torliaal  tiacicniui ;  ar  uiil  ia^.  tlie  npwmrJ  ountiiiuatiuu  u(  lti«  intarnal  aod 
nUnal  tlinnoiii  o(  iliv  utwriM'  root-coiu  oJ  tbe  tpinol  oord ;  t,  laadcoliM  ««(«•■ 

of  origin  of  tlie  Bixth  and  ftcventh  nerves  {Fig.  S76),  the  cxtre- 
mitira  ant)  half  the  toDgoe  oo  the  siJe  opposite  the  Ie»ion  are 
panlyaed  from  compreasion  of  the  pymmidal  tract  before  it  lias 
croBsed.  vbile  the  facial  mueclee,  iDclmling  those  of  the  eyelid 
and  eyebrow  suppHeil  by  the  ^tereoth,  and  the  exteroat  rectus  are 
paralyBcit  oa  the  Hide  of  the  lesion.  Under  tbeeo  circuoistaooes 
the  facial  paralysis  is  caused  by  corapresstOD  of  the  Bbrc«  of 
the  Dcrro  or  dcDtructiun  of  the  facial  nucleus,  and  the  facial 
muscles  often  manifest  the  reaction  of  degeneration.    In  a  cose 


666 


FOCAL   DISUSEa,   ACCOBUIXG  TO 


of  ttiis  kmd  under  my  owd  obMrvatioa  the  reaetioo 
curr«DU  was  dimioUhed  io  the  paralysed  tnuadu;  bat  ik 
reaction  of  degencrKtioD  u«ver  api>earcd,  so  that  UiU  ngi  ■ 
uot  alwsya  trustworthy. 

It  is  remarkable  how  seldom  disturbances  of  Ibe  seaw  ol 
heftfing  havo  boon  observed  id  tumours  of  the  poos,  wnkiua 
of  hearbg  ou  the  side  of  the  lesion  being  mei)tioa«<d  s  bff 
times,  but  unilateral  deafness  has,  so  &r  as  I  know,  nerer  \mm 
described.  Ana^^lhe^a  of  the  opposite  half  of  the  bcal^ud 
extremities  has  been  observed  only  in  about  one-third  of  tkt 
n:[>oru-d  cases  (Ladame),  and  ts  never  so  promineol  a  symplcai 
as  the  motor  paralysis.    If  the  tumour  be  situated  iu  th«  rifh 


Via.  877. 


til 


;5^ 


^^ 


Tia.  7n  (ModlfM  hom  T.tt>).     Trantrant  SmChm  4/  **«  f^w  m  ■  but  •«] 

oriffin  if  (Ac  Triffminu*.  frvm  a  ni'm  woiaU*  Ammob  0*4*10.— /*. 

tmot  t  r,  aeoeoKHT  nortuii  of  th*  DTnmdUl  Irxrl  -,  Tr,  TV,  tmwwi. 

iIm  pom  i  at,  Mooidiag  root  of  tA*  IriKCralntu  ftml  nkUacnw  mHaa^ami  * 
drMxfnillnit  mot  at  ttw  trirrmiDm;  r,  roM-Uma  of  Uw  Ui«atBiai«  na  li«> 
vsiwily ;  V,  loTitor  nudvoa  of  Iba  tarigauinat ;  v',  nUdla  MMJKjf  bjnaail 
Btiislfiu ;  BV,  MMt  «f  trli^Biintu ;  C^  note  of  Uwi  flftli  [iiiiimiH»|  rnMU»  m^ 
bellaiD  ;  L,  FtisMriar  l<in|,iMi(bul  fOMioilliM ;  ar  Mul  a/',  opwanl  cMtinrilB 
of  tbe  inUmal  and  oxttfaal  portiou  napcoliirclj  of  tbeanWrior  »•»■■># 
tlw  •ptaal  oofil. 


THE  U)CALISATIOK  OP  TBE  LESION. 


667 


half  of  tbe  pons  on  a  level  vith  the  fibrea  of  ongin  of  the  fifth 
Derre  {Fig.  277),  and  if  it  grow  forwards  so  a«  to  compress  tbe 
pjraaaidal  tract,  the  extremitien  and  otie-half  the  tongue  arc 
parnljscd  on  the  opposite  side  of  the  body,  and  the  face 
may  stilt  he  paralysed  on  the  side  of  the  IcsJOD,  sitber  from 
oompressioa  of  tbe  fibres  of  tbe  pyramidal  tract  belonging  to 
facial  nuclciu  after  tliey  bare  crossed  in  tb«  pons,  or  from 


■■>f>; 


S' 


fnclifinl  from  HevDort).    T'-annrrtt  Sertiott  cf  tlu  Potu  oa  « tntlfiA  ttr 
«)>d  /,/ IA£  f mirth.  VtntritU, /rcrm  a  mii4  immtkj  hutnam  enbnK,—I'.  Jijt*- 

ttnwt  ;  p,  tctxworf  portinn  of  thr  pjmuaujal  tr»cl;    Tr.  Tr'.  Inntverte 

Sfansof  ths  puD«  ;  fi;  superior  bi*cbium  of  the  poo* ;  L,  poatvtioi  Icmipttuliu*! 
faaeicvltu:  •iPkftilar',  upmtrd  c«ntl&niittr>n  Af  the<ni<?rnalkn(1#ii«ra>lpnrtioni 
wp^rtitaly  of  tbu  anterior  not-aome  ul  the  MiAntl  oonl ;  V.  iuidill«  •nuorjr 
iriKMoinaJ  sticUtu ;  dt,  dttceaAaig  rwit  of  tbe  trigcioiniiB  ;  iv,  nudctia  ot  (be 

exKDsioD  of  the  tvimour  downwards  to  reach  the  fibres  of  origin 
of  Ihft  facial  Qcrre.  Tbe  masticatory  rauscLca  will  also  be  paia- 
Ijsed  on  the  side  of  tbe  lesion,  and  various  aeosory  and  trophic 
disturbances  ivlll  occur  in  the  region  of  distribution  of  the  fifth 
70,  such  a»  bypencsthesio,  aoumlgic  pains,  ana»tbesia  often 


668 


FOCAL  DISKASI8,  ACCORDtNO  TO 


auoming  the  form  of  aDa»tfaeeia  dolorosa,  and  aeoroparaljlie 
opUtbdiDia.  Tbo  taste  of  the  correspoadiog  b&lT  of  tb«  toB|w 
u  often  aboliahed,  white  smell  U  impaired  to  the  MSinl 
of  that  mde  owing  to  loss  of  oommon  Mnsibilitjr.  Btmi- 
aoffisthesia  of  tho  opposite  side  maj  eziat,  and  then  the  kokit 
dUlurbaiQce  presents  ao  alternate  dtstributJon  like  the  ponljm 
Wheu  the  tumour  is  situated  in  the  middle  of  Uie  poiu  ^ 
the  lirat,  or  exteuds  from  one  side  to  the  other  daring  iti 
growth,  all  the  extrcmitios  may  bo  paralysed,  either  nmulth- 
neousty  or  guocessively,  the  mu&clee  of  the  lougua  oo  both  mim 
may  be  veakened,  giving  rise  to  difficulties  of  artioulukt 
(anartliria)  and  deglutition.  There  ma;  bo  doable  (mad 
paralysis,  complete  masticatory  paralyHiH,  paralysis  of  botk  tht 
external  recti  muscles,  various  sensory  and  trophic  diiturbucd 
in  the  region  of  distribution  of  the  fifth  nerves,  and  abolilioa<f 
taste  on  both  aides  of  the  tongue.  The  dtHtribution  of  tW 
paralysin  may  preitent  varieties  other  than  those  just  deMiibai 
Both  sides  of  the  face  may  be  paralysed  and  the  eiCremities  n 
otto  aido  only,  or  tbo  latter  may  be  unaffected ;  oo  the  otW 
band,  only  one  ^de  of  the  face  may  be  affected  and  the  d- 
tremitic-8  on  both  bides.  Similar  variationa  may  occur  *ith 
regard  to  the  distribution  of  Uie  hobotj  distUTbaDcea,  oltkNgh 
they  are  seldom  so  well  marked.  I^sorders  of  motor  »■ 
ordination  may  be  observed  in  lesions  of  tho  pons,  eapeetiDj 
tumours,  ftimtlar  to  thofie  which  will  be  immodiaiely  deMfiM 
in  connection  with  diseaac  of  the  peduncles  of  the  cerebellm. 

ATieuTiani  of  the  baaiiar  artery  does  not  appear  to  aim 
symptoms  which  enable  ua  to  distinguish  il  from  a  d«w  forai' 
tion  pressing  on  the  pons  in  the  same  situaliun.  It  is  pcDbsU* 
that  uuilatoral  or  bilateral  deafness  is  a  more  fm^ueot  sympUs 
uf  aneurinni  than  of  solid  growths. 

Psychical  disturbnnces  arc  frequently  observed  in  tumoiint' 
the  pons,  consisting  of  lo8s  of  memory,  apathy,  and  ntupor.d 
of  them  itymptoms  indicative  of  oomprcaaion  of  the  hrsia 
These  symptoms  are  not,  however,  directly  cauaed  by  tb«  a0ir 
tion  of  the  pons,  but  by  effusion  into  the  veotrioles  of  tba  bnil. 
with  which  the  affection  of  the  pons  is  fret)ueutJy  ooRiplicat(<il 

When  the  lesion  implicates,  cither  directly  or  iDdtrwtly.  lit 
pneumogastric  norvea  or  their  nuclei  of  origin,  varwoi  diMidin 


TH8  LOCAUSATION  OF  THE  LRStON. 


669 


of  respiration  and  ciroilatioD  mny  "he  present,  but  these  anmlly 
beloog  to  the  tennioal  phcoomcDa. 

AlUimiDuria  and  ffljcoatiria  have  been  observed  in  local 
diseases  of  the  pons,  but  Uy  do  moans  with  exceptional 
fre4]^ueDcy. 

(S.)  Lmom  n  tm*  Pmi'itrui  or  rut  Ctniiinvw. 
§  7G1.  The  ni03t  characteristic  features  of  lesions  of  tLe 
cerebral  pednnclo  are  afforded  by  an  fl/(cma?«  hemiplegia,  in 
which  the  extremities,  half  the  face,  and  half  the  tongue  are 

Fio.  7n. 


»' 


;<>: 


-/'- 


'ar 


ry 


7lO.  S70  (Undidtcl  frmi  Knrna*).  Tfontrrrtr  Sttlifin  c/  lAr  Crn«  Cfnhrt  «m  m  Itrtl 
wM  ttc  OMO-Mir  pair  of  Ctirpiwa  tjiuidriffnnina,  from  a  nin« tMaChlcmtovo.— 
fit,  scwAa ;  P,  pynuniUftl  Iracl  -,  p,  aco^Murr  uuTliou  vt  tLt  tiynatHil  trad  ; 
pt,  ata^trj  pt^lunciiUr  inut :  LPl,  loms  nlnr ;  XK,  rt«  iiucl'>ii«  of  th« 
Mvawntiim ;  /•,  pt»t*hnr  InngitiKlinBl  fmadonliw :  ar  knd  ar',  n]in'«rd  cao* 
tiauktioa  tit  llii  anti-iiur  rmt-toii*  of  tii«  tpinkl  Dord  i  Jii,  tbm)  servo; 
Itf,  naolrnt  «l  th«  l1iir<l  nonci  iv,  fourth  SOTVa;  IV,  nticloiM  of  tha  fourth 
narve:  iv*.  cnmiait  uf  Ilia  tibrM  u[  tlif  fo'irtb  nervM  to  oppotite  aidw;  dl, 
itMcendinl  mil  nf  ibc  tritioiniiiui  i  ee,  atpicdaat  of  Svlriua  i  «,  avHtns  of  llw 
Sbrw  ol  iiDv  iiu|>rnar  pGiluiif:U'ii  of  tbo  cerelicllum ;  p/,  fwoioulua  of  nudullatcd 
fibns  ptooMdlBg  to  tiM  uterlor  pur  nl  enrEKirik  quMrls«miiw. 


670 


FOCAL  Ul$EA»e».  ACCORDrnO  TO 


paralysed  od  the  sido  opposite,  and  the  oculomotor  tm 
the  same  ^idc  «s  the  IgbJoii.  If  the  le<uou  implicate  tbe  lenw} 
peduncular  fibres  {Fi(f.  279,  ps),  homiaDaj8th«ia  maj  be  p* 
8«nt  oQ  the  side  opposite  the  leaion,  but  tbe  amies  of  mcO 
jLud  sight  aro  not  affected  tinteea  aeighbouring  partx  be  in- 
plicated,  or  tbere  be  aecoadary  atrophy  of  the  optic  dUea  in  ibt 
case  of  tumour.  A  localised  lesioD  ia  the  auperior  part  of  Um 
cms  may  givo  rise  to  isolated  paralyata  of  the  fourth  atm. 
Tumours  of  the  crura  may  paralyse  the  oculo-motor  vemtm 
botb  Kidoit.  The  form  of  alt«niat«  paralysis  jost  described  isdal; 
indicative  of  lesion  of  the  crus  curcbri,  when  tbe  parBlytia  of  tbt 
limbs  and  of  the  motor  ocuU  occur  simultaueoudy.  It  mtW 
ho  rCiuumhcrcd  that  multiple  leitioos  iu  syphilid,  situated  in  dd- 
ftirent  parts  of  the  brain,  aro  very  liable  to  cause  a  grouf^Dgof 
symptoms  closely  aimulatiog  those  produced  by  a  eiDgle  Itooi 
in  the  cni3  cerebri. 


6.  LesioTW  in  the  Pedanclea  of  the  Gsretoiiwoi. 

§  762.  Ooe  of  the  mosr  remarkable  examplee  of  bttOKiT 
mto  the  middle  pc<luncle  of  tbe  cerobellum  is  a  case  d( 
by  Nonat : — 

A  wuiiuu,  nlwut  60  ymra  of  aga,  had  aa  &po|ifeoti«  mttadc,  tiim^ 
tcriMiil  \>y  uiioouBcaotuticHt,  lom  at  scoand  oco^lnUty,  and  lunljiift 
Ttic  ptLivut  lajr  on  luir  right  bmIb,  with  Uw  haul  ttnut^y  ruUtcd  in  tk 
■ttiui:  direction,  lira  oysboUa  wera  iuttuavahl*,  tho  right  Mag  raUA 
dowuvr;udH  uid  oiitwanb,  and  tbo  left  U|)inirdfl  and  uiwuUh.  ThvpAMl 
died  oD  tb«  day  foUowiug  Uiu  oiiiwi  wf  the  nltaoL  At  the  autopny  a  Mi 
luuuiurrhiigiu  fuciw,  about  the  aixu  uTsolieftmit,  wu found  situated  mtle 
rigbl  middle  poduuule  &f  tlie  oenbeUuni,  extcudli^  to  »oiu«  latKut  iiM 
the  «on«8|MDding  hemisphere.  Tbe  nauahtder  of  the  bnin  ead  da 
tnembrUM  •xun  baalthy. 

Tamours  of  tbe  middle  peduncle  of  the  cereMlum 
rise  to  headache  and  dizxiuess,  trifacial  neuralgia, 
paralytic  ophthalmia,  and  partial  dealben  on  the  sid«  of 
leaioo,  and  diitonlerH  uf  mutorco-ordinalioD,  tbe  teodoncy  toj 
being  in  u  lati^rul  direction  and  towaids  tbe  side  of  tbe 
If  tbe  tumour  press  forwards  on  tbe  poos,  then  all  the  tjniptow 
of  a  lesion  in  the  pons  itself  may  be  present.  Any  of  tlie  hiilbif 
nervea  may  iheu  be  iiapUcatad  according  to  tbe  position  «f. 


THE  LOCALISATION  OP  TUB  LKSION. 


669 


>f  respiration  and  circulation  maj  be  present,  but  these  usually 
t>elong  to  the  terminal  pbenomeiia. 

Albuminuria  and  gIvcoBuria  have  been  obsorvcd  id  local 
liaeftaea  of  the  pons,  but  by  no  means  witb  excepUonsl 
frequency. 

^H  (ii.)  Lmom  ik  tbb  PtDrKcUB  op  the  Cebibbcu. 

§  761.  The  most  characteriatic  features  of  lesions  of  the 
crebml  peduncle  are  afforded  by  an  alternate  hemiplegia,  in 
rUicb  tlie  extremities,  half  the  face,  and  balf  the  tongue  are 

Pis.  V9. 


ri* 


rt- 


1>^     it 


■4.- 


^y^^?  ?'■ 


1 


I '  r 


J  fHodMied  from  Knuw;.  Fi  a  iintne  Stctio*  nj  tkt  Crts  Cert6ri  «n  a  Icrtt 
Ihc  owCtHcr  pmir  <>f  Oarpmra  ^tMHtrliraniiM,  frvma  ikkie  m»TMt  atibryt. — 
cximU  1  P,  fwrnaiiU.!  l»ot ;  p,  •ecMaotj  txtf tua  of  Ui«  PTrMditUI  tr*ot  g 
f,  MiMory  pctluiiDuiHr  tnot :  /..V,  l»eiui  Ertm;  JUf,  na  xraclmt  of  tbo 
MgninituB  i  f..  poclerioc  lunKiiuiliaal  faadciuui  i  or  and  ar*.  upward  eon- 
tiuualioD  of  the  ultcitor  root-ton*  of  the  ■|>itud  oord ;  Itl,  tmnl  n«rT«; 
III',  tmolnu  of  th»  thini  itvnoi  iv,  fourtli  nuv*  ;  iv'.  ciudniui  at  lh«  lourth 
•r>e  ;  rr*.  ofoninic  of  iba  flbrea  of  ibn  fourth  nnren  Vi  njip^Ut*  idda*:  dt, 
niUu  root  of  Uk  Lrigcmliiiw;  <C  WjiUKluKt  of  Kvlvmi  i  m,  ot«Miu  of  llw 
t  «f  tju  mpcrior  |i«iltinolM  of  Iha  ceretieltuui ;  p/,  f  Molcalus  of  nitdBllllwl 
'~~        ]\at  M  tb«  ftoUrioT  pair  of  oniixira  qnndrigcmina. 


672 


FOCAL   DISEASES,   ACCOKDIKO  TO 


sudden  apoplectiform  symptoms,  speedily  termiDfttiojf  In  dcilk 
Id  bs^tnorrliQgcs  of  smaller  size  tbe  sjrmptoma  are  len  tnuktd 
or  wanting.  Hemiplegia  is  Dot  so  freqaeotl;  present  u  is 
lesions  of  tite  lateral  lobea,  nod  id  about  uae-tbinl  of  tt* 
reported  cues  excitation  of  tbo  geoital  functioDs  is  mvnlicwil 
Large  stationary  lesions  may  occur  io  the  cerebellum  wltkna 
giving  rise  to  any  recognisable  symptom8  during  lif«. 

AbM^ftea  of  the  oerebeUum  liare  frequently  boea  ahmnaii 
tbe  nymptoDis  on  the  whole  are  like  tfaose  caused  by  tin 

Tumours  in  tfie  eer^>eilum  give  rise,  in  additirm  i>i 
paToxysmal  cepb&latgia  and  roiDiting,  to  cbaracturisti 
diaturbances.     The  most  ttsual  of  these  area  atsiggvii 
reeling,  or  a  tendency  to  fall  to  one  side.     When  the  tumnii  i. 
situated   iu  the   upper  part  of   the  middle  lobe,  tbe  padat 
frequently  manifests  a  tendency  to  fail  backvarda.  while  H  il 
be  situated  in  the  inferior  part  of  the  same,  it  is  probable  tlM 
the  tendency  in  lo  full  forwards  or  to  revolve  forwards  rainida 
horizontal  axis.     Whco  the  tumour  is  situated  io  ooe  o{  At 
latvral  lubes,  the  patient  has  a  tendency  to  fall  towards  tbaal* 
iu  wliich  the  tumour  is  situated.     If  tbo  tumour  be  grownf 
slowly,  the  teudeucy  to  fall  to  one  side  is  couot«nkct«d  ta  sacb 
an  extent  by  cerebral  action  that  tbo  symptom  is  not  reai% 
cUcit«d.    A  slight  etaggt^r  may,  however,  be  obtenred  to  ao« 
side  wbcti  the  patient  ia  asked  Co  turn  ronii<I  snddealy,  aal 
especially  if  the  eyes  be  closed. 

Symptoms  of  motor  irritation  are  also  observed  in  eaam^ 
tumour  of  tbo  cerebellum.  The  most  usanl  of  tbow  ■■  • 
louie  contractioD  of  the  touHctes  of  the  neck,  causing  reUailiW 
of  the  head.  This  tonic  contraction  may  extend  to  tlM  tDin^ 
of  the  trunk  and  extremitJes,  giving  rise  to  tetautc  amaiM 
(Hughlings-dackson).  During  these  attadcs  the  tmok  ishsmI^ 
arched,  the  bead  retracted,  and  the  varioua  aegtneDU  of  the 
lower  extremities  extended  upon  one  another  and  the  tnolL, 
so  that  the  body  rests  upon  the  head  and  heels,  as  in  i«i 
The  r&rious  segments  of  tbe  upper  extremities  an  flexed 
one  another,  this  boiog  the  poaition  occupied  by  ibcm  in  teuOK 
llie  tonic  contractiotu  may  be  more  pronounoed  oa  one  ndc 
and  then  the  body  may  be  arched  towuds  that.  mde. 

JJovfm«ntt  </fthA  ey«bail»  are  frequeotly  obeerred  ia  chh^ 


THE  LOCALISATIOS  OF  THE  lESIO.V. 


873 


cerebellar  tumour.  These  movementfl  may  bo  vertical,  hori- 
zenta).  or  oblique,  and  arc  generally  parallel  (Mackenzie). 
Sometimes  tbcy&ro  only  observed  during  tbo  coavul^ve  uttacks. 
but  when  there  is  perraaneDt  rigidity  the  eyes  may  be  rotated 
ID  ouc  direction  and  6xed,  or  present  slight  pciraJkl  o^cilbttory 
movenieuta. 

Tumours  of  the  wrebellum  arc  rtry  liable  to  be  complicated 
by  effusion  into  the  ventricles  of  the  brain,  due  either  to 
pitttUTC  OD  the  vena;  maj^aie  Galcni  or  to  obliteration  of  the 
oonimunicntion  between  the  spinal  and  cerebral  subarachtioidal 
ipaces  (S.  Uackenzic).  This  cfTusion  in  children  give-s  rise  to 
ralargement  of  ibe  head  and  distension  of  the  fuutauelles, 
similar  to  that  occurring  in  chronic  hydrocephulua.  When  the 
foDtanelles  have  closed  before  effusion  has  taken  place,  the 
tieftd  is  prevented  from  enlarging,  btit  in  these  caees  sudden 
death  is  very  liable  to  occur  from  compression  of  the  Boor  of 
the  fourth  ventricle,  and  con)ie«{uent  arrem  of  the  function  of  the 
respiratory  centre. 

As  already  remnrkcd,  t!ie  ma<t  marked  clinical  characteristic 
of  a  tumour  of  the  RHperior  part  of  the  middle  lobe  of  the 
cerebellum  is  a  tendency  to  fall  backwards,  or  to  rotate  back- 
WAnls  round  a  honiointnl  axia  In  a  case  nndcr  the  care  of 
th.  Leech,  in  which  this  symptom  was  very  marked,  and  in 
wbicb  the  post-mortem  examination  was  conducted  by  myself, 
a  tubercular  tumour,  the  size  of  a  hen's  egg.  was  found  in  the 
right  occipital  fossa,  immediately  under  the  tentorium  and  close 
to  the  falx  ccrebelli.  In  the  case  of  a  child,  o^td  4  years, 
under  my  own  care,  there  was  a  tendency  to  fall  diagonally 
backwards  and  to  the  right.  I  expected  to  Bnd  a  tubercular 
tamonr  in  the  superior  surface  of  tho  corobelhim.  nituated  be- 
tween the  right  lateral  and  middle  lobes.  Instead  of  that  I 
foODfl  a  tubercular  tumour,  the  size  of  n  pigeon's  egg,  situated 
ander  the  tentorium  in  the  occipital  fossa  to  the  left  of  the  falx 
cerebelli,  and  a  second  tumour,  about  the  same  size,  in  the 
right  middle  peduocla  The  tendency  to  fall  In  a  diagonal 
direction  was  evidently  the  result  of  a  composition  of  forces, 
the  6r8t  tumour  causing  a  tendency  to  fall  backwards  and  the 
second  a  tendency  to  fall  to  the  right. 

The  following  case  is  an  inintance  of  tumour  of  the  inferior 


L 


RR 


674 


roCAL   UISKASeS,  ACCOKDIXO  TO 


part  of  the  middle  lobe  of  tbe  cerebeUum,  although  U)«leiM 
wu  not  limited  to  that  regioa  ^— 

Jolin  Tboma«  Oonld,  (ot.  1-4  jrunKiWan  odmitttd  tuta  tti«  Rojrtl  liiKiMq 
nil  ^txTcb  5, 1877,  uudcr  the  care  of  Dr.  W.  Roberta,  lo  wbow  loDdw*  I 
nm  IndcMol  for  permiaaioQ  to  (wbUali  the  cmml  Ha  wm  •  atmf  mi 
Itcalihj  toy  until  a  few  uioiithH  ofpi  his  parents  wae  alan  Iwahhr,  al 
tbaro  VON  aa  tutulj  histtotj  of  ooBBtUD{)tioii  or  uijr  oUmt  «oORtltieliad 
dincsM;  Ho  wuo  a  briiikBctter  bj  tn«le,  aad  three  iiKitithii  prerinailj  to 
utImLwion  fell  froui  k  lAilder  and  utradc  tiut  liack  of  hui  h«ad  oo  tlw  {M» 
mont,  and  Hinoe  tbab  tunc  he  has  nuflerod  from  oKin  or  Igm  oonilai 
ooai>ita1  heiulachp. 

Coi\duion  on  admueian. — As  be  Uoa  in  bed  bs  eaa  mOTV  Ua  IcpiftH^ 
to  any  fiirectiou ;  but  on  AttenptUif;  to  wiUlc,  the  ieet  ai«  •lUntAblj'  |i» 
ject«d  fiirwanla,  tlid  hoel  comiiiK  dova  forcibljr  m  in  looaoDtii?'  ittq; 
He  ctmnot  lufljiibun  the  orvc-t  [w«tuiv  ui»u{i^)it49d ;  wul  wtwn  all  sTtuMl 
aid  ii  luunieiitfinly  vnllidravm,  liin  bmd  nboota  dovmranb  mmI  ftna^v 
aa  if  tlie  IhhIj-  vvn  atwut  Ui  nivolre  inund  s  tmnsraw  faunnata]  ol 
Wlieu  the  iiAtiont  ia  t»u(^t  in  th«  Mi  of  lUUng  uul  nWI  •(■ta  ll 
tiuf  unxt  jHixtuni,  ho  cotnplaiiis  of  diidiwn,  sod  wcs  objedx  iK»iiha| 
from  right  t«  left  On  directing  hia  «yoa  to  tbe  right,  a  ^^t  mdSUi^ 
uioToiuont  of  tbe  cyebftlU  is  oboerved,  but  then  Bi  no  ttyvttagatam  «!■ 
be  luokti  8trfti>:lit  in  fnxiL  The  imtivnt  n  •haoal  qiiito  liLtnd  in  IhsM 
eye,  LuC  lau  distinguiBh  object*  ctearlj  vith  the  right  ejv. 

Whua  thv  rigbt  ey«  infised  on  bd  object,  ituoh  as  a  &if(er  twdt*  haba 
in  front,  iL  second  flnger  moved  laterally  oiid  to  the  right  to  aeon  oatS  A  ft 
okaost  nine  Ini^es  from  the  fiivt,  lowing  that  the  held  of  vUon  totti 
right  is  not  neiiaibly  diuiniMheiL  Rut  xtaiting  ovuii  fratu  tha  ta^  m 
whi<^  the  cyo  ie  fixed,  and  monng  tbe  aecood  lateratlj  to  l^  itlX,  A* 
Utter  dienppeuni  from  mw  nhvn  it  ia  fmm  one  to  two  inohaa 
from  the  fumier.  I  eay  fWiia  one  to  twv  inches,  bcvanse  bis  replia 
jUwxys  the  same,  tbuti  indicating  thnt  the  aeflaitiTO  oud  bUod  | 
the  rvtiiiu  urv  not  separHtml  front  one  another  hy  a  iiharp  and 
twrder,  bill  £ule  inwnKihty  into  web  oUmt.  Tht  yapiU  an>  aqoal, 
beingdilotedoud  very  eluttgish  to  light  An  0[ihth>bDoa«>|iJc 
n-Teolii  ilnuble  oiitio  neuritis  with  turnlli^n  dine,  bat  then  ia  do 
Tbu  other  special  aenaes  and  tbe  mentAl  faculties  am  Hnalftctad,  the 
in  fwe  fniin  «t\gu  or  nllnimeii,  the  a])|M>tit«  is  good,  and  aQ  iha 
Auictio«w  of  life  OK  iitimml.  He  waa  oid<Tod  iod.  potOM.,  gis,  s^  to  W 
taken  thruj  tinioi  a-dAy.  Oii  Miircli  31,  fourwecia  after  ■■faiw^ufy  kfe 
cvidimt  that  the  ttym{>toDU  havo  oltucd  oonddefahly.  Tba  |<atkM  ■*■ 
buliitiially  lica  mi  bb  bach,  or  eligbtly  inclined  to  one  Hide.  lie  laiiwi*  A 
mot  without  auiiport,  but  ha  haa  still  aocne  depve  of  nkmbaj 
over  bis  lepi,  akboiigb  the  tnorcmenta  an  feehta  ColatMoaa 
ia  ini{Mirc<l  in  the  lower  extnuutJea;  he  can  sUll  feel  when  lonehed, 
be  oaiuiot  luooliso  tbe  tovch  vdL  ScnatUlit}'  to  variatiois  of 


THB  LOCAUSATIOS  Or  THE  LKSION. 


675 


to  |nin  is  alw  imjninNl  Tbore  is  opmiilete  Uindtien  of  botli  oyee, 
ut  tbetv  id  ooly  tilif^it  tttrgphy  of  Uio  optic  discs.  Two  day*  ago  he 
Ilia  urinu  in  Iwl  for  Dm  tirat  tiiDe.  Ills  boweU  are  very  ouuittipntMl, 
id  tbde  in  geneml  rtuAciatioD. 
Ajml  Ibtit.-'Ui:  (vtD]JAitis  much  of  &oQtal  beadacbtt,  Thero  is  ooDt- 
ite  snuHthMin,  and  eatiro  looaofvoluntiu;  motion  of  the  lower  eitiwiui- 
B :  tlic  BtooU  auil  urine  are  paAsed  under  luni,  iud  Ibcrc  v*  a  Lu-gc  bod- 
«  over  tbo  aacnim.  H«  cannot  hew  the  tickiug  of  a  watoh  no  well  niUi 
)  left,  as  with  the  right  car. 

JVay  14M.'-Tb«K  is  complete  ftQiuathe«ia  of  all  puia  bolov  a  line 
BBUif  rouud  the  boily  mi  h  leuti  with  the  anterior  siiiHsriar  procvwoB  ot' 
I  ilium.  Reflex  trritAbilityii>cntir<!lv'ftboli))hi>i  in  tht'Iowiu-crtiumities, 
tnted  Iaj  tioklitif;,  prickiug,  nnd  ihe  fiiradic  ciun-nt.     Ttie  iiiiisclc«  of 

I  lega  auU  thigh*  do  not  rooot  to  cither  the  fnniclic  or  caantant  curroutK. 
B  cait  at  lliv  right  kg  lueaaurait  (It  and  that  uf  the  left  oul;  7^  iiii:hQs. 
ofa  tliigh  meosuroa  S  j  inirhos.    The  muscles  of  the  thighs  mid  of  the 

it  1c£  Appear  only  to  Iw  eiuadAttd  in  iimiiortioii  to  thu  rest  of  the 
Ijr;  but  it  IB  monifoBt  that  the  uiuHcleH  of  the  left  leg  htd  K|>ecially 
ofilustL    TImib  are  deep  lied-auica  over  the  tuivnuu,  tbu  promincaoea  of 

II  thi£^,  tlie  eattenal  maleoli  of  both  ouklutt,  and  the  iiiside  of  the  left 
w.  Tbo  intoUigenca  is  greatl/ bluuted)  luid  he  lies  inabolf  «tu{>or,  bat 
itea  rasdily  to  aaj  aimple  queKtiint  lutlwd  liiiu.  Hia  pulse  is  xvry  (ewbUi 
I  beats  ubuut  140  iu  a  auimte.  His  apiictitc  coDtitiiiun  nuuiirkAbljr 
id,  Jtbout  Awoek  ago  it  was  noticed  Umt  the  Itift  eyelid  was  only 
r  elowed  when  ho  wan  adeep,  and  ho  could  not  close  it  ctittrvly  by 
Rilantiuy  e&vt.  Theve  waa  also  slight  parnlTsiB  of  the  Ivft  fiuual 
■all,  so  slight  that  Uie  differenoe  between  the  two  sidas  could  scorocly 

■detected  when  ths  taao  wan  quiuacent,  but  rMxigclUBhlG  when  the  [)atisiit 
■fled.  Tlus  alTcotion  of  the  fmnol  aorvc  only  lontod  a  few  (Uyn,  iuid  haa 
■nrmtiruly  disaiiwomL  The  otuiition  uf  hia  hmriiigcariiiul  be  Mtiw- 
iutonljr  U»t<.-d,  owing  to  thu  aiwitbctic  state  of  hia  iutvUigcuoc. 

From  tbix  timo  ht-  linyerod  ou  without  any  further  BjieeiiU  Hym^ituui 
anifntiug  tt«vlf.  Qc  bijciuiic  more  and  mvrc  apathetic  nnd  lutrccuely 
aacMtnl,  and  diud  on  July3ni,  faurmanths  aftor  entering  th«  Intinuory, 
id  aavea  naouths  oiler  Uie  fall,  to  which  in  all  prubaUlity  the  urigiu  of 
0  llissaM  loay  he  traced. 

S4eti»  coi/cuvrM. ^Twenty -four  hou»  after  death  rigor  iiiorti.s  ia  ni<xl»- 
tely  veil  eat-tbliahed  in  lioth  eitrviuilie«.  The  bidy  id  greatly  eiiiadated. 
w  c^VM  ol  tlic  le^s  each  lueuauiu  7  iuchcn,  and  thigba  7|  inohea.  Thv 
cnun,  both  ttvchaut«ni,  and  th«  vxtvmal  uiaUeulua  of  tht<  left  foot  are 
jjoocd  and  deiiuJfd  ia  conaoquoiwu  of  sstouaire  bcd-eorts.  The  tipi  of 
ilh  ean  are  tdso  ulcerated,  as  well  oa  tJie  inside  of  the  Ivft  kner. 
Ob  mnoring  thu  ca]variLui>  tli«  bnuii  n]ip«arcd  to  [iroject,  niid  the  con- 
lutious  wers  fUttened  The  aiinmes  iUtd  the  veins  on  the  surface  of  the 
■is  were  gofgrd  leith  blood.  Th*  eulmtaiicv  of  the  brain  was  Miueo'hat 
rcatricles  were  distended  with  fiuidi  but  the  cerebrum  waa 


678 


FOCAL  DISEASES,  ACCOBDtNO  TO 


bcdltliy  in  oihrr  raipvcta.    Some  gminotia  torbiil  flnkl  naafMd 
b«tir«en  the  oereliollinn  nnd  oorpora  <)iut(lnfp'raitM.    Oa  tivfwotlBKl 
oeiebdliua  the  nlgo  of  ft  tumour  was  notaood  bcivDm  tlw  iataiar 
of  the  nuddle  lobe  at  its  posterior  maigia  uxl  the  tcupefloir  matttxiii 
medulln  dltlangnt*;  while  tlie  (uiteriur  vwl  uf  the  ttnnour  cobU  it\ 
bct-vccn  tbi.'  (wrcWUum  iwd  oorpnrn  qundrigeminiL    Ou  "if*f*^  • 
MctJou  of  the  cerebcUitm  in  tli«  micMIt!  tiiuitlownUi  the  Sour  «f  ill 
viM^mclo,  the  tiimeiir  vm  seen  ta  occa^y  the  itbok  of  tit*  m 
tlie  tnidcUe  lobe  of  the  cocbcUiUD,  being  soaaewluit  tnnni 
Hie  ri^  than  on  th«  left  Bide.    In  oanaiBteoce  tba  trnkoor  «M 
of  B  gnyiab-red  colour,  the  centre  beJtig  bnJtco  down  lo  m  Id 
umall  cavity  from  whiuh  ih»  turbid  fiuid  already  laeatiaDed  htd 
The  tumour  waa  oot  drcumscribed,  ite  marpns  gndaatlj  UgoCaf ' 
the  eorrounding  norroua  tiaaue.    The   growth  f«ned  liaat  the 
ooperior  pcduDcIo  of  the  ocrob^Ium  to  reach  the  oorpom  (pi*iln)(flH^ 
and  the  Utt«r  were  Bomemtrnt  aonened  and  fhlletud.    On  openUtdi 
tifinai  aaial  the  cord  was  Km  to  oouupy  the  whole  of  Ukc  tmjiij  la»- 
VEtraely,  the  dinnieter  of  the  eord  being  about  oiiA'tttird  laiyi  tfcw  te 
in  heottb..  The  whole  of  the  cord  folt  brKwii}-,  Ulu  UMon.     Oantav 
tmiavenw  acctlitiifl,  ttom  abors  doimwjmU,  liidf  aii  iiwh  ofiMt,  ihea^ 
bnuMi  in  tliv  ocrviotl  region  were  M-cn  to  be  odbcnnt,  atighUy  tlti^HA 
hikI  the  citnl  wiw  itofleuwl ;  but  in  tbu  u|)por  <loraal  n^ioa  tba 
umiiHT,  <M[ieciall/  on  the  pontorior  aupcct,  wan  tbive  tiincM  m  tliick  aa 
healthy  oonL-    In  themiddloof  tbadonal  n^ion  the  thideenad 
had  dcrclopod  into  a  dcuMc  wcU-doAocd  tanoor,  wbich  p««i 
ooid  (nun  bshiiul  foawanlB,  m  tfaai  onl;  a  amall  put  of  th« 
tDout  of  the  ootd  wan  lofU    (n  Um  lualMr  r^ion,  agun,  the 
raunilMl  the  cnnl,  no  that  a  oential  otin,  about  the  nae  of  a  gouM  (|bO,< 
eoFtcnod  nervous  tiaeue  was  all  that  was  left  to  repwaoi  tba  afuil' 
11m  tumour  was  the  oolour  and  teitore  of  b*ooo,  and  macii  doMV 
that  of  the  ccmbelluui. 

The  left  luag  vna  adherent  tn  the  cbcM  walls.     Doth 
healthy.     The  beart  wan  nonuaL     The  ulxlaaitnal  ocjiUia  w 
MimoHoopIc  «iaJaiiiiaiuH  Hhowod  that  th«  liiiDaar  orariatad  4f 
lU'lioatc  oelU  imbctkkil  in  a  finely  gnuiulor  subvtanoiL    Tbc  gnwIkHI 
oon)  la^MBDted  aimilar  micRMootMC  vharacten  to  tbe  oorabvflar 
but  containod  a  larger  amount  of  ioteroelliilar  iraWtMiaa. 

The  first  time  I  examined  the  patient  ray  diftgooM 
"  tumour,  probiibljr  ft  glioimt,  situated  ia  the  iufcnor  ponioarf 
tho  middle  lube  or  the  cerebellum,  fwd  proarit^  (armwaJt 
the  corpora  qu&drigemtna."  The  reuoDS  for  regBidinf  ihk 
case  aa  one  of  intracraoui  tumour  are  ao  inaotfeat  aa  Kand|f 
t«  require  meotioo.  The/  are  the  history  of  sn  tojniy  i«lh» 
bead,  the  graduRl  deTelopnieat  sod  progreiHnva  titumctei  at  At 


THE  LOCALISATION  OP  THE  LESION. 


077 


jnnptoms,  the  constant  beadach>e,  and  the  cxUtCDCO  of  doublo 
lptic>  neuritis.  My  reason  for  beticviiig  tbat  the  tumour  was 
ituateU  in  the  iuferiur  portion  of  the  middle  lobe  of  the  core* 
lellam  was  the  remarkable  manaer  in  wlitch  ihe  bead  and 
boulJera  shot  forwards  aud  dowuvrards,  aa  if  the  patient  were 
ibout  to  revolve  round  a  horizontal  axis.  The  circumntanceA  in 
vour  of  the  tumour  being  a  glioma  were  that,  if  the  diagnosia 
iti)  rcapoct  to  thu  iucalisacion  was  correct,  it  probably  gri^w  in 
be  sabstance  of  the  aervous  tiaaue  itself,  and  not  from  the 
ftembraaes;  whtlo  the  appearance  of  the  patient  and  the  family 
tistory  were  against  tuburclc ;  tliuro  was  no  cvidcucu  of  con- 
loit&l  syphilis  ;  sad  the  age  of  the  patient  put  cancer  almost 
mt  of  the  qnestion. 

M.y  reosoo-s  for  thinking  that  the  tumour  pressed  fortv&rds 
ipoD  the  corpora  quadrigemina  were  tbat  I  thought  this  would 

0  some  extent  explain  the  excessive  staggering  prc-i^ont  during 
Ittempts  At  walking;  but  much  more  tbat  it  would  explain  the 
great  impairment  of  vision  present  at  such  an  early  sts^  of  the 
(tiscase.  But  the  peculiar  character  of  the  disorder  of  vision 
damandi  au  oiplaDation ;  and  for  ibis  purpose  let  us  take  Char- 
cot'i  scheme  of  the  decusaatioa  of  the  optic  tracts  as  our  guide. 

la  this  case,  viuon  was  almost  totally  lost  in  the  k-ft  oye, 
id  the  state  of  vision  of  the  right  eye  simulated  nasal  Uemiopia. 

1  ny  simulated,  because  it  was  not  a  case  of  bemiopia  at  all. 
The  condition  of  vision  iu  both  eyes  was  that  of  amblyopia  in 
ita  prograss  towards  amaurosis.  The  amaurotic  condition  was 
nearly  reached  in  both  sidea  of  the  retina  ia  the  left  eye;  but 
in  th«  right  eye  the  right  half  of  the  retina  bad  become 
hPMOXotic,  while  viiiion  was  tolerably  good  in  the  Left  half;  and 
between  the  halves  of  the  right  retina  there  was  a  relatively 
broad  border  huid,  where  the  comparatively  good  vision  of  one 
aide  faded  gradually  into  the  blindaess  of  the  other.  Sucb  a 
condition  as  i\uM  could  not,  therefore,  have  been  caused  by  the 
pressure  of  a  tumour  on  the  commiesure  or  optic  tracts;  it  was 
not  likely  to  have  ariaoa  directly  from  the  optic  neuritis, 
inaamuch  aa  there  was  no  atrophy  of  the  di^c ;  aud  it  must 
therefore  have  been  caused  by  a  lesion  interfering  with  the 
optic  fibrts,  either  directly  or  indirectly  beyond  the  termination 
o£  tJhe  optic  tracts  in  the  external  geniculate  bodies. 


678 


FOCAL   DISEASES,  AOOOnDINO  TO 


It  appeared  to  me  very  probable  tbat  a  tumoar  pmnni  <■ 
the  rigbt  side  of  the  corpora  queilrigemtna.  and  cxtea&f 
gradually  to  tlic  left,  vould  produce  the  oooditioD  of  visioa  tMt 
with  in  this  caao.  The  wlurliug  of  objects  from  i^bt  toM 
which  the  patient  deecribed  Khoired  tbtU  there  waa  a  gieriv , 
amount  of  irritation  of  the  right  than  of  tlio  left  lobflfiftht 
cerebellum,  and  this  rendered  it  probable  that  tbo  tunMtlf 
the  middle  lobe  extended  farther  to  the  right  than  to  tlie  Wt 

Suppose,  then,  that  a  tumour  la  pre.«ing  on  the  ctufrnt 
quadrigemina  from  behind  forvards,  and  from  right  to  l9h,tb 
tibree  (b  a)  coming  from  the  left  eje,  and  meeting  at  LOD,  wooU 
be  first  interfered  with,  then  the  6bre«  (rO  coming  from  (Ih 
right  half  of  tbo  rolina  of  the  right  «J6  would  be  intereeptiri 
in  their  pasKage  behind  the  corpora  geoiculata  to  the  of^aaM 
nda  The  fibres  6' coming  from  the  left  half  of  the  letiM  d 
the  right  eye  would  be  the  last  to  bo  iujured,  so  ll>at  the  en- 
dition  of  viaiun  which  was  present  iu  this  oise  would  bep» 
duced.  It  may  be  urged  that  Charcot's  scheme  of  decutntices 
merely  diagrammatic,  and  that  the  points  LOO  and  LODm 


•-KQ 


ICC 


100 


Pm.  no  (Ari«r  CbHwi).  iXapraNAf  DcnuvMVMo/OcC^Mlr  TW«f -T.-*** 
dtmsMtuui  !■  tha  chiwa* ;  TO,  DfcWMtinn  of  flbna  poManor  w  t^  nM*> 
nalCMhU  hodiM  (VQt  -.  <i  b.  KbrM  wUch  do  not  ihiiiwirii  »  Um  tataiMt 
V  a",  Ktbn*  omaat  fr<>a>  tbe  right  cro,  aad  mviat  tog^Oar  Is  llw  Wl  t*^ 


"U                                       .                - 
BofMdft;  A,  Men  In  Um  Wt  bMDfa|)faN«  (LOtt).  proda 

(ri||bt*]ra).  T. Lwt<» twdwchy lamportl himiMwiiih ;  NNtI 


-me  LOCALISATION  OP  THE  LEISION. 


fi7» 


tppoMd  to  represent  potticionn  in  the  cortex  of  the  homispherea; 
It  my  reply  muat  he  that  I  am  only  makiog  a  diagrammatic 
te  of  it  If  there  is  a  semi-tbcusi^tioQ  of  the  optic  nerveii  ia 
te  chiauna,  and  if  the  fibres  wliicb  do  not  cro»i  In  that  place 
Runate  bebimi  the  corpora  genicuIaU,  then,  whatever  may  be 
lO  further  coune  of  tkcse  (ibreH,  some  such  tffecl  as  that  indi- 
ited  would  be  produce*!  by  a  tiinionr  preasing  from  behind 
nranls,  and  from  right  to  left  ou  the  corpora  quadrigemina. 
hifl  at  least  was  tbe  proceas  of  reasoning  by  which  I  came  to 
le  coQclusion  that  the  case  was  one  of  tumoiir  of  the  anterior 
irt  of  the  middle  lobo  of  tho  curchulluni,  tnciiuiu^  to  tbe 
gbt  side,  and  pressing  forwards  on  the  corpora  riuailrigeraina, 
id  thifl  conclusion  waa  verified  to  a  cotiaidembk-  <  xtent  by  the 
Mt-mortem.  One  serious  objection  I  always  Lad  to  thin  view 
as,  that  it  was  oot  maaife&t  how  the  Boor  of  the  fuiirth  veti- 
idc  could  escape  under  such  circumstancca;  and  yet  there 
u  DO  sugar  in  tbe  urine,  no  polyuria,  arid  the  breathing  was 
^Hoteifered  with.  Tho  autopsy  explained  tliie.  It  showed 
bit  the  corpora  quadrigemina  were  probably  not  so  much  in- 
irfered  with  by  prefiaure  aa  by  esteusion  of  tho  glioma  along 
w  superior  peduncle  of  tbe  cerebellum  into  the  subotance  of 
leee  iKxlies. 

As  the  cose  progre^ned,  it  became  evident  that  there  wan 
S  independent  affection  of  tbe  cord,  an  evinced  by  the  com- 
leta  anxMhesis,  and  loss  of  reflex  irritability  la  the  lower 
[tremtUes.  as  well  as  by  the  trophic  changeii  already  described. 

Two  suppositions  could  be  made  with  regard  to  the  afiectioD 
rtbe  cord.  Eittier  that  there  was  tumour  pretratDg  on  the  cord  of 
le  same  nature  &n  that  in  the  cerebellum,  or  that  there  was 
ttensiTe  softening  in  the  lumbar  region.  1  must  acknowledge 
lat  I  felt  inclined  to  adopt  the  hitter  riew,  iuumuch  m  1  wuii 
aly  thinking  uf  a  circum»crih«d  growth,  and  was  not  prepared 
>  find  a  new  furmation  extending  the  whole  length  of  tbe  cord. 
i  u  very  probable  that  the  new  growth  bad  begun  to  develop 
t  tbe  spinal  cord  at  tlic  time  the  patient  was  admitted  into 
Id  lofinuary,  and  that  the  symptoms  of  motor  inco-ordinntion 
bwrred  were  due,  in  part  at  least,  to  implication  of  ibe  posterior 
wt-zones  in  the  morbii.1  process^ 

the  following  case  several  tumours  were  found  in  Ihe  e«rc< 


G80 


rOCAL   mSEASES,  ACCOBDIKG  TO 


brum  as  well  &a  in  the  cercltoUnm,  yet  it  was  not  difficohli 
diajjDosticato  tbe  presence  of  a  tumour  iu  the  Uct«r  :— 

Louis  Udii,  mi-  3^  yvara,  eatora)  the  Southern  Hoaptul  od  OobJw 
3rd,  1677.  Qi<  BU>tber«tatocl  th«t  tMi«n«»d«nya  luMJtlty  antil  14  bm^ 
ago,  when  hv  hiul  an  attack  nf  cbickcn-pm,  aRvr  wUch  lie  ■nflend  b» 
sure  «v<a.  i^>an  Arum^nrrla  he  bc^ui  in  jiut  faiM  hiu>d  to  hia  frwhaat  wJ 
to  oomiilain  of  ]<«uii  tha^  and  bo  gmluaU>  loot  floalL  tliece  watife 
80DM  discharge  from  the  Hj^  nr.  Tliuse  ^ym^nma  ooittiniMd  In  abitf 
d^it  ino<n;h9  without  anj  Appmanblc  cbongQ;  bat  ait  mcaitlw  liAn 
■dintmuHi  thu  umllicr  was  avmlnniKl  ilttriDg  the  aighc  lif  a  icwl  mgma 
from  tliL'  child,  who  vaa  foiuid  qd  tb«  floor,  baring  baoii  tffuaiif 
projecW  front  liU  btxi  by  tbe  viol«noe  of  a  ooovulaioii.  On  being  {tdii 
up  he  was  found  ooinpletely  imalj-aed  od  Uw  ngbt  half  of  tbe  ba4;>«' 

The  panJftio  tjmiAotua  gnuivaHiy  iiaproved,  but  oonniUma  m^v^ 
reuMl,  tlie  Bjntnni  being  limited  tn  the  [NUMic  ddo,  and  not  ktlcnU If 
looa  of  ooQscioasneas.  Uq  bnd  had  tbo  bat  of  tbow  aitadn  a  f-niu^ 
prerioua  to  adntinion.  The  connalsiTe  BtorcBuiiti  alwa^  hmpa  In  lb 
right  lukud  iu)d  ana ;  bat  tbe  moUior  oottld  not  be  sum  wbotbor  tbi  q^ 
Aide  ofthe  faceor  theleg«-iisDeit  iiiraded.  Tbe  pannta  had  alrtad;  V* 
oa«  uf  tbvir cbiUtrva  Crou  "water  uu  tlui  Lruuii"  aud  auotber,  *)i»M 
readM^I  the  a^e  of  «tgbt  yeun,  had  never  heen  able  to  wpmk  mon  IIm 
a  fan  vmrde  (mngenital  aphuou). 

Prueat  Co>utition.—''VhvTv  \»  a  kli^ht  dagraa  of  rigbt-aidsd  ft^ 
paralTsis.  only  ap]karcDt  wbea  tbo  child  crioa  or  Kiuiloe.  Then  it  th^ 
poreeia  of  thv  right  arm  aod  kg;  bat  be  boa  oonsiderklile  Tnlimtaf7  {im* 
over  both.  The  fingers  of  thv  tigbt  baud  uro  Mnui-flvxad,  nod  tb«  tbok 
bent  iuwards  oti  the  ittim  under  thi^  fingaa.  Then  b  eonie  tuucd* 
rigidity  on  Attempting  pftWra  diotdilk'DU  of  the  fiiiget«,  haad,  onl  (■•- 
ano,  Biid  thciv  is  also  some  degree  of  ngidit;  on  attcmptins  to  vaxft  di 
right  le^  and  foot.  Tho  child,  on  beiDg  plaoed  on  hia  ftet.  wo  ^mA  wk 
oven  walk  a  few  at«pe  if  tbe  upper  pari  of  llu!  bodj  be  au]i(nrt«iL,  but  aba 
eirer;  support  ia  withdrawn  bis  fiiee  nenmes  a  (Hght«uud  bx^rK^m:n, m^ 
bo  woolil  immediateljF  fall  on  the  iiondyaed  aide  uulow  (wnRtlcd.  Tli 
aot  of  falling  doaa  not  oanaiBt  of  a  ainipio  fielding  of  tba  [«i«tio  h^M 
the  beaii  and  upjwr  init  of  tbo  tnuik  aboot  ktotaUjr  to  tbe  ri^itt  elit 
tlie  leg  of  the  saine  aids  Ja  tnnintahied  extended. 

Uis  aight  ia  not  good.  Be  acaa  on  objeot  bcld  oat  hofofv  faiai.  M  • 
putting  liit  left  hiuid  out  to  gmtf)  it  ho  twM  to  grofv  for  it  Tb«>> 
double  a|ittc  Dcuritin  witb  oomnwooing  atrojifay  uf  tbe  dia«K,  IDs  «fMft 
is  ftlmoet  lost,  tho  oiily  word  he  can  say  Imng  "  Mamma.* 

Konniber  10tb.~About  tcu  dava  ago  be  bwl  a  oonniUaa  wUiA  1* 
mainlf  limited  to  the  left  side,  this  being  the  Snt  oliiwveii  aioc*  ke 
entarad  Iho  boapttd.  He  baa  bad  aa  many  m  thno  attMln  to  a  dv< 
while  wjine  days  i«ssed  without  hia  havlof  an/  aUoolc  Altoylbtf  bt  k« 


TBE  LOCALISATION  O?  TUB  LESION. 


681 


[ftbmt  tvvTDtj  aitUdca  in  the  ten  da>-s.  I  wm  n»l  fortiinaU)  eiiau^ 
I  OBc  of  tboM  ftttAcks  najMlf,  bnt  I  g*vo  particular  inxtnicliotix  ta 
Ftitinfp  to  ohserrc  whrllicr  tbo  cotivulaioti  began  in  ihc  hatiA,  face,  or 
{.  TIh'  <IoH<Ti|)ti'in  i>f  tlio  rtnrsD  wns  alwavs  to  ihe  same  effiKrt,  ttut  the 
lade  bupiD  with  a  Krtam.  tlii^t  thi>  body  vma  ticiit  liki-  a  Ijuw,  aa  tlutt 
■  left  onklfl  nDil  1«R  sid«  of  the  face  nearly  met,  and  that  iiiunedjat«ly 
Btiw  attack  tiw  child  munied  ita  usual  maimer,  witliuiit  iiuuilfeating 
ptiiiilniiiji  to  sleep.  Then  is  do  diBUoet  pomlfiiifi  of  the  left  oxtn- 
iUo. 

ihtr  I  Stb. — The  child  hm  only  had  a  fe^  oonvulsivo  attacks  Kince 
nport,  nad  none  nt  all  during  the  liut  furtiii^'hL.    He  U  mw 
blind,  being  abl«  only  to  see  an  object  pinccd  ia  the  loft  of  the  left 
Tluore  m  slight  nystagmiia.     Tlte  tntiwulnr  rigidity  mi  atti^iniititig 
I  iDommenta  of  the  right  arm  and  leg  u  now  more  morlced,  and  the 
I  on  tliat  aide  is  obi)  more  pronounued.    The  luwer  eitreuUtlee 
liB0est4>d,  of  n  blue  eolour.oad  ookl,  bat  thi>ru  in  noRuucular  atrophy. 
I  eatii  lua  food  vrell,  and  tburc  is  a  fair  amoont  of  tfuhcutauccnu 
_    [a  Is  hvooniDg  a])athvtie  and  paimw  hiH  «-aU;r  mid  sIodIk  under  biui. 
Jautiary  Sfltb. — lie  now  lies  on  hin  back,  and  is  getting  more  and  moi* 
i«it  and  apatbetio.     The  nystaKniua  is  more  |ironouno>d  and  tbore 
ju^t«  deriattof)  of  the  eym  tii  Lltu  It^ft.     He  soreunu  at  night  aud 
rba  the  other  children  in  the  wiml,  ou  acoouut  of  vhicb  he  was  dis- 

;>ntinued  to  riail  thtt  luttittnt  vot'iMi'iTiiilly  at  hi«  Iwmo,  fcnt  the  only 
aw  of  notv  oln^rvi'd  wore  thuev  of  a  gntdiud  twnipn»t)i<^Q  of  the 
t  etilarsenieiit  r>f  the  haad,  Mparmtion  of  tlic  fontaiiellea,  and  lluctuft* 
■tbem.    He  dk'd  on  March  13th,  187& 

port  tnortcm  vm  conducted  £4  hourt  oiler  death.    The  veatridM 

[much  dJKtcndud  by  a  fluid  effusioa.     Pour  tubercular  tiuuoum,  each 

■  the  MHO  of  a  hojKl-nut,  wona  found  lying  along  the  nidctiH  of  Rulando 

t  left  bomisphere,  one  of  them  hciog  wtuatcd  at  ita  inferior  citiumity 

'  po6t«ior  ertreiaity  of  the  third  festal  convolution.    Another 

I  about  tlic  aios  of  n  haul-nut,  won  fnund  in  tlie  cortex  of  the 

near  the  Kii]iorinr  t^xtivnuty  of  tbb  uacejidiiig  (lariotaj 

A  tumour,  about  the  aizo  of  a  pigeon's  egy,  ww  situated  in 

tontieular  nucleus,  and  oomprcaxitig  the  internal  capsule.    The 

Mur&OQB  of  ttie  right  and  middle  lobes  of  the  oerelMnuin  wore 

[tied  by  a  tubc^rcular  ma^,  which  ettcud'Ml  ixtui  liitn  the  left  Lotend 

A  niicn»ou|}ical  examiuivtioii  of  the  spmal  cord  revcalod  8clcn»H 

I  right  latcnd  oolttmn. 


le  first  time  I  cxaToiDed  this  child  the  presence  of  doultle 

□euritu  rendered  it  clear  that  the  cnso  vtus  one  of  intra- 

litil  tumour,  the  flight  stagger  to  tbe  right  and  the  puruleut 

jaige  from  the  right  ear  poioted  to  a  tubercular  tnmoar  of 


683 


FOCAl.   DISEASES,  ACXX>ILDIXG  TO 


the  right  lobe  of  the  cerebelloin  ;  while  tfa«  btrtoiy  of  ttniUtenl 
convulsiona   hegtnQtng    io    tfae   right  krm    and    tha   uphin 
poioted    to  the  presence  of  one  or  more  tobercular  tum<n;-> 
aloDg  the  sulcus  of   Rokoda     M;   diagnoaU,  therefore,  «u 
tubercular  tumour  situated  in  the  yulcas  of  RoUndo  of  the  Ub 
hemisphere,  and  another  in  the  right  lohe  of  the  cerrbellnir 
As  the  case  progressed  the  betniplegia  became  so  cotnpleto  ti:^' 
a  cortical  tumour  would  hardly  he  sufficient  to  aocoaot  bi  : 
and  I  coD£e<iueDUy  assumed  the  exieteooe  of  another  ivu. 
ia  the  left  lenticular  nucleus,  and  compreuiog  tb*  bUfBu 
capsule.     Had  I  adhered  to  this  diagoosi*  it  would  hsf«h««9 
absolutely  accurate  up  to  a  certain  point     But  vbco  the  c' 
viilBions  began  in  the  left  half  of  the  body  I  b^^o  io  watrr : 
my  previous  opinion  with   regard  to  the  localiaation  of  t^ 
tumours.     The  unilateral  convulsions  of  the  left  half  of  tbetc! 
waro  L'ither  due  to  irritation  of  the  motor  area  of  the  oortu 
the  right  hemisphere,  or  to  irritation  of  the  cerebdium.    F^<- 
the  uniform  description  of  tfae  nuise  I  came  to  the  concloii 
that  these  coDvuloioos  vcre  of  the  nature  of  tetanic  wixun' 
and    therefore   due   to   cerebellar    irritation.     The    uniltten. 
character  sHsumed  by  them  I  explained  by  sapponing  thai  tW 
tumour  was  growing  in  the  left  lobe  of  the  cerebelhtm  and 
causing  irritation  of  the  left  middle  pedaocle,but  it  tsof  coane 
doubtful  whether  there  is  any  justification  for  such  a  nippo«tiB& 
I  also  tboagbt  that  the  presence  of  one  tumour,  aituat<<d  iathf 
centrum  ovate  of  the  left  hemisphere,  in  such  a  position  •■  t* 
interrupt  the  fibres  of  tbo  pyramidal  tract  aud  the  fibru  of  tU 
corpus  calloeum  connecting  the  posterior  extremities  of  tb«  tkiii 
frontal  convolutions  with  one  another,  might  aCoounl  for  tb* 
right  hemiplegia  and  aphasia,  without  assuming  tho  "f***^** 
of  ft  tumuur  in  the  cortex  and  another  in  the  lonttcular  nuekn 
I  made  a  commuoicatioa  to  the  Maacbester  Medical  Sf/dHj, 
several  weeks  before  the  death  of  tb*  patknt,  in  wbtefa  tkw 
various  opinions  were  discussed,  and,  owing  to  the  reloetaMit 
felt  in  assuming  the  existence  of  five  or  six  tamoat*  BtvatsiB 
variooa  parts  of  tlie  cerebral  hemispheres  and  oeielMllui,  I 
corae  to  the  conclusion  tliat  a  tumour  in  the  oeotrum  orali  tf 
the  left  cerebral  hemifiphere  and  anothur  iu  the  lafl  kibe  of  ik 
cerebellum  might  accoaot  fur  tho  symptoms.     Had  1  asnns' 


THE   LOCALISATtOK  OF  THE  LESION. 


6S8 


the  eiistence  of  the  larger  number  of  tumoum  my  diagnoBia 
would  have  been  almost  absolutely  correct  I  am  cveu  now 
nn&ble  to  decide  whether  the  unilateral  epiLXiiif)  of  the  left  half 
of  tbe  body  were  of  the  nature  of  tetanic  seizures  or  were  true 
cerebnl  conTnlsJoDS  caused  by  the  irritation  of  the  tumour 
found  in  the  cortex  of  the  right  hemlHphere,  near  the  superior 
extremity  of  the  ascending  parietal  conTohition. 

In  the  following  case  the  sympbotos  pointiug  to  an  intracranial 
lesion  were  very  obecure,  yet  the  preseDce  of  double  optic 
■Kuritia  and  a  alight  stagger  in  the  gait  of  the  patient  rendered 
it  poeaible  to  di^nosticate  a  tumour  of  the  right  lube  of  the 
cerebellum  For  the  notee  of  the  case  I  am  indebted  to 
Ur.  Lackman : — 

Annie  E.  SI ,  ast  31  yean,  dnmc«tic  fwrviuit,  fnterotl  {li«  MAHchntcr 

RoyiJ  Infimoiy  oti  Octobvr  21st,  18S0.  under  the  cArc  f4  Dr.  Rois. 
Tha  patknt  vtw  hesitth;  until  about  mx  mnntfan  ago,  when  she  began  to 
m&r  tma  a  <Iull  b«niliKh«,  oooupj-iwR  tte  ytrtes,  and  «atcnding  to  attbm 
twinfilti.  Tin-  lnvwiuvlii:  ili»i  nut  [irevtnt  her  froco  sleeping,  it  wna  vum,aa 
4  rute^  00  gvttiujc  up  in  tho  ruorrting.AndgenemUy  improved  nftrrshahad 
hid  a  warm  cup  of  tea.  The  hfuuWte  van  linNv  tci  iiit«iiiK!  [laroXTsai&l 
t^fnvatiuQ,  and  during  theee  attncks  the  pntiont  gtrtvi-olly  Tonuted. 
About  two  months  ago  she  felt  a  little  uuHte^diiifaK  in  wrilkiiti:,  tbo  liead- 
mIms  incvmuMl  in  iattnaity,  nnd  she  sufiered  bo  much  Trom  rvtohing  and 
Tfnulttng  that  hIu)  wan  L-(itu]x!llcd  tn  ipvf  up  her  aitiiatjan. 

Ori  preienting  hcrMlf  at  tko  Inlinuary  tut  on  out-patimt,  a  week  ago, 
tlie  oiiljr  sjniptonu  curaplattiMl  of  were  intewte  headache,  while  there  n-cre 
great  emotional  dutarbeuicM  like  tbow  of  hyvtecia.  A»  tbe  |>nticTit  irolk<>d 
acnvBtbe  floors  alight  stngKcriag  towanl»  the  right  niilc  vnn  otxienred, 
this  beiag  <wj)i>dally  ruarkod  wlicn  sho  tumwl  niddMily  rmind  or  eloaei) 
her  oyoa.  It  voa  Dot  then  coovcoicnt  to  mako  an  <i|)hthalruowopiR 
exrauoation.  When  ■ho  appeared  at  the  end  of  a  wwk  am  au  ont-patient 
the  eymptoma  were  »ti11  tho  aoiuo,  only  the  hysterical  nyuiptoma  irore 
dMidodly  tnnre  pmnounccd,  and  Hhe  via*  ndroitteJ  as  an  iTi-|iatii'iit. 

Promt  ContiiCi«m.—OTi  admimitiii  an  niibthalinfiscojiio  cxantiimtioii 
nwealed  double  optic  ncuritia,  but  ithc  ctm\d  read  the  smalleat  |>riut.  Sba 
never  had  diplopin,  aud  thore  ynm  tto  Htrahinnuiti  or  n.vRtagmtu.  There 
ma  no  paralyBia,  no  rutonooua  Mnitory  disturtHinoM,  and  uo  affection  of 
the  RpacJal  aeuoeai  Tbe  [patient  Aill  aafTorcd  fVom  hMtduohv,  diaractariwd 
by  TemiMMoa  and  paroxynDUl  exaoeFbationa,  as  well  w  from  ntta«la  of 
hicoongh.  In  wrillclni;  n  iJI^hl  ataKRer  I'a  oocaaionally  obiorvod,  the  teudeucy 
to  Ckll  h«ng  ftlwavs  totriLtvUi  tho  right.  She  also  progrempd  in  a  tlightly 
cvmd  BiM!,  iii»t«a(l  of  walking  in  a  tAnuKlit  otiunw.  Tho  tendency  lo 
etngger  is  incnatud  when  tho  patient  clweo  her  eyes  or  turaa  suddenly 
nxuuL 


68  i 


FOCAL  D1SEA8BB. 


\ 


KoT«iulior  9ad.~No  nev  STmptoma  w«n  eimemd  tiaot  lut  tipcl 
untj]  I  o'clock  bwlit}-,  vrltfii  it  wim  nuticcd  thai  tbi!  lutiral'i  ba  ai 
1J1»  bod  1i«o«fiio  liriJ ;  hIio  aha  complolnfid  of  a  dull,  lusirj'  iK^Juk* 
Beat«d  oil  tlie  vertex  of  the  bead.  At  3  p-in.  raa^ntiaD  nMlfleBljr  ommA, 
uid  Dr.  Steele,  who  wm  immedintelj  sent  for,  ntaUd  to  atAeiJ 
nspinititu,  aiid  maintMued  the  aolkai  of  the  hewt  for  apwirdft  oC  tm«j 
minatw,  but  the  {wIm  oeiifled  to  beat  foiir  niiiiutM  nflv  tlM  utifioil 
respimtioa  was  diiioantiaucd.  During  thia  time  it  wma  noUoed  IW  iW 
right  ]>ui>il  W)w  dUated  luid  the  right  <aAa  of  the  taae  tii^Oy  ^mnlprni. 

Tbo  iKMt-DKH-tcfD  Bxiuntoatioii  was  aiDduet«(]  tor  Dr.  A.  H.  Ywoi, 
eighteen  hows  kft«r  (loath.  Tha  eerohml  heniaphorw  utd  bud  gufb 
were  noniud.  Tho  vontrioleK  were  diittendod  with  fluid,  buI  IIm  aqiMlM 
of  Sylvius  was  contidembly  diliitMl.  In  the  eeMbeUuia  a.  w«U4dW 
tumour  was  fimnd,  ronuing  n  wvU-ntorked  {vajectiao  ta  Ibe  rifbl  hMd 
lobe.  The  coiuIwHilt  mibirtauai  ajitieend  promineDt  bi  tb«  nfiwif  ttl 
fMwmen  miiKuuio,  ab  though  piu^cd  out,  tud  Mvmtxl  lo  praa^Mlli 
floor  of  tlu)  fourth  ventricle. 

Tbe  follonmg  case  illustrates  tb«  moTem«tit»  of  th*  oyaWli 
Bomotimes  observed  in  tumours  of  tho  cerebellum : — 

In  the  cMe  of  »  boy,  tffii  IS  ymn,  onAer  mj  euw  nt  the  HgwlhM 
HiMpltal,the  (jmptonui  od  «dmi>iMOQ  wen  bo4d»di«,doaU*  optic  iwv9% 
Amhl>'o[)ia,  lUid  a  slight  stagger  on  waUdng,  the  tatidency  to  UU  tvN  bm^ 
gr«at«r  to  ono  «ido  IUod  to  tbo  otbor.    Uo  Uved  in  tlM  ba«]iiU]  immtI;  Him 
montlia.  nntl  during  t^at  time  the  optic  Deiirids  gavo  |ilace  to  atnf4;  <f 
thddiiiM,  ftnil  the  AmKlyopiii  to  omnuroms  j  whjl»  the  cbaui^  is  tl»<l!b> 
«jrm|itoiaa  cDDsiatod  of  b  jirogtcarive  impunnent  of  th«  tnenta] 
ftom  gmdual  aonpiesrion  of  the  brain,  the  patient  oltiniAtdj  <i*iii( 
tuae.    During  tbe  last  Have  dajn  of  life  tbore  waa  rigiillty  of  ibc 
af  the  back  ot  the  neck  alonj;  with  vertical  and  ponllel  movcnxaiUuf  Ito 
eyebolb,  consiBting  of  ad  upward  alteinBtiaic  with  a  dutrnwiLnl 
Tbo  time  occupied  by  each  rotatory  Rwvemeiit  wu  ROuultaU; 
and  as  manj  aa  twcuty  of  theao  oociured  iii  a  niimta.     At  tl>e 
two  tubercular  tuniaun,  each  about  tbe  tdee  of  a  (Hgcoti'ii  e^, 
aymtuolriuUlj'  uituatvd  in  tbe  iiifcrinr  MirlncG«  of  tbe  Intcral  lobea  A 
third  tumour,  ahout  tbe  ain  of  a  baad-nut,  wm  found  in  the  tatftim 
portjoa  of  tbu  middle  lobe. 


685 


CHAPTER    X. 


It    DIFFU8ED  DISEASES  OF  THE  ENCEPHALOX. 


(1.)    ANEMIA    AND    HYPRltrEMIA    OF   THE    BRAIN. 

0-)  Ayjtjtix  or  THE  Buik. 

§  784.  SuU>ry.—X>T.  MarabkU  Boll  van  on«  of  the  fint  to  ditvct 
kttcctiou  ti  the  ejinptoma  {iroiliin^il  liy  coret'nil  uMtniia,  luiil  as  thc-fo 
•jniptomB  iu  childrfii  cloMly  Kimulnto  those  cf  ncutA  bj'drDCi![khalii«  bo 
{tnipVBed  to  oiUI  the  coii<lilJoti  h^drocei>haloicl  ur  hydreDcviihiiloid  diasanc. 
Hq  k1«o  poiut«d  ont  that  symiitonM  which  had  hitherto  boon  attrihiitod 
to  osnbrBl  h/porniaua  ircro  rrall;  du»  ti>  tuianmai,  and  wcro  eucb  as 
fr«(iu«Dtl]F  oocumd  artur  eihau^tiii^  hEomorrhagBa.  About  tba  saine  tune 
Aberorombio  gftm  iL  eimiliLr  iiatcrprotatioo  to  tho  ajiaptoma  of  a;n«<ip« knd 
of  appftexia  ex  inanitiont.     The  titudy  of  tho  etFacta  of  lig&t-ira  of  the 

KDtida  by  Sir  Astlej  Cooiier  led  iLe  vaj  in  the  us]>fihmei)tal  iuveatig&tiiMi 
Denbful  aD»a)is,  vhiuh  wiu  cotn[iloted  in  tdotq  reosiit  yean  by  the 
Duxa  of  Sduff,  RusawAiil  uid  Teiin«r,  uid  mail/  otbcre. 

§  785.  £jrperiinental  Inv€ftiyatwn. — Wheu  one  of  tho  conimon  carotirl 
uUriM  Uco[D{)nMMl,  Ui«r«is^Tsti»diaUuctu«Miof  risioD,  aad  afurafev 
tMNsooda  a  prickliug  seiisAtioi)  is  r«U  in  htdf  the  fac«,  followed  by  a  umiLar 
••oMtioii  io  tb«  limb*  aad  opiKuiito  half  of  tho  body.  QeQersl  Mueibility 
IwcoiiMa  iodistiQct,  tbo  aenae of  touch  i-t  iitipaired,  and  erea  trembling  and 
0<>uviilaiv«  twibohiiiga  ma;-  occur;  but  »ft«r  thrvo  or  four  miuutea  tbeoo 
aytaptomit  duiappuiu-,  b«onuM  thu  colIntorAl  cirr.ulatioti  Aonri  ootupHiiiMtwi 
tbe  efilBOtA  of  tb«  «oin)ir«Mion.  CoEnprvtiiiioa  of  both  car->tida  is  followed 
by  iDdistlnctneu  of  vision  niaoiintiiig  to  alui(»t  coi)i[ilL-te  l>liudn«M,  oon^ 
tr«ctioD  followed  bj  dilatat)i>ii  of  the  puplla,  tha  n<«i>irMtion  becomn  alow, 
■l«ep,  nod  aghing,  and  there  is*  n  aanae  of  oppreasioQ  about  tho  thoni. 
ThMO  Rjmptoais  aro  fi>llon«d  by  droivHioose,  •taggcring,  and  lom  of  ooo- 
Kioiuiisia ;  and  if  Cha  comprewilou  he  conLlnued,  universal  musoular 
twitching,  iytaptoms  of  oholciug,  and  TouttiDg  appear  (Schitf). 

If  the  circulation  throujib  both  carotid  auJ  vertebral  arteries  be  aud> 
denly  lutcrru{>t«4,  tho  [>ii^iU  &rat  wiitraot,  but  soon  dilate  again,  tba  •ya- 


686 


DIFFOSKD  UI&ELAS^  Or  TH8  BKCEPUALOy. 


bftllHToU  ujiwiu^aaud  Qatff«rd»,  tlw  jawa  twi  claudwd,  tndtlw  w^wlia^ 
at  fint  dhort.  livcoiaas  alon  aod  dMrp ;  tbw>  qnaptoaw  an  aoMi  MInri 
by  gsuwal  uiuscular  relaxation.  Ion  of  cooacMOSDMi,  utd  geoKi)  and' 
HioDk.  SimiUr  ajoptomji  att«ud  blwdiog  to  <I«alh.  If  tb«  asiMl  4t 
Ijreriounly  earwbled  bj  losa  of  hlood,  death  naalte  froui  sjucupQ  vithMt 
ovupuUiouo.  Tbv  animal  mar  '^  ^f^  '*>'  ^"boft  titue  in  a  mkIUmi 
8im\iUti:i;{  t]<uitb ;  but  If  artiAdal  mpintioa  ba  maiiitained,  gndod 
r«e9rcry  takca  pUc«  wb«Q  th«  bloo4  IB  aUo«*d  to  Sow  a|uo  UllH^ 
tJis  Tflrtobral  arteries. 

It  bM  b«eii  foimd  tbat  cb«traoUati  of  tb«  cireulatJaQ  UuiMgh  Ha 
carottda  iu  Boimala  only  cauaea  triBiag  eSeots  In  oocatwtiaop  -with  Ita 
B^littitua  i>ro<tuo»d  to  man,  ahomng  that  tha  anterior  lobaa  an  of  mnA 
greater  tiu[)ortauc«  la  man  than  in  anioiala. 


§  7<>6.  Etiology. — AaEemUt  of  the  brain  U  catiMd  by  b- 
flueaces  which  act  upon  the  vascular  ejstciD  of  the  bnio  olQat, 
or  it  tuay  form  only  a  part  of  geDeral  ancemia.  The  entire  bnia 
may  bo  aftectod,  causing  uniivrstti  ancemia,  or  it  auj  bt 
limiUid  to  certain  pam  causing  pariitU  anctmia.  The  ^n^ 
toms  also  ditTer  tnucb  according  as  the  aniemia  is  suddeolycc 
gradually  produced. 

J.cuf«  'tniveraal  cet'^ral  anannia  n  caniiod  in  iti  nual 
typical  form  by  a  sudden  toss  of  a  large  quantity  of  blooi 
The  most  frequent  causes  of  this  form  of  cerebral  auaimia  an 
pmt  parlfint  bsmorrbagej  bajtnorrbagtst  from  the  note,  lanfi 
Btomacb,  and  intestines,  and  large  lomea  of  blood  from  eit«nd 
iojuriea  A  sudden  fall  of  arterial  tension  from  the  relaxatkntf 
large  rasoular  areas  in  other  parts  of  the  body  may  aUa  tamm 
cerebral  annimia.  The  f^oLneas  which  frequently  accompsuM 
the  rapid  withdrawal  of  oacitio  fluid,  or  immediately  after 
parturition,  in  probably  caused  by  the  flow  of  a  htrge  c|naiiti^ 
of  blood  into  the  relaxed  abdomtoal  yeesela. 

Cerebral  anaimia  ia  a  fr«qnent  accompanioteot  of  oajaak 
diaeaaeM  of  the  heart,  more  especially  of  aortic  regutgiutlan. 
in  which  death  olYen  reaultt  from  ayocope.  WealcQMB  of  ibt 
muscutar  walls  of  the  heart,  whether  temporary  as  afier  acuta 
febrile  diseases,  or  permanuut  as  iu  fatty  dej^oeralioQ.  ta  apt 
to  produce  faintaeas  from  cerebral  ansmia.  Irritation  of  (ki 
TAgus  may  catise  cerebral  anemia  by  a  temporary  arreit  of  tkt 
heart's  action,    fainting,  the  result  of  mental  impreiaioiii^  aaj 


DIPPCSED  DISEASES  OF  THE  EiICEPHAU>N. 


687 


.'produced  in  this  way,  altliough  apastn  of  the  cerebral  vesaela 
Dm  irritation  uf  the  sympatlietic  nerves  may  be  tho  causo. 
lotetute  pain  may  csuae  faintness  or  oven  syncope,  which 
ly  result  from  reflex  irritation  of  the  vagus,  or  direct  irri- 
^oQ  of  tlie  syrapathetia  But  the  direct  effect  pruduced 
Bbe  nerre-centreg  miisc  also  contribute  to  the  result.  The 
mig  DorvouH  di»cliargi?fl  caused  by  tlie  esteraal  injury  aMcend 
mg  centripetal  fibres  and  produce  a  corresponding  strong 
rroua  discharge  from  the  higher  iiervc-centceB,  which  is 
3duct«d  along  c«atrifugal  fibres  to  the  periphery,  giving  rise 
the  criea  and  varioiui  bodily  contortions  which  imiicaie  pain. 
gaio,  strong  nervous  dischai^ea  frotu  the  higher  centres  niu^t 
followed  by  exhaustion  and  consequent  impairment  or  aboli- 
b  of  functioD,  just  as  the  ditjcbargea  of  epilepsy  ore  accom- 
lied  by  uncouaciouau^s. 

4,cut*  uaiTcrsal  cerebral  antcmia  may  probably  be  caused  by 
}as  poisona,  altbough  aosesthetic  agents,  like  chloroform  aad 
f,  probnhly  act  lesa  upon  the  circulation  of  the  brain  than 
Ihe  cerebral  tissues  theniBelvea. 

tie   Univerml  Cerebnd   Aiifemia, — This    variety    is 
by  any  condition  which  withdraws  a  large  quantity  of 
nutrient  lluids  from  the  body,  such  a«  repeated  losses  of  blood, 
diarrhfea,  chronic  suppuration,  and  all  cauaeH  of  general 
ia.     Chronic  anemia  of  the  brain  also  occurs  in  certain 
lesioDS  and  fatty  degeneration  of  the  heart.    The  Intro- 
3n  of  foreign  matter  into  the  cavity  of  the  skull,  as  inflani* 
exudations  in  meningitis,  the  fluid  which  trausudta  in 
I,  ha-raorrhagic  foci,  and  cerebral  tumours,  may  also  cause 
kic  aojemia  of  the  brato. 

irtial  Certln-al  Anamiia. — Partial  anaemia  is  caused  when 

the  vessels  uf  the  brain  is  obstructed,  or  wheu  external 

ire  is  exerted  by  a  tumour  ou  a  vascular  area,  but  these  cases 

already  been  described.    Unilateral  aooimia  is  seen  after 

iro  of  the  carotid  oq  one  aide ;  but  the  symptoms  arc  only 

>nu>y,  except  in  the  caaee  in  which  there  is  an  impcn'ious 

Ition  either  cougenilal  or  acquired  of  the  communicating 

of  the  circle  of  Willis. 


69S 


DITFUSED   DISUSES  OT  TEIC   ENCKPBALOW. 


§  767.  Sym^ploms. 

Acuit  Cniveraal  Cerebral  A  namin, — ^Tlio  initijU  urmpumi 
are  obecuratioQ  of  Ibo  senses,  buzzing  in  tlie  eaiB,dizziim^et» 
iroctioa  followed  by  dllatatitMi  of  tbi>  pupils,  impsrfect  rautlN 
to  oxterual  gtimnli,  and  loss  of  ooDseioasacM.  The  laifKB 
becomes  cold  uud  pale,  llie  leepirator;  movements,  sooelonttdtt 
6rtit,  l>econie  slow,  and  tliis  condition  is  freqaeutly  IbUomd  If 
general  coavalaloBS  and  coma.  Tbe  sympioma  wbicli  «i«  p*- 
duoed  \>y  tbe  tcmporaiy  uun^mia  caiued  by  powerful  nwntil 
improfisiotui  differ  coDsiderabljr  from  tboao  jiut  deacnbod.  At 
6ret  tbere  is  some  degree  of  mental  iocobereoce  UMnii&Ui  If 
the  ioabilily  of  the  patient  to  direct  bis  atteotaon  to  a  partiMlir 
object,  a  foeliag  of  oppression  in  tbe  cheat,  along  with  « t«»- 
dency  to  gape.  Tbe  face  hecomea  p:ile,  a  cold  penpiratM 
breaics  out  on  tbe  forehead  and  somotimM  oo  tbe  entire  hofy 
and  there  is  general  muscular  relaxation.  There  i«  rii^iag  ■ 
tbe  ears,  dimness  of  sight,  naasea.  and  sometimM  voritivi 
Tbe  pulse  is  storU,  compreiwible,  but  regular.  The  patii^atii^ 
now  begin  to  reoorer  or  fall  insoneiblo  lo  the  ground,  and  lAtf 
a  few  moments  in  the  recumbent  position  he  bogies  to  reeom 
This  coDiititute8  an  ordinary /ait)fin<^_/tt  or  nyseope. 

Chrfmic  Universal  Cerdjrai  Avumiux. — In  theae  ca*et  *< ' 
marked  mental  irritabUitj  is  observed,  assodaced  with  fnn' 
uesa,  restlessaess,  uneasy  steep  di«Lurl>ed  by  dreams,  ai.!  ' 
certain  amount   of   intolerance  of   light  and    sound.      Thtrf 
symptoms    are    frequently   succeeded   by    the   pbeoooMos  ^■ 
depression,   and   sometimes  tbe  latter  predominate  from 
first.      Tbe    patient   suffers  from   almost  constant    bcadi: 
vertigo,  nau)tea.  and  faintoess.    The  pulse  is  sm&U  and  c 
pressiblc,  tbe  cardiac  impulite  feeble,  and  there  is  great  dii'^ 
nation  for  either  mental  or  physical  exertion. 

Iq  tbe  aevere  forms  of  chronic  or  sub-acute  cerebral  SJWBlii 
such  as  that  produced  by  starvation,  or  Ibftt  <«liicb  arises  dalilf 
tbe  course  of  exliausting  fevers,  delirium  become*  a  pn^ 
ncnt  symptom.  Occasionally  delirium  comes  on  aTier 
rhage;  but  it  is  genorilly  a  late  symptom,  and  ocean  ■ 
frequently  with  robust  than  feeble  pc-opla  This  synf 
is  more  common  when  the  anemia  is  due  to  starvatieo. 
under  these  circiimstancea  It  is  eallcd  the  "  dalirium  of  jt^ 


DIFFUSED  DISKASKS  OF  THE   ENCKPHALOS.  688 

tioD."  The  dolirium  whieb  comee  on  after  the  crisis  or  diiritig 
coDvalesceoce  in  febrile  diseases  is  also  to  be  attribubud  id 
great  part  to  tlefoctive  ittitritiou  of  tbe  brain.  During  the 
lieliritim  of  cerebral  aiia-mia  '.he  patii'tits  are  cxciti^d  and  some* 
times  maniacal ;  there  are  illustoos  of  sigbt  and  hearing,  and 
deluaionij  of  ponteeution.  The  duration  of  this  condition  is 
variable ;  it  may  last  a  few  hour*  or  days  only,  but  it  somotiiiics 
coDtiQues  for  weeks  and  occasionally  parses  into  permanent 
ioaanity. 

Cerebral  anaiiiiin  is  seen  in  infants  after  severe  diarrhcca,  or 
other  exhausting  disease;  and  an  this  in  the  form  which  was 
called  by  Marshall  Hall  kydivcephtUotd  or  ki/dwruxpkaloid 
dbease,  it  demands  special  notica  The  aBectiuu  may  be  divided 
into  two  stages — the  first,  that  of  irritiibiiity ;  the  second,  that 
of  torpor,  resembling  the  first  and  second  stages  of  hydrocephalus 

Pipeclively.  In  the  first  stage,  the  iufnut  is  irritable,  rvslless, 
th  tlu.shed  face,  warm  skin,  and  freqiituit  pulse;  Uiu  patient 
starba  on  being  touched  or  on  bearing  &Dy  suddeo  noise,  sleep 
IB  disturbetl  and  interrupted  by  uigliK,  moaus,  or  screumti. 
Daring  the  second  sta^e  the  cuimteQaDCe  becomes  pale,  the 
cheeks  and  extremities  cold,  the  eyclida  are  half  closed,  tbe 
ejrcB  sunk  in  their  sockets,  there  is  frequently  slight  etrabiamus. 
and  tbe  pupils  are  diluted  and  do  aot  contract  to  light.  Tbe 
breathing  i«  irregular  and  sighing,  tbo  voice  husky,  and  there 
is  umetimcs  a  teasing  cough  with  rattling  in  the  tliroat  A 
raoflt  important  symptom  which  distinguishes  this  diaease  from 
bydrooephRl us  lb  that  the  fontuuelle,  iusload  of  being  tense  as 
in  the  latter  disease,  ia  depressecL  The  child  iiicliuu»  almo»l 
confitaatly  to  fall  into  a  sleep,  which  may  pau  into  coiua  and 
dcftth,  but  under  appropriate  ireiitmcut  gradual  recovery 
tmialty  takes  place. 

§768.  Horbid  Anatomy. — ^The  blood-vessels  of  the  mem- 
brunes  of  the  brain  are  usually  more  or  less  empty,  but  there 
is  almost  always  a  certain  quantity  in  the  larger  veins  and 
mnuaea  A  very  characteristic  appearance  is  presented  by  the 
pta  mater  in  cases  of  chronic  ansunnta  osaociated  with  condi- 
tioDs  which  induce  general  tedema.  Tbe  pia  mater,  especially 
ver  the  su  pcrior  surfaco  of  the  hemispheres,  is  of  a  pale  colour, 
88 


tfdO  DirrCSED  DISEASES  or  THE  ENCEPBAUllf. 

»ome*r1iftt  opaque,  and  no  <eilematou3  thai  it  piu  on  {iRinn' 
This  condition  in  especially  marked  in  cbronic  Bright'i  <)'w>^l 
and  I  bavo  frequently  b(<«n  able  to  prsdict  on  opening  tlio  Ad>j 
at  a  post-mort«iQ  thnt  wo  should  lind  contracted   kidoeTv. 
these  catieB  the  cavities  of  the  arachuoid  and  the  l&ti'ral 
tricles  contain  together  about  two  ouncea  of  serous  Btrid, 
the  choroid  plexuses  are  oedematoua     At  the  junction  of  < 
posterior  and  descending  horns  of  tbc  reotricle  liie  ledema  ofl 
choroid  plexuses  is  so  great  that  it  gives  the  appeaimoca  of  I 
or  three  cysts,  each  about  the  size  of  a  pen,  growing  from  < 
The  grey  substance  is  pale,  and  somewhat  dccoIourtMd 
whito  aubetance  is  pnter  than  usual,  and  there  is  an  at 
of  blood-poiota. 

§  769.  Morbid  PAyffiofoj/y.— Cerebral  amemia  ia  a 
condition,  depending  not  merely  upon  a  doficicncy  u/ 
quantity  of  blood  supplied  to  the  brain,  but  also  upon  a  cba 
its  quality,  nnd  upon  a  diminution  in  the  iutracranisl 
It  iH  exceedingly  difficult  to  apportion  to  each  of  thi 
due  ehoro  in  the  production  of  the  itymptoms.  A  glaiwx;  I 
ever,  at  the  empirical  laws  of  nerve  irritjibility  will  afiiwdl 
key  to  the  interpretaLion  of  the  more  prominent  sympi 
the  disease.  When  a  nerve  is  imperfectly  noumbed  its  k 
bilily  is  first  increased ;  or,  in  other  words,  a  slight  degree) 
nsual  stimulus  will  cause  it  to  diacbarge  its  enei^.  Wbcnl 
deficiency  of  nutrition  'a  continued  the  increase  of  the  il 
bility,  which  is  only  a  temporary  condition,  is  followed  bjral 
crease,  and  complcto  withdrawal  of  nourishment  again  ts  fo 
by  exhaustion.  This  principle  will  help  to  explain  the . 
phenomena  pruduved  by  cerebral  ana'mio.  When  a 
individual  suddenly  losoa  a  large  quantity  of  blood,  ifaetr 
bilily  of  the  nervous  matter  becomes  increased,  and 
of  irritation,  aiich  as  contraction  of  tho  papiU,  restlevnsi  I 
ringing  noises  in  the  «an,  are  produced,  and  there  may 
a  large  discharge  of  nervous  energy  from  the  eoit«t  cf 
brain,  giving  rise  to  general  convuiaiooa  followed  by 
ttciouBUens. 

Whea  the  anccmia  takes  p1.tce  more  gradually,  ttis  oet 
disdiarges  will  bo  less  powerful,  and  they  will  only  pnxluni  i 


DIFFUSED  DISEASES  OF  THE  EKCEPHALON.  691 

I  of  mental  irritability,  to  be  followed  by  a  drowBy  or  sow.' 
lent  coadition  inttt^axl  of  complete  loas  of  conacioasoesa  If, 
tbe  other  hand,  tho  ncrrous  energy  of  tho  cortex  of  the 
ivbrum  be  already  exhausted  by  overwork  prior  to  tbe  loei  of 
lod,  the  phenomena  of  dopre^-tion  may  exhibit  themselves 
m  tho  bogiQDiog  without  beiag  preceded  by  any  sigus  of 
ilatioD,  and  under  these  circurostanccR  iinpon»ci(>u guess  may 
anduced  without  being  preceded  by  gun^ral  con  vulaiona. 

yTfO.  Courne  aiid  DanUioii. — Simple  faintoeM  firom  omo- 
ual  causes  usually  soon  ends  in  recovery,  akbouf>h  a  f»lal 
e  U  rarely  meo  wilb ;  but  it  is  probable  thai  in  these  cases 
n  is  some  amount  of  degeaeratioD  of  tbe  muscular  walls  of 
t.  Tlitt  syncope  which  attactu  paticntu  convalescent 
te  disease,  when  they  aaiume  the  erect  posture  for  tbe 
h,  is  more  dangerous  and  liable  to  prove  faUl. 


1.  Diuffnosia. — The  Bymptoms  of  cerebral  anasmia  are 
ike  those  of  hyperemia  of  the  brain,  and  the  deltrtum 

mia  which  arises  ia  the  course  of  acute  diaeases  may 
tcadily  bo  mistaken  for  tbe  delirium  of  active  congestion, 
and  hypenemia  of  tbe  braia  can,  indeed,  only  be  dis- 
frora  one  another  by  careful  attenlioa  to  the  coa- 
symptoms.  The  cerebral  symptoms  themselves  are 
be  relied  upon,  as  tbe  delirium  iu  unieraia  may  be  an 
t  as  in  cuutjexlinn,  and  the  colour  of  tbe  face  is  nut  nlvvays 
ibful  iudes  of  tbe  condiLion  of  tbe  cerebral  circulation. 
liagttOHts  must  be  founded  upon  the  general  history  of  ihu 
the  nature  of  the  concomitant  symptoms,  and  the  treat- 
wbicb  bas  been  adopted  prior  to  tbe  onset  of  tbe  dt-lirium. 
rther  aids  to  tbe  diagnosis,  it  may  be  tried  whether  the 
or  horizontal  posture  has  any  iuBuence  in  aggrarating  or 
liahing  the  symptoms,  and  whetiier  they  arc  increased  or 
leil  by  alcoholic  stimulants.  Tbe  i^tate  of  the  general 
attoD  must  also  be  carefully  examined. 

2.  The  pro<pi08^is  in  a  case  of  bydrocepbaloid  disease 
leially  favourable,  provided  that  ihu  true  nature  of  the 

>□   be  recognised   and  appropriate  treatroent  adopted. 


092 


DIPFUSED   DISEASES  OF  IHB   KKCBPIULOX. 


n 


A  nmil&r  remark  ma;  bo  made  witli  respect  to  the  ildina 
of  atiamiia,  allhoiigh  it  ma;  MimeUaiM  be  prolooxed  w 
occuitionallj  prove  incurable.  Tbe  progoosii  of  ibe  oerebi 
auKtuia  otusetl  by  livarl  iJi»riuic  will  tlopeati  upon  tbo  ffV* 
of  the  cimliac  nfiecUoD  ;  auti  fatal  ayncope  ia  very  apt  to  oon 
in  aortic  regurgitation  wliOD  accompaned  by  dilatAtioo  of  ti 


left  ventricla 


§  773.  I'ltatmtnt. — ^Tho  trc»tmeot  imi»t  vary 
tbeani^min  ia  acute  or  ehroni^^  liinit«d  to  tbe  hmio, 
tbe  CDtire  body. 

In  aa  ordioary  fainting  JU  the  patient  should  ai  tpwdily 
possible  be  placed    iii    the   recumbent   posture,   and   neon 
usiiHliy   takes  placo   without  any  further   treataieot     If  1 
aymptoma  are  more   peraistenl,  some  fonn  of  cutaneooa  il 
tAtioQ  may  be  employed.    The  most  usital  and  readicaffMtil 
is  to  sprinkle  thu  face  with  cold  water,  or  to  Seek  tbe  fast « 
the  corner  of  a  towel  dipped  in  cold  water     A  coora  eSoI 
method,  however,  \%  the  application  of  tbe  metallic  tlMk 
bruab  if  a  battery  happen  (o  be  at  hand.      Mnalanl  tf 
catioDD  have  been  employed,  but  they  are  too  alow  ia  d 
action.     The  preparatlona  of  ammonia  and   other  (tnhriaa 
which  irritate  the  trigeminus  and  olfactory  ncrrea,  are  i 
uHoful   adjuncts  to   the   treatment, '  and  Mimulating   eod 
may  bo  rcMtrtod  to.     As  soon  ax  the  patient  cau  swallow, 
especially  if  the  heart's  action  he  feeble,  stimolanta,  nd 
Coffee  or  brandy,  must  be  administered.    The  more  volatil* 
agent  the  eouncr  will  it  bo  alworbud.  hunco  ether  ia  CMpfd 
useful;  and  the  fame  may  be  aaid  of  obampaijDr,  uaM 
cxpcnmcuts  of  Benoatd  have  proved  that  the  prOTcoce  of 
carbonic  acid  promoteo  tbe  abeorplioo  of  alcohoL 

Id  severe  cases  of  cerebral  aoieinia  after  profuae  bcmnt 
in  addition  to  the  meus  alraady  mentions],  the  bodjtf 
patient  ought  to  be  covered  with  warm  blaaketa  or  ■ 
clothing  and  aurroitDdod  by  bottles  containing  hot  Wats; 
in  order  lo  increase  the  flow  of  blood  towards  tbe  bnia 
head  ought  to  be  kept  in  a  low  position,  while  prwM 
maintained  over  the  abdominal  and  axillary  arteries,  a 
oeediog  which  wilt  direct  tbe  stream   of  blood   lowardi 


(^ 


DirrUSED  DISEASES  OF  THE  EKCCPUALON.  693 

carotids  aod  will  conseriuently  raise  the  teostou  in  tlie^e  vessels, 
[a  case*  of  screre  and  prolonged  cerc-brsl  aii»!inia  rrom  low  of 
bluod  transfuaioD  sliouM  be  tried  as  a  last  resort. 

The  cerebral  anu-inia  wliicli  arises  duriug  tbe  ooursQ  of  ucutd 
diseases  must  be  treated  by  the  judicious  utce  of  wine  and 
uouri&biug  diet,  and  if  tbo  case  adroit  of  it  by  such  t^iuici  as 
tiaioitie  and  iron.  The  patient  nhoitld  also  be  toiitnicted  Dot  to 
raise  bis  bead  froin  tbe  pillow  so  long  as  tbc  action  is  accom< 
paoicd  by  dizxiacxa  or  other  symptomit  iudicativo  of  annimia. 
Wlien  delirium  or  other  forms  of  cerebral  excitement  accom- 
pAuies  the  nuieniia,  tbe  g^eat  aim  of  treatraeut  should  be  Lo 
procarc  aleop.  A  full  dose  of  chloral  sometimes  acts  very  well 
ID  these  cases;  but  according  to  my  experience  an  opiate  ia 
muob  more  reliable  and  eBicacious.  A  single  subcutaneous 
iojectioa  of  morphia  ia  fret^ueDtly  followed  by  calm  sleep,  and 
the  patieut  awakes  witb  restored  montal  facultifs,  The  dose 
Hbould  not,  as  a  nile,  b«  mora  than  horn  one-eighth  to  one- 
fourth  of  a  grain. 

IIjf'.trooi'i}fi'dotd  diaeaw  must  he  treated  on  the  same  geueral 
fMinciplea.  Tbe  disrrhifia  or  other  diitease  which  has  produced 
tbeaoA-mia  muiit  be  attended  to;  and  the  cane  must  be  treated 
by  wann  applications,  appropriate  nouriabmeut,  and  stimulants, 
mob  aa  wine  and  musk. 

(li.)   UinaMUu  or  tbs  Gaaw. 

(j  77*.  Eliolofftf, — Congestion  of  the  brain,  like  congestion 
of  other  orgaos,  may  be  either  active  or  pa&sive.  The  furiuer  is 
»l«o  called  tbe  kyperamia  of  fixuxion,  and  tbe  latter  tbc 
ht/ii^)-<tri\ui  of  Bta»\9. 

Active  Cong<^ion — Irritation  of  the  tissues  of  tbe  braio 
«aus4»  congestion,  but  such  cases  gcocrally  tcrroinnto  in  en* 
c«phaliti8,  and  tbe  congestion  is  unuaJly  more  or  less  local.  The 
DkUM>s  of  universal  active  congestion  must,  Ihenifore,  be  sought 
in  the  state  of  the  general  circnlation  rather  than  in  the  brain 
itself.  Alt  coudiiious  whicb  raiae  the  arterial  tension  must  tend 
to  produce  coogetitiou  of  the  brain,  untesx,  indeed,  the  increased 
tension  be  caused,  as  in  chronic  Bright's  diiiease,  by  a  diminu- 
liioc  of  the  lumen  of  the  arterioles  all  over  the  body,  including 
iboea  of  the  brain.     An  increased  flow  of  blood  to  the  brain 


L 


698  PIFFOSED  DISEASES  OF  THE   ENCCPHALOV. 

the  attack,  there  i«  littlo  or  oo  elevation  of  teQ)pentiu«,Ukdlk* 
diecftse  tenninates  in  recovery  in  two  or  ihreo  i1fty«  at  ntwL 

{e)  Tb«  apoplectic  form  in  cbaracterioed  by  sudtlea  aod  tAl 
losa  of  consctousneas  aud  complete  rasolaiion  of  the  limW  kl 
reflnic  cxcitabtlit;  is  preserved.  The  patient  reooven  oonac»» 
DMe  in  a  few  boum.  nnd  after  a  short  time,  tvo  or  three 
at  moet,  all  the  symptoms  disappear  without  leaving  a 
behind.  SomeUmes,  hovrerer,  after  complete  restoratioo  to  on- 
iciouetiesx,  a  certain  amount  of  muitciiUr  paralygii  reoiuni  ii 
one  limb,  or  asaumea  the  bemiplegic  form  and  penistt  forKot 
time. 

§  776.  Moi'ind  Anatomy. — It  is  necesaary  to  be  oo  one'i 
guard  against  certain  causes  of  error  with  respect  to  pot- 
morttiin  appcaranociL  Both  arterial  and  renou»  bypOBBM 
may  disappear  at  death  without  leaving  a  trace  behind  Os 
the  otter  baud,  vrhfu,  an  ls  usually  tbo  case,  the  body  a 
laid  on  it«  bock,  a  large  quantity  of  bloo<l  may  be  (cnxA  u 
the  veins  and  Giniues  of  the  occipital  fosMe,  caused  by  tla 
inlluvuce  of  gravity  after  death,  aided  probably  by  bypXitit 
coDgeetion  during  the  last  few  hours  of  death.  The  act  tf 
dyii>g  by  respiratory  paralysis  may  also  cause  a  hyperraua  of 
the  cerebral  veins  when  there  wace  no  symptoms  of  ooQgistioe 
during  the  course  of  the  diaeasa 

In  pathological  hypenpmia,  when  the  calvarium  is  reaioTM. 
the  vetiseU  of  the  diploc  arc  frequently  found  congested.  TV? 
veins  of  the  dura  and  pia  mater  are  proraiueol  and  fall  ofbl-- 
atxl  HO  alao  are  the  choroid  plexuses  and  sinusca  In  i 
severer  fomu  of  congestioD  the  brain  is  swollen,  and  thegjn 
are  flattened  from  compresaioD.  The  grey  aubatanoe  k  ef  a 
dark  red  colour,  its  coDsist«Dce  is  increased,  aoJ  the  cut  sarbfii 
uf  the  white  euhetaoce  preeents  a  large  number  of  red  pudAfc 
from  which  drops  of  blood  exude.  The  white  subatanc*  may  b 
of  a  yellowinh-reJ  colour,  white  at  other  times  its  oolour  ii  &ttfr 
altered. 

In  chronic  congestion  the  veadels  tbetnselvn  beoone  aftirsd. 
In  the  venous  variety  the  veins,  especially  those  of  the  n*iB- 
brance,  the  fturfiicti  of  the  brain,  choroid  plaxuscsi,  and  rcluB 
ioterpotitum  are  enlarged  and  tortuotia.     In  cbiouir  aitens) 


DIJTUSED  DISEASES  OF  THE  KNCEPnALON. 


G<I5 


CRM,  ADd  it  is  mamfest  tbat  the  organ  nhose  vessels  bc^n 
firat  to  dilate  must  become  more  or  less  congested. 

Some  poisonous  agents  appear  U>  b&vc  the  efTect  of  producing 
coogcstioo  of  the  brain  ;  most  or  the  narcotics  and  sUmulaaU 
t}^>ear  to  me  to  act  upon  the  tissues  of  the  brain  Bret,  and  to 
produce  conge^tioD  as  a  ficcoodnry  Action.  The  more  dill'iisible 
ttimulatits,  as  ether,  chlororvrni,  and  alcohol,  uu  doubt  cause  a 
etttaio  amount  of  congestion  of  the  brain,  just  as  they  produce 
fliuhing  of  the  face  by  paralysing  the  sympathetic ;  but  nitrite 
of  ainyl  and  its  aUle»  appear  to  be  the  oaljr  known  agents 
wbich  act  specially  on  the  vaso>motor  system  before  affecting 
the  timue  of  the  cortex  of  the  bniiu. 

The  cerebral  symptomii  in  hyperpyrexia  and  insolation  were 
ai  one  time  referred  to  coogcstion  of  the  brain  ;  but  it  ie  much 
iinore  probable  that  the  high  tompcrattire  acu  in  &  deleterious 
VMliDer  on  the  cerebral  tissuee.  The  cerebral  symptoms  of 
feren  aru  probably  duo  quite  as  much  to  qualitative  aa  to 
quantitative  alteration])  of  the  bluud  in  tlie  braio. 

Active  cerebral  congestion  appears  to  be  moic  common  id 
malee  than  in  femalf^fi,  and  in  adulta  than  in  oithor  the  old  or 
the  young.  The  statistics  of  Andral  and  of  IJammond  tend  to 
show  that  tho  disease  is,  as  might  be  expected,  more  common 
in  winter  than  in  summer.  Heredity  undoubtedly  exerci«ea 
some  influence  in  causing  cerebral  bypersmia,  but  it  is  pro- 
bable that  the  influcnee  is  indirect  rather  than  direct,  as  in  the 
gouty  diathesis. 

PoMive  Comjeation. — Venous  congestion  of  the  brain  may 
be  only  pari  of  venous  congestion  of  the  whole  body,  or  it  may 
,b«  pioducod  by  special  causes.  General  venous  congestion  is 
caused  by  diseases  of  the  heart  and  lungs;  and  for  the 
mechanism  by  wbich  this  congestion  is  brought  ubout  the 
reader  is  referred  to  works  devoted  to  diseases  of  these  organs^ 

Congestion  ix  also  caused  by  all  local  diseases  which  retard 
the  return  of  blood  from  the  braio. 


§  775.  Stfmplorn^. — Congestion  of  the  bmio  gives  rise  to 
symptoms  vrhtcb  vary  widely  in  difieruut  cases;  but  for  clinical 
purposee  three  varieties  may  be  described — (u-)  the  tliyht,  (6) 
9re,  and  (c)  the  aiMfplectic  torm. 


ttAOMre,  an 


"i      f  TT 


uu{{uiiiuiuK  iiY}wiieuiui  iiviu  luuiiiUMWiui^  uiMMavaui  tn 
but  its  inilicalioDs  ara  not  ti>  be  too  implk'itJj  relH 
Congestion  may  he  ditlmgahhed  frutn  IVjcal  JiMfta^ 
absence  of  the  vsaal  aymptomg  of  n  localised  ImUhl.; 
ploctiu  form  of  ooDgoslioQ  is  (llstiD};uisliod  frum  ti 
by  the  transitory  iiaturu  of  ibe  sytnploiiu  in  the  fa 
miisl  be  acknowledged  llial  rupture  of  a  blood-rc 
part»  uf  Uie  braia  may  give  rise  tu  symptoiDS 
rcsciuble  those  of  oongeetioa. 

The  form  of  coagestiou  atteoded  witb  deliiiur? 
Utkeu  for  fluliriutn  Lremeiu ;  but  the  two  dk 
disUaguiebed  by  a  koowledge  of  tho  babiu  of  the  pati 
the  circumiitAiices  whicli  bare  preceded  the  attack. 
KUine  time  the  treaibling  of  tbu  lips  aod  haoda,  1 
b&tbed  in  pei^piration,  the  soft  comprettible  pulM,  I 
and  frightened  look,  and  the  busy  character  of  the  i 
form  a  group  of  symptoms  m  chuoetc-rialic  tbat  it  it 
for  a  practised  dyo  to  mistake  tbo  aleobolie  disease 
other.  A  certnin  kind  of  delirium  may  be  caoMiJ 
poiMning,  which  may  simiilatc  that  from  ooogosttoa ; 
two  may  be  diutingu tubed  by  the  history  of  the  case  . 
condition  of  the  gumM. 

The  reepiratory   movemoots  aod  the  pulM   are 
greater  intt^rity  in  ooDga<itive  apoplexy  than  in  nyneof 
coma  wbicl)  succeeds  nn  epileptic  attack  may  be  mixti 


1 


DIFFCSED  DISEASES  OF  THE  ENOKPIIALON. 


701 


After  having  determined  that  the  symptoms  are  caused  by 
cerebral  bypencmia,  it  in  theo  necessary  to  decide  whelbcr  tho 
Coogcetiun  be  artorinl  or  venous,  and  wbcllier  it  be  primary  or 
tecoodary.  A  careful  examiuation  of  tlie  luiign,  heart,  and 
blood-ve&9cU,  and  the  condition  of  the  urine,  will  enable  lut  to 
decide  whether  nuy  mechanical  condition  is  present  which 
would  cause  venous  or  arterial  congestion.  If  none  of  theso 
(undition!)  be  presont:,  then  the  congestion  must  bo  regarded  na 
active,  nnd  its  primary  or  secondary  naturo  will  bo  revealed 
by  A  k&owledgo  (if  its  cause.  The  rooet  ordinary  cauHea  of 
primary  cougeKlioa  are  insolation,  tmwonted  mental  elforts, 
■skefutnp«8,  nnd  excess  in  eating;  while  tho  mo»t  oriliuary 
cauws  of  secondary  congestion  are  gout,  rheumatism,  stippren- 
sion  of  the  menses  and  other  habitual  discharges,  and  cerebral 
lesions,  as  tnmonrs  of  the  encepbalou. 

||§  770.  Crmree  ami  Prognosis. — Great  difFerence.>>  exist  in  the 
■verity  and  duration  of  cerebral  congestion.  The  severer 
orms  inaj  cause  death,  and  even  tlio  lighter  fomm,  if  they  do 
not  present  any  iramcdiiite  danger,  are  apt  to  recur  aud  to 
produce  permanent  bad  effects. 

The  proguosii  in  the  severer  forms  of  congestion  is  Knva, 
and  when  delirium  is  prcfient  the  case  often  tenninatea  ia 
haemorrhage. 

Ccrcbml  congestion  is  moat  dangerous  in  old  people,  because 
^^e  degenerated  vea-tels  are  apt  to  rupture. 
^^  Jn  cases  of  chronic  disease  of  the  brain,  as  ttmiour  or  vaAcnlar 
F    dcgcaeratioD,  cerebral  congestion  may  aggravate  the  symptoms 
^^v  prove  tbe  imme<ltate  cause  of  death. 

§  780,  Tfeutment. — The  treatment  of  cerebral  congestion 
wilt  vary  aooonling  m  its  cause  is  found  In  general  plethora, 
organic  diseases  of  tbe  heart,  vaso-inotur  distntbancea,  or  a  pre- 
existing focus  of  disease  in  the  brain. 

During  the  attAcIc  the  patient  »bou1d  lie  in  bed  with  the 
upper  part,  of  the  body  raised,  tbe  room  darkened,  and  the 
utmost  quiet  enjoined.  If  delirium  he  present  and  the  puticut 
of  a  plethoric  habit,  a  small  (^uanrity  of  blood  may  he  drawn 
from  the  arm,  followed  b;  the  administration  of  a  Mliue  pur- 
gative. 


70« 


DIFFUSED   DISEASES  OF  THE   EXCEPBALOV. 


In  tlte  coQgestioQ  of  tbo  brain  cautod  by  supptAttloft  4C  Ihi 
mCDSce,  or  of  bffimorrhoidal  discbarge,  leocbes  loaj  be  nfflui 
to  tUe  aouB  or  to  the  upper  p«rt  of  tJie  thigh,  and  b«  fvUoni 
by  a  smart  purgative.  Aloes,  or  a]oe8  in  eomfcioatiOD  «iA 
salphate  of  magnesia,  is  very  useful  ia  these  caaes. 

Id  the  treatment  of  active  ooDgesUoD  wi  th  irritative  syniptaa 
from  sucli  cauBes  as  iosolatioQ  and  excessive  faiigoo  genni 
bleeding  is  no  longer  permissible,  and  the  maia  reliaoce  mat 
be  placed  upon  saline  or  other  bydragogae  purgatiras,  niiMiil 
pediluvia,  and  cold  >(U»di)y  applied  to  tbe  head  by  mesiacf 
an  ice  bt^  or  evaporating  lotions.  If  tbe  patient  be  of  a  goal}' 
coustiiuliou.  a  saline  mixture  witb  cxilchicum  may  bt  ■!- 
minialtired  after  ttio  bunrela  have  been  acted  upon.  AconiMla 
a  uaeful  remedy  in  many  ca«es. 

Tbe  diet,  of  courac,  must  be  plain  and  un^titnuUtiD);  *lura>s 
tbe  attack.  !a  veoous  coageslion  a  small  blveding  Bay 
uccosioually  be  advisable,  inasmuch  oa  the  lowering  of  tbe  Ua- 
sioQ  within  the  vciaa  permits  tbe  arterial  blood  to  past  nMCt 
freely  through  tbe  capillaries,  and  tbe  tisauee  beoooH 
uuurLHbcd.  The  main  reliance  in  the  tmtttDont  uf 
hyperaeniia  of  the  brain  must  be  placed  upon  draatJc  pu 
diurotics,  and  cardiac  tonics  as  digitalis.  TboM  wbo  hare 
suffered  from  one  or  more  attacks  of  active  eerobnU  ooogi 
should  adopt  certain  hygienic  precautions  to  prevent  a  repetii 
of  tlie  attack.  Their  diet  should  be  plain,  canaiKling  in 
part  of  herbaceous  vegetables  and  fruits,  and  all  8tiinulaota,ss 
wine,  tea,  and  coffee,  should  be  proscribed,  ^bey  sliould  sToid 
everytliing  tending  to  cause  mental  excitemont,  such  as  pnUic 
speakiug.  tbuatrv^  and  concerts,  intellectual  cflbru,  lata  boon 
and   venereal  excess. 


( 


I  CHAPTER  XI. 

^^L   DIFFUSED  DISEASES  OF  TUB  ENCEI'BALON  (Costikdid). 

^H      (U)    ATBOPHY  AMD  BTPKBTROPHT  OP  THE  BUAIX. 

^^P  (iO  AnwruT  or  tux  Butg. 

W  §  781.  Atrophy  of  ih£  Corptis  Gallo9um.—The  corpus  cal- 
loauin  begins  to  devL-lop  towiLnlii  tbo  cud  of  the  fourih  month 
of  iotra-uterine  life  by  Uie  outgrowth  of  two  lateral  stumps 
from  the  iateraal  Burface  of  the  hemisphere  veeiclea.  These 
graw  towards  ona  another,  ildiJ  uuitu  butweea  the  sixteuuth 
and  twentieth  weeks  of  iDtra-utcriDc  life,  the  uuiuu  taking 
plaoe  from  before  backwards.  The  deTelopmeot  of  the  corpus 
alloaum  m»y  be  arrested  at  any  pcriwl,  so  that  it  tnny  be 
cnttri'ly  wnnting,  or  it  mny  grow  on  each  side  to  nciirly  the 
normal  size,  but  unioa  failu  to  take  place  in  the  middle  liae. 
At  other  lim(!.<i  the  union  may  he  partial  and  the  corpus  cal- 
losum  be  reprtsonied  by  a  rudimentary  bridge,  or  sieve-like 
plate  of  tif<Bu«.  When  the  corpus  calloHiim  is  entirely  wanting, 
its  ratliating  fibres  arc  also  absent,  the  cavities  of  the  lateral 
ventricles  are  unusually  large,  they  are  at  the  same  time  tiltod 
witli  seruufi  fluid,  the  ependyma  is  granular  and  thickened,  and 
the  choroid  plexuses  are  generally  found  diseased. 

g  782.  Symptoms, — Congenital  deficiency  of  the  corptui  cal- 
losuiu  baa  generally  been  found  associated  with  idiocy,  or  at  least 
with  some  degree  of  mental  deficiency.  The  mental  defects  in 
such  cased  do  not  present  anything  chsiracteristic.  so  that  this 
condition  cannot  bo  recognised  during  life.  Some  cases  of 
arrest  of  development  of  the  corpus  callosum  have,  however, 
be«D  reported  in  which  no  marked  mental  deficiency  was  ob- 
Hsrved  during  life  (Paget,  Jolly,  Malinvcrui,  EichlerJ, 


ihe  fuuctionB  of  the  organ. 


>;  lM 


§  78i.  Etiology. — la  the  cases  reported  by 
Otto.  iLDil  prububly  also  to  some  ezteDt  iu  Combettes  < 
airopliy  was  congenital.  In  a  caae  reported  bj  Hoffl 
imotbvr  by  Pierret,  frigbt  is  asaigaed  M  tbe  CMiSA.  ia( 
rase  tho  nervous  symptoms  appeared  after  meule«.Ukd  | 
diiuiniahed  in  severity. 


reus  In 


§  785.  Symptoma.—  Tho   following  were  the 
Combette'e  case:  The  gir)  Labrorse  at   12  yt 
miodtid  ood  sutTem)  from  epileptic  atUicka.     Sbc 
stand  or  wa.lk  until  five  years  old.     Al  sereD 
tremitieg  were  feeble,  and  sbcofien  fell.    During 
raoDt^H  of  life  ehe  was  bedridden  and  could 
legs,  and  her  articulation  was  imperfecL 

Motor  disturbnnces  were  observed  ia  tbe 
Meynert,  Pienet,  Fiedler.  Clapton,  Dugnet,  and  tforui 
auxhont  de-scribe  these  as  those  of  ataxia;   while 
that  tbe  patients  could  walk,  but  only  slowly 
that  tbey  fell  frequently,  especially  bocknaniii; 
walking  tbey  seized  bold  of  objects  within  iheir 
these  patients  Lad  also  either  pereuteDt    or    tei 
turliance  of  epoecli. 

Jjo  rool«r  di^tyrbaace  wt 


i:  am 


DlFPt^SSn  DISE&SKS  OF  TBE  ENCEPHA.LON.  705 


Sjiuptoms  occosiftnally  noticed  are  nniilgeaia  (Fiedler)  and 
tligbt  disturbances  of  sensibility  (Pierrct), 

§  78C,  Morbid  Anatomy. — In  Combelte's  case  the  entire 

oi;gaa  bad  ditappeared.     There  was  ao  trace  of  a  pons,  although 

tbe  cerebral  artena<j  were  present  and  of  normal  size.    In  other 

^nrt«d  CMea  the  oerebetlura  has  been  found  reduced  to  about 

HVtbe  DOTcnal  Ase. 

Lullcmcnt  mcntioDH  a  caac  Ui  which  the  left  tubes  of  the 
eerebellum,  including  its  Diidiilc  and  superior  peduncles,  was 
redacod  to  the  size  of  a  nut,  and  the  transverse  fibres  ol  the 
I0D8,  th«  right  oorpiis  striatum,  and  the  right  olivary  body  were 
itrophied.  In  Diiguet's  case  the  cerebellum  was  about  half 
the  normal  weight.  The  atrophy  was  bilateral  and  general, 
ud  the  sabstance  of  the  organ  ahowed  well-marked  Bclcrosin. 
Mjmewhat  similar  cases  have  been  reported  by  Claptou  and 
Fiedler- Bergmaan.  No  statement  is  made  with  regard  lo  the 
cooditioD  of  the  pona. 

MejQcrt  describes  a  similar  degencrcttioD  in  the  ponii,  which 
le  regards  as  a  secondary  degeneration,  and  not  as  the  starting 
K>int  of  the  affection.  The  cerebelliun  itfielf  was  much  altered, 
Np^ally  oQ  the  right  aide.  The  posterior  pyramids  of  the 
medulla  were  implicated  as  well  as  the  pons  and  the  crus 
Der«1xilli  ad  poutem.  Iq  Pierret's  case  there  was  an  intense 
3^ree  of  Hcleraiio  atrophy,  which  affected  cbieDy  the  Tertical 
iiameter  of  the  oi^n,  the  grey  substance  being  specially 
fiffectud.  The  transverse  fibrea  of  the  |M)ua  and  both  olivary 
bodies  were  atrophied  and  replaced  by  coonective  tissue.  In 
Otto'M  case  the  left  lohu  was  the  more  atrophied,  and  the  poos 
on  the  left  Hide  was  narrower  thnn  on  the;  right.  The  space 
uualiy  occupied  by  the  cerebellum  was  replaced  by  hyperostosis 
oi  tbo  occipital  bone. 

§  787.    Comjilieaiifm»  and  Duiynons. — Atrophy  of  tlie 

al«Tal  lobe  of  the  cerebellum  has  been  found  associated  with 

Atrophy  of  the  trausverse  Bbres  of  the  poos  on  the  same  side, 

nod  with  atrophy  of  the  olivary  body  and  cerebral  hemisphere 

«D  the  opposite  aide    Id  some  few  cuacs  the  atrophy  of  the 

rvbnira  and  cersbellum  oocura  on  the  same  side. 


706  DIFFUSED    DISEASBS   OF  THE   EXCEPBAUWt 

Atrophy  of  tbe  cerebellum  u  difficult  to  di«tufiiia)i 
chroDic  affections  of  the  organ,  hut  headache  aod  twmilil 
which  are  common  in  the  latl«r,  arc  raw  in  tho  former.    T 
aeniiory  »ud   reflex  dialurbaoces  of  locomotor  atiixis  sen* 
dislinguish  it  from  atrophy  of  the   oerobellom.     The  irn 
toma  of  the  initial  stage  of  insular  Eclcioeis  may  be  umiUij 
thoM  of  atrophy  of  the  cerebellum,  but  whoa  the  chi 
tremors  of  the  former  a-ppear  tlie  diagnosis  it  eaay. 


(U.)  HTrnnorar  or  niK  Buts. 

Hypertrophy  of  tbe  brain  includes  several  difTereot  omW 
couditionn.    It  is  also  usual  to  include  along  with  by pertropfcj »j 
uew  formation  of  cerebral  substance  within  the  subaUDC«  of  I 
brain  itself,  a  condition  which  Virchow  has  called  Het«f 
of  the  brain.     Hypertrophy  may  be  divided  into  penemf 
partial  hypertrophy. 

§  788.  £(ioIoiy J.— Hypertrophy  of  the  brain  appean  la  toj 
goDerally  congenital.  Several  of  the  reported  ca««i 
aasocinteil  with  peripheral  multiple  neuroma  (He 
Hitchcock,  Beta),  and  both  of  these  condiliona  are 
aceompauTmenta  of  idiocy  or  delayed  tuental  developvOL 
The  affection  is  almost  alwajra  developed  soon  after  birth  « 
in  early  infancy.  A  few  cases  appear  to  have  developed  «^ 
Bequently  to  an  injury  to  the  head  (Tuke,  Dance),  while  tbe 
disease  appears  to  have  been  a  result  of  chronic  lead  poll 
(Andral,  Laeunec,  Bright). 

Symptoms.  —  Severe  headache,  with  remisuoni  or 
complete  intermissiona,  ia  a  promiaent  symptom  of  Ir 
trophy  of  the  brain.  Epileptiform  convulaioai,  local 
attacks  of  laryngismus  atridulus.  and  tremora  are  also 
moaly  observed.  The  pulse  is  usually  retarded,  bat  it  atf 
occasionally  be  much  acceiemted  (Steinor).  The  ajnaptom  tf 
chronic  cerebral  hypertrophy  are  not  well  known.  Th«aA»- 
tioD  in  children  baometimesastiiKiated  with  prenkature  dvnh^ 
ment  (EllliotsoD).  or  at  least  a  degree  of  developmeot  oow- 
sponding  to  their  age.    Id  other  cwea,  again,  there  is  nor*  « 


DimrSED  DISEASBS  OF  TOE  BSCEl'llALON. 


707 


IcDca  of  miod,  amounting  even  to  the  bigbe«t  degree  of 
dioe;.  The  tonguo  is  often  increased  in  Mze,  and  often  pro- 
trades  frcitn  the  moutli.  Drowsineeg  is  an  occasuonal  but  by 
DO  m€ADS  constant  symptom.  Some  of  thu  affected  childreo 
tre  liable  to  fall  frequently,  being  ovet-baliinccd  by  tbo  great 
vrigbt  of  Cbe  bead.  Disturbaoces  of  the  nerreis  of  the  general 
v  special  scQiK-Ji  are  comparatively  rare.  The  optic  nerve  in 
■articular  in  seldom  meutioued  ;  Steiner  and  Neureuthar  alone 
peak  of  tbe  sudden  occurrcnco  of  blindness,  otbera  mention 
iboiopbobta.  A  careful  opbthalmnscopic  examinalioa  of  tbe 
iptic  discs  might  have  given  more  positive  results.  Tinnitus 
l&d  aiibjecUve  noisei)  in  the  head  are  somctimoe  proseat.  Death 
lAeB  reeults  from  an  attack  of  c«Q\iilBioD8,  or  in  coma  due  to 
mebral  comprc^ion,  while  many  of  those  affected  die  from 
Oine  intercurrent  disease. 

§  789.  Morhid  Anatomy. — The  anatomical  appearances  differ 
leeording  as  tbe  hypertrophy  is  partial  or  general. 

O^fural  hyp$>in>i>liy  begins  in  (he  earlier  years  of  child- 
lOod,  and  the  skull  enlarges  just  as  in  hydrocephalus.  If  the 
BsBMe  appear  for  tbo  firxt  time  after  the  hones  of  tbe  skull 
Lftve  become  ossified,  tbe  boues  are  subjected  to  comprcxition 
rom  within  and  andergo  atrophy  at  certain  polnu.  U  ia 
bable  that  this  condition  is,  however,  connected  with  tbe 
wbicb  the  cranial  bonee  are  known  to  undergo  in 
ital  ^rphilis. 
Tbe  oerebroZ  vwn^ranes  are  generally  compressed  against 
.nd  become  adherent  to  each  other  and  to  tbe  bonee  of  the 
kull.  The  membrauea  are  thin,  their  blood-vesselfl  are  scarcely 
ible,  and  every  tmce  of  cerebral  spinal  fluid  id  absent. 

e  lateral  reniricUs  are  compressed  so  that  they  ehhet 
in  no  fluid,  or  only  a  small  amount  The  convolutiooa  are 
Hattenecl  and  so  prewed  together  that  the  auici  seem  entirely 
Dbliterated.  Tbe  brain  substance  shows  a  marked  change  of 
roosistenuy ;  it  is  tough,  like  boiled  white  uf  egg  or  checsa. 
Tuke  could  make  no  impression  on  it  by  a  column  of  water 
fire  feet  higb. 

Tbe  brain  is,  aa  a  rule,  found  anjpmie  on  section,  anil  tbe  grey 
QCe  »o  pale  that  it  differs  little  from  tbe  white.     This 


70S  DIFFUSED  DISEASES  OF  TBE  ESCKPlUtOX 


extreme  aniemU,  lioweTor,  appears  to  bo  a  termioal  pltenom 
due  to  the  increased  compresidoii. 

The  average  vreight  of  the  braia  in  adults  U,  acoordini 
Huschko,  from  l.SOO  to  1.600  grammos;  although  the  w<^ 
of  the  brains  of  peraona  prominent  id  literature  hu  cooaiderJ 
exceeded  3,000  grammea  The  abAolute  weight  of  the  be 
oousiderod  witlrout  reference  to  its  deaeity  and  other  ctfc 
stances,  only  warrants  the  diagoosis  of  hypertrophy  wtMt 
average  w  considerably  exceeded. 

Tho  ^ecific  gmvity  q(  iho  CKKhrid  mass  shouJd  also  be 
into  account  Tuke  found  the  specific  gravity  UDcbattga 
the  diseased  side  in  his  case  of  unilateral  byportropby,  h 
1,036  on  both  sides,  but  the  result  differed  from  that  obu 
with  normal  brains  in  the  fact  that  it  was  the  wmo  ia  th 
as  ill  the  white  subfttance. 

The  oerebnim  is  as  a  rule  alone  aflect«d  with  liypert 
hut  there  are  a  few  cases  in  which  the  ceiebellum  oUoj 
to  hare  been  affected  (Sweatmann). 

Vitchow  attributes  the  increased  sise  of  the  bmin 
plasia  of  the  neuroglia. 

Partial  hyiitrtrophy  is  rarer  than  the  general  form  of 
affection,  and  even  some  of  the  reported  case*  are  not  be^ 
snspiciou,  inasmuch  as  gliomatous  tumoura  were  pnb 
mistaken  for  partial  hypertrophy  of  the  braia.  HencS 
mentions  the  onae  of  a  man  who  inherited  the  diiioaae 
father,  and  who,  besides  multiple  neuromata  of  the  peripb 
nerves,  presented  a  considerable  ealargemeDt  of  the  syoapatli 
gai^Ua,  and  of  one  of  the  middle  cerebellar  peduDclo^ 

g  790.  Cottwe.— It  is  very  difficult  in  many  cases  to  estii 
the  duration  of  the  disease,  inasmuch  as  even  in  the  eaaea  « 
appear  to  be  primarily  acute  the  course  may  acloiUly  baveti 
protracted,  the  disease  being   latent  until  the  space  ia 
cranium  bei;ame  limited.     Many  chronic  cases  suddenly 
an  acute  cliitracter,  and  terminate  quickly  to  death.     Tb»  I 
tormiuntion  is  often  caused  by  an  intercurrent  disease,  see 
diarrhcoa  or  bronchitla 

Chronic   cases   may   extend  over    many   years,    th<!  Aa^ 
apparently  remaining  stationary.  A  sudden  increase  to  tqIe 


DIPFtrSBD   DISEASES  OP  TBE   ENCEPBALON. 


709 


vhether   io   &    braio   proviaiifily   healthy  or   m    one   already 
chronically  enlarged,  ma;  caune  rapid  death. 

Acute  h!/pertrophi/  produces  the  symplvmB  commoa  to  all 
diaeaseB  cauaiog  compreeaion  of  the  brain ;  while  the  chronic 
form,  especially  in  children,  can  scarcely  he  distinguiahed  from 
chronic  hydrocephalaa. 

§791.  Diaffnoai$,  Progno9i«,an(lTreatinent.~~The  diagnosis 
»  alirays  UDCortain,  but  the  possibility  of  this  condition  ought 
certainly  to  be  borue  in  miud  before  puucturiDg  a  hydrocephalic 
besd.  The  prognosis  is  atwuya  unfavourabie,  but  on  account  of 
tbe  impossibility  of  making  a  diagnosis  a  prognosis  cannot  well 
be  given.    No  treatment  is  of  any  avail. 

§  752.  Heteroiopia  of  Brain  Svhsla-nee. — ^Thia  condition  wan 
6rrt  described  by  Virchow,  and  has  hitherto  been  principally 
of  interest  to  the  morbid  anatooiitit.  Simon  found  small  acces- 
sory gyri  situated  on  the  mimmitof  the  i^onvolutiona.  Virchow 
observed  in  one  case  au  apparently  new  formation  of  gyri  nitbin 
the  white  substance  of  the  posterior  lobe.  He  also  found  a 
hyperplastic  malformation  of  tbe  candate  nucleua  Klob  found 
■  mass  of  while  cerebral  substance,  tbe  size  of  a  bean,  bangiog 
ftom  a  pedicle  between  the  optic  ncrven. 

Miorose^pie  exandnation  of  the  heterotopic  p^y  Bubstanoe 
diowB,  as  a  rule,  similar  elements  to  those  of  the  normal  corlec, 
but  the  ganglion  cells  in  the  former  are  pigmented  and  fatty. 

These  conditions  have  hitherto  been  found  in  epileptics, 
idiota,  or  in  persons  otberviao  mentally  affected,  but  their 
dtnical  signilicanco  is  somewhat  doubtful.  All  authors  regard 
malfonnatious  as  congenital. 


712 


DIPVCSCD   DISEASES   OP  THE   EHCKPnUA5. 


movement  of  tho  diaphragm  lUAy  generally  be  diteoTcni 
careful  observation.     The  tempormure  of  ttie  body  U  de] 
The  patient  suSeni  from  vertigo  and  dimness  of  TJatoa,  wlnU 
the  leas  severe  cases  there  is  nAuseft,  Tomitiog,  and  biooooglL 

The  p^chical  symptoms  consist  of  mental  depreorioo, 
ness,  coofunion  of  thought,  incoherence,  or  tlrowinDCv,  all 
the  patient  generally  gives  rational  repliw  to  definite  qni 
At  other  times  the  patient  appears  Kingularly  calm  aod  latii 
while  the  various  senses  remain  unaffected,  bearing  being 
times  unusually  acut«. 

(ft)  Erethiemie  Sltoek. — 'ITiig  form  of  abock  u  fin-.  As 
majority  of  caaes  in  which  »ympto«is  of  prostratioQ  are  miael 
with  tho-ie  of  excitement  being  preceded  by  a  di&tinct.  tboagli 
it  may  be  trunaiunt,  sl^e  of  coUapsa  The  ftkin  id  at  firtt  brt 
and  dry;  the  face  is  Siished  and  wears  an  anxious  eipwia. 
the  piilso  is  frequent,  quick,  and  bounding,  but  always  txmr 
prcs&ible;  tbo  resjHrations  are  burriod,  imperfect,  and  iota- 
rupted  by  sighe;  the  tongue  is  tremulous;  and  the  pabiM 
oomplaiosofthirst,  rigors  arc  occasional ty present,  white  Tootliil 
ia  a  frequent  and  soroetimes  obstioate  syoiptoto.  The  ihmI 
Aod  bodily  proatraiiou  of  collapse  is  soooeedod  by  tTemor  sad 
tmtchiugs  of  the  muM^les,  there  is  restleasiMM,  jaetitatioo,  pw- 
cordtat  anxiety,  and  deliriam.  The  psydiical  dt^turbuMi 
obecrvod  are  somewhat  variableL  At  times  tho  pntieut  OMn^ 
presents  a  peculiar  irritability  of  manner,  with  an  inenHll 
disposition  to  talk,  sometimes  nitionally,  occasionalty  inooW- 
rently.  At  other  times  the  patient  has  strange  illusions.  itttn'M 
with  a  p<icti1iar  dread  of  impending  evil.  In  name  cases,  bo«- 
ever,  there  is  the  Beicest  maniacal  raving,  which  is  most  {■•■ 
DDunced  daring  the  night,  or  the  delirium  may  assume  alt  tlw 
charactenHtics  of  that  obeon'cd  in  iteliriam  trmienA. 

The  patient  either  obtains  no  sleep,  or  it  ia  partial,  ioUf' 
rupted,  and  uorefreshing.  As  the  exbaustion  increasa  ite 
skin  hitcomcs  covered  with  a  cold,  clammy,  and  often  pnAw 
sweat.  The  toce  b«comos  pale  and  the  cxprmioo  haggii4 
the  pulse  ia  frequent,  irregular,  fluttering,  and  unoountaUa 
Subsaltas  and  slight  convulsions  supervene,  and  tbe  palMM 
dies  comatoee. 


DIFFUSED  DISEASES  OP  THE  ESCEPHALOK.  711 

itres^  aod  coaBequeulIy  during  this  utaga  s  second  tnjuiy 
luces  a  much  lean  effect  than  tbe  first.  Xhinog  the  stage  of 
reaction,  how«rer,  the  irritability  of  the  Dervoiis!  system  is  ex- 
Mwve,  so  that  a  slight  stimulus  may  produce  a  prorountt  effect 
Id  persons  of  powerful  will  and  stable  nervous  systemii  tbe 
effect  of  an  unexpected  injury  is  greater  tUim  if  the  patient 
were  prepared  for  it*  reception ;  while  in  emotional  patients. 
ttitb  im.'iUble  nervous  systems,  previous  knowledge  of  rd  im- 
pending injury  greatly  iuteiiiiifies  its  cffcctd.  Injuries  of  tbe 
abdominal  viftcera,  geuitala,  Joints,  and  bone«  produce  more 
profound  uffccts  tbuu  iiijuiica  of  otlior  parts  of  the  body. 

Tbe  exciting  causctt  of  shock  are  sudden  and  severe  or  ex- 
tetuive  iujuriee  of  any  part  of  the  body,  whether  produced  by 
aoadeutal  wounds  or  burns,  or  by  surgical  operations.  Sbodc 
is  al&o  produced  by  strong  omotioual  excitement  of  auy  kind, 
although  the  dcpressuig  paasioaa,  as  fear  and  anger,  are  more 
liable  to  cause  it  than  pleaaarable  passions,  like  joy. 

§  795.  S^ptonts. — Casea  of  shock  may  be  divided  clinically 
intu  two  formx — (a)  casee  in  which  tbe  symptoms  of  depression 
predominate  and  (6)  oases  in  which  the  symptoms  of  prostration 
are  mixed  with  those  of  excitement  (Traven;,  Savory).  Dr. 
Lauder  Bnintoa  bas  proposed  to  call  these  forms  respeetively 
torpid  and  e^-etkimnie  ahock. 

(tt)  Tvrjttd  Shock. — In  the  torpid  form  of  shock  the  patient 
lies  utterly  prostrate ;  the  surface  of  the  body  is  pale,  cold,  and 
covered  by  a  clammy  sweat,  which  o)tlect8  in  drops  on  the 
forehead  and  eyebrows;  the  lips  are  bloodless,  tbe  nostrils 
dilated,  and  the  couutenaucc  of  a  dull  oitpect  and  shrunken, 
while  the  eyes  have  lost  their  lustre,  nr©  sunk  in  their  sockets, 
and  partially  concealed  by  the  drooping  lids.  Tliere  la  complete 
muscular  relaxation,  which  may  even  extend  to  tbe  sphiuctcrs. 
If  the  patient  be  conscious,  be  may  complain  of  feeling  cold  and 
laint,  while  the  whole  body  may  tremble.  The  pulse  is  frequent, 
irregalar,  unequal,  and  feeble  or  imperceptible  at  the  wriat, 
although  the  fluttering  action  of  the  heart  may  bo  beard  on 
au&cultatioo.  The  respiratory  movements  arc  irregular  and 
gasping,  or  short  and  feeble,  the  respirations  boing  sometimes 
80  superficial  that  tbey  are  ticarcely  visible,  although  a  slight 


71* 


niFTCSSD   DI3BiSBS  OP  TBt   CHCKPOAUHt. 


ID  mcb  cas««  the  abdominal  veios  Iiave  not  anfraqoeoUj ' 
CDonnoody  engorged  witb  blood. 

§  798.  Morbid  Pht/sialOgy. — lu  lU  widest  aocepUiUoD 
is  the  sudden    impaimtont   or  abolition   of  the  funvtiooi 
protoplasin  by  tbe  application  of  an  exceanre  ktimtdin. 
functions  of  tbe  protopUno  of  all  the  on;ans  of  tbebgdjr 
doubtleiB  impaired  by  vevere  iojuries ;  but  iu  the  ht{;her 
tbe  disorder  occatioDcd  in  Uie  functions  of  tbe  aerTooi 
becomes  no  prcdominoat  tliat  the  direct  efltnts  of  tDJarici 
the  protoplasm  of  the  other  tiasues  of  the  body  may  be 
cally  diftre^rdcd.     Tho  most  striking  phiioomciub  of  sb'idt 
those  which  chister  around  the  organs  of  circalalion.     Tb» 
poriments   of  Ooltz,  rcpcat«d   by   Btunton,  nbow   that 
probably  results  from  cardiac  poralysia  and  vaao-inolor  ponl; 
of  the  large  vascular  trunks  of  ibu  abdomcu.     Brunioa 
that  blows  of  moderate  severity  ou  the  abdomen  of  fi 
duoo  in  some  stoppage  of  the  heart,  without  dibtati 
abdominal  vesseU,  And  in  others  vascular  diUtuttoo, 
arrest  of  tho  cardiac  pulsations,  whil^  severe  blovrs 
produce  both   effects  simnllaocously.     Thu  vv^mIs  of  the 
dumen  are  so  large  that  when  fully  relaxed  tboy  are 
of  containing  almost   all   the  blood   in    the    body,  ar 
scqaently  the  ooDditioti  rwulting  from  their  rapid  d 
is   ecjuivnlent   to   a   sudden   ba>aKinliaga    Tbis    doubts 
dition    of    cardiac    failuro    and    vascular    dilatatton 
anaemia  of  the  nerve-centres,  and  ibis  accounts  fur  the 
and  coldne^  of  tho  sarfaoe  of  the  body,  and  the  wcaL 
prciuible,  and  fluttering  pulse.     It  must  not,  however. 
gotteu  iliut  the  injury  which  has  disordered  the  functiw- 
vafto-motor  and  cardiac  centres  in  the  medulla  oblongu: 
also  bavepioilucwl  a  direct  deleterious  effect  upon  othrr 
centres.     The  disorders  of  respiration,  the  cri«  of  pain,  'i     _^ 
various  bodily  cootortions  which  are  caused  by  bodily  bj«^H 
or  severe  mental  excitement,  show  that  oxoeanve  stimali  «S" 
sion  powerful  outgoingdiitchar^ges  from  tbe  higher  Dervo^oM 
But  a  powerful  discharge  from  a  nerve-centre  u  fiiUoVffd  ^ 
tempOTary  impairment  or  abolition  of  itsfonctiona,a&d  itJip^ 
btUile  Uiat  tho  arreei  of  the  functions  of  the  bighar  oefrv-ocnttw 


mirPtJSED  DISEASES  OF  THE  GNCEPHALON.  715 

by  the  appUcatioa  of  a  suddca  and  powerful  Ntlmulus,  U 
I  moat  importout  factor  id  the  productiou  of  the  phenomena 
iiock. 

lie  Dymptoms  of  the  orethismic  variety  may  be  expIaiDed 
ly  ou  the  supposition  that  the  ncrrotu  tii!«uo$  ore  in  the 
ritable  condition  frequently  observed  wben  they  are  imper- 
elly  nourished,  and  partly  on  the  mipposition  that  the 
lomena  of  excitement  arc  in  great  part  due  to  the  abolition 
fiinctions  of  the  higher  nerve-centres,  thus  permitting  a 
ar  activity  of  tlie  tower  centres  to  take  place. 

g  799.  Dinffnosin. — ^The  HymptomH  of  Hhoclc  maybe  mistaken 

t those  »f  syncope,  but  the  former  are  more  protracted  than 
latter.  If  a  history  of  an  injury  or  of  the  presence  of  some 
her  exciting  cause  of  shock  can  be  ascertained,  the  diognouB 
rendered  easy.  It  is  not  always  eafiy  to  distinguish  profound 
Ifepse  from  actual  death.  The  difficulty  can  only  arise  in 
m  rare  cases  of  collapse  in  which  the  action  of  the  heart 
h«ca  to  be  heard  ou  auscultation  and  the  respiratory  move- 
ants  fail  to  be  detected,  or  powerful  cutaneous  irritanU  cease 
excite  any  reflex  action.  The  most  certain  test  conaiat*  of 
e  electrical  examination  of  the  muscles  and  nervea,  all  ra- 
tion in  them  ceasing  in  from  one  aad  a  half  to  three  bouis 
^  death. 

§  800.  ProgTUtsU. — The  prognosU  depends  upon  the  degree 

shock,  and   the   conatituiioa  of   the   patient.       Speaking 

■Klly,  the  prognosis  is   the  more  favourable  the  Ims  the 

tensity  of  the  xhock,  and  the  shorter  the  time  which  elapses 

re  reaction  takes  placa 
301.  Th^inent — The  treatment  of  shock  is  the  same 
aerally  as  that  of  syncope,  the  great  aim  being  to  excite 
kc^n.  It  must,  however,  be  con.'itantly  bomo  in  mind  that 
tioo,  once  excited,  h  apt  to  become  excessive.  In  the 
forms  of  shock  the  heart  must  bo  excited  to  acdon. 
mode  of  procedure  to  be  adopted  depends  upon  whether 
arrest  of  the  heart's  action  is  of  purely  ncn'uus  origin, 
it  is  complicated  or  caused   by  great,  htemonliftg^.    la 


7lfl 


DirruSED   ULSBASES  OP  THK   r.NCErBA.LC»r. 


the  former  case   the   bearC    ia    probablj    dtstendsd   vti  ik 
cervical   veins   engorged,  and   oonaequentl}*   Tencaortiflp  fna 
tbo  oxternal  jugular  vcioa  sliould  be  itomedUtcly  rsMftadto' 
(Savory] ;    wbtle  ia   ihe  latter  coaditioD   tbe  cavitiea  a(  Al 
heart  nre  empty,  and  transrusion  of  blood  appe&ni  to  bi  tb 
oolj  meaas  offering  a  cbance  of  aucces*.    Iq  any  case  wsnaA 
is  indicaled,  aud  tbe   putieDt  Hhould  be  well  wrapped  of  a 
warm  blankeU  aod  surrounded   by  boC  bottlea.     Stimolutt 
mast  aov  be  given   iateraallj',  braudy  being  gaoetallj  ik 
rendicst    and    best     If   tbo    pationt    be    unablo   to   ivalla*, 
ammonia  or  etber  may  be  administered  raboit&Deontlj.grAl 
rormcr  may  be  injected  Into  a  vetD,  or  a  stimulating  tmem 
may  be  given.    Tincture  of  digitalis  inny  be  admialitend  ii 
bair  dracbm  doses,  but  ita  octiou  ia  mucb  too  alov  to  Im  tf ' 
mucb  use  io  tbe  early  stage  of  urgent  cases. 


(ti.)  Contmmvxi. 

ConcuBsion  U  n  special  form  of  shock,  the  ditturWoee  iatti' 
fuDCtioQS  of  tbe  nervous  Bjstcm  beiog  caused  by  dir«ct  i 
motion  of  tbe  substance  of  tlie  brain. 


§  80S.   Etiohgy.—Tht  exciting  causes  of  ooncuanuB  ■ 
severe  injuriea,  aa  falls  firom  a  lieigbt  or  blows  on  tb*  hitit} 
wbicL  cutiSL-  the  whole  iQa«s  of  thv  eucepbalon  to  be  joMedtf ' 
shaken.     Concussion  may  be  complicated  by  fiacture  td  tkl 
akuU,  and  in  such  cases  the  effects  of  the  ooocuasioa  an  A 
less  severe  than  in  uncomplicated  casss,  apporeiitly  beOMS  •  | 
certain  amount  of  tbe  applied  force  is  expended  la  pndadit  j 
the  fracture. 


§  ft03  Symptom*. — The  symptoms  of  concussion  may  be  d^ 
scribed  under  Tour  stages:  (a)  Tbe  stage  of  eoUojpm;  {h)  ito 
stage  of  rallying  or  of  vonUting;  (e)  the  stage  of  rtadi^i 
((2)  tbe  stage  of  rfnuttuil  convaUacence  (HulcbinaOD). 

(a)  yA«  Stage  of  CoMapse.— The  symptoms  during  this  itip 
arc  very  variable  both  in  character  aud  duration.    In  tbe  ili^W 
forms  the  patient  suffers  from  truosient  coofosioD  of  tdcai  i 
slight  giddiness.     He  may  feel  weak  and  faint,  aod  be  omUb  ' 
tomointain  the  erect  posture,    la  tbe  more  seTere  fenas^i 


^H  DIFrVSBD  DISEASES  OF  TUB  EXCEI'BAILON,  717 

W  vyTaylomn  are  those  of  coUapae.  with  loss  of  coDSciousness ;  but 
■  paralysis,  such  as  occurs  iu  cumprcssiOD  of  tbe  brain,  is  never 
present.  The  patient  is  semi-conscious  or  ineeusible,  moat 
reflex  actions  are  abolisheil,  tbe  skin  i^  cold  and  pallid,  tb« 
respirations  superficial  and  shallow,  the  puloe  fcobic  or  imper- 
ceptiblu  at  the  wriul,  whilst  the  pupils  may  either  be  ooq- 
tracted,  dilated,  or  unequal 

(6)  The  Stage  of  iiattying  cr  <>/  VomitiTtg. — Afl«r  a  period 
varying  from  a  fev  minutes  even  up  to  days,  according  to  the 
•everity  of  tbe  attatk,  tbe  patient  ii»un.lly  begins  to  show  signs  of 
nlljtiig-  This  stage  is  often  uahtTcd  iu  by  Tomiting,  or  very 
occasionally  by  an  epileptiforra  attack;  the  pulse  improvea  in 
ttrCDgtb,  the  respirations  become  less  shallow  and  mure  per- 
ceptible, the  body  Ijtcomes  warmer,  reflex  actions  cau  be  exciteJ, 
uid  tbo  patient  gives  evidence  of  returning  seasibility,  while  he 
nay  exhibit  signs  of  mental  dittlri'iut. 

(e)  The  Stage  of  lUaci'um. — The  syinploms  of  the  stage  of 
lallyiog  are  succeeded  by  those  of  reaction.  In  this  stage  the 
phenomena  of  febrile  reaction  manifest  themselves  by  the  usual 
lyiDptoms,  hot  and  dry  skin,  quick  and  hard  pulse,  and  scanty 
mine;  while  the  patient  is  drowsy,  yet  quite  conscious  when 
roused  by  a  question  addressed  to  him.  In  some  cases  these 
eymploma  gradually  develop  into  those  of  compression  and  the 
patient  die«  comatose,  while  in  other  cases  the  symptoms  of 
reaction  give  place  to  those  of  inflammation  of  tbe  brain.  Tbis 
sta|^  may  continue  from  three  to  twelve  days  iu  cases  which 
recover. 

{d)  The  Stage  of  CoTiwiMCfncfi. — Reactioo  is  followed  by  a 
prosreuive  ^absidenoe  of  the  symptoms,  and  either  by  a  gradual 
restoration  of  the  patient  to  health,  or  the  establishment  of  one 
or  other  of  several  chronic  affections  of  the  nervous  sy.ilem, 

Cer^Tiil  Irritatuyn. — In  another  form  of  nervous  disturbance 
foUoving  iujuries  of  the  bead,  and  described  by  Erichseu  under 
tbe  lume  of  cerebral  irritation,  the  phenomena  of  cerubnil  ex- 
citement are  mixed  with  those  of  loss  of  function.  Tbe  patient 
aaaaioes  a  peculiar  attitude;  be  lies  with  the  body  bent  for- 
nrdi,  the  knees  drawn  up  on  the  abdomen,  the  legii  bent  on 
tbe  thighs,  the  forearms  flexed  on  tbe  arms,  and  tbe  hands 
drawn.     Tbe  patient  is  restless,  and    frequently  changes  bis 


718 


niPFUS&D  DtSEASB  OF  TOB  BKCETQALO:!. 


position,  but  never  stretclies  lilnuetf  out  nor  aaramu  tltL> 
posture  (Ericbseo).     The  eyelids  are  firmly  doeed,  the 
are  cootrac^jij,  tlio  surface  of  tlie  body  is  pale  and  cold,  ud ! 
puUo  18  small,  fei^ble,  and  hIow,  being  seldom  above  70  bttUa  | 
miDute.     Tbe  sphincters  remHiD,  as  a  rule,  unafiected. 

The  patient  is  iudiifureut  to  CTerythiDg  arouod  him,  aod  ' 
only  paruiLlly  conscious.     He  may,  however,  be  roused  «l 
addressed  la  a  loud  voice,  and  then  looks  up^  matien  ii 
tinctly,  or  frowua  aud  lunm  baatily  away.     His  aloep  b 
stertorous. 

After  a  pciiod  of  from  oae  to  three  weeks,  the 
improvess  t^c  body  Itecomes  wanner,  the  fleietl  attitude  7* 
abaudoned,  and  the  mental  irritability  ^ree  place  to  uc 
fcebl&ncsa  and  torpidity. 


■OTona 


§  804.  Ctmrw,  Dumtion,  and  Terminaiitmt — The 
cases  of  concussion  usually  makea  speedy  recovery,  althongh  Ai 
patiau  t  may  suffer  for  many  daya  £nun  coufusion  of  tboogiit,  bt- 
lessneas,  and  indispoMition  for  mental  exertion.  In  the  htoiM 
cases  rapid  death  may  occur.  Between  theiie  extreme* 
intermediate  degree  in  the  severity  of  the  syiiipt(»D« 
served.  In  some  cases  tbe  patient  may  never  rally,  but  die 
morv  or  les«  prolonged  stage  of  collapse.  In  other  cases  tbe 
rallleti,  but  the  symptoms  of  reaction  are  excessive,  and  toUowti 
either  by  those  of  compression  or  of  encephalitis.  But  even  «te 
the  period  of  reaction  is  aaiely  passed,  serious  oonsequcBO* 
may  be  observed  during  and  subaetjuent  to  the  period  nf  oar 
valesceitci;.  In  some  ca^cs  complete  nooxety  may  appanally 
take  place,  and  the  patient  reeumes  his  ordioary  avocaliiM; 
but  he  remains  excitable,  and  gives  way  to  unoontroUable  boali 
of  passion.  He  complains  of  per^stcat  headacbee,  bis  nctfii 
powers  are  unpaired,  his  speech  nwy  bo  indistinct  and  stvMir 
iag,  while  vision,  smelling,  and  hearing  may  be  peraasMBtly 
impaired.  The  severity  of  the  remote  oonsequenees  of  coodwiaa 
do  not  always  bear  a  direct  ratio  to  the  severity  of  the  symfWW 
of  the  lirvt  »tagc  of  concussioD,  apparently  tririal  oases  bcisf 
sometimes  followed  by  serious  cooaequenoes. 

In  cerebral  IrritAtion  recoveiy  is  slow,  hot  may  ahtBatdy  W 
perfect,  although  remote  consequences  are  not  unfi 
manifested. 


DIFFUSED  DISEASES  OF  THE  ESCEPflALON.  719 

Morifid  Artatomy. — In  most  cases  of  death  from  con- 
lasion  the  autopsjr  revesU  actual  structural  chaugefi  in  tlie 
coDsisting  of  sti  perBciul  larcratioua,  or  of  mmutc 
bvmoiTfaagic  extravasations,  either  studded  oq  the  surface  of 
Ibc  bnuQ  or  in  its  substance,  and  occasionally  of  diffused 
DCcbjmoMt  of  tbo  pia  mater  (tfutchinson).  The  most  common 
lites  of  these  superticiaJ  hs&morrbagic  extravasations  are  oppo- 
site bony  rid|;cs,  and  at  projcclinf;  parts  of  the  braiD.  In  some 
rses  DO  atruclural  lesions  of  any  kind  have  been  discovered.  It 
probnble  that  ta  the  majority  of  the  caiies  which  recover  no 
Itmctunil  chnngos  which  could  be  recognised  even  by  micro- 
icopical  examioatioQ  are  produced.  It  is  mucb  mora  likely 
that  the  essential  (ttructural  alterations  in  concussion  conRiHt 
of  a  mulocuUr  disturbaQce  of  the  substance  of  the  cerebro* 
Rpioal  centres. 

g  800.  Morbid  Phi/s'iology.-~yanoiis  hypotheses  have  from 
time  to  time  been  adroncud  to  account  for  tbo  phenomena  of 
ooncussion.     Nothnagel  thiokH  that  the  strong  irritation  of  the 
leiMOly  nerves  produced  by  the  injury  cauaca  coutractiou  of  the 
voaaels  of  the  brain,  which  in  it«  turn  ptoduccs  anu^mia  and  loss 
of  futictiou  of  the  cortex.  Fiachcr,  on  the  other  hand,  attributes 
the  phenomena  with  more  justice  to  vascular  paralyais;  but  if 
the  shock  of  the  blow  is  sufficient  to  paralyse  the  vaso-motor 
centres,  what  ia  to  prevent  it  from  paralyaing  a  more  extended 
portion  of  the  nervous  system  ?    By  far  the  readiest  way  of  ac- 
counting for  the  loss  of  function  of  the  cortex  is  to  assume 
that  the  injury  has  produced  a  molecular  disturbance  of  the 
protoplasm  of  the  titisues  of  the  brain,  which  i-i  accompanied 
by  an  impairment  or  abolition  of  tbcir  functions. 

g  SU7-  Diaj/noaig. — Concuwiion  may  be  distinguished  from 
most  other  aAections  by  the  preseuco  of  the  syniptoras  already 
described  directly  following  a  diatinct  injury.  It  is  most  likely 
10  be  mistaken  for  compression  of  the  brain.  It  nmy  bu  dis- 
linguished  from  com  preusioo  by  ihe  abecnco  of  any  obvious  cause 
of  pressure  on  thebrain,  of  paralysis,  and  of  stertorous  hrealhiug. 
In  compreasioD  from  hfemorrhuge  a  short  iuCerval  elapxes  before 
tbe  aymptoms  are  developed,  and  tbey  gradually  become  more 


722 


OHAFTER    Xnt. 


II.  DIFFUSED  DISEASES  OF  THE  ESCEPllALOS  (OoJ 


(IV.)  ENCEPHAUTia. 

EKCEPBALiTisconBistaofpriouu-y  iDflatnaiatioDof  the  nil 
of  the  brain  foUowod  by  aofteaiDg  and  in  ccrtaia  inalMOW  ' 
abscess.     Two  kindn  are  aaually  described,  aaniel;.  (1}  difttd 
or  <fe7ieral ;  and  {'2)  puriuH  or  local  enoepbalitii. 

§  ftl2.  Etiology. — The  mo«t  frequent  caase  of  scato  hA^ 
raatioD  aQil  abscen  of  the  braia  19  recent  injury.  R' 
trauniadc  eDoepbalitU  U  most  acute  wht>D  tbs  atnu 
U  allowed  to  gaia  acoen  to  the  wound,  aud  in  wicb  caaa 
asMcialC'd  with  meningitis;  but  eocepbalitta  may  renlt 
oontusiona  of  the  brain  id  the  abseoce  of  any  perfonial 
wound  of  the  skuU,  and  such  caaea  often  tenDinate  to  ckreM 
abscess  of  the  braia. 

Affeclioiu  of  the  boaee  of  the  skull,  such  aa  auin  tat 
accumuhktioDS  of  pus  to  tbc  petrous  portioD  of  the  faftol 
boue,  may  cau«e  encephalitis,  either  by  an  ioward  extewm  rf 
the  inflammatory  process  or  by  infection.  The  p  rat  saw  if 
tumours  giT««  rise  to  inflammation  of  tbo  mrrouDding  boa 
tissue,  and  a  certain  amount  of  uucvpbaUtia  ia  alwayi  bmC 
in  caaes  of  infantile  apoj^exy. 

Uulriple  cerebral  abaoeasM  occur  in  connection  with 
febrile  affections,  more  especially  typhoid  fever,  and  aM 
generally  occasioned  h^  metafltaais  from  otbar  orpna.  b 
scarlet  fever  abscesses  of  tfae  brain  result  from  aflectioaii  of  tkl 
iotemal  ear  and  petrous  part  of  the  temporal  bocw.  Iifntifr* 
iuflammatory  procecKS   occur  in   the   brain    iu   mwali.  aad 


armm 

3 


DIFFUSED   DlSKASeS  OF  THS   RNCEPH ALOM. 


rs! 


\Ud  tbat  the  part  ofloctcd  may  prc«GDt  tbo  appiianuiCd 
fttnorrbagic  infarction.  At  giber  times  the  extravasations 
mor«  diffused.  Tfae  brain  i.i  liable  to  be  lac«rat«d  by  loose 
Dtere,  or  a  depregsiou  of  tbe  bones ;  and  when  there  is 
ture  uf  ibu  tikull,  large  portiuiiii  uf  the  train  may  be  die- 
uiseiL 

Ite  symptoms  of  cootusion  are  always  compHcatoiJ  by  tliose 
DQOusuou  and  of  comproHaiun.  The  diaguubis  uf  cuutuslou 
it  be  made,  in  the  absence  of  tbe  signs  of  a  fracture  of  the 
[1,  bora  the  presence  of  symptoms  iuJlcative  of  a  local  lesloo, 
DOBOSpaiinui  and  monoplegia,  in  a<lditioii  to  the  symptoms 
led  by  a  general  injury  to  the  br&iu. 

he  prognosis  of  these  ciues  is  usually  serious,  but  not  neces- 
jKistaL 

H  §811.  Comprvasion  of  the  Brain. 

Bnipreasioii  of  the  brain  may  occur  after  injuries  from  tlie 
sure  of  a  fractured  purtiuu  of  the  booes  af  tbe  skull,  the 
leoce  of  cxirarasateil  blood,  pua  formed  within  the  skull,  or 
k  foreign  budy  loJgud  there. 

Im  patient  becomes  uucoa&cious,  tbe  breatbing  is  slow,  deep, 
.  stertorous,  while  tbe  cheeks  arc  pufTcd  out  dunng  respira- 
t  The  iturfftce  of  the  body  ia  cool  at  first,  but  soon  becomes 
mkI  bathed  in  perspiration.  The  pupils  are  dilated  or  un- 
tkl,  tlie  pulse  is  slow  aud  full,  the  iWces  pass  iavoliintarily, 
t  thsre  is  retention  of  urine.  This  condition  of  stupor  soDie~ 
iH  altemnti;s  with  paroxysms  uf  delirium,  while  local  Bpafiins 
laralyxes  are  &om«timuK  observed,  but  it  in  probable  that  in 
le  cases  the  motor  area  of  tbo  cortex  has  been  lacerated  or 
tnsed. 

''or  further  iaformatlon  with  regard  to  contusion  and  com- 
m»ii  of  the  brain  the  reader  is  referred  to  surgical  worlcH 


vv 


IK  vury 


'  BUMVEU 


if  acofl 
iDini 


§  S13.  SymptoTiis. — No  general  dcBenpiioD  of . 
litis  can  be  gpvea  wbich  will  npply  to  all  caioa.  loji 
head  are  ofbeo  accompanied  by  coulugiona  of  tbe  bnll 
may  be  followed  by  acute  localised  eocepbalitiR,  Si) 
le-iiotis,  provided  tbev  be  exposed  to  the  air,  lead  to  ret 
iug,  with  coDsecutivL*  acute  diffustrd  suppuratioa  of  th( 
while  deep  contuaioiu  may  be  fullowud  by  red  sofWn 
suppuration,  which  tend  to  develop  into  rhroDic  enoi 
absceasea  The  stage  of  encephalitis  without  mippal 
generally  traositoi^,  and  its  »yraptotru  ore  difficult  to  n 
more  especially  aa  the  symptoms  often  commence  dtt 
period  of  uncoDSciouHDesd  caused  by  the  original 

I.     UlrWHZD  OR  GiMIBAL  BucmuuTu. 

When  the  contuBton  is  superticial  eucepbalitis  is 
by  meningitifi,  and  it  ia  impo&iible  to  distinguish  thi 
which  belong  to  each  alfectioD. 

WUeti  ditTuite  moningitta  superrenos  after  injury, 
toms  such  OS  isohited  spainn,  paralysin,  or  aphasia  ma 
and  a  distinct  spot  of  red  aofteoing  be  found  at  ibe  aa 
account  for  tbeio.   But  when  the  lesion  of  the  oortexji 
beyond  the  motor  are-a,  psychical  symptoms  of  a 
:;haracter  are  alooe  produced. 


J 


DlKftTSiED   DISEASES  OF  THE  E.VCEPHALOK. 


7M 


following  an  injury  of  the  h(uul  without  fracture  may  coose- 
queatly  run  its  course  without  our  having  a  «u9pi(uon  of  ito 
ezistBDce. 

When  a  contasioa  io  tho  ioterior  of  the  brain  baa  takon 
place,  the  patiout  fiiHt  suficre  from  the  usual  ftjrmptoms  of  con- 
cmsioD,  and  tt  is  only  when  tbcso  have  disappeared  that  the 
•yuptoms  of  local  enoephalitia  can  be  recognised.  The  patient 
lies  in  a  somi -conscious  condition,  nnd  when  roused  complains 
of  headache  and  dizzinean,  and  staggers  on  attempting  to 
walk.  The  pupilfi  are  variable  in  Bi/e,  generally  ec|ual  and 
reacting  slowly  to  light  Tiio  couoteuance  is  usually  suffused, 
but  at  timee  turuti  pule,  and  tbe  pulse,  which  was  frequent  and 
intigular  during  the  stage  of  concussion,  sinks  to  GO  or  70  bents, 
and  the  thermometer  may  reveal  the  existence  of  fever  of 
remilteat  type. 

The  Bymptomii  are  at  times  bo  insignificant  that  after  a  few 
the  patient  feels  quite  well,  or  iud«Guite  ayiuptoms  may 
tinue  for  two  or  three  weeks. 

udileidy,  however,  theae  symptoms  become  more  intense, 
fever  increases,  but  is  iitill  uf  irre^lar  type,  the  tlizxineKS 
aad  headache  become  more  marked,  vomiting  ia  not  un- 
fr«picpt,  the  piipib)  are  dilated  and  fixed,  the  pulse  is  slow, 
the  patient  falla  into  a  conilition  of  sopor,  which  may  be 
accompanied  by  delirium,  or  may  pa^  directly  into  complete 
OBconsciousnesa. 

Afi  the  case  progresses  graver  symptoms  appear  in  rolling  of 
the  eyes,  transitory  divergence,  sudden  pentrnQCot  poralysia  of 
fcbe  abtittceaa,  motor  oculi,  or  facial  nerve,  and  in  a  few  cases 
bemiparetiis  or  hemiplegia.  Convulsive  symptoms  are  some- 
times present,  umially  consisting  of  twitching^  of  both  bands, 
or  there  may  be  clonic  convulsions  of  the  limbs.  In  some  eases 
a  general  convulsion  occurs  which  varies  greatly  iu  duration 
and  intensity  in  ilifierent  case*.  The  Kopor  now  gixjws  deeper, 
the  previously  tdow  pulse  becomes  quick  and  irregular,  and  death 
takes  place  in  coma.  The  course  of  the  temperature  varies, 
but  a  continuous  elevation  until  death  is  exceptional. 

The  dwTxdion  of  the  symptom-i  is  variable.    Beck  found  an 
abacess  of  the  brain  on  the  Gfth  diiy  after  an  injury  of  the  head, 
Huguenio  on  the  twelfth  day.      When  the  air  obtaios 


to  more  or  lesH  pvrmaneut  Kympioios-     Tbe  more  nraal 
of  symptoms  caused  hy  these  changen  are  ibe  foUowing 


1 


IWIMItlllg 


(i.)  CbroDic  psychosis  in  the  form  of  irriUible 
followed  by  recovery  (Uuguenio). 

(iL)  A  pfiychosU  characterised  by  severe  bcad&cbe, 
anxiety,  and  hallucinatioDS ;  the  intellectual  fscultiei 
paired,  aad  there  are  iutercutreni  periods  of  cxcitem 
cuustaat  illusioQS  of  tho  soDaoa.  A  few  cases  reoover. 
the  majority  this  cooditioa  coDtioues  for  years,  aod 
ia  complete  imbecility. 

(ill)  Symptoms  reserobliog  those  of  demon 
Buporveno  at  a  variable  period  of  veokfl  or  yi 
injury.  Tlie  dovelopment  of  the  dii»eafie  aAer 
slow,  and  the  couiso  is  protracted. 

(iv.)  A  psychical  vnlnerability  fre<|uently  romaio*,  i 
apt  to  devflop  ioto  some  form  of  iosaoity  from  aoai 
exciting  cause.  In  these  casefi  the  disposiiion  of  the  p 
generally  changed,  there  is  great  meatal  irritability  ao( 
tosthesia  along  witli  dimioutioo  of  the  power  of  si 
thought,  and  ioaanity  may  suporreoe  many  yeara 
injury. 

(v.)  Epilepsy  is  a  freijueiit  reaull  of  the  ehra&io  du 


i 


DIFFUSED  DISEASES  OF  THE  ENCEPHALOlf. 


727 


AcuU  EiieefAalUi»,  complkaiing  affections  of  the  petrotu 
poTTtion  cfthe  Temporal  Bone,  and  of  olhcr  Bonea  of  the 
■     SkuiL 

^n  814.  Symptoms.  —  The  syraptoms  caused  by  the  acute 
^Beephalitiii,  which  acoompanie;)  caries  of  the  petrous  bone,  are 
ofteD  obeciirod  by  co-existiug  mentDgitis  aud  thrombosis  of  the 
Mouses.  Au  abacess  in  tlie  temporal  lobe  may  attain  a  con- 
Biderablo  sise,  and  causo  general  symptoms  of  compression 
before  giviDg  rise  to  liymploms  of  local  disesM,  luafimucb  as 
this  lobe  does  not  contaia  auj  direct  sensory  or  motor  ooo* 
ducting  tracts.  Acute  abscesses  of  the  temporal  lobe  are  cod- 
seqiiently  seldom  reco^ised  during  life.  Otorrhaia  may  occur 
ftt  all  age*,  altliough  it  is  most  commun  iu  scrufuldiLs  children 
BBpocially  after  attacks  of  scarlet  fever;  while  a  jwiriileot  dis- 
charge from  tLii  war  hiis  cKwasioiially  beeu  obstjrvcil  iramediately 
after  birth,  the  afi'vction  being  then  apparently  congenital. 
Acaie  cerebral  abBcesa  from  otorrbfca  runs  a  very  rapid  course, 
its  duratitfQ  beiug  from  four  to  twenty  or  more  day& 

The  symptoms  are  those  which  usually  result  from  a  sudden 
aud  progressive  compressioa  of  the  bruin,  but  general  convul- 
tioos  may  precede  the  development  of  complete  com;i.  Fever, 
of  variable  type,  is  usually  present,  the  pulse  is  slow,  and  tbo 
pupils  ooutractcd  and  sluggittli. 

Severe  hcndiichc  is  iiBunllytfao  first  symptom  of  the  aSe>ction, 
but  it  is  saon  followed  by  vomiting,  ringing  in  the  cars^  con- 
fusioD  of  ideas  and  loos  of  memory,  and  mild  dotirium.  As 
the  disease  advances  the  headache  becomes  more  and  more 
inteose,  th«  patient  is  delirious  and  at  times  unconscious,  epilep- 
tiform convulsions  supervene,  and  the  coNe  soon  terminates 
fatally  amidst  profound  coma. 

Id  some  cases  the  general  symptoms  just  described  are  com- 
plicated by  tho.ie  of  a  localised  di»easc.  Id  such  cases  tbo 
absemB  increaaes  rapidly  in  size,  and  involves  tho  base  of  the 
lenticular  nucleus,  compressing  the  fibreu  of  the  inlerual  cap- 
sule, and  thuR  canning  an  incomplete  hemiplegia  with  various 
sensory  dlstuibaoces.  It  may  also  compress  the  cerebral 
peduncle,  and  thus  cause  paralysis  of  the  oculo-motor  nerve, 
rhile  paralysis  of  the  facial  nerve  has  occasionally  been  observed 


728 


DIFFUSED   DI8EAS88  OF  TBS   ENCEPnAl/Ut. 


Cues  of  tliis  kind  pursue  a  r&piti  couno,  And  tMtoiute 
ID  a  abort  timo. 

A  few  casoa  ctre  associated  with  aoiLe  m«niDgitu  or 
boais  of  tbo  lateral  sinas. 

h.  Acute  Pffonac  BnoepkalitU. 

The  iaitini  tiyniptonis  of  this  affbdioa  ara  sotnewhat 
aod  oftcD  matiked.  There  are  frequently  rigors,  but  tbi 
symptomatic  of  the  general  dHeoec.  The  bnuo  afleotiai 
usiicred  in  by  mvero  headache,  usually  frontal,  dizzinesa, 
disturbance,  slight  somnolence,  ocoasinQklly  deliriuro.  unUat«l 
coavuUioon  in  an  arm  or  leg  or  both,  rormicalion  and  otbr 
forms  of  dy^a'sthesia,  or  a  slight  dUnioutiou  of  B(>nftibllily 

The  diaease  unually  makes  rapid  progroM,  and  graver  tyv^ 
tomit  Boon  supcrrene.  There  is  intense  headache.  dizziMail 
80  great  that  the  patient  cannot  stand  or  walk,  the  auii4  B 
confused,  aad  delirium  BuperreDoa,  but  soon  gives  place  b)  pis- 
found  coma. 

The  local  ayroptoois  consist  of  conmlsivc  moTemcotsflf 
eyes,  faco,  or  of  one  of  the  limba,  which  may  eud  iu  uail 
or  gencml  convulsions.     There  may  be  at  times  a  coaaii 
elevation  of  temperature,  but  the  intvDsity  of  tlie  fcbrik 
touts  is  variable. 


c  £nc«plialUi4<nroundpre-tsei^ing  leHontinAibraintt 
09  twnom%  nwrotie  K/teninga,  and  atrat 

blood. 

(a)  Cer^hml  Barmarrhagt. — Within  a  variable  period 
A  cerebral  liiemorrhage.  a  xone  of  red  sofieuiog  is  found 
the  primary  focus,  in  which  an  abundance  d  migrated 
may  bo  ob8or\'cd.  Suppuration,  hovrCTcr,  is  ran.*,  ifit  even 
Beyond  the  areo  of  red  sofleoisg  a  second  zone  may  bo  ol 
ID  which  the  tisaues  of  the  brain  are  unusually  de&sc,  omi^n 
a  great  iDcrease  of  the  neuroglia  corpiiscIe«,  wbila  Ut«  ^mm 
surrounding  this  zone  may  be  eztensivety  (edematous.  Seoofr- 
dary  ha-morrhageii  mny  occur  in  the  drcumfersnee  oflbe  |B- 
mary  apoplectic  focus. 

(6)  ICeerotie  Sofietiing  from  Tkromhofw  nnrf  E-mhoHMm— 
The  primary  focus  consists  of  a  haimorrhagic  infarct.  wUA  » 


DIFFUSED  DISEASES  OF  THE  BSCEPHAJLOS.  729 

foUowed  bj  initaiTimatiou  of  tbe  surrauniHDg  tissues.  The  in- 
farct ii  tliuB  BurrouuJed  by  a  red  areola,  studded  with  capillary 
eitiavasatioDs,  which  in  ila  turn  is  aurroundcd  by  a  yellowiiih 
sone,  and  the  latter  by  a  more  or  les»  extensive  zone  of 
[rdeTnatonB  tisauv. 

The  inflainmatory  prtx;ca.s  arouud  the  focus,  aa  a  nile, 
gradually  ceases,  the  central  portion  of  the  part  alTected  be- 
coming tranaformed  into  a  cyst  coDtaioiDg  a  clear  acroiie  fluid, 
and  sometimes  conoectivo  tissue  ecpto,  or  ioto  a  Dumber  of 

kmftll  kcumt  coDtaiDiDg  a  cloudy  ecrum. 

^Hb)   Tu.monT. — The  secoadary  nofteniag  caused  by  tiimoiirH 

^Bbo  brain  is  usually  most  marked  around  tumours  like  tb« 

"Sircinomata,  which  grow  quickly. 

I     The  processes  nround  tumours  rany  be  divided  into  several 
varieties : — 

(i)  Simple  softeaiag  and  a'dema  of  the  surrounding  tissues, 
ioaed   by  retardation  of  the  circulation,  and    probably  by 
iboais. 

(ii.)   Capilliuy  and   larger  extravasations,  probably  duo  to 
lily  degeaeratiuu  of  llie  walls  of  the  veKsek 

(iii.)    Genuine  encephalitic  red  softeningr,  accompanied  by 
ptiirc   of  minuto  vetsels,  migration  of  colls,  and  extensive 
la  of  the  hrain. 

'.)  Suppuration  around  tumours  is  occBaioiially  ob«erved. 

§  815.  Sjfmptoma. 

!)  Cerebral  B<xmcfrha<je. — Some  of  tho  symptoms  which 

w  a  cerebral  hemorrhage  must  be  ascribed  to  consecutive 

encephalitis.     The  patient  may  have  made  a  good  recovery 

ftY>in  the  early  symptoma  of  an  apoplectic  attaek,  but  seroral 

rfays  afterward*  there  is  a  frosh  elevation  of  temperature,  and 

the  pulse  becomes  hard  and  fn>quent.    The  patient  complnins  of 

pMulaoho,  there  may  be  slight  wandering  and  confusion  of  ideas, 

FaDd  be  may  fall  into  a  somuoleiit  cuuditi^oa.     The  general  are 

iooQ  followed  by  local  symptoms,  confii.'iting  usually  of  the  well- 

koown  secondary  contractures.    Some  patients  may  manifest 

only  alight  tremor  of  the  paralysed  limbs  ;  in  others  the  flexors 

ue  in  a  state  of  contracture,  while  in  a  third  series  of  cases 


730  DIFPCSED   DISEASES  OF  TBB   ESCVBUJDS. 

these  conditioiu  ftUeraate.  Tbe  tempemtard  of  the  pftnljwi 
ud«  is  oft«D  coQsiderobl;  «ievat«d,  aod  >nom>liet  in  Um  mo» 
tion  of  sweat  Aro  observed.  The  MnmolaBoe  may  nov  immm 
to  a  deep  sopor,  which  lasts  seTeni  dftyi,  and  nuy  paa  in 
profound  and  fatal  conin. 

Id  those  oases  tbat  recover  symptoou  frAqoeDtljr  psnift 
which  show  that  a  cfarootc  eocephalitifl  ia  estaUbhed.  Tbm 
is  penistent  headache,  fre<|D«at  attacks  of  diziioess^  aad  te 
patient  is  subject  to  coDgeetire  attacks,  each  of  which  BSf 
cause  new  couvuliiionB  in  tbe  pimUjiied  litnha.  The  panljisl 
limbs  are  generally  subject  to  paioa  uf  variable  chandcf, 
sitaated  either  in  the  jointo,  bonee.  skin,  or  muscles.  Seaiodsij 
encephalitis  ia  also  the  chief  cause  of  tbe  atrophy  of  the  bob 
observed  in  many  of  these  patieuta.  and  wbich  is  sfvsp 
associated  with  profound  psychical  diRtuTbancea. 

(6)  ThrombMis  arid  EmboUmi. — Id  aeoile  enoephalooiaisoi 
tbe  symptoms  of  seoondaiy  eccepbalitis  ore  caused  by  u  is- 
creaae  of  the  intracrania]  presnure  on  the  one  hand,  and  inils- 
tioD  of  the  surroundiag  parts  on  tbe  other.  Tbo  syioptonsif 
iDflammatory  reaction  are  slight ;  and  when  a  certaia  dtumU 
senile  atrophy  of  the  bioin  bad  existed  previous  to  tbe  OMV- 
rcDcc  of  the  attack,  tbe  mental  functions  become  |>iin;nisriidj 
abolished  without  being  preceded  by  symptonw  of  active 
tioQ  or  by  those  indicative  of  a  gradual  oompremoo 
brain.  It  frequently  happens  tbat,  after  the  fonnatMB 
diseased  focus  in  the  brAiD,  a  febrile  condition,  attended 
drowsy  dcliriutn  or  somnoloDce,  continues  for  eooie  tiese,  tti 
either  develops  into  permanent  imbecility  or  givea  ^aas  *• 
partial  reatomtion  of  tbe  mental  faculties.  When  tfaa  la«t  mdl 
occurs  tbe  mental  condition  of  tbe  patient  t«  cbaract«nss>l  h 
weaknesB  of  memory,  irregular  and  oauseJess  outbunrtaof  tanpK 
and  R  dinpositioQ  to  the  shedding  of  tears,  asd  other  MDOtisirf 
dUplaya  Tbe  patient  is  liable  to  coageaUTa  atteefca  viMh 
occasion  temporary  unconsciauaoess,  and  during  tlieae  new  (in 
of  softening  may  be  developed  in  the  braia  CooTttlnoiis  of  A* 
partially  paralysed  limbs  may  oootir,  and  in  mr«  omss  gsMoi 
convulsions. 

(tf)  TuTnour. — A  great  many  of  tbe  sympLums  obeorved  a 
tumours  of    the  brain    must  be  aacribed   to  iba  aMfldMT 


I 


DIFTiraED  DISBASB9  OF  THE  ENCEPHALoy.  731 


iiiMpbalilis  in  the  surrouodio^  tiHUc.  Tho  fiymptotns  which 
nay  with  prob;ibility  bo  ascribed  to  encephalitis  during  the 
pxiwth  of  a  cerobral  tumour  are  the  occurrence  of  sudden  apo- 
llectiform  attaclcs,  tiie  rapid  convorsion  of  alight  muscular 
reakness  into  complete  piiraly&U,  partial  oonvulaions  folloved 
tf  paralysis,  general  conTulsionii,  and  the  graclual  development 
if  ooma.  Whea  ooma  is  suddenly  developed  in  the  course  of  the 
|r«wth  of  a  cerebral  tumour,  it  is  more  likely  to  be  caused  by 
iBsraorriiage,  (h-  atidden  cedema,  than  by  encephatitlH.  Every 
econdary  eQcephalitis,  however  slight,  produces  violent  head- 
tdie,  altbougb  aucb  attacks  may  be  due  to  a  congestive  swetliog 
^  the  tumour  itself.  Encephalitis  around  a  tumour  which 
DTolves  the  senaitivo  fibres  of  the  coroua  radiata  is  liable  to 
disturbances  of  sensation  in  the  oppoiuto  side  of  Ibe  body. 

d.  Chronic  AbvxM  of  the  Brain. 
ironic  abscess  of  the  brain  may  be  Aubdivided  into  (I) 
ry  and  (iL)  seecmdary  chronic  abeoess. 
.^  Primary  chronic  ahaceaa  is  usually  caused  by  eomft 
Djtiry  of  the  brain.  All  tlie  sytnptoms,  or  nearly  all,  may  dia- 
tppear  soon  after  the  injury,  aud  a  period  relatively  free  from 
lyinptoms  may  follow,  forming  the  latent  stage  of  cbroQic 
■bKess.  The  average  duration  of  tbe  latent  stage  is,  according 
io  Lebert,  Irom  one  to  two  months,  but  the  period  may  vary  in 
udividual  cases  from  a  few  days  to  years.  When  once  a  chronic 
KfaBceas  is  formed,  the  Hymptomji  cai]sc<l  by  it  are  more  or  tees 
nmibir  to  thase  of  cerebral  tumour;  and  when  the  former  is 
■ttialod  in  the  motor  areas  of  the  cortex  and  centrum  ovale, 
injure  tbe  sensory  peduncular  fibres,  the  symptomn  of  a 
lesion  are  present  from  the  beginning.  Tbe  symptoms 
be  divided  into  those  of  (1)  the  latent,  and  (2)  the  ier- 
ninal  stages. 

(1)  Syi»*ptoma  of  the  Lattnt  PmoA. 

(a)  in  some  cases  a  persistent  headache  subject  to  paroxysmal 
oacerbations  is  tbe  only  symptom  present  which  could  lead  to 
^hc  suspicion  of  the  existenca  of  an  intracranial  aflGeclion,  and 
n  a  few  rare  cases  this  symptom  may  be  absent. 

if})  In  other  caws  symptoms  of  a  local  disease  appear  which 


uiutMf  m — w~uiaasnsoe~ve^rvB  im    uiuaunHiuii — pi^^HBH 

coQKiBt  of  conKtant  heailnche,  with  parox^'smnl  exmof 
accompfinied  by  slight  febrile  dtslurbance,  dizziii^| 
and  occasionalty  vomiUog.  Tlie  beaJacho  may  bo  limH 
spot  wtiere  the  injury  wan  receiveil,  or  oorreHpood  to 
of  the  braiD  where  the  abftcess  is  utuated,  the  latter  bd 
at  a  poiut  of  tlie  brain  exactly  opposite  tho  acAt  « 
Potoxj'SuulI  exaccrbatioaa  of  the  headache  are  ii 
congestion  around  the  ali^esa,  luid  when  these  freqt 
the  abBcc&8  i^  likuly  to  proTc  fatal  witbiu  a  brief  i 

(il)  la  a  fourth  series  of  caaea  Ihi;  syinpU>m» 
of  intermittent  preasare  on  the  brain,  with  int 
parativo  freedom  from  all  cerebral  symptonu.  The' 
the  midst  of  comparattro  health,  niay  suddenly  ooea 
intense  beoJoche,  bo  becomes  aoninolcnt,  and  fJalU  ini< 
but  tratBitory  coma  of  several  hours*  duration,  from  i 
rapidly  recovers.  Such  attacks  are  probably  dao 
pressure  on  tho  brain  from  congestion. 

(e)  Tlie  »o-called  latent  stage  ia  sometimes 
epileptiform  convulsions,  whicli  may  be  regarded  d\ 
true  epilepsy  (Huicbinsoa,  Jackson).    General  oei 
rare  during  this  Htage. 

(S)  Sipaptomi  qf  tA«  Termiital  Penod. 

When  ooco  the  tcrmiattl  period  begins,  ab«««»  ■ 
ffeneratW  lends  to  deAth  in  a  few  dav 


DIFFUSED  DISEASES  OF  THE  CNCEPDALOS. 


7S1 


je|dialitis  in  the  sarroundiog  tUsue.  The  symptoms  which 
J  with  probability  be  Mcribed  to  encephalilia  during  the 
wifa  of  a  cerebral  tumour  are  the  occurrence  of  suddeD  apo- 
stiform  attacks,  the  rapid  coDremion  of  olight  muscular 
ikoeas  ioto  complete  paralysis,  partial  coavuUioDS  followed 
paralyoa,  geoenU  convulsions,  and  tbc  gradual  development 
oma.  When  coma  is  suddenly  tteveloped  in  the  course  of  the 
(rth  of  a  cerebral  tumour,  it  is  more  likely  to  be  caused  by 
nonhage,  or  sudden  oedema,  than  by  eocephalitia.  Every 
liurf  encopbalitifi,  however  slight,  produces  violent  head- 
•llbougti  such  attacks  may  be  due  to  a  ouagestive  snelling 
ttimour  it»el£  Enccphalitiii  around  a  tumour  which 
e«  the  sensitive  fibres  of  the  corona  radiata  is  liable  to 
dkturbaooBs  of  sensation  io  the  opposite  side  of  the  body. 

d.  Chronic  Abaoess  of  tlie  Brain. 

Dnic  abscess  of  the  brain  may  be  subdivided  into  (L) 

iry  and  (it.)  secondary  cbronic  abscess. 

Primary  chrvnic  abKesn  h  usually  caused  by  some 

of  the  brain.      All  the  symptoms,  or  nearly  nil,  may  dis- 

eooQ  after  the  injury,  aud  a  period  relatively  free  from 

>mH  may  follow,  forming  the  hitent  stage  of  chronic 

Tbe  average  duration  of  the  latent  stage  if),  according 

m,  from  one  to  two  mouths,  but  the  period  may  vaty  in 

lual  canes  from  a  few  days  to  years.    When  once  a  chronic 

is  formed,  the  Bymptoms  causud  by  it  are  more  or  less 

to  thoee  of  corubrul  tumour;  and  when  the  former  is 

in  the  motor  areas  of  the  cortex  and  centrum  ovale, 

ijure  the  sensory  peduncular  fibres,  the  symptoms  of  a 

Jesiun  are  present  from  Ibc  beginning.     The  symptoms 

divided  into  those  of  (1)  the  iatent,  and  (S)  the  tor- 

stagca. 

(1)  Symptoma  qf  Me  Laltai  Period. 

Tn  some  cases  a  persistent  headache  subject  to  paroxyitnial 
rbations  is  the  only  symptom  present  which  could  load  to 
tupicion  of  the  exintence  of  an  intracranial  affection,  and 
lew  rare  cases  this  symptom  may  be  absent. 

In  other  cases  symptoms  of  a  local  disease  appear  vhkU 


734  DlFFirSID   DISEASES   OP  TBE   fOfCIPHALON. 

more  or  less  partial  coavuleioos,  such  m  spasms  of  botb  \tp,  M 
of  the  facial  mu9cle6  ou  both  aidea,  is  ao  iodicfttioD  of  nf- 
ture  into  the  ventricles,  provided  tho  patient  be  oo(  lUiw^ii 
an  unconscious  oondiliun.  Ueocral  coovuNions  bav*  muuitiaui 
been  observed.  Cloaic  spusms  of  the  ocular  maidM  Kor 
appear,  causod  probablj  by  irriution  of  the  corpoia  qwl* 
rigemina.  The  patient  becomes  rapidly  uncoDsciotu,  beouphpi 
and  death  in  profouod  c(Hna  take  place  geoerallf  in  frooi  fto 
to  tweoty-four  hours  after  the  rupture  of  the  absosM. 

(ft)  Abscess  of  the  cerebellum  may  termioate  luddaiily  fan 
arrest  of  the  respiratory  functiona  produced  by  proasufe  oo  tk 
medulla  oblongata. 

(«)  Occasionally  the  brain  is  found  in  s  conditioo  of  rffHik- 
able  aoxmia,  and  in  such  cases  tho  imravdiMe  cause  of  doA 
is  not  evident. 

(il)  Secondary  Chronic  AbMcea  of  Ihe  Brain. — Steambi! 
chronic  abscesses  are  generally  caused  by  affeciioos  of  ibe  nocf 
ear.  The  diagnosis  of  the  preaenoe  of  obroaio  abaoim  <t  t)k 
brain  is  difficult,  inasmuch  aa  only  a  small  proportion  ol  mk 
cases  giro  rise  to  cbaiacteiiatic  symptoms.  Wbeo  tbc  abow 
is  encapsulated  it  may  remain  latent  for  a  long  periMl,  m  ibM 
no  disease  of  the  brain  is  suspected  until  the  terminal  ftnA 
Even  the  terminal  symptoms  present  rarieties  which  tcftd  B 
obscure  the  diagnosis,  these  symptom*  sometimH  rasealAlf 
those  of  ditfuso  meningitis,  and  at  other  times  tboae  of  thio 
bosis  of  a  sinus. 

§  816.  VarietUs. — The  following  varieties  of  chronic  abM« 
aeoondaiy  to  disease  of  the  ear  may  be  dlHtiDguiibed :--{«} 
Chronic  nbKe^  with  distiuct  typical  course ;  (b)  Qinmic  abMi 
with  terminal  stage  alone  distinct ;  (o)  Chronio  abacoH  villi 
thrombosis  of  the  lateral  sinus ;  (<£)  Chronic  abacass  oospA- 
oated  during  the  terminal  period  by  meDiogttto. 

(a)  In  affections  of  the  inner  ear  abscea  may  bxm  n  f^ 
tcmporo-spbeuoidal  lobe.  In  a  loug-stauding  case  of  diMSf* 
of  the  internal  ear,  where  rigors  and  other  general  ioiiO' 
matory  symptoms  are  associated  with  serere  paio  in  tbt  bwi 
vomiting  coovulsbna^  and  otliar  cerebfBl  symptoms,  ibe 


DIFFUSED  DISEASES  OF  TUE   ENCEPHALOM. 


7S5 


tioo  of  KD  absceu  in  the  Lraia  may  be  suspected  These 
^mptoiDS  may  pass  oS,  oud  tho  paticut  c-ojoy  apparoat 
,hwltb  for  months,  with  probably  occasional  hcndachos.  The 
lermmal  stage  is  aaDouoced  by  iut«ase  headache  aud  dizziueBs 
Boon  foUowod  by  loss  of  coosciou^acsa  and  siertorouii  breathing. 
Consciousoess  may  be  partially  re»torod  in  a  few  hours,  and 
tbe  patieul  tlieu  HufTere  from  iuteuse  headache  aud  vumitiog. 
After  a  short  time  the  patient,  htpses  n  second  lime  into  a  senii- 
-ooQBcioua  condition,  aud  couvulsious,  generally  unilateral,  Huper- 
rene.  Spasm  followed  by  paralysis  of  the  ocular  muHcti^s  is 
not  an  unfretiuent  symptom,  and  when  tbe  abscess  is  so  large 
IthAt  it  extends  to  the  lenliculv  n\icteua  and  compresses  the 
internal  capsule,  or  the  fibres  of  the  pyramidal  tract  in  tbe 
crusto.  a  certain  di-grec  of  hemiplegia  may  be  present. 

(6)  Chronic  abscess  of  the  brain  is  sometimes  observed  in 
icaaes  of  caries  of  the  petrous  booe,  in  which  tbe  tennin&t 
Bjmiptoms  have  not  been  prcccdt-d  by  those  iuJicative  of  irn< 
:tetion  or  encephalitis 

it)  Cbionic  abecess  of  tbe  brain  sometimes  precedes,  at  other 

times  succeeds  to  thrombosis  of  the  lateral  siuus.    Tbo  chief 

liaitial  symptoou  are,  besides  those  of  the  car  affection,  dizziDena, 

litttttOM  headache,  and  occasionally  transitory  dolihum,  followed 

Iby  Bomnolenee.    The  patient  suffers  from  frequently- repeftted 

ngors  if  the  temperaturo  of  the  body  b©  raised,  and  the  fever 

asBumes  a  remittent  type.    In  the  further  progress  uf  the  case 

the  symptoms   may   pursue    either  of  two   directions.      The 

tymptomH   may  be  thoeo  of  progressively  increasing  pressure 

npon   the  brain,  ending  in  coma,   or   the  general   symptoms 

indicative  of  compression  may  be  associated  with  those  of  a 

'localised  disease,  provided  the  abscess  has  attained  a  sufficient 

size  to  press  upon  the  intemal  capsule.     General  convulsions 

maj  occur  immediately  before  death. 

(d)  Chronic  abscess  of  the  brain  may  lie  complicated  during 
the  termioat  period  by  mtitiiogitis,  and  when  tho  iuilial  stage 
of  the  former  is  latent,  the  terminal  symptoms  may  be  so  similar 
to  thoM  of  primary  acute  meningitis  that  tbe  two  aETuctions 
caBDOt  be  distinguished  from  one  anotbvr  during  life. 


In  conBe(]ueDce  of  thia  cedema  the  affected  portioil 
brain  beoomes  voluminoua,  and  the  cut  eurfnco  risra  al 
level  of  tliti  fiuirouixling  tissues,  tbc  latter  of  wkij 
different  sbadea  of  colour  from  the  imbibitioo  of 
matter  of  the  blood  set  free  in  tlic  ceotral  port  of 
When  tbo  inftamed  focus  presents  a  dtop  r«d  eoloi 
rounded  by  a  red  xooe,  whicb  shades  oil'  into  browi 
yellow,  and  finally  ioto  tbe  normal  colour  of  tbo  etnt 

Tho  miero9copic  changes  observed  ia  the  first  i 
inSauimatiou  are  great  hypenemia  nod  dilatstion  of  ihj 
and  capillniiea  Huyem  asserts  ihot  be  bassecQ.  tiieveMfll 
to  six  times  their  normal  catibro.  The  vesseUare  surruv 
migrated  white  blood  corpuscles  and  tbe  lisauea  arei^ 
by  leucocytes,  probably  derived  rtoni  multiplication 
of  the  uourojflia  auJ  proliferation  of  the  cellular 
tbe  walls  of  tbe  resscls.  A  largo  number  of  granule  < 
coipuades)  way  also  be  observed  in  tbe  iaflameil  fo 
art'  probably  derived  from  the  gaogliua  celta,  ibt*  nt 
nouro<;ltu,  tbe  uuclci  of  tbc  capillary  vecsols,  and  tlia 
cells  of  tbc  sbcatbs  of  the  vesaeU.  Tbe  large  size  and  j 
appearance  assuined  by  these  cells  are  supposed  by  Hayi 
due  to  tbe  abaorption  of  uutrimcnl  and  to  be  oiuUf^otil 
cloudy  Bwelling  of  Vircbow,  but  the  granular  appeoxu 
leaat  more  lilcely  to  be  caused  by  commeociiig  degei 

■The     gODglioO     Ceila      BWeil     HP,    1^"'     nmtnnU^r^     hi 


DtFFUSKD   DISEASES  OF  THE  ENCEPUALON. 


737 


piooeas  oeaaw  before  .ui  absr^ss  fonoa,  anil  the  lUTci-ted  jiftrl 
fsvacuta  a  fltroos  nacmhUuice  to  a  (iriruitry  tietatMie  with  subsequctit 
pnfiphefal  eneephoUtis.  The  rmitlttng  oonditiona  an  sJtiular  in  the  tmi 
tUMktoa,  althoagti  thej  nrc  cncntiallj-  (lifff4H:^it  in  nature. 

(1)  Ad  onoaphnlitis  or  slight  intmiait}-  atid  nnuiU  cxt«nt,  such  as  t3ut 
OMmkI  l>jr  tnuoiBtic  coiittuiiou,  may  unJorgo  vompictc  rcvair. 

(2)  After  the  itiftfuumAtory  ^woceM  in  the  Ijirger  foci  ^as  ceaMd  A  r^ 
ddiutm  ia  left  Uliind  nlucL  uudcrgov*  the  wdl-biovrD  deatructiTi)  change*, 
bUownl  by  ulMdrjitii^i  of  t.lir  dniil  i3inL>-iit».  All  tlm  cdlukr  cIcJiicuUi 
S  tlto  fi>C(U  juv  traiufi;miod  iuto  gnwulc  c«lll»,  which  underxn  ^  gnuliiAl 
BmiHTgrnli"ii :  tho  ouDti»it»  of  the  focus  bocntueM  tliua  <»DVcrtc<l  intort 
Ikiok  cmtilBioD,  CAlouml  brownish  or  ydlowiMh  l>y  th«  blood  pigment.  All 
the  Duclei  of  Uiv  ^-mmU  and  the  neuroglia,  aiitl  the  wliitu  blixxl  cdlis 
irbicli  are  enelmMxl  in  thv  focus,  disappear,  uid  it«  contcntx  bemmv  mare 
MDOiEencoaA.    After  a'tioie  a  focus  of  yellow  aofU^ing  fonim  whkh 

jpwliiAJh-  bcc<oaic«  mure  wlourlcM,  and  at  kutt  maj  b«  tnuufomiG4  into  a 
mv'Ay  tilled  hy  a  thin  mitlcy  fliud. 

(3)  But  tltefoeusaflvratimo  EaanifMtH  n(lu1iait«>  wtiotua  supplied  with 
iUicat«  \'mm;U,  thv  iobenpaoes  of  which  an  flllud  by  a.  thin  tiirbld  fluid 
The  Htroau  onnnxts  of  deUcate  oonnoctivo  tiwtii;  HUppliiHl  witli  vefiBclii ; 
tbe  f<^uiv^  vlbiuviita  of  the  fluiil  couaist  almost  wholly  of  Urge  ijuautities 
-of  graxiiiliu-  Eat  aiid  oltuminoiu  Ixulim,  tA^«tb«r  with  a.  little  five  pigment 
TIm  spoixa  beconiB  K^^i'i^b'  birg^r  lunl  the  fluiit  clearer,  an  that  a  cbaaia 
mnaitw  which  ia  tritveitiuii  by  n  iiurolitT  of  dutimte  aepta  of  cutiiiectiv« 
tiaeue,  aiA  »un\>uiiiteil  liy  Bomewbat  oundciwod  oerekrol  suhetance.  Apo- 
plaxy  Aod  inCcuvt  uay  tvituinato  Ln  ttui  mido  vra.y,  and  iha  nature  of  the 
ptvoediiif;  oSvction  conuot  bo  podtiTcly  dBtcrminwl  Erom  the  ntudj  of  the 
lariona  tu  their  later  sta^^ 

(4)  Local  enocpbolitis  may  lead  to  the  prodnotilOB  of  ftrm  aclerotic 
idcBtrioeB  situated  imuAlIy  near  tho  tttirfocv  of  the  braio,  mon  nrvly  Ai»p 
in  tbc  uitvTtor  of  the  «rgaD,  Thc«c  ciiutricoii  arc  of  a  dirty -whitv  oolutir, 
tuugti,  and  linii ;  the  timiie  aiirroundiug  thein  is  atruphiod,  wi  tlmt  Ute 
affecieJ  hcmisplwrv  ia  lean  tbau  the  other.  EroQ  diatoat  puitiont  of  the 
tiraiii.  e»i|)Ccially  of  the  oorUfX,  may  U<  found  in  astato  of  atrophy.  When 
Ibe  cicittrtccx  atv  »ituiit«>J  deep  in  thi»  bmin,  CAvitiiM  an  found  within 
Umhh  at  Ko  lurly  period.  At  a  Ia1«r  period  tbe  cicatrix  oontniiiH  a  uucleua 
dilfcriog  team  tho  met,  and  ootitAininj  fnt  and  pignont  gmnuleA,  listmi- 
loidin  crystals,  and  amorphous  detritus^ 

Sttcfa  ibflaniiuatory  pr>ocwva  iu  the  briiiu  ven>*  aoldom  bocorui?  quiawccnt; 
tbejr  *ra  fUlowed  by  a  grHdually  progrvaaing  atrophy  td  the  ectire  brain, 
wludi  oaoBea  aymptonut  during  life  that  even  nt  the  preaont  il&y  ore  fVe- 
qneoUy  iududed  among  thoao  of  dvmontia  jmnilytiai.  HawR  liiui  also 
dnwn  attentlnn  to  tba  fact  that  an  oncapbalitic  cicotrii  may  M^ite  freata 
jaftommatkwi  at  a  later  period  resulting  in  tbe  development  of  a  new  sane 
VV 


(Of  inai 
which  mnj  be  sulidiridal  into  noeai  end  old  at 
Boid  to  be  new  or  fnwh  whra  H  hoa  bMD  dev«V>ped  nf 
poaseaB  a  capsule,  lut  this  (llattnction  rlo»  Dot  buU  ipiod  io  ail  a 
acute  aheoeaa  hua  a  teodeoc;  to  spnad  to  every  ditvctioo  «nd  H 
an  irre^ilar  caritj'  in  the  Hubatimce  of  tUe  bnto,  wboav  val 
roug^,  ahnggy  aurfaoe.  Ttw  ■hdggf  pmJMtwfu  conaiat  of  i 
cerebral  Uhhuq,  wliioh  wv  attaduMl  to  Ifae  Urger  Uood-ruieW  1 
around  the  abcoeoH  k  in  n  eonditjan  bI  red  Ksftening,  anil  in  ml 
tlie  Hofbonn]  tdimic  is  of  a  pndomiiiantlj  jrcDtm  ooloar;  wfatit  at 
diKtaDoe  from  the  fociui  the  ccralwBl  tiaaua  la  CDdtBUitouB.  Am  i 
the  oentrol  cnvity  nccumulatra  pnsaBun  ia  cnrtcd  on  the  wbc 
aurrouniling  tiwuiu,  which  uuMtii  ita  drcutation  ajvl. 
dcxtructinn,  und  (uItiujgo  of  tita  abaooH. 

The  abacaaa  bj  virtue  of  its  tendency  to  eolu^  may  i 
of  tint  bnun«  aul  as  aoou  as  perf«tmki<Mi  oooun  ao  asnto  ] 
mntion  of  the  pia  mater  ranihai 

(6)  Otd  triiiwww  </  tA«  bram  poeaeaa  a  fibniua  oapmla  r 
a  thickama  of  several  aiiUiuwtraa.     Biudflttbch  affiima 
gradual  tranaitioQ  friini  the  oa{Mule  to  thu  auntiuuiliug 
tlie  ouiinevtttiu  ia  not  olwnj-a  wTj  cloae,  iiuumacb  u  tha  . 
emulMited  without  much  difficultf.     The  inivmal  mufaoe  of  tin 
awmbnao  m  aniooth,  and  «a  «|Mqa»  jntUowiah-wbita 
to  ll  by  a  ooutinuoua  layer  of  oelb  in  a  Mate  of  bttf  • 
aide  tliis  thvnt  ia  a  lajrer  of  cmbrjMnic  tissue. 

The  pu»  of  the  abaoess  is  of  n  greaush  ooloor,  and  ; 
is  odourioo,  and  Las  an  add  reaction.  Afltrr  a  variaMi;  | 
the  ab«c«tw  onlarKoa  and  ]>n>duaee  nwuiif(4d  "h'H'yf'  in 
TLc  iuLracHuiitd  preaauie  boooaiwa  jjuamtJ,  tt« 


DlPPirSED  DISEASES  OF  THE  ESQEPOAhOS. 


739 


iMomia  0/ li^  bratnt  00(1  more  mpecinllj  of  th«  oottcx,  «laa  reaulU 
u  the  incroue  uf  tho  iutracmiiiHl  I'rasHiira. 

AroiM  Mftrnoi  AyJro«phaliu  rtaulta  wlicncvcr  an  absoosB  it  8ituat«d 
tbt  oarebeUum  in  such  a  position  that  it  leaaens  tbs  oavity  of  tbe  fourth 
Ibido  or  of  tha  BTlviao  Miuediiut. 

§819.  Diagnosis. — The  symptoms  of  abscess  of  ttio  broia 

I  very  simitar  to  those  of  tumour,  but  the  two  atfectiouH  may 

lerally  ha  distinguUbed  by  the  history  of  th«  case  aod  tho 

igtesH  of  the  HymptocD!!.      Abscess  U  more  frequently  pre- 

leii  by  a  lUatiuct  biittury  of  iujury  to  the  liead  tbau  tumour, 

longh  tlie  tatter  also  occasioaally  develops  »oon  after  iDJary 

be  slcull    Ttie  course  pursued,  tiowever,  hy  the  two  affections 

aequeot  to  the  injury,  diffeni  widely.     If  the  symptom.s  of 

;te  encephalitis  occur  immediately  after  the  injury,  and  tic 

foliowed  bj  a  remission  or  complete  intermission  and  brealt 

gain  after  a  latent  period  of  variable  duratioa,  either  with 

bout  tho  phenomena  which  indicate  a  local  disease,  alscess 

be  diagnosticated  rather  than  tumour. 

the  other  causes  which  give  rise  to  abecess  of  tbe  brain, 

ironic  otorrboea,  caries  of  the  temporal,  frontal,  or  nasal 

I,  bronchiectasis  and  purulent  cavities  in  the  lungs  with 

secretions^  and  pyn-mia  nro  present,  along  with  tbe  symp- 

i>f  a  localised  texiuu  of  ttie  braiu,  then  al»o  tbe  existence 

abscess  rather  than  tumour  may  be  inferred. 

ie  symptoms  of  tumour  are  sonieiimes  characterUtKl  by 

ent  remissions    and   exacerbations,  while  in  al>sces5  the 

>ms  may  be  latent  or  stationary  for  a  comparatively 

time,  but  when  the  lermiDal  period  is  ushered  in  the 

ioDS  are  of  short  duration  and  never  frequently  repeated. 

cases  of  tumour  the  course  of  the  disease  is  con* 

and    progressive   from   the  first,  and    tbo  symptoma 

not  only    in    intensity  but  10    uumtwr   and  extent, 

encml    symptoms    of    headache,    diiuiuess,    and    vomit- 

the  first  period  l>ecoming  slowly  complicated  by  local 

unilateral  coQvulsiooi^  poreses  passing  on  to  distinct 

ea,  sensory  di8turbance^  slight  at  first  but  becoming 

profound,  and  various  disorders  of  the  special  senses, 

bugh  these  symptoms  may  all  be  present  at  a  given  time  in 

<urse  of  chroaio  abscess,  yet  tbey  never  appear  in  tbe  same 


briun  from  cereWal  tiajcnonbage,  or  oodasion  of  ■  Inrga 
but  if  there  b«  a  history  of  injury  to  the  skull,  followed 
a^mptoms  of  acute  encephalitis,  then  the  dingoooil 
difficult.  This  difficulby  i»  likelj  to  arise  wboo,  uftd 
latent  period,  the  abscesn  makes  its  nay  into  the  vectl 
vhen  sudiloQ  cedetna  uf  tUt-  braiu  occurs.  Whua  tiu 
rupturea  on  the  surface  of  the  brain  the  termiDsl  aymp 
tboae  of  Bbciite  meuingitis,  aud  ibe  diagnosis  between 
mcDingitis  and  ubaccss  must  again  bo  made  ^m  tbo  h 
the  case  and  tbe  symptoms. 

Ab9ce»  of  the  brain  is  difficult  to  distingiiisb  from 
softening.  The  diagnosis  must  be  made  ou  the  one 
tbe  history  of  an  iojary  to  tbe  skull  or  the  proMiiee  i 
the  other  cnn^cs  which  give  rise  to  abscess ;  and  on 
band  by  a  carel'ul  general  examination  of  the  patient,  t 
of  the  orgaoH  of  circulation,  to  ascertain  the  pre«eaos 
the  couditious  which  lead  to  embolism  or  throtnboiis. 

§  820.  Pw^mU. 

(a)  Meninffo-Encephalitia. — A  superficial  contiwia 
brnia  usually  terniiDates  in  acute  suppuration  aawdA 
meningitis,  nnii  tho  atTection  is  gcnvrally  fatal  Bo 
possible  only  when  diffuse  meningitis  does  not  take  f 
whea  the  pus  ta  discharged  through  a  wound,  proda« 


DlPrUSED   DISEASES  OF  THE  ENCBPHALON.  7*1 

lall  Dumber  of  coeea  have  recovered  Rpontaneousty  after 
wfomtioD  through  the  skuU.  The  pus  has  heeo  evacuated  by 
rtuoatc  txephiaiag,  but  the  nomber  of  caaea  in  which  tfao 
ktient  wM  MTed  is  aniall. 

(d)  Oton^aal  Absceaa  of  the  £ram.— Several  cases  of  re- 

Tery  of  otorrhteal  cerebral  abscess  are  on  recoiJ  Id  which  the 

IB  made  \U  wny  through  the  diseased  ear.     Acute  otorrhtsal 

of  the  bniri  often  passes  luto  the  cbrauic  ford),  but  the 

te  pnignosii)  in  both  varieties  is  unfavourable. 

'«)  Ptfojmie  Ahacessea  of  the  brain,  vhatever  may  be  thoir 

are  always  latal. 

Amiie  TratnAciiic  Encephalitis  wUhoxtt  formation  of 
of  recovery  from  undoubted  traumatic  encephalitis 
beea  collected  by  Bnina.  The  prognosis  of  encephalitis 
)und  chronic  absce^aea,  tumours,  chronic  softening,  and 
plexiea*  depcads  upon  the  nature  aud  extent  of  the  primary 
use.  The  prospect  in  \enAt  favourable  in  abscess  and  lumour. 
age  and  8trea<;th  of  the  patient  is  au  important  factor  in 
matiug  the  daoger  of  encephalitis  Kccondaiy  to  necrotic 
toing  and  cerebral  btemorrhage,  but  the  complication  la 
lya  a  uerious  one,  aud  even  if  the  patieot  survive  the 
ftral  and  local  symptoms  are  usually  aggravated  by  an  in- 
10  in  the  deatruction  of  tiaauc  caused  by  the  primary  foouia. 

821.  Treatment. — The  phyBician's  advice  may  be  sought  to 
i"tbe  surgeon  in  determining  questions  ofccrebml  locatisation, 
tbe  other  dolicAto  poiut^  of  iliaguosis  which  aro  likely  to 
in  the  progress  of  Huch  caaes,  but  tbe  decision  with  regard 
treatment  to  be  aiioptcd  must  rest  with  him. 

rie  secondary  iciflammalion  which  is  lia.ble  to  supervene  in 
course  of  necrotic  softening,  cerebral  htemorrhage,  and 
Iracranial  tumours  i.^  the  form  of  encephalitis  whicb  is  most 
riy  to  come  under  the  care  of  the  physician.  This  variety 
t  treated  by  complete  rest  in  a  darkened  room,  mild 
ioD,  and  cold  applied  to  the  bead  ;  more  active  meaaiirea 
bleeding  and  blistering  are  worno  than  uscleiw. 
ibronic  absceas  of  the  brain  doea  not  ailmlt  of  any  special 
dical  treatment,  but  the  general  health  of  the  patient  must 
attended  to,  and  his  diet  ftod  babita  carefuU;  teguAsAed. 


!>. 


742  DIFFUBKD  DISEASES  OF  THX  KHCKPHU/HT. 

FaroxyamB  of  severe  headache  may  sometimes  be  reliered  b; 
chloride  of  ammoDium,  while  more  active  symptoms  like 
delirium  may  be  combated  by  bromide  of  potasmum,  either 
alone  or  in  combination  with  chloral,  and  an  opiate  may  sonw- 
times  be  found  useful  Dra.  Russell  Reynolds  and  Uammaxl 
speak  favourably  of  Cannabis  Indica  in  the  treatment  ot  the 
more  active  symptoms  of  suppurative  encephalitis 


743 


CHAPTER    XIV. 


DISEASES  OF  THE  MEMBRANES  OP  THE  BRAIN. 


I.   DISEAJSES  OF   THE  DURA  MATRR. 

IFLAlOUTION  of  tbo  <lura  mater  ma.y  1iq  divided  into  (i.) 
tt'Craal,  and  (il)  iDtemal  pacbymeDin^tis. 

(L)     EXTmilL  PjUnCTMKKISOIT[«. 

External  pnct^ytaeDingitU  consistB  of  inflatninfttion  of  the 
outer  lamella  of  tlie  dura  mater. 

§  Sa.  Etwlnrfy. — The  chief  causes  of  tbe  affection  are  tlie 
follomDg  :— 

1.  lajariotf  which  detach  the  dura  mater  from  the  iiiTier  eur- 
bce  of  tlie  skull,  and  occauiou  an  extravasation  of  blood 
between  them.  The  clot  may  be  so  largo  as  to  coropresa  th« 
braiu  and  cause  death  in  a  short  time.  At  other  times  inflam- 
maiiuu  is  set  up  in  the  surroundiag  tisKiies  and  the  bone  ti 
threatened  with  necrosis. 

2.  Ferforatiag  iDJunes  of  the  skull,  as  iDcised,  punctured, 
and  bullet  wounds,  which  either  directly  or  iadirectly  injure 
the  dura  mater. 

3.  KxtensioD  of  inflammation  from  neighbouring  tissues. 
Cariee  of  the  petrous  portioii  of  the  temporal  bone  is  one  of 
the  most  frequent  causes  of  external  pachymeDingitiii,  and  it 
osaally  gives  ri»e  to  the  suppurative  form  of  inflammatioa. 

Purulent  inflammatiou  of  the  external  lam,cllB  may  sJso 
follow  caries  of  other  cranial  bones,  espedally  the  ethmoid  and 
the  flat  bones  of  the  skult,  as  well  <ls  by  caries  of  the  upper 
eerrical  vertebrse  and  their  Ug&menta 


m 


DISEAflBS  OP  THB   MEMBRANES  OP  TBG  BBAIV. 


-3 


4.  The  external  layer  of  tbe  dura  mater  is  auUject  to  ciiraar 
fibrous  tliickeuing  in  old  age,aod  becomes  ulherent  to  tbc  beac 

g  823.  SifTiiptoms. — Id  tbe  traumatic  form  of  extamal  ]b^ 
meniogitls  the  patient  may  recover  from  tbe  immediata  tffi— 
of  the  injury,  and  appear  for  a  time  in   perfect  health,     il 
Uie  end  of  two  or  three  weeks  he  complains  of  pain  is  tW 
head,  is  fovorish,  aud  should  there  be  an  exteraa)  wood,  it 
aasumes  an  unhealthy  aapocL      If   tbo  iuftiimEnaticMi  apmt 
further,  tbc  headache  increases  in  intensity,  and   tbe  patital 
Buficnt  from  vertigo,  nausea,  and  romtttag,  while  monuspiia 
or  unilateral  convtilsiona  may  occur  if  the  motor  area 
brain  bo  implicated.    Tho  lotenial  mecabrane*  of  th« 
now  become  affected,  the  previously  oonvuUed  liniba 
paralysed,  the  patient  becomes  delirious,  and  fatal  coma 
suptsrvenes. 

When  an  abscess  forms  between  tho  dura  mat«T  and  tbi 
bones  of  tbe  bkull,  tbe  symptoms  may  be  those  of  gaiSmi 
cerebral  compreBsloo,  and  when  it  is  nitunted  over  Ui«  «ataf 
area  of  the  cortex,  monospasms  or  monoplegiiB  may  result 

Tlie  pacbymeaingitis  of  old  age  is  often  discovered  site 
death  without  having  been  susp^ted  diirini;  life.  Fd  otto 
cases  tbe  meningitis  may  have  manifested  itself  merely  bya 
persistent  dull  headache.  After  death  atrophy  of  tbe  fanii, 
compensatory  hydrocephalus,  and  serous  infiltration  of  the  pit 
iDutcr  arc  obsert'ed. 

§  824.  Morbid  Anaiomy. — ^Tbe  Jura  mater  is  at  fint  e» 
gcsted,  and  presents  punctiform  escravasatious.  In  a  mam 
advanced  stage  the  membrauc  becomes  awoUco  and  infiltnicirf 
with  numerous  white  blood  oorpasdes.  These  cells  mar  after 
a  time  become  transformed  into  spindle  colla,  and  ultinutdf 
developed  into  bundles  of  oounoclive  tissue.  Forlioos  of  At 
membrane  may  sometimes  become  ossified. 

If  the  inflammatioQ  progress  to  actual  suppnratKia,  tftft 
white  blood  corpu9ole«  become  more  □umeroos,  and  makt  Uir 
way  through  the  internal  lamella  to  the  free  surfaoe,  ao  tJial  ■ 
purulent  internal  pnohyraentngitis  is  added  to  tbc  eitanul 
pacbymeningitis.    At  times,  however,  the  abK«w  b  cat  f^ 


DISEASES  OP  THE  MEMBRANES  OF  THE   BRAIH.  745 

•  from  tbe  iDtenuU  layer  by  the  dcvcloptncnt  of  adhesioni),  aad 
ID  that  case  the  external  layer  hecomea  disintegrated,  soft, 
and  friable;  while  tho  internal  layer  becomes  ndhereDt  to  the 
pia  inat«r  and  brain.     lu  the  large  majority  of  cases  the  io- 

BHannnatiou  spreads  to  the  internal  lamella. 
835.  Prognoirii. — The  prognosis  in  traumatic  coHes  turns 
on  the  posaibiltly  of  the  pus  finding  a  free  escape.  If  a  free 
-ducbatgc  can  be  obtained,  the  affection  of  tbe  dura  mater  may 
occasion  but  tittle  trouble;  while,  on  tbe  other  band,  if  tbe 
niatU'T  is  peat  up,  grave  *ymptoms  must  result,  both  on  account 
of  tbe  increased  intracranial  preiv<!iure,  and  tbe  rapidity  witfa 
whicb  tbe  suppurative  process  spreads.  The  prognofus  of  pnni- 
leDt  inilammatioQ  v{  the  dura  mater  resulting  froDi  cariua  of 
tbe  petrous  portion  of  tho  temporal  bone  is  very  unfavourable. 

§  820.  Trefitment — The  treatment  of  the  acute  stage  must 
be  conducted  according  to  general  principles.  The  ciuestioo  of 
trephining  will  arise  in  connection  with  tbe  formation  of  an 
abscess  or  extravasation  of  blood  lietween  the  dura  mater  and 
tbe  bone,  but  tbia  belongs  to  surgery. 

^^k  (it)   IitTBitHAL  K.mniiKKAiui:  rji<iiiTvr<(iNOms. 

^^H  (Baniab/ma  oj  Utt  Dura  MaUr.) 

^^  827.  Etiology. — Hi^matoma  is  associated  with  all  those 
diseases  which  profoundly  a,lfect  nutrition,  and  many  of  them 
are  diseases  like  scorbutus,  in  which  haemorrhages  are  liable 
to  occur  in  other  parts  of  tbe  body.  The  disease  is  found  in 
atrophy  of  the  brain  accompanied  by  (edema  of  tbe  pia  mater 
mad  hydrocepbaluB  intemuB.  Ou  the  whole,  therefore,  it  seems 
probable  cltat  when  hematoma  of  tim  dura  mater  does  Dot 
rwult  from  direct  injury,  it  is  caused  either  by  constitutional 
dicMae  prodacing  profound  alteration  in  tbe  quality  of  tbe 
Uood,  degeuerutiou  of  the  vessels  of  tbe  brain,  or  by  disoMce 
UBOciated  with  passive  congestion  of  the  brain.  It  ia  not 
therefore  surprising  that  the  afiection  should  occur  chiefly  in 
aUag& 

§  82S.  Symptomf.  — ^The  eytnptoms  of  hematoma  rary 
greatly  in  different  cases,  but  the  following  are  tbo  more 
nsual: — 


-""f-J  "•  -■■■' 
eenite  atrophy, 
without  causiug 


r  am 


,....-.,  M..  —    ...   .  .  ..         r — —J -  ■'■■a 

a  bfeinatoiia&  tDa3r  atlaio  a  ooondoi 
much  headnclio.      On  the  other  bH 
there  is  no  sbriaking  of  tbo  braUi  a  thin  lajer  of] 
violent  pain. 

The  motor  diaturbancea  consist  of  muwular  ti 
one  or  both  sides,  followed  by  rigidity.  In  other  mJ 
fint  of  ono  and  tben  of  the  other  extremity  of  th^ 
occurs  followed  by  distinct  hemiplegia,  the  fecial  and  lt_^ 
nerves  becoming  involved.  In  some  caaea  the  paralysi 
to  the  other  Hide,  showing  eitber  that  the  affection  h 
to  the  opposite  hemisphere,  or  that  a  fresh  hsmoiT 
occurred.  Trnpnirment  of  con^rdinate  moTeineDta  f. 
occurs,  as  uDcert&iaty  of  gait,  difficulty  in  writing  audi 
Conjugate  di;viatioa  of  tfae  eyeballs  towards  tbasid< 
is  not  unfrequently  observed,  but  strabismus  and 
if  ever  occur. 

ScntoT}/    dtstu/rbtmeea   are    oob    very   oommon 
Patients  sometimes   complain   of   formtcation   and 
on   the   paralysed   side,   but   impairment  of  sei 
absence  of  par^ysis  is  not  met  with. 

pHycidcal  diatiLrhance  occurs  in  a  large  oumi 
This  is  sometimee  due  to  the  primary  disease, 
paralytica,  while  io  other  coses  it  is  duo  directly  to  thi 
rbage.  Symptoms  of  irritation  are  present  in  the  h 
enuctid  br  creat  mental  irritabilitv.  aboonnal  laiiBii 


audi 

1 

n    I' 

^ 

and  I 

1 


DISEASES  OF  THE  HEUBHAKES  OF  THE  BE&IK. 


747 


SIovneRH  of  the  pitlso  occurs  in  tho  majority  of  cases  duriag 
the  ha<morrbage,  but  the  quickness  of  the  pulso  varies,  nud  it 
becomes  Frequent  and  irregular  before  death. 

The  pupils  are  genorally  contracted  and  ini^enitihle  to  light 
duiing  the  irritative  Ktage,  hut  dilatation  predominates  when 
tbe  symptoms  of  compression  supervene. 

g  $S9.  VcwUtici. — The  symptoms  may  be  subdivided  into 
several  groups,  according  to  the  extent  and  localiBation  of  tbe 
bsemorrboge  and  the  discasos  with  vbicb  it  is  associated. 

I.  In  the  finit  givup  tho  luouiorrhfl^  ia  ko  novoro  from  tlio  beginning 
tiiat  death  looa  occurv,  nad  in  tb«w  vmm  tho  syupUitiia  comiot  b« 
ArtiogtiUud  &Tini  those  of  onlinarjr  apoplexy.  Contmcturee  of  ths 
tCtKBlitMS  Mtd  aliglit  transitory  tniti^ee  am  Honietimoi  oV«orvod  in  these 
nmm,  and,  as  a  rul«,  tbe  pupil  ia  more  coiiLi-actcd  oqiI  ftxnl  in  hEBmatomB 
than  in  tatra-c«!rel>fttl  hasawnliage.  In  a  null  nuubcr  of  coms  tlie 
extmvajntiDns  on  one  aide  aaiue  convukilro  niDveinotita  uf  tlie  oiipooite 
Mtb;  but  tlie  txni)|<nx«i«it  sooa  bococovH  k>  gT««it  that  tho  inttabili^ 
gflhe  onrtcx  ix  atxilinhcKL 

S.  In  a  certain  numher  of  autw  extr&viuuUons  are  found  after  death, 
tfri(*"E*'  tbtt«  bad  been  uu  nuiiiciau  of  their  exiitteui'e  duriuf;  life.  Thoae 
homarriiftgea,  however,  on  luoally  noall,  anil  are  generally  found  in 
CSMB  of  demeatia  imnil^rtioa. 

3.  In  a  third  iwrint  th«  symptoms  atc  nt  fint  iili|;ht,  but  ftrailuaUy 
inoraMM  in  iKsvcritf  and  soon  prove  fatal.  The  chief  isTmi>toiu  In  the 
bsgiiuung  ift  M<v«ro  cepbalnlgijt,  with  or  without  vprtif^o,  followed  hy 
dnmauon  incroaiuDg  gmdually  to  aopor,  and  ending  in  profound  coma. 
Th«  pnpib  ai«  contracted  in  the  early  stage,  but  when  ooma  auperveoea 
they  gradually  dilate  and  may  become  unequal.  Hemipareaiii  geuerally 
dwwaHself  on  the  Kile  nppowto  to  tho  U«ion,  while  aymptoinscfirritAtion 
may  appear  on  the  wune  aide,  but  after  a  time  all  the  extrvuilieu  may 
be  yan&jwed.  SimiUr  njinptonui  an  nmtciA  by  any  meningeal  afiection, 
and  eepecUIy  by  tulwroular  meniiigitui.  In  CBtahli^ing  a  dlagnoeia, 
IharaliDve,  tho  oonditionn  imdor  which  the  iUsoom  has  developed  mnat  be 
token  into  aoouont.  Hrcmatomu  ia  niurc  likely  to  he  pretwiit  in  nld  per- 
■una,  when  atrophy  of  the  brain  ih  to  W.  stucjiit^Uvl ;  tulieiuular  meniiifiitiB, 
OD  the  other  band,  usually  oocmre  in  young  poraoiui, 

4.  In  a  fourth  tianm  of  cikaea  reoorvry  takes  place  from  a  firat  hajuar- 
rhage,  but  aftt^r  an  Juterval  of  apparent  health  a  second  oocure  which 
rosulto  in  death.  Ui  th(»e  uukxi  mulucuhir  ur  uultiluutdar  aace  are  found 
no  one  or  both  Hidm,  and  »ue  uf  the  Kiil)i)n)i nato  wujk  always  oontains  a 
oonaidDrablc  cffuaion  of  blood  which  haa  cjiuacd  death  by  ooaiptcHdon. 


t/unug  uia  idtervKi  me 
leaioa  which  produces  a  certain  lunount  of  init 
with  compi-essiou  of  the  brftia.    These  consUt 
4]tminiition  of  intollig<!DCe,  impairment  of  memory,' 
partial  paralyses,  disturbaoces  of  apeech,  and  em 
excit«ment  withont«iiase,  frequcotly  mixed  with 
demeDtia  paralytica 

The  duration  of  the  affection  is  not  w<;ll  knoi 
as  it  18  not  always  possiblo  to  fix  with  accuracy  it 
meut.  The  majority  of  cases  of  pcwhymoningitia 
but  recovery  may  take  pUce  in  many  cases,  ooly  tni 
affection  remaining,  such  as  a  alight  degree  of  pare 
ache,  BleepleKsness,  and  some  weakness  of  intellige 


irritjj 
nry,^ 

1 


§  S31.  Morbid  Arutiomy. — fiiemurrb^c 
prenents  itself  aM  an  orgaaised  maas  sitaated  bet 
mater  and  surface  of  the  arachnoid,  and  present 
appearances  in  different  casts.  Various  opinions  ll 
entertained  with  respect  to  the  seat  and  nature  of  the 
but  the  explanation  which  was  6rst  given  by  Vircha 
pretty  geoerally  accopled  by  pathologists.  Accot 
view  the  pachymeningitis  begins  with  bypertemia 
maWr,  occupviog  generally  the  area  supplied  by ' 
mcQiugcAJ  artery.  The  inner  surface  of  tbedannwM 
a  rosy  colour,  and  after  a  time  a  loose  yellowish  ooiti 


)rUu| 

^1 


disi:a5ics  of  the  mehdranes  of  the  bbaih. 


749 


"blood-veBsels  of  the  sab-epitheiial  layer  of  the  dura  mater,  and 
jdevelup  iuto  a  looee  connocLive  tissue.  Ha-morifangcs,  varying 
\d  quantity  at  ditft^retit  time!!,  take  place  from  the  vessels  which 
enter  tbe  fiilsu  membraae  ;  the  clots  become  partially  organised, 
Vid  tbc  delicate  capillaries  wbicli  develop  in  tbcm  became  the 
•ource  of  new  ha^morrbagea,  so  that  a  large  quantity  of  blood 
may  in  this  maaner  be  poured  out  between  tbe  tbickeccd 
.nctnbmnoii.  It  is  right,  however,  to  state  that  Uuguonin  be- 
iUaves  that  the  tirst  stage  of  hu-inatoma  its  not  the  formation  of 
to  Iklse  membrane,  but  nimply  lui  extmvasatiou  of  blood  on  the 
inDer  turface  of  the  dum  mnter,  which  undergoes  the  changes 
'which  osually  take  place  in  a  coaguliim.  This  coogulum  uuder- 
.goes  partial  organisation  so  an  to  form  a  vancutar  layer,  from 
jwhich  haemorrhage  takes  place,  giving  rise  to  further  extrava* 
isacion,  which  in  its  turn  becomes  orgaDiseii. 

PacJiymeningitiB  hieraorrbRgica  is  most  frequently  found  id 

the  upper  ptirt  of  the  brain  along  the  falx  cerebri,  spreading 

down  the  curved  portion  of  tbc  frontal  and  occipital  lobes,  and 

laterally  tovreu'ils  the  Sylvian  ticiHure.     KruiniunKky  found  that 

in  fifty-four  out  of  eixty-livo  cases  its  extent  exactly  corre- 

spoaded  tn  the  parietal  lioncs.     In  caees  uf  demcutia  paralytica, 

I  to  which  the  brain  is  frequently  found  shrunk  and  atrophied, 

,  the  blood  often  cxtvnds  much  further,  and  may  reach  the  base 

ltd  the  brain.    In  rather  more  than  half  of  the  cases  described 

the  bttmorrbage  exteaded  over  the  surfaces  of  both  hemispheres, 

wbile  in  the  remainder  it  was  limited  to  one  hemisphere. 

Changes  in  the  sbuU  have  been  deecribed  by  various  authors, 
but  none  of  them  are  constantly  present;  some  of  these,  such 
at  elevation,  thinning,  and  thickening  of  the  bones,  are  in  all 
probability  anomalies,  which  aro  entirely  independent  of  the 
bstmatoma.  Osteophytes  on  the  inner  surface  of  the  skull 
have  been  described  by  Rokitantsky  and  Cniveilhier, 

The  pia  mater  is  often  ihe  seat  of  changes,  such  as  are  found 
m  atrophy  of  the  brain,  consisting  of  slight  opacities,  uedema, 
and  email  fibrous  thickenings. 

The  substance  of  the  brain  is  variously  affuctod  according  to 

the  thicknemi  of  the  hiematoma.     The  tbin  extravasationa  aod 

merDbranes  do  not  cause  any  marked  changes  in  (be  brain,  but 

,  Urge  btL'matomata  compress  it,  and  produce  consecutive  ausmia 

,  and  atrophy. 


DISEASES  OP  THB  HEMltlUNEK   OF  TBB  BRIDI. 


Tbc  brain  is  ofteu  found  KlropMed  and  oontncted  iutep 
dentlj  of  the  luematoma.    Tbe  decrease  In  the  tixa  toA  w*: 
of  Uio  brains  of  drankards,  and  Benile  atropby  are  iBspor'- 
foctoni  iu  tbe  proiluctioo  of  baematoma.    Tb«  affectioo  u 
quently  associated  witli  atheroma  and  calcificalioa  of  th«  il'. 
cranial  arteries.     Diffused  sclerous  and  the  chronic  dageocn: 
which  accompaaiea  dementia  paralytica  are  oden.  ai 
with  hsematoma.     A  glanco  at  all  tbe  varied  changn  fiaad 
associated  vrith  haematoma  will  show  tbat  thin  oilMrtiiia  i 
great  majority  of  caees  occuni  along  with   alteralknu 
occasion  a  reduction  iu  the  size  of  tbe  brain. 


§  832.  Profftiosia — ^The  prognoeia  depends  in  great 
upon  the  fundamental  affection  which  is  }Hn»ent  along  vtlfc 
the  pachymeningitis.  It  ia  always  grare.  although  not  Mo*' 
earily  fatuL 

§  &33.  rrva<m«n(.— Tbe  treatuent  of  bjematoma  of  the  da 
mator  will  greatly  depend  upon  tbe  underlying  affection,  i>4  it 
it  is  consequently  desirable  to  examine  carefully  for  diMSNif 
other  orgaoGL  If  vcnoua  stasis  bo  present,  a  snull  bleMliog  9 
a  murt  w&teiy  purgative  gives  temporary  relief  to  tbe  drati- 
tioo,  but  ener;getia  antipbtoigistic  treatmeot  nmst  be  eanfa^f 
avoidiMl. 

During  the  stage  of  htefDorrbage  ico  sboald  be  applied  to  tbt 
bead ;  but  couQCer-irriCation.  if  osed  at  alt,  should  be  iiMiui 
for  a  .later  period.  The  patient  must,  of  ooono,  be  kept  qnt 
and  all  excitement  prevented. 


751 


CHAPTER   XV. 


DISEASES    OF   THE    SIEMBRAKES   OF   THE    BRAIN 

(CoSTUd'KD). 


n.    DISEASES  OF   THE   PIA   MATER. 

FnJUtmmation  o/tlte  Pia  Mater  (LeptomeniTtgitis). 

HTPERfUiA  of  the  pift  maker  is  always  ocoompauied  by  con- 
I  g«stioD  of  thti  brain,  nod  does  not  demand  separate  notice. 
Attempts  bave  b&en  made  to  distioguisb  ioSammatioiis  of  the 
Tisceral  luy«r  of  tbv  aracbnoid  from  thoso  of  tbo  pia  matur, 
,  but  anatomists  are  now  a^eed  that  the  former  membraae  ia 
only  the  thickened  cxternnl  [aver  of  the  latter,  and  clinical 
MCorda  show  that  in  the  cases  of  so-called  arachnitis  the  in- 
tcraal  layer  of  the  pia  mater  19  always  affected. 

L  LsiTOXnniraiTli  Invavidm  [ffgdrtxtj^hal^u  titu  Tvbrrttitia). 

kcute  inflammation  of  the  pia  mater  may  occur  in  infancy 
^Ati  the  entire  absence  of  tubercle,  and  the  simple  Uko  the 
fabcrcular  variety  is  attended  by  cffiiiion  iato  the  vcntriclw 
of  the  brain.  Acute  ventricHlar  effusion  from  simple  inSam- 
mation  of  the  pia  mater  is  most  common  in  children  betweea 
one  and  two  yoars  of  ago,  but  somt-umeB  occurs  in  youugcr  and 
somut'uues  tu  older  children. 

§834.  St^niptoroA — The  clinical  history  of  this  affection 
may  vary  in  no  important  particular  from  that  of  tubercular 
meningitis,  but  the  premonitory  symptoms  are  not  so  well 
loarked  in  the  former  as  iu  the  latt«r. 

The  symptoms  of  the  period  of  invasion  differ  considerably 


'I 


lids  ate  only  half  closed  duriog  deep,  tbe  eyeljall^B 
the  pupiln  are  coDtracieci  but  react  well  to  ligbt,  an^ 
be  slight  convul«ve  twitching  of  the  extremities 
110  pamlysis.  The  cliitdreti  are  ftbaormally  aexudt 
aod  Hound,  and  the  light«At  touch  on  the  akia  nuj' 
Older  cliildreo  are  eitlier  iioable  to  stAiui,  or  toUer  w 
attempt  to  walk,  tboy  oomplaia  of  bazziag  tn  tbe 
firetful,  morose,  aad  taciturn.  In  younger  children  k] 
nelles  may  be  seeu  to  puUite  strongly,  but  they  are  ttc 
Tbo  couDt«uuuce  has  a  vexed  or  angty  cxpresRion.  Tlu 
are  at  times  distorted,  tbe  forehead  ia  wrinkled,  ufl 
ing  moaa  is  frequently  uttered.  ™ 

These  symptoms  may  oontioue  for  two  or  tbtee  i 
then  the  child  may  he  attacked  by  coqvuImoiu,  TIM 
by  conjugate  deviation  of  the  eyes  and  rotatton  of  1 
the  upper  and  lower  extremities  of  one  ride  are  ehiefiy 
and  then  the  epasms  croa  over  to  tbe  oppodite  lide,  t 
convulsion  becomes  general  The  state  of  the  pupiU 
tbey  are  generally  dilated  and  fixed  during  the  eon 
The  temperature   rises  daring    tbe  attack,  and   ^M 

Death  may  occawonally  occur  luddenly  during  t2i 

and  when  the  convuUioa  ia  not  fatal  tbe  uibeeqnei 

of  tlic  affection  is  marked  by  an  aggravation  of  tbe 

■■ymptoma.  Yomg  children  lie  ia  a  di»tttrbed  ileep.  witii 


DISHASeS  OP  THB  MeMilOAKGS  OP  TUB  BHAIK.  733 

irregular.  The  tempcnitQro  coDtiniioa  more  or  lees  elevated, 
but  its  coune  Is  very  irrognlar.  Persistent  vomiting  and 
obstinate  coostipatioa  are  common,  vbile  the  power  of  deglu- 
tition tnay  be  impaired  at  an  early  period. 

Th«  child  rapidly  emaciates,  the  akin  is  dry,  with  the 
(txceplion  of  that  of  the  face,  which  may  be  bathed  with  per- 
■piratioD. 

The  patient  now  sinks  into  a  condition  of  profound  coma, 
bal  tetanic  spasnu  of  the  mtisclea  of  the  neck  and  extremiUea 
tuny  persist  for  a  time. 

The  temperature  often  falta  below  normal  before  death,  but 
hyperpyrexia  has  been  observed  in  rapidly  fatal  cases.  Tbc 
pulse  then  becotoea  very  rapid,  irrcguhir,  and  intermittent 

§  SZa.  ConrM.  Dumtwn,  and  TenniTuUions. — Complete 
recovery  may  take  place,  probably  even  after  «fiusion  has 
oocuiTcd,   but  a«  a  rule  recovery  is  partial,  and  the  patieut 

bsequently  suffers  from  mental  ft^ebluuesa  ur  depraved  moral 
character.  In  the  latter  ca^e  the  cortex  of  the  brain  bas  pro- 
bably iindurgoae  some  degree  of  atrophy  from  the  pressure  of 
the  effuatou.  The  majority  of  cases  terminate  fatally  in  from 
nine  to  fourteen  days,  some  die  at  an  earlier  period  in  an  attack 
wT  ooaviilsioDs.  white  lu  oth«r  cases  the  disease  may  be  pro- 
tntctcd  beyond  thirty  days,  its  course  being  marked  by  remis- 
BOOS  and  exacerbations. 

§836.  Morbid  jliMidmiy,— The  cranial  bones  present  dif- 
ferent degrees  of  congestiou,  and  the  fontaneltea  are  dLsleoded. 
The  ooQvoIutiona  of  the  brain  are  fialtened  and  the  sulci  oblite- 
mtod.  owing  to  the  pressure  exerted  by  the  distended  ventriolea. 
The  fluid  is  never  found  between  tho  dura  and  outer  layer  ut 
the  pia  Diater,  and  the  outer  surface  of  the  latter  is  usually  ro- 
warkably  dry.  The  cortex  and  white  substance  are  compressed 
«nd  but  moderately  filled  with  blood,  and  no  capillary  extmva- 
<TU  are  found  in  the  cortex.  The  dilatation  of  the  ventricles 
tuually  symmetrical,  and  a  considerable  amount  of  softening 
•t  unfrequently  existe  around  the  ventricles,  but  this  may  be 
ue  to  post-mortem  changes. 

The  choroid  plexuses  are  unusually  voluminous,  they  often 
w  w 


754 


DISEASES  OP  TBB  MEMBRAKIS  OF  TUB  BBXIS, 


coDtftin  punctUbrm  extraTasaUoiia,  and  the  aquedoet  n(  Sri 
aut)  fourtli  veotricle  me  ofteo  Uilsted  and  dUteoded  witfaf 
Xo  cxudatioa  is  found  at  tlie  bnae  of  tbc  braio. 

§  837.  jPro<77U)m — The  prognoais  U  alvvujrs  tio&r 
alUiough  a  few  cases  recorer  either  partially  or  oompli 

§838.  Tlie  diugnosls  will  be  discussed  io  codiii-'" 
tubercular  uitiuiugiliii,  aod  the  treatment  of  tbe  twu  j 
is  the  Hanie. 

§  8S9.  Etioloffif. — Mo«t  of  tbose  who  suffer  fnnn  tab 
meningitiD  belong  to  families  id  nbich  tlit:  tubercular  ■ 
is  distinctly  marked.    Tbo  inUueuce  which  improper 
meat,  want  of  pure  air  and  light,  exposure  to  cold  mJ 
and  ncglcccsd  bygiui9  excrt«  in  tbe    prixluction  <)f ' 
cular  affectiouB  gooerallj  is  well  koowo.     It  is  not 
therefore,  to  find  that  tbe  largest  proportion  of  caaacfl 
cular  meningitis  sbould  occur  in  crowded  populatimu  ul| 
cities,  and  amongst  the  poorest  and  most  neglected  pull 
populatioQ.     Season  doea  oot  appear  to  exert  any  tofl 
tlie  productiou  of  the  diseasa     Tubercular  meuliijilisi 
in  at  any  age.  but  it  is  much  more  frequent  balwo-t  tlrtl 
of  two  and  seven  years.    Tbe  numbers  iliminiiih  frotn  ibei 
to  the  tenth,  aod  in  stilt  greater  proportiuo  from  ifc< 
the  fifteeDib.     It  is  tnoat  oommon  in  adults  bctwL'ea  tbe  ( 
twenty  and  forty,  and  occurs  very  exceptionally  aftertJHl 
£fth  year.    Thu  male  sex  appears  to  bo  more  frotiaontlji 
than  the  female.     In  adults  tbe  proportion  is  £15  nUO  "I 
women  (IIugu«ain);  ajid  the  prupvrtiun  of  males 
cbildreo  is  still  greatw. 

§  8*0.  Htfmptomg. — Various  premonitory  symptomii 
themselres  for  a  variable  period  of  weeks  or  raoDth*  I 
development  of  tlje  distinctive  pbeaomooa  of  tubemltf  ■ 
gitia.     The  moat  constant  precursor  of  the  affeelion  bi] 
loes  of  flesh  without  any  perceptible  cause,  aoil  tbiiii' 
Doticoable  in  the  tnink  and  llraba  than  in  th«  (»e*. 
low  Qit  v^^\.ti«,  iU«  bowels  are  oonstipaied,  or  disn^B^I 


times  a  profound  coma  is  rapidly  developed,  whicli  in  children 
[ueatly  tuhered  ia  by  a  convuUioD.  and  wbicb  generally 
cnntinufs  unbroken  until  the  fatal  termination,  but  iu  some 
caaw  tbcre  are  sbort  clear  intervals.  Tbe  hydrocephalic  cry  in 
tbe  case  of  children  ia  must  frequent  at  tbis  time,  and  adults 
in  the  midst  of  Ropor  give  eviilenco  of  oevore  huadacbc  by 
gnMUks  and  geetun-s. 

Spwniodtc  movomonts  and  muncular  rigidity  arc  moro  fre- 
quC'Ot  timn  in  the  first  stage.  Contractiona  ol  the  ocular 
mascletf  give  rise  to  combined  movements  of  the  eyeballs 
(nj^tagmui)  and  inequality  of  the  pupils,  vbilo  slight  con- 
vnlsive  moToments  occur  in  the  facial  musclos  and  in  thoee 
of  the  extremitiea  Tlie  automatic  movements  of  cbeniug, 
winking,  whiatling,  or  grinding  of  the  teeth  are  alsa  frequent ; 
while  uemont  of  the  extremities  ,or  of  tbe  whole  body  ofton 
occur.  A  case  is  recorded  by  Dr.  Hughliugs-Jafksou  in  which 
tht)  movcmeuts  of  th«  extremities  and  face  correHj^nded  exactly 
lo  tboAe  of  acute  chorea.  At  other  times  the  muscles  are  main- 
taioe*!  in  a  state  of  cataleptic  rigidity,  and  tbe  extremities  may 
then  assume  various  forced  attitudes. 

The  btiifness  of  tbe  muscles  of  tbe  nape  of  the  neck  becomes 
more  iatense,  ho  that  tho  head  is  drawu  back  and  tbnist  into 
th«  pillow.  The  rigidity  may  aIdo  extend  to  the  muscles  of  tbe 
trunk,  so  that  tbe  body  is  maintained  in  a  condition  of  tetanic 
rigidity,  tbe  opisthotonos  either  appooring  in  paroxysms  and 
la,bting  only  a  few  minutes  at  a  time,  or  remaining  continuous 
until  death.  Paralyses  of  various  extent  and  distribution  now 
make  their  appearance.  Paralysis  of  th«  ociilo-motor  nerve  is 
common,  and  gives  rise  to  divergent  squint,  ptosis,  dilatation, 
and  fixity  of  one  pupil.  Tho  trochlear  nerve  may  be  paralysed 
along  with  the  third,  but  is  never  nffccted  alone.  Pnratysis  of 
the  nbduccns  may,  however,  occur  as  a  aaparate  affection.  Tbe 
paralytic  form  of  conjugate  deviation  of  tho  eyes  and  rotation  of 
tbe  head  and  neck  may  appear  at  this  period  of  tbe  disease. 

Facial  pamlyHis  is  manifested  by  tbe  usual  signs  of  paralysis 
of  cerebral  origin.  In  some  coi^eH  total  paralysis  of  the  facial 
bsfl  been  observed,  and  iu  these  tbe  affection  is  due  to  inter- 
fereoce  with  tbe  nerve  by  uHuslon  at  the  base  of  tbe  brain. 
In  other  cases  the  ocular  and  frontal  branches  wcro  affuctcd, 


lU,    ^ 

tvholsB 


-(»»N9u  iw  bwt!si]r-iiwir  uvun  n  uww  di»  vniunHu.j  m 

fltipntioD  is  proseat  as  a  rule  iLrougbout  tlie  wholo  oon 
disease.  Alilioiigb  there  are  occfutioos)  exoeptioos  t! 
pation  is  not  orten  obstinnUi,  nnd  it  is  geimally  M 
cara  action  of  ttie  bowels  by  ordioary  meaiUL  I 

Headache  is  another  important  symptom  of  the  ftnj 
the  iliiieaiie,  and  mny  be  of  a  dull,  heavy,  or  I4 
chnractcr.  The  headache,  although  contiouoiu, 
paroxysmal  exacerbatJoiu.  It  U  sometimeti  refei 
init  of  the  Trontal  bone,  bat  more  frequentlrthe  whole 
seat  or  pain.  Headache  la  usually  an  urgent  synpC 
conaoiousoess  is  retaioed,  and  its  temporary 
iiuidu  known  by  moaning  or  ahrieks;  vhile  eveni 
sciousnesa  has  ftel  in  the  patient  puts  bis  baod 
wrinkles  Ills  foichtaul,  and  distorte  his  face  aa  if  & 
Vertigo  is  alwaytt  present.  PaticntJt  feel  as  if  tbey  wc 
in  bed,  or  aa  if  surrounding  objects  were  revolviog  nut 
aod  the  gait  ia  oflen  reeling  uad  unsteady;  but  th«j 
vclopmcDt  of  eerere  symptoms  mou  prevents  all 
station  And  locomotion. 

Alotw  di^ui-baneee  arc  almost  nlnray*  prcMOt 
of  tbe  affection.'  Spasmodic  movements  occur  ta 
partial  convulsions,  giving  rise  to  tremor  and  ooojogri 
tion  of  the  eycbnlls,  strong  convergent  and  diviMrgeiil 
grinning  contorlious  of  the  muscles  of  tbe  face,  grindi 


mSBASES  OF  THE  MEMBRANES  OF  THS  BRAIB. 


757 


HprewioD  of  the  fnco  is  not  that  of  sufforing.  Aay  period  of 
the  disease  may  be  alleudetl  by  tb'is  cry,  which  may  occur  every 
lour.  balf-hour,  or  even  every  five  minutes."  BcHides  upaaraodic 
norement^,  sposuc  rigiJity  of  one  or  more  groups  of  muscloB 
nfty  occur,  the  mo-it  important  of  these  being  stiffness  of  the 
ntudes  of  the  nape  of  the  neck  and  back,  and  retraction  of 
lie  abdomiaal  mugcU's.  Slight  paralysis  of  Bome  of  the  facial 
inil  ocniar  musclcit  may  occur,  conAistioj;  of  inequality  in  the 
Ripils,  ptoflis,  strabismus,  or  slight  f&cial  paralysis. 

Sensory  di^urbatuxs  uru  not  bo  well  marked,  and  they  are 

idoally  Booo  obscured  by  loss  of  consciousness.     At  times  a 

eaeml  hypenestbeeia  of  the  vrtiole  surfuco  of  the  body  may  \m 

ibaerveJ  at  the  beginning  of  the  diamwe,  while  at  other  tinjea 

Ilia  coadiliea  may  bo  limited.     Qeneral  or  p^irtial  aniestheeia. 

S  IkOt  an  unfrequent  symptom  at  an  advanced  period  of  the 

GsMse,  and  it  has  occasionally  been  observed  as  a  premonitory 

gwptnm  ^Urcyfous).    Intolerance  of  sound  and  light  is  a  pro* 

Binent  symptom  :  the  child  is  impatient  of  the  slightest  Doise, 

tnd  avoids  the  light  by  lying  with  tlio  fiice  buried    iu  the 

Qloir  or  turned  towardti  the  wall,  keeping  the  eyelids  Hrmly 

lIoBed.     Id  Ibis,  the  usual  attitude  of  the  first  period  of  the 

disease,  the  kuees  are  drawn  up  towards  the  abdomen,  and 

Dreyfous  belleveK  that  it  is  n»t  vohiRUirily  assumed  in  order  to 

Eiroid    the  light,  but   corresponds  to    the  forced  attitudes  of 

iuiimals  arising  from  experimental  injury  of  the  brain. 

Pgyckiod  disturbances  are  not  always  present  in  the  early 
iod  of  the  aflectioii.  The  patient  cannot,  however,  form 
cutive  trains  of  ideas,  and  children  soon  become  somnolent, 
wiih  their  eyes  closefi.  and  reply  to  questions  curtly  or 
lerety  by  a  nod.  Wbuu  raised  up,  Ihcy  compluin  much,  knit 
ibeirbrovs,  throw  back  their  hcatU,  and  slip  down  in  bed;  they 
not  bear  the  slit^litent  disturbance,  and  will  clench  their 
ith  a^aiuit  food.  Delirium  U  of  frequent  occurrence  whcD 
le  patient  ia  half  asleep;  and,  in  the  case  of  children,  the 
ijdrocephalic  cry  is  not  uofrequ«ntly  hoard  at  this  time,  being 
mpaaied  by  starting  up  in  terror.  At  other  timet)  the 
tient  may  spring  from  bed,  or  make  defensive  movements, 
a  consequence  of  hallucinations  of  sight  and  of  hearing.  The 
olence  soon  iacreases,  the  eyes  stare  without  expressloD 


( ^ B ^ 

termioa)  phenomenaa,  aod  it  is  ihen  difficalt  to  did 
aaylbing  beyoud  a  meningitU  of  UDknowii  cause. 

In  other  cases  tubercular  meuiugltU  niDs  a  ntpiil  a 
may  lermioato  id  fivo  or  six  days.  In  loin*  of  tbeac  i 
tricular  effusiou  is  wauling,  and  Aeath  ia  due  to  so 
process  id  llie  braio  itAeir  Some  cases,  od  tliu  o 
have  AD  exceedingly  protracted  coarse;  tUe  iDYoni 
and  itiMdiitua,  ttie  symptoms  are  gradually  tlevelo 
diseasQ  may  last  from  thirty  to  tirty  or  eren  aixtj  d«; 

In  all  caaea  iu  which  the  disease  \itfftn  by  sudden 
orparalysia  combined  with  aphatdit  the  miliary  tuba 
been  found  limited  to  the  area  of  distribution  of  U 
artery,  while  the  cburoid  plexusea  have  been  free  from 
and  great  effuaion  abeent 

The  disease  is  usbercd  in  by  depre«sion  of  apiriti 
anguish,  halluoi nations  of  hearing,  eelf-aocuaatioaaf  an 
*t  escape  from  puaisbmcat  After  alwut  forty-eq 
uoconsciousneas  supeiTeoes,  ptosu  and  facial  pan 
follow  with  all  the  other  signs  of  tubercular  meningil 

Sometime*  the  oounte  of  the  disense  is  very  sirot 
of  typhoid  fever.     In  other  cases.  odpectaUy  iti  chit 
vooscioasaeas  ooines  on  at  an  early  period  of  the  did 
constitutes  throughout  the  most  promiuoni  ^tnplH 
aSectioD.     lo  these  cases  lai^ge  ventricular  etfuaioDl 


iJ 


HSBASE8  OF  THE  MEHDBANCS  OF  THB  BEAIN. 


763 


ul  iu  the  brain  ititelf  and  to  morbid  chnngen  found  in 
er  organa.  Various  diatiges  may  be  found  in  the  cranial 
e«.  and  caries  of  tlie  petrous  portion  of  the  temporal  bone 
requeotly  the  primary  caufte  of  the  diseiise.  On  removing 
calTarift  tubercles  may  be  found  iu  tlic  dura  mater,  and 
[Id  probably  bo  found  more  frequently  if  a  careful  search 
made.  They  are  sometimes  found  between  the  two  Inycrs 
to  small  braacbeit  of  the  middle  meningeal  artery,  white 
urn  appear  to  he  situated  in  the  inner  lamella  of  the  dura 
er  (Huguenin). 

h«  changes  in  the  pia  mator  ore,  (a)  those  which  are 
CCLy  connected  vith  the  fonnation  of  miliary  tubercles, 
t]io»e  caused  by  the  inflammation  Kurrounding  tbem,  and  («} 
IB  which  arise  from  the  pffuBion  into  the  ventricles, 
to)  The  pia  mater  ia  studded  with  miliary  tuhcrclcA.  They 
pear  aa  greyish-white  granulatinnit,  varying  from  n^ize  scarcely 
lie  10  that  of  a  millet  seed,  while  masses  as  targe  as  a  pea 
be  produced  by  aggregation. 

e  tubercles  are  always  diBtributed  in  the  neighbourhood  of 
Iu  some  coses  the  whole  length  of  an  artery  from  it« 
jo  jn  the  circle  of  Willis  is  covered  with  numerous  tuberclee, 
e  in  rare  cases  the  granulations  arc  ciueBy  situuttiil  on  the 
iberal  branches  of  the  vusauls.  At  times  all  the  arteries 
en  oft'  from  the  circle  of  Willis  arc  studded  with  tubercles, 
le  at  other  times  particular  portions  of  the  surface  of  the 
ji  are  either  exclusively  alTccted  or  aBtcted  to  a.  much  greater 
tat  than  the  remikiniug  portions. 

'he  territory  supplied  by  the  Sylvian  arteries  is  particularly 
le  to  be  afl«eted,  and  tubercles  are  also  commonly  found  at 
bottom  of  the  great  longitudiual  fisHure  along  the  vessels 
ch  supply  the  corpus  callnsum.  At  other  times  the  tubercles 
must  abundant  in  the  pia  mater  coveriug  the  upper  and 
surfaces  of  the  cerebellum,  or  on  the  median  surfaces  and 
rior  Iobc«  of  the  cerebral  hemispheres, 
bt*  number  of  tubercles  present  varieH  greatly.  At  times 
may  be  so  limited  that  a  careful  search  is  necessary  to  6nd 
while  in  other  cases  they  are  numbered  by  thousands, 
granutationn  may  be  isolated,  or  collected  in  dense  groups ; 
casionally  tbcy  form,  along  with  the  inOammator^ 


764 


DISEASES  or  THE   MGMBRUfKa  OF  TBS   BBAW 


products  of  the  pia  mater,  tlnck  inaMbB  wbJcb  exert  pronit 
on  bbe  biain. 

Tbe  tuberclc«  are  found  ia  oU  8U};c«  of  dsvelopmcaL  At 
times  all  of  tbeia  coosist  of  tbe  small,  grey,  miUai7  gna^ 
tioiis,  but  at  oiber  times  tbese  are  iaix.ed  with  lar;ger  tubcfdo^ 
wbicb  are  yellow  at  ihcir  ceotrofl  from  f&tcy  degwantiifc 
Callositiea  mainly  compoeed  of  conaective  tissue  and  CBtlowg 
old  tiiborclos  ore  found  on  variouH  porU  oa  the  mirtae*  ai  tka 
braio. 

(h)  Tbe  inflamnuUori/  cbanges  in  the  pia  mater  nuy  ot  hii 
not  be  well  marbod,  acoordiog  to  circurastancea.  Wboi  lk> 
pceaeare  caused  by  tbe  effusiou  bas  be«o  great,  tbe  luriH*  t( 
tbe  pia  mater  may  be  dry  and  ita  veasets  empty.  The  oaor^ 
lutioiis  are  flattened  and  tbe  sulci  more  or  leaa  oarTDired.  A 
moderatti  bypenemia  of  ibe  pia  mater  is.  bowever,  frequm^ 
present,  ^specialty  at  tbe  base,  where  the  TeaseU  are  Ism  InUl 
to  be  subjected  to  preaauro. 

Evidences  of  suppuration  are  generally  foaad  at  the 
of  tbe  brain.  Under  these  ctrcumstances  tbe  whole  linoe  ■ 
swollen  and  yeUowUb,  and  cloudy  streaks  of  cxadatioo  i 
bd  obeerred  passing  ulon^  tbe  Teaela.  Tbe  cODveatty  u 
80  liable  to  be  the  seat  of  euppumtioa  In  aomo  cnaea,  howwrv. 
a  scru-purulcnt  cGTuaion  is  observed  in  the  pia  mater  of  the  obb* 
vexity,  while  at  otber  tJmea  tbe  evidences  of  auppuration  im  tbe 
convexity  arc  stUl  better  marktxL  In  the  latter  case  tbe  pia  kn 
lost  its  delicacy  and  transparency,  is  inelastic  and  eavtly  Uth, 
and  IB  everywhere  infiltrated  with  a  ■ero-fibrinoni,  yaUewMb 
exmlalion. 

The  exudation  often  extends  hackwarda  over  tht  uttM 
surface  of  the  pons  and  ineiluUa  oblongata,  creeps  npwatdalB 
tbe  upper  surface  of  the  medulla,  and  implicates  tbe  pia  of  tbt 
entire  cerebellutn.  Tlie  suppurative  process  may  extend  6aB 
the  cbiasma  forwards  to  tbe  under  and  internal  surfiuce  ot  A* 
anterior  lobe,  along  the  olfactory  lobe  and  the  artecy  d  tW 
corpus  callosum. 

The  clianges  are  net  always  symmetrical,  but  in  gcMsalfc 
may  be  said  that  tbe  greateat  suppuration  will  be  foond  what 
the  tubercles  are  most  numerona. 

Tbe  iDflammaticm  may  extend  along  tbe  proceaM*  of  pia 


DISEASES  OP  THE  MEHBRA}IES  OF  THE  KRAIX. 


763 


lieh  enter  the  descending  cornun  of  the  Intoral  ventricles,  and 
also  be  traosniittcd  tlirougli  ibc  great  transverse  fissure 
to  the  vtilum.  interpOHitum.  At  tiroes  the  choroid  plexiise<<  and 
vetiiin  interposilum  may  be  covered  with  a  yellowiKh  piinilcot 
ftxudaiion. 

iraTasatioDS  of  bluotl,  varying  in  size  from  minute  specks 

m  patch  an  inch  or  more  in  diameter,  may  be  found  in  the 

,efl  of  the  pia  mater.     The  growth  of  tubercle  in  the  walla 

vessel  presses  upon  the  media  and  iutima,  and  thuH  dimi- 

les  its  lumen.     The  vessel  is  thus  partially  obslnicted,  and 

a  thrombus  may  form  ut  Ihia  poiut,  fwilowed  by  softening 

tbo  ooata  of  Uie  vessel  and  extravasation,  or  the  internal 

middle  coats  of  the  vessel  are  perforated  directly  by  the 

:1c. 

;)  The  ventricles  are  generally  distended  with  eerous  flutd, 
effusion  is  absent  in  almut  20  per  cuut  of  uU  ctun:».     The 

;um  lucidum  in  frequently  broken  dowa;  whiiu  the  third 
ventricle  is  distended,  but  to  a  less  degree  than  the  lateral 
ventricles,  oning  to  the  resistance  offered  by  the  optic  tbalami. 
The  soft  commissure  is  generallymore  or  Icjistom  and  speckled 
with  capillary  hiemorrhages,  and  the  anterior  portion  of  tbo 
verttriclo  may  be  so  distended  that  the  pin  mater  covering  the 
lamina  cinerea  is  exposed.  The  aqueduct  of  Sylvius  is  fre- 
quently dilated  and  the  fourth  ventricle  distended.  The  fluid 
is  at  times  purely  Reronci,  while  at  other  times  it  is  clondy 
from  the  presence  of  epithelial  calls  and  while  blood  cor- 
jmiclca,  and  purulent  effusions  are  occaaiooiilly  observed.  In 
some  cases  the  fluid  is  tinged  with  blood  derived  from  rup- 
ture of  small  vessels  in  the  choroid  plexiisosi  The  choroid 
plexuses  are  byperwmic,  and  miliary  tubercles  may  be  found'  in 
litem,  though  never  in  large  numbers;  small  extravanations 
of  Uood  are  not  uncommon.  Tim  (rpeudyma  of  the  vcutricles 
it  aomeCimcs  dcnao  and  opaciue,  and  when  viewed  by  a  side 
light  its  tmrface  looks  oa  if  sprinkled  with  fine  dust^  At  other 
times  larger  granulations  may  bu  obsurved  intermediate  in  size 
between  the  fine  dmst  and  miliary  tubercles. 

The  distribution  of   tubercles,  inflammatory   changes,  and 
eflfuaion  may  be  combined  in  various  ways.     In  the  majority  of 

ts  miliary  tubercles  arc  distributed  over  (be  entire  pia  mater 


766 


DISKISES  OP  THE  UEMBfiUI£3  OP  TUB  BBAIS. 


and  clioroid  plexuses,  there  u  a  largo  TentricaUr  eSimoa.  ni 
the  ba»ti  of  the  braiD  is  oftea  coreieil  by  a  ^uralcDt  cxtuiktiaii. 
which  iu  some  cases  exteoda  to  the  coDvcxity  of  the  bcoi- 
gphercs.      (a  a  few  cous  miliorjr  tuberclt«  are  acatterod  a 
am&ll  Dumhers  over  the  pia  mater,  the  choroid  pteiaaes  are  at- 
ofiected,  veulricular  etfusioD  is  absent,  aod  no  pu«  is  riuUito 
thu  Doked  eye  cither  over  th«  bojsc  or  convexity  of  the  bnia 
In  other  cases  the  tubercles  are  limited  to  the  re^oe  of  Ai- 
tribution  of  one  or  more  of  the  arteries  of  the  brato,  tha  •eni' 
tories   of    the   Sylvian   arteries   being   spocialljr   lialil*  to  la 
affected.     The  base  uf  the  braJu  aud  the  vascular  regie*  ift 
which  the  tubetales  are  developed  are  covered  by  a  puralnt 
exudation,  aod  there  it  a  modemU!  ventricuhu'  effaiioa.    Ii 
Bouie  caaert  the  evidences  of  recent  tuberculotti^  are 
pauied  by  drcumacribed  thiclcemogs  aod   lamios  of 
conDective  tissue,  in  which  old  miliary  and  caaeoaa  tabada 
are  embedded. 

The  braiu  itaelf  undergoes  many  important  cbangca.  If  Al 
effuaioD  he  large  the  cortex  and  neighbouring  while  sobitaitt 
are  dry  ami  anaemic,  but  when  cfiuaioo  is  ahsent  those  parti  ■( 
congested  and  unlematoiia  The  cortex  ia  often  etudded  tff 
punctiform  beemorrhages,  caused,  according  to  Rindfleiidl.  If 
tubercular  degeneration  of  the  nutritive  arteries.  Tbe  v«mIi 
of  the  cortex  are  aarrounded  by  clusteoa  of  white  aod  nri 
blood  corpuBcles.  Wbcn  the  pia  mater  is  stripped  ofil  poftias 
of  the  substance  of  the  brain  will  be  found  clinging  to  tia 
T«88eU  of  the  cortex,  and  consequently  the  eurface  of  lbs  bin 
assumes  a  rough  oppoarftoce.  White  softening  of  the  aobil— 
of  the  hemispheres  is  often  obeerred.  It  may  IdvoUq  portiwi 
only  of  che  fornix  and  oorpiia  cajloeum,  or  may  extend  into  tb 
centrum  ovale  and  basal  gangUSb 

T)iu  cranial  nerves  may  all  be  affected  in  grestsr  or  )m 
degree  in  tubercular  meniagitis.  The  inflammatoiy  pro 
up  at  the  base  of  the  brain  may  extend  to  tlie  shsatba  of  At 
nerves  aud  gives  rise  tu  nu'uritis,  and  when  effusion  taksa  phcs 
they  are  injuriously  afiecled  by  pressure. 

Tlie  spinal  cord  ia  not  unfreqnenUy  affected  in  tabetEolv 
meningitis.  The  inBnmotatory  affection  of  the  pia  mater  pa** 
dowQ  a  varying  distauce  into  the  spinal  canal,  and  (abvdo 


DIStUSKS  OP  Tne  HKUDRANES  of  the   DlUiH. 


767 


.re  found  in  Die  Bpina]  pin  mater.  Tuborculoaia  of  the  lungs, 
ilearaj,  pericardiuoi,  peritoQeum,  liver,  epleec,  lymphatic  glaods. 
ad  kidueya  is  frcqueatlj  assocuit«<l  wltb  the  nffuctiou  of  the 
Mrebrai  tnembraDca  Clmeay  cl&gcneralion  of  the  mesenteric  or 
itro-peritoaeal  glands,  or  of  the  bronchial,  cervical,  or  axillary 
gl&ntlii,  is  almost  always  found  associated  with  the  cerebral 
affection.  Suppurations  of  the  vertebra*,  of  the  bones  of  the 
extrt^mttiea,  aud  pelvis,  atfcctions  of  the  pcrioateura  and 
jcrints,  caries  of  the  nasal  bones  tcom  syphiliB,  coriog  of  the 
davicle,  eterwim,  and  petrous  portiun  of  the  temporal  bone  are 
KKne  of  the  most  frec)nent  causes  of  tubercular  meningitiii. 

§  8+3.  Harind  Physiology. — Miliary  tubercles  act  as  foreign 
bodies  and  produce  an  attack  of  meniogilis.  In  the  early  i^tage  of 
inflammation  the  symptoms  are  mainly  those  of  irritation  of  the 
oortex.  it  is  manifest  that  the  initial  symptoms  of  the  disease 
most  largely  depend  upon  the  distribution  of  the  tubercles 
and  resulting  inflammation.  If  the  tubercular  iufiltratiuii  be 
mainly  limited  to  one  or  more  of  the  Sylvian  arterioa,  tho  disease 
will  be  ushered  in  by  symptoms  of  motor  irritation,  such  as  alight 
CpMiBS,  unilateral,  or  even  general  convulsions.  In  those  caseH 
which  begin  with  aphasia  the  lesion  is  situated,  as  a  rule,  along 
the  left  Sylvian  artery,  the  branch  which  siippliei  the  posterior 
«ad  <rf'  the  third  frontal  convoluliou  being  specially  implicated. 
In  tbe  recorded  cases  it  is  not  mentioned  whether  the  loss  of 
qwech  was  preceded  by  any  evidence  of  irritation  of  Broca'a 
oonvolutioa.  Ditficullies  in  the  articulation  of  word.''  may  oocur 
wben  there  is  no  aphaaia.  When  tbe  area  of  distributioQ  of 
the  posterior  cerebral  artery  is  chiefly  affectetl,  the  initial 
ijmptoms  will  bo  sensory  disturlaaces,  as  h%tlucinations  of 
sight  aud  hearing ;  wbUo  the  motor  disorders  consist  of  aaao- 
eiaced  movcmcDt^,  as  those  of  defence  against  threatened  blows, 
or  attempts  at  escape  from  apprebeoded  punishment.  When 
tb«  anterior  cerebral  arteries  are  mainly  affected,  the  disease 
begios  by  sopor  alternating  with,  slight  delirious  eicitemont, 
atul  coma  usually  supervenes  at  an  early  period. 

WheQ  tbe  cerebellar  arteries  are  affeoted,  stiffness  of  tbe 
muscles  of  tho  nape  of  the  neck  and  back,  and  tetanic  seizures 
are  prominent  symptoms.    Tbe  various  irregularities  of  gait 


also  obserretl  at  au  earlier  period.     In  the  Brat  sta, 
Ij-ses  are  prubtibl}-  caused    by  irriiatioo  anil  tu 
Imustion  ul'  a  motor  c«nlre,  but  in  the  secoad  st 
caused  by  destructive  chaoges  ia  tUe  motor  area  of 
Peripheral  parulyvia  roa;  bti  produced  by  the 
bticoniing  implicated  io  the  exudalton  as  they 
base  of  the  braio.    Tbc  sciuory  poritOQ  of  th« 
Derrot  of  special  sense  as  well  as  tbo  motor  d 
injured  by  the  QxudatioD. 

Tbo  final  stage  oi  general  paralysis  of  teoaory 
fuDCtiunfl  is  explained  by  the  gradual  compression  of 
due  to  incrriLsiDg  ventricular  cfTiision. 


itentTI 


§  844.  Diftffnons. — ^Tubercular  meningitis  is 
taken  for  cerebro-spinal  meningitis,  nmple  purulent' 
faypersemla  of  the  brain,  the  terminal  stage  of  abaoM^ 
of  the  brain,  thrombosiii  of  the  sinuses,  and  leptoai 
infantum,  but  the  diagnoHs  between  it  and  tiiene  i 
have  either  been  or  will  be  bemfber  considered. 

Typhoid  feocr  with   severe   brain   aymptotns    ro^ 
aiuiulatu  tubercular  meuingitia     DiSiculties  of  dii 
ariHe  in  liiecuee  of  ubeiranb  forms  of  typhoid  fever  i^ 
bowcU  are  confined  and  empty,  the  abdoui  iual  ut 
and  (be  spoU  absent,    Oa  the  other  hand,  it  mnst^ 

bAnwH   r.hnt  (liarrkoin    mav    It*    >W«a«>nL   in    UlltAMnJoV  ttki 


ms  ro^ 
f  dii^ 
rer  i^| 
luaclfl 


DISEASES  OF  THE  HKMRRANES  OF  THE   BRAtN. 


769 


lUic  demngement  in  young  obildrcn  may  cause  sj^mptoms 
■Imwi  idcatical  witb  those  of  the  etulier  periods  of  tubercular 
meDiDgitU ;  but  tbo  diagnosis  is  soon  cleared  up  by  the  progress 
nf  the  case. 

I(  should  also  be  r«menibered  tha-t  many  acute  dieeasoti  are 
attflnded  by  cerebral  symptoms  closely  resembling  those  of  the 
onset  of  tubercular  meningitia. 

§  345.  PrOffnosig. — The  prognosis  is  in  every  iostaoce  ex* 
ceetliogly  grave.  Many  presumed  iuntauces  of  recorary  are 
recordt-d,  but  these  c;ises  are  probably  examples  of  leptome- 
luogitis  infantum  or  other  affectiou,  and  col  genuiue  tuber- 
culosis of  the  piu  mater. 

§  S46.  Treatment. — Prophylactic  treatraeot  is  of  the  utmost 
importauce,  since  ihu  prospects  of  rocoTcry  arc  «o  uufavuursble 
wbea  odcu  the  disease  is  established.  The  children  of  scrofulous 
parcDts  should  be  most  carefully  reared.  Mothers  of  strongly 
marked  tubercular  diathesis  should  aot  suckle  tboir  cbildreo, 
«Bd  this  applies  all  the  more  to  the  case  of  those  iu  whom 
widences  of  tubercular  or  scrofulous  diseases  arc  already  np- 
pareoL  The  children  should  be  seat  to  the  country,  fed  with 
[good  milk,  and  the  greatest  care  taken  in  attending  to  the 
Coondition  of  tbo  digestive  organs ;  the  Hiigbtest  diarrlicea  should 
Iraoeive  immediate  atteottoti.  Change  of  climate  to  a  moun- 
tainous district  or  to  the  seaside  is  sometimes  attended  by  tbe 
most  decided  benefit.  With  regard  to  medicines,  iron,  iodide  of 
itrou,  and  cod  liver  oil  most  be  administered  according  to  the 
ctroumstanceti  of  the  case. 

Tbe  children  should  also  be  specially  guarded  from  the 
iolectious  diseases  to  which  they  are  liable  ;  because  au  attack 
of  meaales  or  whooping -cough,  or  indeed  any  acutu  disease, 
is  Apt  to  lead  to  irritatioa  of  tbe  glands  and  subsequent  cheesy 
degeoeratioo,  and  tbe  dcgencratod  glands  tu  tbcir  turu  may  be 
the  Murcfl  of  tuberculosis. 

When  the  symptoms  of  meoingitis  have  once  appeared,  tbo 
grave  nature  of  the  prognosis  should  not  prevent  the  attendant 
bwn  adopting  appropriate  treatment.  There  is  a  possibility 
most  cases  that  the  mcaingitis   may  not  be  tubercular. 


770 


UIUS^BS   OP  THS   MEUBRAKBS   OP  THK   BBAI5. 


and  at  aay  rate  sttemptH  should  be  made  to  allay  taflaauMti 
octjon.  Local  blood-letting  often  relieves  the  severe  hmik 
and  gives  at  least  temporary  relief.  The  head  should  bo  thk 
aad  ice  applied  persiateutly.  I  Uato  oever  ee«D  tbe  digh 
good  result  5x>ni  couoter  irritation,  and  its  use  should  be  at 
doncd.  Smart  putg&tivcs  may  be  of  •ome  use  io  rUm 
symptoms,  and  senna  in  conjuoction  witb  sut[^tQ  of  in*){i 
or  the  compound  jalap  powder  answers  the  purpose  well.  1 
parations  of  mercury  and  iodine,  and  a  Iftrge  number  of  tpa 
remedies  have  been  used  in  the  treatment  of  thg  affoetioa, 
with  questionable  succqbr, 

When  ouce  the  progress  of  the  ease  bati  rendered  tht  4 
noais  of  tubercular  meningitis  undoubted,  the  less  Aoeq 
treatment  the  better.  During  the  second  and  thinl  atag«i< 
to  the  head  may  be  exchanged  for  warm  applicatioiu.  I  h 
seen  delirium  ami  restlessness  much  diminished  by  the  omi 
warm  fomeiiution  to  the  head,  aud  oue  great  &im  of  treaw 
is  to  soothe  the  sufferings  of  tbo  patient  as  much  u  poai 
With  this  view,  when  there  is  jactitation,  deltrium.  aad  acre 
ing,  Hmali  doses  of  opium  or  cblonit  should  be  adminLctci 
suob  stimulants  as  ammonia  or  ctoq  small  qu&ntitiea  of  | 
may  be  of  use. 

Chronic  Sydrooephtdua. 

§  8*7.  De^nition. — Chronic  hydrocfphulus   com 
abundant  serous  accumulation  within  the  cr&oium, 
the  general  ventricular  cavity.    A  chronic  aooomalation  df  I 
into  the  sac  of  the  arachnoid  has  been  described  undtr 
name  of  external  hydrocephalus,  but  it  is  doubtful  wbf 
condition  bos  any  real  existence. 


§  84$.  Etiology. — Cbrooic  iutracranlal  eSuaioiu  in 
are  probably  always  the  result  of  intTacmni&l  tonic 
oc^lusiim  of  one  or  both  of  the  lateral  sinnsea.  or  proloai 
venous  congestion;  while  in  old  age  it  may  be  oompatumlfil] 
the  cerebral  atrophy  occurring  after  bn;mctrrfaage  and  ciMfj 
litis.  These  conditions  have,  however,  been  already  saSoiei 
conaiderL-d,  and  we  shall  bore  deal  excluoively  witb  the  cfat 
hydrocephalus  which  is  coDgeilital  or  acquired  aoon 


DISEASES  or  THE  MEMBRANES  OF  THE   BRAIX        771 

ie  etidlogy  of  oongenitat  hydmcfphalue  is  not  well  koowii; 
lit  licrcditary  prediBpositioo  uppours  to  «xert  some  intlueace 
i  it>  production,  for  more  than  one  cliild  may  he  atfecced  io 
le  tame  hmily.  Congenital  sypliilis  h  probitbly  the  most 
Bport&Dt  predisposing  causv,  aiiij  it  is  possible  tliat  too  much 
nponance  has  been  attributetl  to  ricketa  in  its  production.  Of 
le  eiciting  causes  little  is  known.  CbroQic  bydrocepbalus  is 
imetinics  preceded  by  an  attack  reaembtiug  acuiu  bydro- 
Bpbalus. 

§  849.  Symp(om$. — Chronic  hydro roplmhis  is  generally  con- 
Doital,  and  cerebral  symptonta,  nucb  aa  daily  recurring  couvul- 
ons,  slrtLbistnus,  or  roltiug  of  the  eyeballa,  arc  apparent  from 
he  infant's  birth,  wbil«  in  a  few  days  or  weeks  the  h«ad  is 
baerved  to  undergo  progressive  enlavgemeot. 

Impairment  of  the  general  nutrition  Is  one  of  tbo  first 
rmptoma;  the  child  may  ec«m  otiger  for  food  and  suck  well, 
Bt  it  loses  flesh  and  strength,  and  tko  skin  hangs  in  loose  folds 
I  its  BtttiQuated  limbs.  The  bowelH  are  g-etierally  cotixtipatod, 
r  diarrbosa  may  alt^jruate  with  cousltpaiion,  and  the  evaciia- 
oos  ore  always  unlieallhy.  TIte  child  i&  rvatlens  and  may  be 
rawsy  during  the  day,  but  wakeful  and  fretful  during  the 
ight.  The  fontaoelle^  and  sutures  are  now  unusually  open, 
le  aDt«rior  foataaelle  i«  teiiitu  and  pulsates  strongly,  and  the 
lild  is  subject  to  paroxysm.^  of  reHlle.<i3ne.s8.diiniig  which  there 
<  increased  heat  of  the  head. 

Thts  sutures  become  gradually  wider  with  the  increase  of 
foaioo.  the  fuutanelles  iucreaae  in  size,  the  head  uastimes  a 
lobubir  form,  an<l  the  pliyaiugnomy  of  tbu  child  soon  ac«|^uin» 
«  cbaractetistic  features  of  chronic  hydrocephalus.  As  the 
iid  accumulates  witbiu  tlie  crauiiim,  it  presiii^  equally  in  aJI 
Mctioos.and  the  cavity  of  tliu»kiill  must  ctil&rgc  in  the  direc- 
M  of  least  resistance.  According  to  West,  the  great  incrca«u 
,  the  tizG  of  the  head  is  effected  chiefly  by  enlargement  of  the 
tterioT  fontanelle  and  by  widening  of  the  sagittal  suture, 
i«8e  being  the  points  which  are  the  hu^t  to  be  ossified,  and  at 
bicb  the  bones  of  the  skull  are  less  firmly  fixed.  Tho  frontal 
mes  are  consequently  pushed  forwards,  reudering  the  forehead 
ond  and  prominent,  the  parietal  bones  are  pressed  bnckwards 


are  punuvu  iroiu  ui«  uunvuiiuu  w  aa  ouui|ue  or 

atmoHt  vertical  positioo,  smi  thus  eocroacti  upoa  i 
of  the  orbits,  llie  eyeballs  ar«  couacqaently 
anil  rviidcred  promincDt;  lliey  are  at  the 
(lownwiu-ds,  so  that  the  white  eclorotica 
upper  lids,  while  the  pupils  am  hall'  hidden  beof 
lide.  Ou  plaviug  the  haud  over  the  opeo  foDi 
BUtures  the;  are  felt  lenDo  and  Huctuating.  Tho  I 
scantilj'  over  the  bead,  the  akio  is  tetue  and  abtninj 
in  thiK  renpect  from  the  wrioklcd  condition  of  ibat  i 
of  the  body,  distended  veiaa  are  seen  lo  ramir^ 
«calp,  and  the  enlaq^ed  bead  offen  a  remarkable  < 
the  small  face,  which,  arocordutg  to  West,  retaius 
lime  itH  infantile  dimcoiiionii.  The  child  haa  a  di 
expressioo ;  he  cauDot  hold  his  head  up,  mod 
obliged  to  maintain  tbe  recumbeDt  pwition  on 
half-aittiug  posture,  white  his  lu-ad  is  nupported 
or  propped  up  with  pillows.  Tbe  cerebral  synipM 
appear  during  tbe  progreaa  of  tbe  case  axe  variabU 
usaaL  being  conrul&ioos,  attacks  of  laryDgtHtuaa 
paralyses,  of  varying  distributioD.  with  contracturea,  i 
rolling  of  tbe  eyeballs,  and  amblyopia  progreeuog  lo 
Hearing,  aa  a  rule,  romatos  unafieeud  until  a< 
termioatioo. 


i 


DISBASSS  OF  TBB  MEUB&AKES  OF  THE  BIUIN. 


773 


851.  Morbid  ATUUomy. — In  chronic  liydroeephalus  the 
general  ventricular  cavity  of  the  «ncepliaIon  is  distwDiled  with 
seroas  6uid,  wlitch  raries  \a  quantity  from  a  few  oimoes  to 
maoj  poiiDilii.  The  veotriciilar  cavitieR  are  consequently  greatly 
mlarged.  the  openings  by  which  they  communicate  with  one 
i&olher  are  dilated,  and  the  Hcptum  hicidum,  commissureR, 
braiz,  and  corpus  callosum  are  stretched  or  lorn,  while  the 
■oiTOUuding  cerebral  suhstance  may  be  Hoftcni>d,  of  uarmal  con- 
■Bteooe,  or  nnusnally  dense.  The  cerebral  hamispheres  are 
eonipiessed  and  ftatteucd ;  the  courolutioua  arc  prc&scd  out 
and  till!  sulci  diaappcur,  the  white  and  grey  fluhatances  being 
•carccly  diistingulshablo.  The  basal  ganglia  are  pressed  down- 
wards, the  Cdrdbral  peduncles  are  separated,  the  opti<:  commis- 
■nre  is  comprcBsed,  the  pons  varolii  and  corpora  fiutwlrigcmina 
■le  distorted,  the  superior  surface  of  the  cerebellum  is  Hattened, 
and  the  nerves  at  the  base  of  the  brain  are  compremed . 

The  membranes  of  the  brain  are  rendered  thin  and  !u>ftened, 
bat  the  ependyma  of  the  veutricles  is  sometimes  found 
thiclceaed,  rough,  and  in  a  granular  condition.  The  bones  of 
tb*  akull  are  generally  thin  and  iranepareut,  hut  in  some  cases 
tiiey  are  of  normal  thickocHs,  while  in  a  few  cases  they  are 

§ker  than  normal,  being  then  on  usually  denne  and  resisting. 
862.  ifoHyid  Physiology. — Many  pathologists  bulieve  that 
eSiiiion  of  chronic  hydrocephalus  is  a  passive  dropsy,  but 
I itanslty  and  others  are  of  the  opinion  that  it  results  from 

a  chronic  iuflammatioa  of  tho  ependyma  of  the  ventricles  and 
lira  choroid  plexuses.  The  symptoms  are  partly  due  to  dia- 
plaeement  of  the  cranial  bonce,  and  partly  to  the  compression 
uS  tbe  substance  of  the  encepbalon. 


853.  Diagnoaiti. — CengeiaiUl  hydrocephalus  may  be  mis- 
taken for  encephalocele,  but  in  the  latter  a^ection  the  sirelling  is 
local ;  it  is  doughy  and  clastic  in.it.end  of  being  fluctimting,  and 
il  oot  transparent.  Fungus  of  the  dura  mater,  that  has  per- 
fented  at  binh,  also  forms  a  local  tumour,  which  appears  over 
one  of  the  bones  perforated  by  it,  and  not  over  the  sutures  or 
Ibotuiellcs,  while  the  mass  feels  doughy,  and  when  pressed 
symptoms  of  irritation  are  produced. 


of  the  liraia  may  bo  ^^^^^M  for   bychoccpbaltu, 
former  atTectiqp  tho  bead  enlftrges  at  fint  witl 
symptoras,  anJ  wbea  tliese  appear  tbe  disease 
course  aud  icrminatcs  rapidly  itt  dcAtb. 

§  854.  Proffiwna. — ^The  prognoats  ia  alwaji 
isolated   cases  bare  beea  known  to  live  to 
prognosis  with  regard  to  tbe  restoration  of  tbe  mcnli 
is  QTOD  worse  thaa  tbat  as  to  life. 


4 

bum 


g  855.  Treatment. — Great  attention  should 
(^eiieml  b«iUh,  but  it  is  aeedless  to  exp«>ct  to  obut 
of  tbe  fl[iid  by  means  of  internal  remedies  or  ibe  ■ 
of  coiiutor-irritants.  Methodical  oompranion  of  Uu 
means  of  adhesire  plartler  bas  be«n  recommendc 
been  productive  of  any  good  Tbe  treatment  by 
asptmtiou,  advised  by  Couquet  and  others,  affords 
jHirtial  HuccesH.  Tbe  puncture  should  b^  made  by  a  fii 
or  by  the  needle  of  au  aspirator,  which  should  be  l 
perpendicularly.  "  Tho  best  spot  for  puncturing  the  i 
Ramskill,  "  ia  about  an  inch  or  an  inch  and  a  hsU 
anterior  fontanelle.  near  tbe  edge  of  tho  coronal  snto 
care  to  avoid  tho  longitudinal  sinus  and  some  of  tba  I 
which  empty  tbeiU8clT«s  into  iU"    Only  a  few  ouao 


DISEASES  OF  THE  MKMBRANBS  OF  THE  BRAIK. 


775 


W  hare  alrendy  boca  suffici«Dtly  considered.    That  form  of  basal 

I  moningitifl  only  is  to  be  considered  at  present  which  ariaee 

I  spODtaneously   or  from    unknown   causes.      Nearly  all   thoae 

I  aflTected  nrc  from  16  to  30  years  of  ngo,  and  in  most  of  tbom 

I  bere«liUU7  predisposition  to  tuberculosis  is  wauting. 

§  S57.  Symptoms. —  When  primary  basilar  meningitis  is 
diffused  and  general,  tho  affecLion  bcginH  by  languor,  mcQtal 
dopreasioi),  chilliness  or  eren  rigor,  thirst,  aod  the  usual  symp- 
totaa  of  fever.  The  patioat  complaius  of  iuteasc  cephalalgia 
Aod  giddiness,  and  these  are  followed  by  severe  attacks  of 
vomitiDg. 

Motor  Uisturbaaces  may  bscomplctely  absent  throughout  the 
whole  courHu  of  the  affection.  When  present,  they  con^st  of 
fpasmodic  rigidity  of  the  muacles  of  the  back  of  tho  neck,  with 
retraction  of  tho  head,  and  rarely  of  rigidity  or  clonic  twitch- 
ingti  of  certain  groups  of  the  muxcles  of  the  extremities.  The 
patient  grinds  his  teeth  during  nleap;  and  in  the  later  Rtages 
of  the  aSectioD,  trismun  and  hiccough  have  been  observed. 
Paralysis  of  the  abducens  is  not  uucomtnoii,  but  psiratyBig  of 
tlie  oculo-motor  nerve  is  rare.  Purcui»  of  tho  facial  or  hypu- 
glosaal  Derres  may  occur  temporarily  during  the  course  of 
the  aOectioa  and  aubset^uently  disappear,  but  complete  para- 
lysis of  them  ha«  not  been  obscrvetl.  The  power  of  doglati- 
tioa  may  be  impaired  during  the  course  of  the  affection  and 
be  afterw&rda  regained,  and  this  may  increase  to  complete 
dysphagia  before  death.  Paresis  of  the  eztromitiea  ia  occa- 
sionally observed,  but  never  complete  paralysis. 

The  BOnsory  disturbances  consist  of  cutaneous  hypcrtesthMift, 
especially  in  tho  region  of  distribution  of  the  lifth  HQrvas, 
ringing  in  the  ears,  scintillations  before  the  eyes,  and  occa- 
NOnally  hallucinations.  Aniesthesia  and  dyumthesiu'  have  not 
been  obaerved.  The  peychioal  disturbances  are  raoro  variable 
than  in  any  other  form  of  meningitis.  In  some  cases  the 
mental  faculties  are  unafTected  throughout  the  whole  course  of 
the  disease,  while  ia  others  they  are  early  involved.  The 
mental  symptoms  usually  consist  of  a  mild  delirium ;  but  in 
exceptional  cases  this  may  be  more  active,  the  patient  being 
restless,  (luarrelsome,  capricious,  and  irascible:     Active  delirium 


L 


retracted  as  in  tubercular  Tneniugitia 

Tbe  temperature  curve  is  very  im^iar.     In 
perioJ  it  may  rise  as  high  a«  104"  F.  id  the  «TeniDg  i 
to  the  normal  in   the  momtog.      Id   the  later  tt^ 
disease  the  temperature  remains  tow,   being 
normal.     Tbe  pulse,  as  a  rule,  followti  the  tem| 
ver)*  frequent  in  the  initial  period,  and  sinking  b 
of  tbe  disease  to  belov  SO  beata  in  the  minute, 
eod  of  life   it   agaiu   increasea.   and    becomtn 
irregular,  and   intermittent ;  the  patient  is  core 
aores,  much  emaciated,  and  dim  in  a  stat«  of 

The  chronic  forms  of  basilar  mculngitia  may 
localiaed  inflammatory  products  at  the  baae  of  tbe 
cause  symptoms  scarcely  to  be  distioguishcd  fr 
tumouns  occupyinf;  the  same  dtuatioiL  Tbe  ly 
variable  in  eucli  cases,  the  most  cbaraotttristio  htia 
of  tbe  various  cranial  nerves.  la  addition  to  tbe  bi 
dizziness,  there  are  anosmia,  amaurosis,  or  homianc 
paralysis  of  the  motor  nerves  of  the  eyeball.  setM 
banoes  in  tbe  region  of  <]tKtributioD  of  the  fifth  n 
catory  paralysis,  paresis  of  tbe  sevootb  nerve,  and 
paresis  of  one  or  more  of  the  exuemitiea.  If  the  ii 
extend  to  tbe  lower  end  of  the  poos,  bulbar  panlv 
.nd  dyspnosa  may  be  present 


DISEASES  OP  TQE   MEHBKANES  OP  TRE   DBAIH.         777 

tnmour  situated  al  tbe  base  of  the  skull.  The  afie«tion  g«Qonll7 
tonnuates  ia  death. 

g  859.  Morbid  Anatomy. — The  changes  found  at  the  b&so  ot 
the  brain  vary  aceordlDg  to  the  rapidity  or  the  procewi.  lu  the 
moit  acute  cases  purulent  in61tr&tioii  of  the  pja  mater  of  the 
baao  frorn  the  chiiuma  to  tho  pneitcnor  tnnrgin  of  the  pous 
has  been  found.  Thiii  iiitiltnktiou  may  cstuod  along  the  (isiiure 
of  Sylvius  for  iiotne  distance,  but  does  not  reach  the  convexity 
of  th?  braiu  ;  on  tbe  other  hand,  it  often  extends  along  the 
whole  traoaverse  diameter  of  the  hemiapbere^,  frequently  in- 
Tolving  the  choroid  plexuses  and  the  ependynia  of  the  rentricles. 
Tbe  ventricles  are  generally  distended  with  fluid,  while  the 
convolutions  are  flattened  and  the  sulci  pressed  together.  In 
1ms  acute  cases  the  inflAmmatory  exudation  induces  varioas 
degrees  of  thickening  of  ttie  pia  mater.  Tbe  choroid  plexuses 
■re  increased  in  size,  indurated,  and  may  at  timca  be  covered 
with  pus. 

§  860.  Diagnosis. — Basilar  meningitis  may  run  a  course  so 
nmilar  to  typhoid  fever  that  the  two  aflfcction^  can  only  be  dis- 
tinguished by  long-coDtinued  observation.  When  the  tempera- 
tare  curvEa  of  the  two  affections  are  simihu',  the  points  to  be 
nlied  on  in  fortning  a  diagOMis  are  tbe  presence  in  typhoid  form 
of  diarrhoM,  rose-coloured  spots  over  the  abdomen,  and  enlarge- 
ment of  the  spleen. 

§861.  PrognoM. — Moat  cases  end  in  death,  but  some  ore 
recorded  in  which  the  symptom."*  corresponded  clonely  with  those 
of  basilar  meningitis  and  which  ended  in  recovery. 

^  S9SL  TftaiTtvmt — Counter  irritation  in  various  forms  has 
twen  employed  with  good  effect,  but  this  remedy  should  be 
reacrved  for  the  Uter  stAge  of  the  disease.  Quiniuc,  meicury, 
and  iodine  have  been  employed,  but  with  doubtful  auocesa. 
The  headache  must  be  allayed  by  narcotica  If  syphilis  be 
preeent,  mercurial  inunction  and  iodide  of  potosaum  should  be 
employed. 


rn<)ueocy  from  this  ft^  U  puborty,  when  it  becom 
quent.  Acute  meaioji^lis  is  rare  in  adraoodd  tgi,  Imt 
form  it  frequcot.  Of  adultfl,  mea  are  more  Uabia  to 
than  women.  Tbe  excitiog  causes  are  not  well  Icdo 
Secondary  meningiHa  of  tbe  conrexitj  m&y  hjB 
iQHammntiou  of  tlie  bones  of  tbe  skull,  the  usuafl 
latter  being  external  injury,  scrofula,  aaJ  eyptuU&i> 
may  alao  give  rise  to  tbta  inflammatiotL  OtorrlH 
when  complicated  by  caries  of  the  temporal  booO 
most  frequent  causcii  of  puruloDt  meaiogitu,  and  I 
may  reaull  from  puriform  aofUning  of  a  thrombiu  ii 
sinuses,  erysipelas  of  tbe  bead  leading  to  osteo-phlc 
booae  of  tbe  sliull,  carbuacleg  of  tbe  face  and  neck^ 
of  tbe  eyeball,  and  old  intracranial  diacoaes  111 
afascdSMS,  or  necrotic  softening. 


§  ft©*.  SipnptamH. — The  eourae  of  acute  n»er 
diinded  into  three  stages  :  (1)  The  period  nfexcit 
period  of  transition ;  and  (S)  The  stage  of  coUttpa& 

(1)  The  Period  of  EcaUtmenL — Obscure  pretnon 
toms  are  sometimes  observed,  coniaisting  usually  of 
bcavineas  in  tbe  bead  along  with  paroxysmii  of  viol 
tdgia,  sleepleMoess,  irritability  of  temper,  and  gen« 
Aa  a  rule,  however,  tbe  disease  begins  suddenly  by  a  i 
riror.  intAnae  beAJacbe.  vomitias.  fevar.  and  dalinui 


DISEiSBS  OF  TUB  MEUBKANES  OP  THE  BRA[N. 


779 


the  patient^  especially  if  a  cbild,  may  utter  a  loud  and 

tting  is  a  very  constant  symptom  of  meDioKitis,  and  is. 

the  vutoitiDg  aymptoroatic  uf  olbur  ccrubml  di»(.>a«es.  iinat- 

by  nausea,  and  epigastric  paio  or  teodemefia.     It  recurs 

lly  diirioj,'  the  first  forty-ciglit  hours,  and  may  tben  cease 

r  at  iotermls  throughout  tbe  course  of  the  affection. 

motor  disturbances  ia  this  atajjo  are  not  wull  marked. 

geacnU  convulstoiis  which  ufiher  in  the  disease  in  cbil- 

d  which  may  also  frequently  recur  in  the  course  of  the 

lion,  bo  excepted.    The  pntiont  staggers   like  a  person 

fc  when  ho  attempts  to  walk,  and  when  confined  to  bed  he 

Bsa  and  keepn  chaiigiiig  his  positioa     Stmbiinnu!),  slight 

ing  of  the  muscles  of  the  face  and  limbs,  and  tonic  spasms 

of  the  Deck  and  back  may  also  be  observed.     The 

1  are  u.iually  contract43d  or  unequal  during  tbia  stage,  hut 

readily  to  liglit. 

I  sensory  disturbances  consist  of  bnxzing  in  the  ears. 
I  before  the  eyes,  and  iutoleraace  of  light  and  sound. 
iBOUS  hypenL'Stheaia  is  not  unfrequently  present,  so  that 
gbtest  touch  OQ  the  akin  may  cause  pain,  and  the  reflex 
ility  is  increased. 

psychical  disturbances  arc  well  marked  from  the  first, 
lient  is  extremely  irritable,  and  fierce  delirium  is  apt  to 
the  patient  tihoutiag  and  violently  stni^^glin,^  with  his 
.at&  At  other  times  be  is  morose,  and  buries  bis  bead 
r  the  bed-clothes,  obstinately  refusing  to  answer  questions, 
fcemporature  of  the  body  ia  elevated,  the  pulse  beata 
U20  to  140  or  more,  and  the  respirations  are  increased  to 
;40  in  the  minute. 

7%e  Period  of  Transition.  —  During  this  stage  the 
B  delirium  of  the  first  stage  becomes  quieter,  the  patient 
B  bis  bock,  with  bis  fingers  picking  at  the  bed-clothes  or 
at  imaginary  flies  in  the  air. 

noiinced  motor  disturbances  now  make  their  appoar- 
iatiog  of  partial  or  general  convuUioos,  followed  by 
The   muscles  most  commonly  affected  by  partial 
sions  are  those  of  the  eyeballs,  producing  BtiBbismus;  tbe 
muHcloi  in  coojunctiou  with  those  of  the  neck  cauung 


780 


DI8BASB3  OP  THE  HBKBRlNfiS  OF  TBB  B 


BcbB 


coDJugate  dcTiaiion  of  the  ejres  and  roUtioo  of  the 
mnwlM  of  the  face ;  those  of  the  jaws  cftiuni^  j^rindi 
teetb  aod  trumus ;  ifaoM  of  tbo  tooguo  caonug  varioaa  du 
tiotu  of  the  orfffta  ;  the  small  lauscles  of  the  hood  cw 
jerking  moTemeDt  of  the  flogora,  subsQltas,  and  tremof  of 
bands  ;  and,  lastly,  the  larger  mu»cles  of  the  extrciniUai|ii 
rise  to  varionB  conmUive  moT«ment«  of  the  limbs.  Il 
probablo  that  the  loud  cry  which  the  patient  (<'>ntinM 
ultei  occasionally  in  thU  irtAf^e  U  not  a  voluntary  actioov 
caused  by  spasmodic  contraction  of  the  oiwociat^H  m 
vocAlnation.  The  muBcles  of  the  neck  and  back  an 
be  affected  by  tonic  spasm,  causing  retraction  of  tbe  ha»i 
attacks  of  optstbotonoa. 

These  convulsive  symptoms  are  followed  by  poral^ 
is  very  variable  in  its  distributioD.  some  groiips  of 
being  paralysed  white  others  continue  ooDvolsed. 

The  sensory  disturbances  consist  of  dimness  of  vision  mI 
bearing,  ending  in  blindness  and  deafness,  while  tb> 
cutaneous    hypenestfaesta   of   the    first   stage    is   rcplactf 
wusstbesta.    The  bowels  are  constipitted  throughout,  ul 
abdominal  walls  are  often  retracted  as  in  tuburcular 
The  respirations  are  irregular,  tbe  pulse  frcqueol  unl 
and  there  is  retention  of  urine. 

(3)  Tke  SUu^e  of  CoUafMC—The  third  stage  of  the  ilTi 
DOW    becomes   eetubltahod ;  tbe   couvubiva    pbraontafc 
ptaco  everywhere  to  paralysis,  and  tbe  patient 
profound  and  fatal  ooma. 

Symptoms  of  Secondary  Jtf»iitn<;iiML— The  »; 
secoodary  meningitis  differ  oonsiderably  according  bt 
of  the   inflammation ;   but,   inasmuch    as   inf) 
caries  of  the  petrous  bone  is  the  most  usual  form  of 
tion,  it  will  be  uscFiil  to  describe  it  Brst 

Tbe  affection  may  be  usbered  in  by  cbillinesa  or 
rigor  and  feverish  symptoms;  but  intcnu  heodaeha, 
tinuous  or  marked  by  remissions  and  exacerbatjons,  il 
symptom  to  direct  attcotiou  to  tbo  brain.     Tbo 
be  6xed  to  a  point  in  tbe  vicinity  of  the  discaesd  Mr,  «- 
from  OQO  ear  to  another,  while  at  other  times  it  a  Oitmi' 
IJtA  m\ify\^  \AiiA.    U  the  local  affection  be  atteodid  bf 


il 


DISEASES  or  TBE  UEMBKAKKS  OF  THE  BRAIN. 


781 


mmeocement  of  the  meningitis  in  marked  by  a  great 

of  il9  iQtetiaiLy,  aud  tUe   ouaet  of  ibe  latter   may 

.e£  be  oompt«tely  ina«ked  by  an  increase  of  the  local 

Qniatiou  in  the  ear.    Attacks  of  dizzioess  now  supervene, 

ipanied  by  oausca  and  vomitiog;  the  patient  coraploios 

scs  ID  the  load,  geooral  paiaful  seosatioiLB  diffused  ov«r 

ot]y,  and  obsicurBtiun  of  the  spinal  sensea. 

;er  a  paroxysm  of  iotenHc  cephalalgia,  the  patient  begios 

uider,   or    becomes  actively   delirious ;   th«8Q   symptotns 

however,  disappear  temporarily.     The  ioitial  Hyniptoms 

xsompaDied  or  preceded  by  the  signs  of  local  disease,  coo- 

of  transitory  pbeuomeua  uf  irritation  followed  by  those 

ion.      The  aigns  of  motor  initatluo  ari:  rigidity  of 

!ea  of  tlie  nape  of  the  neck,  convulsive  twitching  of 

ial  muaclea  on  the  aifccted  flidu,  Iriamus,  grinding  of  the 

L  aad  ucoutioually  spaama  of  the  cxtrvmitios. 

ie  deprestiive  symptoms  cousist  of  paralysis  of  the  facial, 

jglossal,  and  glutn>o-pbaryugi.'al  nerves  on  the  same  side  aa 

Utaon ;  while,  if  the  iatiammatioQ  extend  forwards  aloDg 

base  of  the  skull,  the  third,  fourth,  Hizth,  and  probably  the 

:~erves  may  become  involved  in  iDtlammaliod,  The  titate 
pupils  ia  variable  and  liable  to  i'rcquent  changea  during 
iDuree  of  the  disease,  being  generally  contracted  or  unequal 
nt,  and  dilated  and  tixed  when  effusion  has  taken  place, 
l^s  of  the  extremitiea  ia  rare,  but  tbo  patient  bos  an 

Mj'  "t^figiT'ig  «ait- 

|B  tenmri/  diuturbanees  consist  of  marked  hypcra?Ethesia 

^  skin,  joints,  buuea,  and  muucleti,  bo  that  every  movement 

Miful. 

■miting  generally  continues  throughout  the  whole  course  of 

disease,  the  bowels  are  coudtipated,   and  the  abdominal 

les  aio  tender  to  the  toucli  and  retracted.  The  temperature 

lute  cases  ia  usually  high,  but   remits  in   the   morning, 

ligh  it  remaias  constantly  high  in  some  caaee. 

te  pul»c  aa  a  rule  rises  and  falls  in  frequency  along  with 

tuperature,  except  in  the  cnsea  where  symptoms  of  com- 

bn  of  tbc  bnun  occur  during  the  first  days  of  the  dieeaae. 

He  urine  is  oflen  albuminous,  and  this  may  or  may  nut  be 

jiftted  with  amyloid  diMue  of  the  liver,  spleao,  and  kiduc>^v>. 


782 


DISEASES  or  TUE   HEJUlRAKES  OF   TnB  BJUIV. 


The  optic  dines  usually  preseQl  the  same  appeamnceB 
observed  in  tubercular  mtiaiagitia.  The  paycbical  syni 
are  very  vuruble,  coDsistiog  of  jactihitioo,  rMtlewnai^ 
confusion  of  ideas,  eepecioliy  towards  itio  evuning  irbca 
temperature  rises.  After  a  time  the  patient  falls  ioto  •  i 
leat  c^Ddition,  from  which  he  can  at  fint  be  readtlj : 
a  loud  qucBtioD,  but  this  Btat«  soon  giv«  place  to  profo 
fata!  CQiaa. 


§  865.  CmtTse,  Duration,  and  Ternninaiions- — The  dm^] 
of  ^mpk*  puruteut  niL^uingitia  is  variable,  but  as  a  rule  the] 
gresH  of  the  ca.se  u  rapid.    The  diwaae  may  tfrmlDate  in  . 
withiD  a  week,  and   in   infauts  in  a   still  shorter  periot^j 
8ometiuu'»  it  may  asHume  a  uoce  or  leas  chronic  fono, 
re^ulUDg  after  weeks  or  moDtlii. 

The  duration  of  parulent  meningitis,  secondary  to  dti 
the  temporal  bone,  varies  from  a  pcricKl  of  twenty-foar  1 
to  two  or  throe  weeks,  and  the  affection  ia  usually  fatal 

§  866,  Morbid  AiutUnnj/. — ^The  pia  mater  ia  iatiltrated  vift' 
a  6bro-purulent  exudation,  the  convexity  being  muaUf 
volvcd  to  u  greater  extent  than  the  boM.-,  aJlbougb  tha  IstUTJ 
is  generally  more  or  less  implicuted,  and  liie  exudalHA 
cTeo  extend  over  the  pia  mater  of  the  cerebeliuiu  mad 
oblongata.  The  effusion  into  the  ventricles  nuiet  in  qondQ;] 
and  is  genemlly  sero-punilent  in  cbaraeter.  Piu  may 
time-i  be  found  in  tbc  tissue  of  the  choroid  plexuiea.  The  pit] 
mater  is  usually  tulherent  to  the  cortex,  and  on  being  striffiiJ 
off.  portions  of  tbe  latter  ara  torn  off  with  it  Small  capllbrf  | 
extraVMEtioDS  are  found  in  the  cort«x,  or  the  cortex  mi^l 
rendered  ansmic  by  the  iutra-veotrlcular  pressure; 

On  microscopic  examination,  the  protoplasm  of  the 
cells  it  found  to  be  granular  and  the  cells  tfaemielrc 
while  tbe  vessels  are  surrounded  by  emignnt  white  tad : 
bluod  cnrpiiBclea      Secondary  meningitis  pnaesU  the  sa 
general  morbid  appearances  as  the  primary  variety,  all 
it«  distribution  is  not  always  the  same: 

In  tbe  meniDgitis  which  reaulta  from  caries  of  the 
bone,  the  changes  may  at  times  be  limited  to  the  pom 


DISEASES  OF  THK  UEHBBAKES  OF  THE  BRAIN, 


783 


'jbouriug  p«rt8,  while  at  other  times  the  base  and  the  cod- 
f  of  oae  or  of  both  bemispLered  are  implicated.  The 
^matioQ  generaliy  begins  on  the  inferior  surface  of  the 
■raU  tob«,  and  cxteads  to  the  Biiporior  and  inferior  surfaces 
cerebellum,  the  anterior  surface  of  the  poos,  and  even 
ba  vertebral  canal. 

lie  meoiugitis  be  caused  by  tbrom'bosis  of  the  ainuses,  the 
nppearaoces  cbarnct eristic  of  the  latter  attection  are 
odditiou  to  those  indicatiTe  of  meniDgitis. 


Diagnosis. — Simple  purulent  meningitis  is  a  rare 
I  and  occurs  most  frequently  in  youth  and  manhood, 
he  tubercular  varicLy  ix  much  more  common  and  occurs 
re^uentty  between  the  second  and  sevent>h  years  of  age. 

ndrom&ta  ia  stmpte  meningitis  are  not  well  marked; 
lease  is  suddenly  developed  in  apparently  healthy  per- 
>nd  its  onset  is  marked  by  rigors,  while  in  the  tubercular 
lie  [mtivnt  has  been  loeing  He&b  for  weeks  bcfvie  tho 
iQcemeat  of  the  attack,  and  the  disease  ia  developed 

radaoUy. 

I  delirium  is,  as  a  rule,  more  violent  in  primary  than  in 
Olar  meningitis,  while  the  paralytic  symptoms  are  on  the 
tiand  more  pronounced  in  the  Utter.  Partial  coniailsions 
pre  cbaractenxtlc  of  tubercular,  and  general  convulsions 
iple  purulent  raeoingitis,  while  rigidity  of  the  muscles 
I  u«ck,  and  lelanic  spasms  of  tlte  muscles  of  the  trunk 
pally  common  in  botli  affections,  but  retraction  of  the 
Inal  muscles  is  not  so  marked  in  simple  as  iu  tubercular 
jilis.     Cutaneous  hyperesthesia  is  more  commonly  ob- 

in  the  simple  than  in  the  tubercular  form, 
jogitis  arising  from  caries  of  the  petrous  bone  can  hardly 
tinguislied  from  tubercular  meningitis  associated  with 
I  of  the  same  lione.  Meningiti!)  frum  thrombosis  of  the 
I  must  be  distinguished  by  the  signs  of  the  latter  already 
ed  ;  and  the  diagnosis  between  purulent  meningitis  and 
I  of  the  brain  has  already  bi^eu  considered. 


8,  Prvgnoeia. — Several  recorded  cases  appear  to  abow 
covery  may  lake  place  in  the  early  sta^e  oC  siuki^lb  v^iu- 


784 


DBBASIS  OF  TUB  TASUB&ASSB  09  TBK  MUIV. 


leat  meoingitU,  but  in  such  caws  the  diagnous  mait  i 
remaiu  doubtful ;  whea  the  diaeose  is  ODoa  fall/  dm 
reooTery  la  probably  do  longer  puuible.  The  pcogaom  of 
seamdaty  meningiti!!  i.H  always  uofavounbltt;  in  a  few  fort 
cascH.  where  the  affection  Is  atxoad^rf  to  an  abaceai,  the  on 
of  the  lattur  may  escopo  and  rooovery  eosoe. 

§  86d.  Treatment.— la  the  Gnt  stage  at  ihe  disease  iJm 
antiphlogistic  treatmoat  must  be  adopted,  cooststiDg  o(  lea 
purgabloa,  aud  cold  applied  to  the  iharcn  scalp.  WIm 
cephalalgia  is  tatoasc,  narcotics  may  be  cautioualy  admittfa 
the  boat  b«tDg  a  small  doso  of  morphia,  sabcut&oe<Hu)y  ifl] 
Chloral  hydrate,  either  alone  or  in  eombioatioD  with  bt< 
of  potassium,  is  useful  when  tbore  is  much  restleaaea 
mo&tal  excitemenL  Uercury  and  iodiiie  of  potaaiiim 
been  given  with  the  view  of  promoting  abeorpuon,  bai 
affection  appears  to  be  much  too  acute  for  the  aotioa  of 
druga. 

^.   MRisTAnc  Uertwoma. 

Metastatic   meningitis   comprises   certain    varieUt 
affecuon.  which  occur  as  terminal  pheoomeua  in 
acute  diseasea. 


g  870.  Etiology. — The  diseasea  with   which   mc 
moat   (requcutly  associated  are    pneumonia,    uloerati 
carditis,    acute    rheumatism,    purulent    pleurisy, 
diphtheria,  aad  the  acute  exanthematiL      Allhc 
Brigbt's  disease  is  liable  to  be  complicated  by 
of  the  serous  membranes,  meningitis  is  rora 

§  871.  SympUmu, — Tbe  extent  aod  iote&city  of 
mation  rary  greatly  in  different  cases;  ia  some  the 
or  no  eAusion  into  the  ventricles,  and  the  af  mptoms  of  I 
pression  are  absent;  the  LnOommatjon  is  sonietiniOB  linut^ 
tbe  convexity,  and  at  other  times  extends  to  the 
upper  port  of  the  spinal  cord  ;  and  in  tbe  roeDiDgitis  i 
febrile  diseases  tbe  symptoms  are  obscured  by 
disturbance  usually  observed  io  all  grave  acute 


DMCA.SES  OF  TUB  UEURHANES  OF  THG  BKAIN.  785 

§  872.   VarietieB  of  ii^natatic  Menin/fUia. 

feniTigitia  wUK  Vaeumonui. —  Ueoiogitis  may  appear  la 
he  cuunte  or  pneuinonia  from  the  thirJ  to  tbe  eighth  day  or 
iren  later.  The  mcntt  usual  symptotna  are  chilUaess,  inteaee 
leadachc,  rapidly  developed  and  mild,  or  occaaiooatly  fnnoua, 
lelirium,  a  fresh  accession  of  fever,  and  byperpyrexia  before 
IvHtb.  Tbe  delirium  gives  place  at  an  early  period  to  aomno- 
BDcy,  endiDg  ia  coma.  A  sligbt  degree  of  rigidity  and  paLa 
D  tbe  neck  is  uln-uyii  a  valuable  sign  of  meningiLis,  and 
romitiDg  is  a  frequent  occiirrcnca  The  piipiU  are  generally 
notracted  at  first,  aad  may  sub^oqiieutly  become  une<]iiaL  If 
&e  bosti  of  tbe  brain  be  afFccted,  paratyHis  of  the  ocular  motor 
md  other  nerves  at  the  base  of  the  skull  render  the  nature 
)f  tbe  oomplicatioa  mure  apparent. 

,  Meninffitis  with  VUxnd'vve  Endocarditis. — The  cerebraJ 
qrmptoms  iu  ulcerative  endocarditis  aro  caused  by  multiple 
bsBtDorrba^c  infarctioos  of  the  cortex  of  tbe  brain  or  of  the  pia 
pnater,  and  the  Kymptomti  produced  ore  mon;  or  less  like  those 
»f  pysmic  encephalitis. 

A  rkeumatic  nteti inyiti^  hta  been  deecrlbed.  but  poat-moitem 
bTiSeciceof  its  extatencc  u  wantinff. 

§  873.  Morbid  Anatomy — The  amount  of  blood  in  tbe 
reasclft  of  the  pia  mater  and  brain  is  variable.  The  exudattOD 
m  the  pia  umter  ia  URualty  purulent,  and  varies  in  quantity 
Tom  A  few  Bpecks,  scarcely  nppri'ciablo  to  the  naked  «ye,  to  a 
Ajef  extensively  distributed  over  the  surface  of  the  brain.  Tbe 
■yerof  pus  may  be  limited  to  the  convexity,  or  extend  to  the 
Mse  of  the  brain.  The  etlusion  into  the  ventricles  aleo  varies 
{really  both  in  quautity  and  quality.  Tbe  opendyraa  and 
alexuiws  are  not  much  changed.  It  in  probable  that  the  Bub- 
itaoce  of  tbe  brain,  more  especially  that  of  the  cortex,  is 
avolved  in  the  iuflammatory  proct-ss. 

§  8"+.  Diagno»ia,  PrognoaU,  artd  TreatmenL — The  <iiagn<ai« 
Duat  be  made  from  the  presence  of  symptoms  which  indicate 
1  meniDgitis  supervening,  iu  the  course  of  such  diseasBB,  as 
jmonia,  or  ulcerative  eDdocarditis.    The  prognosis  ia  alwaya 

T  V 


§  876.  Etiology. — ^lliis  rorm  of  meaiagitis  ma^  a 
thu  peiioij  or  rc-acttOQ  from  codcussiod,  or  foUovr  a 
the  braia.     Injury  of  the  scalp,  with  t>ubs«qucDt 
of  the  bones  of  the  ekull  ami  dura  mater,  may  alM 
ictlamnintioQ  of  tbo  pia  mator  ivd<J  brain.     At  oth 
iuflammatoiy  process  ui  set  up  by  a  perfurattug  tl 
skull  either  with  or  without  extravasation  of  blood 
dura  mater  and  the  banc,  tbe  eSectH  iti  euch  caaea 
8i6cd  by  the  admisdon  of  air  coutaiuiag  germs  in 
wound.     In  other  case*  the  meningilis  is  a  secooda] 
osteitis,  thrombosis  of  the  sinuses  probably  playing  ai 
part  in  its  production  in  such  casea     The  menia; 
times  may  result  aftor  uecrows  of  the  bone  hag 
HulchiuMu  thinks  that  in  fractures  of  tbe  pe 
tbe  temporal  bone  the  inHammalion  extends  aloi 
of  tbo  (ieventh  nerro,  and  in  this  way  gaioa  acceac 
aracbooidal  spaces. 

§  876.  l^fHiptotna. — This  affection  may  be  dirtd 
rariotics:  (a)  aeiUe,  and  (b)  (Atonic  or  eubacuU 
meniQffo-encepbalitis  (Gnchscn). 

ia)  Acute  TraumtUie  Maningo-Kncef>KcUUis. 


IBMB8  or  THE  HEHBRAXKS  Of  THE  SlUIN. 


781 


L     At  the  onset  of  tho  icflammatory  ftltack  the  patient 

ikuQB  of  serere  and  conlinuous  cephalalgia ;  the  carotids 

forcibly  ;  the  face  is  suffused  and  tho  scalp  hot ;  the  pupils 

mtracted  ;  there  are  intolerance  of  light  and  sound,  opectral 

9D8,   Doiftoa   ID    the   earn,   and   goncral    hyporirathesin  to 

tuil  impressions.    The  patiaut  likewise  BuffcTs  from  the 

symptoms  of  pyreiia;  the  pulse  is  full  and  boiittding, 

■here  h  regtlesmefie  and  wakefulness  with  delirium  of  a 

It  character.     These  symptoms  may,  under  proper  treat- 

gradualty  subside  uutil  health  is  re-established ;  hut  more 

only  the  symptoms  of  the  «tage  of  irritation  develop  into 

of  the  stage  of  oompreaAioii. 

feg  the  stage  of  transition  between  the  uorly  stage  of 
iai  and  the  stage  of  compreeBion  of  the  brain  tlie 
of  &  localiaed  disease  may  maJic  lht.'ir  appearance. 
L'or  tonic  Qpasms,  followed  by  paralysis,  may  occur  iu 
groups  of  muBcles.  Rij^idity  of  the  muscles  of  the 
the  Dcck  with  retraction  of  the  bead  is  usually  preseut 
Eriod,  and  may  also  extend  to  the  musctea  of  the  back 
ive  ri«e  to  tetanic  seizures.  Hemiplegia  of  the  side 
to  the  injury  is,  according  to  UutchinBon,  a  constant 
of  direct  traumatic  meuingo-eDcephalitis,  or,  as  be 
[t,  aracbnius.  The  abdnmin.il  muscles  are  usually 
and  tho  boweU  coustipiited.  When  the  meningitis 
ed  at  the  baee  of  the  brain,  the  cranial  nerves  in  their 
^ong  the  ha«e  of  the  skull  may  become  implicated.  The 
Dal  symptoms  produced  are  ptosis,  strubiHinux,  puratysis 
cial  muscles  or  of  half  of  the  tongue,  and  difliculiy  of 

OQ. 

^mptoms  of  compression  of  the  brain  now  become 
iderelopcd,  the  dcliriiira  in  replaced  by  alupur,  fiom 
be  patient  id  roused  with  difficulty ;  the  pupils  are 
Mad  insecwible  to  light;  the  breathing  ia  slow  and 
is;    the  pulse,  retarded  at  first,  becomes  feeble  aull 

towards  the  end;  the  ekin  la  hot  and  b«thed  iu  per- 
il Convulsive  twitchings  or  jerkings  of  the  limbs  are 
,  but  these  soon  gii-e  place  to  general  muscular  relaxa- 

the  patient  dieit  in  profound  coma. 
tbacuU  Tranmatic  Meningo-EncephalHie. — ^"IVi^a  ?wtiv 


DISEASES  OF  THE  MEMBRANES  OF  THE  DRAIN.         7S9 

I  effuBion  begins  at  the  bftse  of  the  braiu,  and  may  ezt«ad 
irdfl  over  the  hembipheres  or  tbroiigli  tbe  tnmsverse  fissure 

I  the  veQtricles,  and  niay  also  extend  down  the  spinal  cord 
I  oon«durablc  dUtaoco.     The  effusion  is  alwajs  underneath 

fvuoeral  layer  of  the  arachnoid. 

,879.    DiaffHoaia   and  Profftioaia. — Traumatic  meniogo- 

pbalitis  may  be  diatinguished  from  the  reactive  stage  of 

MOD,  aiid  from  simple  cougeatioo  of  tJie  brain  by  Uie 

btiou  of  the  temperature  and  the  persistenne  and  severity 

le  qrmptonis  generally.     The  prognosis  ia  always  grave; 

in  tlto  c«6C6  wlkich  arc  said  to  r«oover  it  is  doubtful 

ler  anything  more  than  intonsc  coagestion  of  the  brain 

preseot.     It   in,   however,   important    to    remember  that 

itbe  flymiltoms  of  the  first  stage  of  traumatic  meaingo- 

pbalilia  may  have  been  preaeut,  and  yet  that  the  paticDt 

'  make  a  good  recovery. 

'880.  Treatment.  —  The  treatment  of  acute  traumatic 
iaga-encepbalitis  is  tbe  same  as  that  of  the  other  acute 
of  meniogititi  and  encephalllia.  The  patient  should  be 
jonfiued  io  a  quiet  and  darkened  room  and  removed  from  all 
MOses  of  excitement  The  head  should  be  shaved  and  ice 
kpfdied  to  it.  Elrichseu  reuommendii  bleeding  from  the  arm, 
nefaes  or  cupping,  free  purgation,  abstinence,  and  the  ad- 
aioistration  of  calomel  so  aa  to  produce  salivation.  As  the 
■IK  aasumes  a  more  chronic  form  the  treatmeat  must  be  lees 
mergctic,  but  the  patient  must  be  kept  for  a  long  time  iu  a 
of  complete  quietude. 


le  iremore  ara  &neBS«i,  on  uib  iibubbi 

Tolaatary  effort  Xbe  txemore  may,  iadeed,  ceaw 
TolunUirj*  effort  is  uncoanecte<l  with  the  to< 
thua  the  act  oT  vralkmg  may  arrest  tremor 
RXtrem'itie!!.  Eveu  at  tbis  early  period  the 
charoctcmtic  features.  If  the  liand  lio  afTected, 
to  quote  Charcot,  "  closes  the  fiiigei«  oa  the  Uit 
in  the  act  of  Bpinning  wool;  at  the  tame  mocnaali 
best  by  rapid  jerks  on  the  forearm,  and  the  fofl 
aroi."  The  tremor  increiLiie!!  in  intsniiity,  and.  ittHtd 
as  at  first  occasional,  it  gradually  becomes  pian 
invades  by  degrees  parU  which  have  hitherto  remd 
The  order  in  which  the  Torious  miucloa  ore  invai 
tremor  is  somewhat  variable;  The  most  usual  mode 
is  that  which  Charcot  ha&  culled  the  kemiplegie  ^ 
form  the  tremor  nsually  begion  in  the  right  hand 
montha  or  years  the  lower  extremity  on  tlie  sarac  ■ 
affected,  and  after  uaotber  variable  period  tho  IcA 
foot  are  siiccosuvely  invaded.  In  other  cftMS  boll 
extremities  are  first  affected,  forming  the  parvpi 
while  in  a  few  cases  tho  upper  extremity  of  cmo  sicU 
the  right,  \a  first  invaded,  and  then  the  lower  exIH 
opposite  side,  forming  what  Charcot  ealla  the  (/anfl 
of  invanon,  Charcot  statex  that  the  mosclee  of  U 
head  are  nearly  olwayg  unaffected  by  tremor  «t  ev 


PARALTSIS   AOITANS. 


793 


(li«ciufi  thoD  asuaily  results  from  great  emotiono]  distur- 
bance. The  tremor  may  sooa  <Iiiniiiisli  or  diaappear,  but  it  recurs, 
ud,  after  a  seriea  of  alternate  exocerbationa  and  remissions, 
beoomes  permaaent.  Whatever  be  tbc  mode  of  invasion,  the 
doratioii  of  the  initial  stage  varies  from  one  to  two  or  tbrcc 
jPMra. 

(2)  StaiUmary  Period. — Whon  the  disimBO  in  fully  developed 
ibe  trembling'  becomes  almost  incessant,  although  it  varioa  iu 
iDtenslLy.  It  is  aggravacod  by  emotional  excitement,  cold,  and 
volnntary  effort;  while,  ou  the  other  hand,  it  becomes  less 
daring  repose,  and  cemea  duriujg  sleep. 

The  different  segments  of  the  liaods  and  fingers  undergo 
iovolimttry  and  rhylbmical  oacllluLtlons,  which  closely  resemble 

fcpItCAtcd  voluntary  movements.  "  Thus,  in  some  patients," 
Charcot,  "  the  thumb  moves  over  the  fingers,  as  when  a 
pencil  or  paper-hall  is  rolled  between  them;  lu  others,  the 
tnovemvuts  are  mora  complicated,  and  resemble  what  takes 
place  in  crumbling  a  piece  of  bread."  The  handwriting  now 
Assumes  special  clianiclerislios.  At  an  early  sb^e  of  the  disease 
tbc  writing  at  tlie  first  glance  prenenta  little  change  ;  but,  when 
examined  with  a  magnifying  glass,  inequalities  are  perceived, 
some  part«  being  thicker  and  hcaTior  than  others.  As  tbc 
disease  advances  the  up  strokes  become  markedly  tremulous, 
pruhnbly  owing  to  the  lumbricaks  and  intorossei  mu9«les  being 
most  profoundly  affected  by  the  tremor. 

The  nutscles  of  the  head  and  neck,  &a  already  stated,  usually 

rawaiu  unailectcd.     The  muscles  of  tbc  eyeballs  are  also  exempt 

froro  tremor,  and  couBequently  uyelagmus,  which  is  so  prominent 

a  symptom  of  disseminated  sclerosis,  has  no  existence  in  para- 

lysia  agitans.     The  raovcraenls  of  the  eyeballs  are,  however, 

often  executed  with  great  slowness  (Debove).    The  muscles  of 

the  face  iDStead  of  trembling  arc  motionless,  the  features  become  , 

I  fixed,  and  the  face  assumes  a  mournful,  stolid,  or  vacant  ex- 

'  pression.     Tbc  utterance  is  slow,  jerky,  and  accomplished  vith 

I  grcatappiircnt  cHort,  soon  inducing  weariness,  and  if  the  tremor 

I  of  the  body  he  intense  it  becomes  tremulous  and  broken,  while 

!  iu  old-standing  cuaes  the  saliva  may  dribble  from  the  mouth  to 

fiCme  extcnL 

After  a  longer  or  shorter  time  the  muscular  power  becomes 


PARALYSIS  AQITJLNS. 


gradually  wenkeocU.     lu  manjr  cases,  however,  motor  vetbics 
is  more  apparent  than  real,  the  phenomena  depeniiog  tjok'Ja 
gruat  »lown«iB  with  which  voluolary  morameaU  an  tncii'- 
the  immense  effort  which  nil  voluatary  acUooa,  eves  apnbi,  . 
ODUil,  aud  tbo  readiness  with  which  fiitigue  is  iiu)iu»i 
although  the  muscukr  power,  when  mcAsured  by  iheij 
meter,  is  often  retained  much  longer  than  might  he  «3f 
yet  ikfter  a  time  motor  power  hecoroes  gradually  dtoinidMil 
find  paralytic  symptoms  supervene  (Oiarcot).    Tbv 
however,   abnoet  always   remiUDH    partial,   and   is  uu^u^.: 
developed  io  ditfereat  groups  of  muticloe;  noil,  as  in  iuiMj 
other  forms  of  pamlysis,  the  oxtengora  of  thu  limha  are  i 
to  a  grf*ater  extent   than    the   Rexora.     The  trembling  i 
abates  io  the  muscles  as  paralysis  iocrea«ea     The  bli 
rectum  are  only  veij  exceptionally  involved  id  the 
The  mujtcles  react  normally  to  holh  the  faradic  and 
oarreota. 

After  a  time  the  mnsclea  of  the  extremities,  trui^  ^1 
neck   Wcome  the  subjects  of  rigidityp  at  first  teiiiF«ai|t| 
but  ultimately  becoming  permancDt,  the  flexors  being 
to  a  greater  extent  than  the  eztenBors.     The  rigidity  of  ibj 
musoles  produces  clmracterifltic  alterations  in  the  attitulatf] 
the  body.    The  rigidity  of  the  anterior  cervical  muiclei< 
the  head  to  be  strongly  bent  forwards,  and  the  pationt  t 
raise  it  or  tnm  it  to  either  side  without  great  difficulty.  1W 
body  is  alfio  inclined  forwards  when  the  patient  it  hiui&^I 
The  olbowB  are  habitually  held  somevhat  removed  fnBit| 
ohest,  the  forparma  are  slightly  tiexed  onthcarms,  and  thaba^j 
are  sometimes  Qexod,  sometimes  shghtly  extended  on  thetv*' 
arms,  and  rest  ou  the  epigastrium.    The  fingen  are  Aaxeditl 
metacarpn-phalangeal  articulations,  the  index  and  middle  I 
are  extended,  but  the  remainiag  fingers  are  slightly  flexed,! 
phalnoguil  arliculatious,  all  of  them  are  slightly  incUnedl 
ulnar  border  of  the  hand,  and  the  thumb  is  extanded  sni  i 
poeed  to  the  index  finger,  so  that  the  attitude  of  Ibe  bi 
fingers  deeply  resembles  that  assumed  by  them  in  bi 
pen  (Charcot — Fig.  281).    In  some  cases  Uie  fingen  an 
nately  flexed  and  extended  at  their  several  artical 
to  »M;iahl«  the  disUHTtiODS  of  arthrUis  <U/i>rmten$  (I 


PAKALVSI!)  AGITA>'S. 


TOfi 


lu  paraljsit)  agiuiin,  however,  the  joints  are  not  anollea  and 
9itifT,  BD(1  piiissive  iDoveineot  of  the  articuUtioos  does  not  give 
rise  to  the  crealting  sontxls  observed  in  the  former.  The 
rigidity  of  the  muscles  of  the  lower  extremities  ia  sometimea 
CO  great  as  to  re^emhlc  paraplegia  with  contracture.  The  t«paem 
of  the  adductors  of  tho  thigliH  nod  miiHcli-«  uf  the  cotf  prc- 
domiaatti  over  thvir  antagaoidtH  so  tha-t  the  koees  are  drawn 

Flfl.  2ttl. 


P».  S81  (After  (nULTMt'.    AUitudeof  Ike  ffindia  Paralytic  jtffitm*. 

|mrdjs,  the  \cg  is  Klightl^  Hexed  an  thu  tbi^h,  am)  Lhe  foot 
jmea  t)io  well-known  position  of  talipes  fquino-varut. 
The  toes  are  extended  at  the  metaUtno-pbalaDgcal  and  fl«zed 
at  the  pholauf^enl  articaUtions  {Griffe  des  OrUiU). 

Via.  282. 


T^O.Stt(Afl«rC*liucot).     AUihiJt  0/  lA^  Band  ti>  ParvtftU  AfiUint  *im<Uatima 
Ual  tif  ArlhriiU  Dffarmatu. 

Id  the  advanced  stage  of  the  disease  the  patienta  move  all 
of  a  piece^  as  if  tbeir  joinU  were,  to  use  Charcot's  cxpreasion, 
■oldcred  together;  the  head  and  body  are  kept  indtned  for- 
vards,  a  poBition  which  no  doubt  largely  contributes  to  produce 
that  tendency  to  fall  forwards  tnanifested  when  walkiug  (Plate 
rV.,  3  luid  +}. 

The  gait  of  the  patient  is  now  charnctcrtgtic.  The  patient 
getx  up  slowly  and  with  difficulty  from  bi» seat, and  hudtates  for 
A  few  moments  before  starting;  when  once  he  has  begun  to  walk, 


Ml  IIUI  Ul    IM  tail   u 


■unmjiju  bucii    uviitc 


forwftrda,  a  t-ecdeDcy  wbicli  bu  been  namiHl 
Qravee  meations  tbe  case  of  a  pntieot  who,  if 
forward  movement,  immediately  began  to  run  back 
Qiarcot  could  excite  tbe  impulse  to  move  backwanliii 
p&iient  by  aligblly  pulling  her  back  by  the  dreaa  wfai 
staodiog.  h  has  already  bcoa  mentioDcd  ibat  a  fl 
paralysis  agitans  are  ushered  in  by  rheamatoid  oC 
paius,  but  iu  tbe  majority  of  cases  paioft  are  abw 
patieut  is,  however,  dlstroased  by  disagree«ble  sen 
cramps  and  seosatioDS  of  teoaion  and  tiactiou  in  tb 
along  with  a  general  feeling  of  weariaeas  and  diseomCt 
BODsatioDS  render  the  patient  restless,  and  cause 
frequent  changes  of  posture;  He  complains  of  a 
sation  of  exeeaaim  hiat,  nlthough  the  thermometer 
the  temperaturt>  of  the  body  is  normal.  In  order 
this  feeling,  the  patient  throws  off  the  bed-clothes  a< 
only  retains  the  lightest  garments  in  tb«  day-time 
This  seniialioii  of  heat  is  especially  felt  in  the 
and  back,  but  may  affect  tlie  face  and  limbs.  It 
remiastoas  and  exacerbations,  and  seems  to  attain  its 
after  n  paroxysm  of  tremblings  it  is  often  acooi 
profuse  p««piration. 

(3)  Terminal  Period.— The  coarse  of  the 
protracted,  and  may  extend  over  u  period  of  many  f 


PARALTSIS  AaiTASS. 


797 


irnus.  The  tremors  disappear  entirely  a  few  days  before 
lb,  and  paralytic  i^ymptomg  become  predominant.  la  the 
city  of  cases,  however,  death  reeulta  from  some  int«r- 
pot  diaeaae,  such  as  pneiimonia  or  pleurisy. 

^  Morbid  Anatomy. —  In  a  very  considerable  number  of 
t-mortem  examinatioa  has  not  revealed  any  lesion  of 

nervouH  system.  Charcot  examined  three  well-marked 
I  of  the  diaeaie  In  which  no  lesion  of  the  nervous  Hyittem 
Uw  found,  and  individual  cases  have  been  examined  by 
^Bt,  Ulivier.  Tli.  Simuu,  und  KiUiiit-  uUo  with  uugativt- 
ItB.  Cohn  fonnd  in  one  case  well-marked  cerebral  atrophy, 
the  brains  of  old  people  ate  frequently  found  in  this  con- 
ID  in  the  abHeucu  of  paralyeis  i^itauD.  Meechudc,  Bava- 
^,  Lobert,  Marshall  Unll,  and  Skoda  found  sclerotic  patches 
rarious  parts  of  the  cord  and  medulla  oblongata,  pons, 
.walls  ot  tbc  vcDtriclcii,  but  these  wore,  doubtU'K«,  caws 
lof  true  paralysis  agitans,  but  of  disaeminated  sclerosia 
tinHon  and  Oppolzer  found  induration  of  the  pon.s,  medulla, 
^cervical  portion  of  the  cord,  but  these  also  were  probably 
'canes  of  f^euuine  paralyRts  ngitans.  Cayley  and  Murcbi- 
Ifouod  Bcleroais  of  the  posterior  part  of  the  epiiial  cord, 
kcning  of  the  septa,   enlargement  of  the  central  canal, 

BggiegatioD  of  Icucocylos  in  spots.  In  three  cases  of 
lyaift  agitnns  recently  observed  by  Charcot  and  JofFroy, 
tcroscopical  exAiiii nation  roveaW  chants  in  the  spinal 
,  consisting  of  ob]iter».tion  of  the  central  cana)  by  increase 
be  epithelium  of  (he  ependynia,  and  pigmentation  of  the 
flion  cells,  eMpecially  of  tbe  columoH  of  Clarke,  In  one 
e  wajB  a  Hclerotic  spot  on  the  posterior  surface  of  the  medulla 
bgata. 

pwse  and  Kesteven  found  pigmentary  degeneration  of  tfao 
■e-cells  neat  the  decut^ation  of  the  anterior  pyramids,  of 
I  cells  of  the  olivary  body,  nucleus  of  the  ninth  nerre; 
(nu-  and  corputi  dentatum  of  the  ccrvbulluui,  and  uuterior 
uaof  the  spinal  cord,  along  with  cortical  sclerosis  of  the 
t  lateral  column  of  the  cord,  aud  miliary  changes  io  the 
le  matter  of  the  corpus  striatum  and  hcmixpbcrei. 


798 


PABALTSIS  AOITAKa. 


§  8S4.  Morbid  Phy9i<^0ffy. — As  juxt  observed,  not  mmki 
Ugbt  has  bitlierto  been  tbrowa  upon  the  p&thologjr  of  puKlfvl 
aj^taDS  b^  morbid  nnatomy.  The  results  ubtoioed,  how«««,j 
favour  the  idea  that  the  morhii)  cbauges  are  due  to  a  dii 
degeneration.  Tf  tbe  chaugeii  begin,  as  the  obsenraUcni 
Charcot  and  Joffroy  aeem  to  indicate,  nrtjund  tbe 
canal  of  the  spinal  cord,  the  small  cells  of  the  aocomarr  iplHil 
may  be  expected  to  suffer  to  a  greater  extent  than  the 
cells  of  the  fundamental  system ;  aitd  if  tbe  losioa  ctmuit 
part  of  a  thickening  of  die  counective  tiasue  septa  of  iLai 
tm  vta»  uhservtid  iu  Murchiaon'it  caae,  tbe  small  fibras  d 
accx's.torj  sjsbeiu,  which  lie  near  tbe  vessels,  will  be  injsnll 
b;  the  usual  cicatrical  contractioD  of  tbe  oew  grvwth  xu  t 
much  grontcr  extent  than  tbe  larger  and  more  rensUng  litm 
of  ibe  fundamental  syatem.  Er«a  aggregations  of  Icococtm, 
in  the  neighbourhood  of  the  veweU,  eueb  as  were  fnuwl 
Uurcbisou'*)  case,  would  damage  tbe  accessory  cells  and 
to  agreater  exteol  than  tbe  fundamentaL  The  results  vi 
by  Dowse  and  Kesteven,  however,  appear  to  abuw  that 
morbid  changes  in  paialysia  agitans  are  not  limited  te 
spinal  cord,  but  are  widely  diffased  iu  the  ceivbeilum 
cerebral  hemispheres,  as  indeed  might  be  expvct«d  wheo  it 
coDsiden^d  that  the  disease  occurs  almost  exclusively  d« 
the  degenerative  period  of  life,  [t  is  worthy  of  tiotios 
Dowse  aud  Kesteven  make  spucial  mentjuu  uf  the  white  maivl 
of  the  corpus  striatum,  probably  the  taternal  capeale,  as 
undergone  morbid  changes. 

TiiniiDg   to   the   clinical   history  of  the  disease,  the 
prominent   symptoms   are   the   tremurs,  the   fdowoeHs   io 
cKccution  of  movements,  and   tbe  peculiar  altciaiion  lo 
allituilo  of  the  hudy  vrilb  its  associated  muscular  rigidilT. 
causes  of  tremor  bave  already  been  discussed  (§§  ti8  and  7SX 
ifl  probably  caused  in  this  affection  by  a  dimioution  in  ib«  <«•- 1 
duetivity  of  the  6brcs  of  the  pyramidal  tract,  wbiob  pretcattj 
impulses   from    the    cortex    reachtag    the    muadve   in 
ciently  close  proximity  to  produce  a  continuous   coal 
According  tu  this  view,  the  tremors  and  tbe  slowoi 
execution  of  movements   are   merely  the  first  iadieatioaa 
tbe    more  prououuced    paralysis   which    supervenes   io    tlw ' 


PARALYSIS  AGITANS. 


799 


period.     Another  view,  which   might   be  adopted 

to  the  origia  of  the  tremors,  is  that  tbc^  are  caused 

>S3  of  the  balance  normalljr  oitisting  between  the  regu- 

ifuDCtioDH  of  the  cerebrum  and  cerebellum.     The  uttituiie 

nlysia  agitaos  is,  as  hafi  been  pointed  out  bj  Ilughlings- 

Bo,  tbe  opposite  of  that  of  teUnua.     Uuriog  a  tetanic 

to  the  actions  of  the  extensors  of  the  truok  aad  lower 

lilies  predomiQato,  aad  the  body  is  arched  backwards;  iu 

Bgitana  the  action  of  the  flexora  predominai^H.  so  that 

Serent  segments  of  the  trunk  and  lower  extremitieH  are 

open  one  anothor.     In  tetaniifl  tho  muscles,  the  nctious 

cb  must    have   gradually  predominated   in    the    course 

|utioa,  ia  the  attainment  of  the  erect  poftture,  are  excited 

activity;    wlille    in   para-lysis   agitnus   tbu   »>ame 

speaking  broadly,  become  relatively   paralyRed,  and 

jia  a  gradual    reduction    nf  the  human   to  the  animal 

K.     A  patient  aufTcriiig  from  paralysis  agitauK  during  the 

1^  propuUiou  ia,  in   hia  attitude,  very  similar  to  n  dog 

ptin^  tr>walii  on  hla  bind  legs.    If,  then,  puralysiA  agitaua 

Ueiiee  iu  which  tbu  acueasory  portion  of  the  ultvouh  motor 

klu8  suft'iin  to  a  greater  extent  than  tho  fundamental  part, 

f  be  asked  how  it  in  that  the  facial  aud  ocular  muscles 

tremor.    I  am  unable  to  give  a  aatisfaclory  answer  tu 

|t«tioa;  but  it  must  he  romomborcd  that,  although  tbeae 

is  do  not  suUut  from  tremor,  yet  they  are  affected  with 

rativo  immobility  ami  rigidity  at  a  comparatively  early 

of  the  dieease. 

HlwDomena  of  propulsion  are  cniixed  partly  by  the  forced 
I^W  the  patient  aud  partly  by  the  great  slownos«  with 
his  movementB  are  executed.  When  the  heel  is  once 
frum.  the  ground  by  coiitraciioo  of  the  musclea  of  the  calf, 
;ieat  must  in  walking  bahince  himself  ou  the  bait  of  the 
It  in  walkiog  the  forward  inclination  of  the  body  tends  to 
heliae  of  gravity  pass  in  front  of  theactive  leg.  The  poai- 
to  some  extent  the  same  m  that  asstimod  by  a  person  run- 
in  the  latter  lliu  ceutreof  gravity  is  held  well  forwards,  so 
e  line  of  gravity  falls  in  front  of  the  foot  of  tho  active  leg 
tbe  greater  portion  of  the  time  it  is  maintained  oa  the 
healthy  runner,  however,  ia  able  to  take  a  ra^id 


become  actire  in  aJvanca  of  the  line  of  gravity, 
sioa  tlie  line  of  gravity  must  ever  tend  U>  (all 
of  the  foot  of  tbe  actire  lug,  wliilu  the  other  le^  can 
backwards  with  sufficient  celerity  Co  eaable  the 
it  far  cuoiigli  behind  the  retreatiag  ti«atr6  oC  gra) 
to  arrest  the  lackward  movemficL 

§  885.  Duignotis. — Pamlyais  agitans  ii  most 
mistakeD  for  seDJlo  or  toxic  tremor  and  dissemiaai 
It  may  be  distinguished  from  Beaite  tremor  by  tbe 
occurs  before  senescence,  and  that  its  tremor  is  of 
fiity ;  the  gait  aud  expression  of  paralysis  agitaas 
teristia  The  tremor  of  merrurial  poisooiog  resein 
tigitans  more  closely  lliao  that  of  aay  other  form  of 
aud  in  diKtinguishiiig  between  them  the  history  of 
be  of  much  value.  Tbe  diagoosig  between  paralysil 
disseminated  sclerosis  will  be  described  when  the  I| 
is  under  consideration. 

§  886.  PrognofU.  —  As  far  as  recovery  is  cot 

prognosis  Is  absolutely  unfavourable,  but  the  palai 

for  a  very  long  period.     The  disease  may,  indeed 

ycara,  and  the  symptoms  of  the  tbinl  or  tormioalj 

linger  cm  for  four  or  five  yeans.     The   sooner  til 

-  **-  -   —  —        f .  --J 


*■*-.* 


^^  .^  i<».MA  ffc*fc*^A* 


HUITIPLE  SCLEBOSia 


>«0I 


d  by  Trouaaeau,  but  Charcot  thinks  that,  instead  of  caltn- 
bg,  itaggnvatos  the  tremor.  Ergot  of  rye  and  bvlladunua  have 
llao  been  tried,  but  witliout  sacceas.  Morphia  and  other  aar- 
Mtics  are  oecessary  adjuncU  of  the  treatmeut  La  thelat«r  stages 
[of  the  afibctiun  whoD  the  patient  is  harassed  by  rcstleBsnvsis  aod 
UMplMBbeu,  and  both  chloral  and  bromide  of  potaaaium  ma^ 
be  of  aae  -,  none  of  those  remedies  appears  to  produce  auy  actioD 
beyond  pnlliatiDg  the  ayrnptomii.  Eulenburg  recommends  the 
mbeutaaooug  iojeclioaof  Fowler'ii  solutioQ,  and  I  must  say  that 
L  sbuuld  have  tnora  faith  in  arseoic  thivu  in  any  other  remedy 
with  probably  tho  exception  of  pboaphoriu.  Quinine,  zinc, 
Utrate  of  silver,  and  chloride  of  gold  have  all  been  tried,  but 

ut  producing  any  marked  effect  upon  the  disease. 


HULTIPLS  SCLEROSIS  OF  THE  BRAIN  A^1)  SPINAL  IX>JU> 

(Diatninated  or  In»u!ar  SiUtrvtuJ. 

DeJiniticTi. — Multiple  sclerous  is,  as  its  name  implies, 
ironic  ioduratioD  dtsBcmioatcd  ia  patches  in  various  parts 
e  nervous  system;  the  affection  is  characterisied  clinically 
by  tho  prtsence,  in  greater  or  lesser  integrity,  of  a  group  of 
•jrmptoms,  the  ni».it  constant  of  which  are  muscular  weakness 
and  tremor  on  voluntary  effort. 

S  889.  Ilittoiy. — Diaaeminftlcd  flcJeroaia  was  first  doBcribed  by  Cruvoil- 
in  hM'*Atlnsdc  rAnatomie  Pathologirfue,"  1S3&— I&4J.  The  clinical 
of  two  vacHM  nf  tlie  ilixewwi  an-  thc^ro  KJven,  whicli,  aluug  witli  th« 
platM  o£  the  Unions  found,  leave  uo  daubt  im  tu  the  nature 
aAotdon  described.  Canifcll  iti  1838  uocunttvly  rujtraseiited  in  his 
the  leaions  obdervcd,  nhilo  MAMhnU  Hnll  In  1841  described  an 
.bt«<]  eHtiapIiu  of  thunficcticiii.  It  was  tlmtora  mivD,  nf,tiI28  veaie, 
from  truinor  of  tho  right  ana  mh)  log,  whii  hiul  a  ixtciiliiir  to(.'lEi»g 
of  tbu  iijrcs,  and  a  degree  of  sttuumtTing  aud  dofcctiw  orticidntioii. 
iD-Owiiiuiy.thodiausewaABtndiedrliiuutillylijr  Kn>richH(l&10),Val)itil>uer 
(1866),  and  Turok  (I8A6) ;  while  its  pathological  anatomy  mu  oxaoiiocd  bj 
Bokitiuukj,  Loydeoi,  Rindfleiacb,  and  Zenker.  But  this  siiijfular  Hfloction 
han  bc«D  studied  with  the  grvatwit  suctoesn  in  the  ijolp^tri^  by  Charcot 
■od  hifl  acboUrs,  aitd  oiu-  present  nocnnit«  Icnowledge  of  the  diaeajw  is 
Biaiul;  owiug  la  thuir  latxxint.  A  voJiinblc  \>»]Kt  on  the  eubjoct  has  bvxo 
ooBtiibuted  by  Stoinu  in  this  oountiy,  Rtid  individual  ouiea  hav«  bwn 
by  many  otbcn. 
ZZ 


thau  the  mule  sex,  but  the  statutica  of  oiben  do  ai 
this  concluBion.  liuUipla  sclerous  u  oomniODljr  c 
youth  and  middle  b^.  and  usualljr  makes  iu  appeui 
the  secDtid  aud  third  decades  of  life,  and  prohabi] 
45  yean  of  ogc-  In  &  large  proportioa  of  the 
iu  EnglaDd,  childreo  under  ten  yeacB  of  age 
subjecla. 

The  exciting  caua«.«  are  exposure  to  cold  and 
montat  or  bodily  exertion,  profoaud   KDotioDal' 
aud  traumatic  iufluencea,  as  blows  ou  the  heail 
from  railway  accideots. 

§  ,891  SymptcmiA— Multiple  sdeiosis  bat 
Charcot  into  three  varictice :  (1)  The 
cerebral,  and  (3)  the  epintU  form.    OTthsM 
form  is  by  far  the  most  frequeot  and  important. 

(1)  T!ie  Cerebro-Spinnl  Form,— This  form^ 
sclerosis,  as  a  rule,  devclopd  gradually  and  iniid 
occasioDallj  abruptly.  In  caaes  the  development  < 
gradual  the  ioitial  symptoms  ar«  veiy  obacora,  m 
referred  either  to  the  spinal  cord  or  brain.  The  i|i 
tomtf  which  usher  in  the  dis«Me  consist  of  paraaii  ai 
extremities  with  n  slow  and   trembling  gait,  or  i 

yarioUB  parmathottiii.   »nHF-l»;»  t»{—   wtltM.  tlwt»«4» 


MULTIPLE  SCLKBOStS. 


803 


in  by  aconvulsire  orapoplectifonn  attack,  followed  by  diplopia. 
unblyopia.  or  Djrstagmutt,  aod  ili«turbances  of  speech. 

The  firsc  motor  symptom  to  sttract  atteatioa  ia  usually 
pftresis  or  paralysis  of  certaiu  muscular  groups.  WcakiieiM 
^aoumlly  begins  in  ouc  leg,  and  subsctjupDtly  extends  to  the 
Qther  leg  and  to  the  arms,  hut  the  order  iu  which  ihe  paml>'ai)t 
•£  the  diflereat  muscular  groups  iii  developed  preacuts  every 
Inagiimhlc  couibiaatiou. 

The  gait  is  usually  of  the  spantic  variety,  muscular  coutrac* 
lliro*  ftet  in,  and  the  legs  are  held  like  rigid  b&rx  iu  the  puaitiou 
Cf  extcosioD  and  adductiou,  just  aa  in  primary  lateral  sclcrosie. 
In  the  later  stages  of  the  dis^aac  fiexion  of  the  different  seg- 
nenta  of  the  lower  extremities  may  preUomiuato  over  cxteDcion 
Xfae  paraljstB  rarely  hecomes  m  well  markod  in  the  upper  aa  in 
the  lower  extremilieeL  When  the  upper  extremitic!)  are,  how- 
•Tcr,  affected  with  paralysis  and  contracture,  they  are  maiu- 
tained  in  a  posiiiou  of  furccd  cxtenaiuu,  and  closely  applied  U> 
4be  aides  of  the  body.  The  aftectiou  itometimea  b«gius  with 
ataxia,  but  in  these  cases  it  may  ofteo  be  noticed  that  charac- 
leivtic  symptomH  of  true  locomotor  ataxia  are  abseut,  white 
Olbera  are  present  which  do  not  usually  belong  to  it.  Iu  a 
patient  under  my  care  at  present,  for  inatance.  the  fiymptoma 

bt!o  I  liret  saw  him,  upwarda  of  two  years  ugo,  were  paralysiii 
gf  both  sixth  nerves,  and  an  ataxic  gait  But  the  gait,  differing 
from  that  of  lucomotor  ataxia,  was  stjmcwhat  reeling,  although 
not  sufficiently  so  to  be  attributed  to  cerebellar  disease,  there 
mre  do  lauciDating  pains  iu  the  extreiuittes,  and  the  patellar- 
teodoD  reflex  was  exaggerated  in  both  legs.    The  patient  is  now 

iSenog  from  the  same  ataxic  gait,  the  characteristic  tremors  of 

altiple  ecleroeis,  slight  nystagmus,  and  scaimiDg  speecb,  while 
Jte  paralysis  of  the  external  recti  mu8cle«  has  diaappeared. 

iiKt-ermiUeni  m-MCu/ar  Iremor  constitute*  one  of  the  most 
ibaructertatic  isymptoma  of  this  alTeetiou,  although  it  has  been 
Ktnd  absent  in  a  few  isolated  caeoa.  This  tremor  appears 
ilmoat  excliuively  during  vaIuDta.ry  niuvemi^utB,  and  diRappeant 
uriog  repose.  So  long  a»  the  patient  remaius  seated  quietly 
he  tremor  is  either  entirely  absent,  or  at  most  tberu  is  ooly  a 
lifling  shaking  movemeut  of  the  head,  or  a  slight  oacillatiou  uf 
^  inioL    As  800D,  however,  as  he  attempts  to  seize  anything 


1 

i:iJI 

H*                              i^tan^  Dot  only  in  betog  intermitteDt  iostead  al 
n                               but  also  ID  having  a  much  wider  sweep  than  that 
affection.    It  holds  an  iotermL-diaUi  poalioa  betwat 
sire  jerking  movameDta  of  chorea,  and  the  fimall  1 
oscillations  of  panJysic  agitans.     The  true  obul 
the  tremor  of  multiple  Bcleroeis  is  be«t  elicited  t 
paticDt  to  cuuvc-y  a  gl&ai  of  water  to  his  moutb. 
is  being  carried  to  the  mouth  it  oseillAtM  from  ij 
the  patient's  baod,  tbeee  oBcillatiooB  appeariag  M 
extent  and  frequency  as  the  mouth  is  approacba^ 
vatod  cases  the  eonteots  of  the  glaxa  are  spilt  in  en 
but  in  milder  cases  the  patient  ia  able,  ntoving  hia 
wards  in  order  to  meet  ttte  ghui,  to  ^pljr  it  to 
1                             then  the  trunk,  head,  and  arms  begin  to  tremH 
1                             that  the  edge  of  the  glan  rattles  against  the  n 
til^                            contents  are  spluttered  over  tfae  patient's  face, 
patient  rises  aod  attempts  to  walk  the  tremor 
entire  bodj,  which  may  be  shaken  with  »ach  violi 
is  unable  to  proceed  or  even  to  remain  ataoding. 
tfae  voluntary  rffort  is  reUxotl  the  tremor  dimini 
long  ae  the  patient  ia  in  the  recumbent  posture  i 
can   usually  be  detected ;    occasionally   the    trad 
knoM'D  to  persist  during  ropoeo.                          f 
Tb«  ttiMory  disturbaticee  are  somewhat  vafQi 

HULTIPLE  SCLEROSIS. 


80.'> 


.0  deep  reflexen  are  usually  exag^rated,  especially  in  the 

)  extremities.  la  consequenco  of  the  iacreaAe  of  the  t^nJou- 

ia  the  lotrcr  cxtrctmtiea,  tho  knec^phcaotneooa  aad 

eloQus  are  usually  ei^gerated,  ani  th«  limbs  may  be 

into  the  state  of  trembling  numed  spinal  fpiUp^y.  Tbie 

0  must,  however,  be  carefully  diatinguished.  from  the 

teristic  tremor  of  multiple  sclerosiH. 

wphw  dUiibrbariaes  are  generally  wanting  for  a  loog  time, 

tlie  later  stages  varioua  nutritive  disorders  usually  make 

ftppearaDce.     The  sclerotic  Dodules  may  encronch  on  the 

argrey  liomB  of  the  spinal  cord,  and  then  muscular  atrophy 

i  as  in  progressive  muscubir  atrophy.     Muscular  atrophy 

Br68«nt  itself  in  ihe  upper  or  lower  extremities,  neck,  face, 

p,  or  iodced  in  any  part  of  the  body.     The  electrical  reac- 

the  nerves  and  muHclo!)  rcmajn  normal  until  tbc  muxcular 

ly  begins,  and  then  the  electric  irritability  of  both  becomes 

lly  dimiutsbcd. 

ting  ibo  terminal  period  of  the  disease  bed-sores  appear 

ibe  Bacrum  aad  other  parts  subjected  to  preaaure,  and 

DUtritioQ  fail8. 

)  blnditer  and  T^um,  as  n  rule,  remain  unaftected  for  a 
ratively  long  time,  but  tbeir  fuuctiona  ore  ultimately  in- 
d  with  ax  in  chronic  myelitis.  TIte  disorderaofthcsexual 
ms  are  somewhat  variable.  In  some  patients  aexual  desire 
B  to  be  increased  at  an  early  period  (rf  tbe  disease,  while 
irs  it  is  completely  nboliahed.  lu  the  majority  of  cases 
Kual  fuuctluQS  remain  normal  for  a  comparatively  loog 
■ 

KIT   Symptoms. — Some  of  the   phenomena   caused    by 

ktioD  of  the  pons  and  medulla  oblonga.ta  in  the  morbid 

i  are  amongst  the  most   important   and   characteristic 

raw  of  the  diBcasc.     The  spcecb  in  slow  and  hesitating. 

kacb  syllable  is  separately  pronounced,  presenting  a  mode 

nilation  which  has  been  named  the  ayllabic  or  Manning, 

(nee  is  weak,  law,  sometimes  whiapcrinj;,  and  monotonous, 

jit  breaks  readily  when  forced  efforta  are  mode.   Laryngo- 

[.«xaminatioD  shows  that  tbc  vocal  cords  move  DormAlly, 

ir  tension  is  dimiuished  and  frequently  changes  (Loube). 

«f  laugbiog  and  crying  are  often  leprecented  by  ^viVux 


If^itopta  witii  stralosmiu  U  a  aal  uofrequedl 
although  it  may  Gubnequeotly  disappear  aa  in  loconM 

yy^agmM  is,  however,  the  most  importaot  of  al] 
symptoms,  bcJDg  preeeot,  according  to  Charoot.  inabtj 
vn-scs.  The  tnovemeatit  of  tbe  eyeballs  may  be  pt 
occur  only  during  forced  ACCommodatioD,  or  when  \ 
are  performed  by  tbe  extremiuea.  At  other  timiM  the 
may  Qot  be  .ipparenl  during  the  ordinary  moTami 
eyeballs,  but  wheo  tli«  paitieot  is  asked  to  took  u| 
outwards  so  as  to  utraia  the  ocalar  miuole*. 
moveraents  may  be  observed. 

Ani^fopia  is  oot  unfrequeotly  obeerred. 
progreaave  weabnesi  of  eight,  accompioted  by  coign 
and  restriction  of  the  6old  of  naioii,  and  may  iaa| 
plete  bliaduess.  The  developmeol  of  amblyopia  » 
preceded  by  photopsia;  the  optic  discs  may  be  nc 
diseased,  or  tbe  subjects  of  «rhite  atrophy. 

The  senses  of  smell,  taste,  and  heariag  i 
cases,  but  these  disorders  are  rare. 

,   Psychical  disturbancos   an  almys  ol 
oerebro-spinal  sclerosia.    They  consist  of  mental 
emotional  excitability  causing  the  patient  U  lau|^ 
tears  witlumt  apparent  motive,  and  impairment  of  m 
intetligenca     At  other  times  tbo  mental  disorder  a 


UVLTtPLE  SCLEB0B18. 


S07 


idlug  objects  were  wbirling  round  them.  Tboj  BufiiBr 
■tly  irom  aleeplessDeae  and  violent  headache. 
■popieoti/orm  or  epileptiform  seisurea  have  beeo  observed 
small  number  of  cases ;  they  are  apparently  analogous  to 
apoplectiform  attacks,  which  occur  in  general  paralysis 
the  insane.  They  are  characteriHOid  by  the  derelopmeot 
fpvn  cerebral  oym  ptoma,  an  d  are  nccom  pan  ied  by  a 
idenble  elevation  of  temperature.  After  slight  premoni- 
aymptoms,  mich  as  a  feeling  of  pressure  in  the  head,  there 
a  partial  loss  of  coD8cioii!>.nessi,  which  in  a.  few  hours  may 
elop  into  coiua.  Tlie  face  is  red  and  hut.  the  puLie  is  (juiclc, 
the  temperature  of  tlie  body  rises  to  t04'  P.  or  105"  F.  Id 
le  cases  the  to«s  of  conscioitsness  in  accompanied  by  unilateral 
rubdons— cpilupliform  attacks;  while  in  other  ciutes  tliere 
no  convulsions — apojilectiform  attacks.  In  most  cases  hemi- 
with  muscular  flaccidity,  and  on  rare  occaaiom  rigidity,  is 
nb  from  the  outset  of  the  sotxure.  After  one  or  two  days 
temperature  falls,  the  patient  sinks  into  a  quiet  sleep  from 
ich  be  may  be  readily  roused,  and  be  feels,  on  awaking, 
parativcly  well.  Hemiplegia,  buworcr,  persists  for  a  few 
longer  and  then  gradually  disappears.  These  attacks  may 
Ti^Msted  sCTOrol  timus  in  the  course  of  the  dlsi^usc.  recurring 
some  cases  every  few  months ;  but  each  is  followed  by  an 
aggravation  of  the  geneml  symptoms,  and  death  sometimes 
oocunt  dnnng  an  attack 

(2)  Cerebral  MultipU  SeleroaU. — In  this  form  of  the  disease, 
which  is  rarely  obaerved,  the  psychical  diRturbancea  are  pre- 
domioftnt  The  tremor  is  said  to  precede  the  paralytic  mani- 
featAtions,  but  in  other  rvspuots  the  coume  of  ihn  atfection  does 

Not  differ  greatly  from  the  cerebro- spinal  vari«ty. 
1(3)  Spimd  Multiple  Schroais. — The  spinal  form  of  the  affec- 
on  is  characterised  by  the  absence  of  the  cerebral  Bymptoms, 
particularly  nystagmus,  tremor  on  voluntary  effort,  vertigo, 
^loplectifcwm  attacks,  and  psychical  disturbances.  The  symp- 
toEOB  of  the  spinal  form  of  multiple  sclerosis  often  simulate 
Ihose  of  primary  lateral  sclerosis,  although  in  the  former  some 
additional  symptoms  arc  usually  present.  In  other  coses  they 
simulate  locomotor  ataxia,  but  in  multiple  sclerosis  eymptoms 
usually  present  which  form  no  part  of  the  former. 


■trklffiea 


"syinptomit,  m  faendaehe,  vertigo,  and  onrteady  gifl 
usually  with  spinal  syinploms,  as  paresis  of  the  lowM 
and  ia  kucIi  canes  the  QBture  of  the  disease  rei^ 
UDtU  the  appeariuice  of  the  chantcteriatk  tremor  c& 
diagnosis. 

In  other  cases  the  developmenl  of  the  dii 
It  begicfl  bj  an  apoplt^ctiform  attadi.  or  gmstralgie  i 
while  paralyses,  disoniara  of  co^orduiatioD,  tnmior 
aymptoms  are  auperadded  in  quick  snccesaiaii.  TIm 
this  stage  is  ofben  interrupted  by  remissiona  or  tm 
but  tbe  nature  of  tlio  disease  is  osMutially  pngn 
patieots  become  more  and  more  helpless,  oompleU 
is  developed,  the  legs  beio^  maintidoed  in  a  cobdit 
extension  and  adduction;  tremor  dcprircs  tb«m<i 
the  baDda,  and  the  iotellectual  power  become^ 
impaired. 

The  second  stage  of  the  disease  is  now 
from  four  to  six  or  more  yean.     Duriug  this 
romaias  more  or  leas  statiooaij ;  tbe  geoanl  noM 
little  impaired.  fl 

The  third  stage  is  eharaoterised  by  impainoj^ 
nutrition  and  the  appearance  of  symptoms  indioi 
hauatioD.  The  patieatloaes  his  appetite  and  beecnnel 
the  bladder  is  7>aralysed,  and  cystitis  and  bed«oviUa 
to  pygmia,  marasmus,  and  death. A 


uieniQ 


MULTIPLB  SC'LKRQSIS.  809 

the  first  stage  •  partial  amelioration  ot  tlie  Bjmptoms  maj 
occur,  either  spootaneouBly  or  uuder  treatment,  which  may 
isad  the  patient  and  bis  friends  to  hope  for  recovery.  The 
improrement  ia,  however,  deceptive,  for  tb«  symptoou  always 
ntum  aod  ultimately  prove  fatal. 

g  893.  Morbid  Analomi/. — The  morbid  altcrationg  in  mul- 
tiple Bclerosiii  Appear  in  more  ox  less  numerous  spots  or 
Dodutes,  which  are  scattered  in  greater  or  lesser  number 
throughout  the  iipinal  cord,  medulla  oblongata,  pons  varolii, 
oorcbciium,  and  cerebnim. 

The  individual  nodules,  when  near  the  surface  of  the  spinal 
cord,  may  be  seen  through  the  pia  mator  a<  brown  or  amber 
stains,  and  in  a^^avated  cases  the  entiT«  surfaco  of  the  cord  may 
T»  Btadded  with  greyish  spots.  Each  spot  ia,  as  a  nile,  sharply 
defined  from  the  surrounding  tisRuea  and  slightly  elevated 
•boT9  the  surface  of  the  cord,  but  it  ia  occasionally  atrophic  and 
depressed  or  on  a  level  with  the  normal  portions.  On  tinnHvenie 
wctioD  the  nodulos  appear  grey  or  grojish-jellow,  and  when 
«atpoeed  to  the  air  change  to  a  salmon  colour;  they  are  traos- 
laoent  or  opaque,  irregular  or  oval  in  shape,  generally  isolated 
and  circumscribed,  but  occaaionally  confluent,  and  are  in  consia- 
t«DC«  dense,  toagh,  even  cartilajginous,  but  rarely  semi-Buid  and 
gielatinwin.  These  nodules  vary  from  the  size  of  a  hemp-seed 
to  that  of  a  bean  in  the  spinaJ  cord,  but  they  often  become 
confluent  and  consequently  appear  to  attain  a  much  larger  size 
in  the  brain.  The  distribution  of  the  nodules  in  iho  Bpinnl 
oord  is  subject  to  great  variations.  On  making  succetssivu 
transverse  sections  of  the  cord  the  nodules  will  appear  in  one 
or  both  of  the  lateral  columns  at  one  level,  in  the  posterior 
columns  at  another,  aud  in  the  grey  substance  at  a  third,  while 
the  nodule  occupies  the  greater  part  of  the  area  of  the  section 
at  oertain  levels.  The  number  of  nodules  which  are  present  is 
▼aiiabto,  a  few  only  being  observed  in  some  cases,  while  in  others 
hundreds  may  be  counted. 

The  cerebral  hemiBpherea  usually  contain  a  large  number  of 
aoduleti,  their  favourite  Etite»  being  the  while  substaneo  of 
the  centrum  ovale,  septum  lucidum,  corpus  callosum,  basal 
ganglia,  and  walls  of  the  lateral  ventricles.    The  cerobellnm 


lations ;  it  penLsta  during  repoM.  may  be  teraporu 
by  a  voluntary  oSbrt,  aod  never  implicat«t  Che  mai 
head  ;  while  the  tremor  of  multiple  ideroinB  i«  man 
ceasee  during  rest,  is  excited  or  a^ravateJ  by  voloil 
menu,  and  invnriably  impliMtOB  the  masoles  of  tb«  li 
lysis  ogitAns  is  a  disease  of  adnmcfld  age,  aod  mi 
of  youth  and  middle  age.  In  tlie  former 
developed  until  long  after  the  appoamoce  of 
multiple  sclenxuH  the  paralysis  precedes  or  soom 
tremor.  The  cerebrul  symptom*  of  multiple 
deacribed  are  wanting  in  paralysis  J^tana. 

The  spiual  form  uf  multiple  sclenMls  may 
locomotor  ataxia;  but  in  the  former  disease  the  , 
may  be  asaoRiAted  with  eicess  of  teadon-refles,  tn 
appearance  or  paralysis,  sciuming  speech,  nystagml 
symptoms  which  do  not  belong  to  locomotor  ataxia. 

The  cases  of  hereditary  atatia  deecribed  by  Fri« 
owing  to  the  presence  of  oystogmus,  very  liable  tOj 
for  multiple  ecleroeis ;  but  in  the  latter  early 
tractures,  excess  of  tendon-rellex.  scacnto^ 
bulbar  symptoms,  and  apopleetiform  att«c1c9  and  «a 
disturbiuiooe  are  absent  The  apinal  form  of  multi|l 
is  moat  liable  to  be  mistaken  for  primary  lateral  sel 
in  Bome  cases  a  diagnosis  is  impossible  If,  in  addil 
well-kno>Tn  and  elaasical  symptoms  of  lateral  »c|g| 


uy  rn« 
bio  tolj 

speeS 


MULTIPLE  BCLKU08I8. 


en 


Cftoeed  by  implication  of  the  lateral  columna;  the  aUtxic  symp- 
toms are  produced  by  Ibo  furuiation  of  oodiilcx  tn  the  poatcrior 
cotumns ;  mtucuUr  atrophy  by  iavasiou  of  the  anterior  coraua ; 
lile  impairraent  of  speech,  disturbancoa  of  rcapiration.  ditfi- 
Itj  of  deglutition,  and  other  bulbar  symptoms  are  caused  by 
'  of  the  nuclei  in  the  medulla  oblongata  and  pons.  The 
itis  is  eauBcd  probably  by  tho  presence  of  no<tulc8  in  the 
quadrif;emina  or  peduncles  of  the  cerebellum ;  whilst 
kirmeDt  of  smell  and  taate,  diplopia,  facial  nod  other  para- 
lyses, and  amblyopia  are  often  produced  by  Hclerotic  pat4.-ltes  on 
the  cranial  nerves  thcmselvoa  as  they  pass  along  the  base  of  the 
skull.  Vertigo  may  bo  occasionally  due  to  an  eiieting  diplopia, 
but  it  is  generally  the  reiiult  of  noduIcH  in  the  cerebellum. 

The  psychictil  dUturbancen  are  douhtless  caused  by  the 
development  of  nodiilea  in  the  hemispheres  of  the  brain. 

The  apoplectiform  attacks  are  di£Bcult  to  explain,  but  the 
most  usual  oxplaDation  is  that  they  arc  occoaioDcd  by  attacks 
of  ■  '  ■  I  congcation.  This  opinion  ia,  howETCr,  opposed  by 
CI'  <  iio  was  unable  to  diKcovbr  nay  evidence  of  congestion 

or  ffidcma  of  the  brain  in  caeen  which  terminated  fatally.  He 
ttiinlcs  that  these  atlackn  are  only  observed  id  cases  in  which 
tlio  pons  and  medulla  oblongata  ore  diseased. 

The  cause  of  the  characteristic  tremor  of  multiple  scleroaifl  is 
very  obscure.  Charcot  attributes  it  to  the  toiif;  pcrBistonce  of 
the  azis-cjlindera  in  the  nodules  of  sclero»t&  Conduction 
through  these  may  Htill  take  place,  although  when  once  the 
medullary  sheath  is  destroyed  the  conduction  will  be  so  retarded 
that  the  inipnises  from  the  cortex  do  not  pass  in  &  gufficieolly 
quick  auccessiun  to  cause  a  cuntitiuou!)  contraction.  Oo  the 
other  hand,  it  is  asserted  that  io  purely  apinal  cases  the  charac- 
teriatic  tremors  are  absent  (Hammond,  Ebstein),  and  that  they 
ore  never  present  unless  the  pons  and  the  parts  of  the  brain 
situated  in  front  of  it  are  affect&d  (Ordenstein).  Erb  eaamined 
tweoty-two  recent  cnKcs  with  the  view  of  deciding  this  question. 
In  all  the  ca»ea  in  which  tho  tremors  woro  present  during  life, 
the  poDS,  medvilta  oblongata,  crura  cerebri,  and  other  ports  of 
tbe  brain  were  involved  in  the  sclerosis;  while  in  the  cases  in 
wbich  there  were  no  tremors  the  nodules  were  absent  or  only 


CHOREA,  AND    MEMEEtE'S    l>ISl 


I.I.)  OHOBKA. 
Two  formtt  of  chorea  are  ofteo  deacribcd,  name 
chorea  mc{joT  mad  chorea  minor,  but  the  former 
aggravated  form  of  li^rsteria,  aud  couK«queull}-  ib^ 
will  here  be  dcscrlbtid  under  thu  name  ut  c/turea.    IP 
nhich  chieH;  attackn  cbildren,  aod  is  characteriaed  h 
clonic  spiutms  of  certain  groups  of  voiuntAr]r  muaGlfl 

§  8S(S.  Etiology. — Heredity  pUya  an  itnportaut  p 
productiou  of  chorea,  but  Ibe  trauamisaioD  is  proba, 
indirect.  The  patient  may  inherit  either  a  rasoeptO 
system,  or  the  rheumatic  diathesis — rheumatum  b4 
the  tnocit  frequent  and  important  cauae«  of  the  dot 
is  an  important  predispoung  cause  of  chorea,  tl 
geueruUy  occurring  during  the  period  of  bodily  doi 
Isolated  cases  of  the  aflection  have  been  obaervfl 
at  the  breast,  vhtle  it  is  not  anoommon  io  young  inl 
states  that  thrve-fourtbs  of  the  ouee  obfl«np«d  in 
Hospital  in  Paris  occurred  in  girls. 


.i.:.~  — i.:-i.  ~..^_ 


CHOREA- 


SIS 


aod  ftttuospbcric  cha.ag«a  io  its  production.  That  some 
relationship  «xtete  botwceo  articular  rhoiimatism  and 
ta  has  been  known  oince  the  beginning  of  the  ceDtur^*, 
tha  true  nature  of  this  relationship  ia  not  yet  accurately 

tloed.  Tbo  frequent  occurrence  of  cardiac  lounnurs  in 
wax  noticed  by  AddiHoQ  and  subaequvutly  by  Tudd.  Out 
cases  collected  by  Hughes  and  Brown,  there  were  lOV 
history  could  bu  carefully  ascertained,  and  of  these  only 
■d  not  siilfered  from  rheunmtiiin]  ur  hud  not  dcvt-loped 
pc  murmur.  Out  of  l'2H  patients  sutlering  from  cliorea 
ibund  64  who  Had  sutTvrcd  from  articular  rheumatism. 
JMh  occum  fn^quently  after  scarlatina,  a  fact  which  may 
K>ly  be  explained  by  the  frequency  with  which  the  latter 
JDwed  l>y  rbouiuatiHra. 

B  relationsbip  between  pregnancy  and  chorea  is  rery 
IK,  inasmuch  as  it  is  only  in  a  small  number  of  amva  tliat 
tack  has  been  preceded  by  rheumatism  or  endocarditiH. 
I  occurs  nio«t  frequently  during  tirst  pregnancius,  although 
lomctimcs  repeated  in  the  snmo  patient  in  subsequent 
UiaeH,  and  llio  majority  of  those  affected  are  from  tweoty 
nty-three  years  of  age.  It  appears  more  frequently  during 
it  than  the  eocond  liiUf  of  pregnancy,  but  aoiiiettmeE  it 
iu  the  later  months  and  uaay  continue  up  to  the  time  of 

or  even  beyond  tt. 
the  exciting  causes  of  chorea   the   most  frequent  and 
t  are  emotional  disturbances,  such  as  fright,  sorrow, 
uleoL     Hysterical  girls  and  those  who  are  iitrongly 
d  to  chorea,  or  who  have  already  suffered  from  an 
may  acquire  the  disease  by  imitation  of  those  suffering 


W,  (Sifmpitmw.— The  dCT-elopmcnt  of  the  cliamcteriatic 
lena  of  chorea  is  generally  preceded  by  yarious  premoni- 
iptoms  for  a  variable  period  of  doys  or  weeks.  TUo 
Bual  of  these  are  afforded  by  changes  in  the  character 
tspoeition  of  thu  patient,  who  becomes  forgetful,  tnatten- 
^tfiil,  and  discontented  or  apathetic,  while  the  intellectual 
^  &ra  impairciL  The  epasmodic  morementa  may  in  some 
d-eceded  by  paralytic  phenomena.    A  «uo  under  nty 


1i     w— 


^  It 

manifestatioiut  of  tbo  approaohiog  diHaase  are  ^roht 
some  degree,  to  irregular  inaacutar  cODtractioDa,  bat 
dependeut  upon  muacular  weakneea.  The  charactaii 
iDOvementa  generall;  begin  in  tlie  iiinAll  moKlaa 
and  in  tlioso  of  a  hand.  Thoj;  coosutat  linn  of  gl 
otlier  contortiooi  of  tlie  face,  and  alight  jerking  nu 
the  fJDgcre  and  at  the  wrist  joint,  with  pronatioa  l 
arm,  wben  tbe  patient  U  corucioua  of  bein^  ofaH 
excited  from  anj  other  cause ;  these  soon  inci 
and  persist  daring  repose. 

Tbo  irregular  contractions  »ooo  extend  eo  aa  to' 
the  ToluQtary  mascles,  wbeo  the  aficction  may 
general  chorea,  or  they  remain  more  or  leas  lita, 
muacleB  of  ono-half  of  the  body,  nhen  the  dJaJ 
tmiiaieral  cAorwa  or  hem  ichorea.  ™ 

Geiteral  Chorea. — Wlieo  ouce  the  dis«as«  it  fuU] 
the  nymplonu  are  quite  cliarocterlatic,  aod  it  fr< 
to  6Dd  phrases  more  expreeaire  of  the  di«orderly 
mentA  than  "  insanity  of  the  maseles,"  adople^ 
and  "  folic  muscuiaire"  by  Bouillavid. 

The  features  undergo  every  variety  of  cont 
is  knit  and  immediately  expanded;  the  eyebroi 
and  the  next  momeut  deprened,  or  one  may 
the  other  is  lowered  ;  the  eyelids  open  and  close  altSi 


fuUr 
rm9 


CHOBEA. 


817 


i,  it  may  b«  with  so  macb  violence  tbAt  tooUi  ar«  brokoD, 
I OT  the  tongue  and  checks  are  severely  bitten ;  lateral  displace- 
facunt*  of  tbe  lower  j&w  are  frequeatly  observed,  and  the  bead 
M  jerked  ttnddvnly  from  one  side  to  the  other,  while  tbe  fociRl 
[riniaces  by  which  the  tiiuvemeuta  of  the  Jaws,  tougue,  and  bead 
aooompaoied  add  to  tbe  comical  appeamnco  preseotcd  by 
the  patient. 

The  superior  extremities  execute  every  variety  of  movement, 

I  fcbe  shoulders  are  eierated,  then  lowered,  and  immediately  after- 

rards  drawn  backwards  or  forwards ;  the  arm  and  forearm  are 

>red  at  tbu  shoulder  and    elbow  joint   in  every   poinible 

[direction ;  the  hand   lb  alternately    pmiiated   and   supinated, 

[flexed    and  extended;   and    the    fingers  are  at  one   moment 

extended   and  epri^ad   apart  and  at    the  next  flexed.     These 

tnovemeatH  are  combined  in  euch  varied  ways  that  a  gesticu- 

latory  agitation  ia  produced  which  defies  descriplioo. 

Tbe  muscles  of  the  trunk  arc  implicated,  and  their  unequal 

dJMrderly  contractions  produce  sudden  lateral   and    antero- 

fosterior  deviationa  of  the  vertebral  column,  which  in  certain 

jOHCs  may  be  so  violent  that  the  patient  is  thrown  from  his 

'eh&ir  or  out  of  bed.    Tim  musclts  of  the  lower  extremities  also 

undergo  irregular  contractions,  causing  cvontioo  and  inversion 

of  the  foot  and  various  contortions  of  the  toes,  an  well  as  move* 

nieut»i  at  the  larger  articulations.     Choreic  movementa  cease  aa 

B  nile  during  sleep  and  under  the  influence  of  chloroform,  but 

ID  aggravated  cases  tbey  may  continue  during  sleep  ;  the  pupils 

are  usually  dilated,  and  their  reaction  to  light  is  diminished. 

The  respiratory  rhythm  become*  irregular  and  jerky,  and  on 

[luyiigoscopii'  cxamiuatioii  the  vocal  cords  hare  been  obtiurved 

lo  act  in  au  irregular  and  disorderly  manner  (roa  Ziemsaen). 

Moht  of  the  irregular  moveiucuta  just  described  may  occur 
tturiug  repose,  although  they  are  much  exaggurated  when  the 
patient  is  under  observation  or  excited   in  any  way.     When, 
however,  tbe  paliwnt  endcaviiuns  to  execute  a  voluntary  move- 
ment, the  motor  disorder  becomes,  aa  a  rule,  greatly  increased. 
I A  distiDctien  has  been  drawn  by  I>r.  Qowers  between  the 
[dioceie  movements  that  occur  during  repose,  and  tbe  motor 
UKO-ordioatioa  observed  during  attempts  at  voluntary  move- 
riBcnts  which  taay  bo  called  choreic  ataxia;  but  whether  this 

AAA 


SIS 


CHOKX&. 


dutioction  be  vaiiA  or  oot,  it  is  uoiloubted  tliai  gnat 
co-ordination  diiriog  attempts  at  Toluntaiy  morement  i 
present  in  cajtes  iu  which  the  choreic  movements  of 
alifjht;  and,  oonversely,  the  voluntary  iocOKirdiiutHHi 
slight  in  ca908  in  which  the  choreic  movementa  of 
exceesive.  In  coses  of  moderate  inteDsitjr  d«l>cals 
operations,  such  as  tboiie  ret|uired  for  writing,  aewui 
playing  upon  musical  instruments,  ftlone  become  iaqn 
while  operationii,  like  eating,  requiring  lees  oorapUcatod 
ments  for  their  performance,  are  still  effected,  ftlihooyk 
imperfect  and  round-about  maDner,  and  after  freqaeot  int 
tions  from  the  iuvoluntary  contraction  of  antagoauttic 

In  aggravatett  casctf  it  bccomos  impossible  to  eiecute 
any  inteuded  movemettt.  When  the  patient  endeafs 
cflTry  aoytliing  to  bis  mooth,  such  as  a  glass  of 
I»ogres8  of  his  arm  is  arrested  by  a  series  of  jerfc 
ooDtradiotory  movements  which  may  scatter  the  oonl4 
the  glass  in  every  direction;  the  patient  cannot  botes 
unbutton  his  clothes ;  the  msintenanee  of  the  eract 
difficult  or  impossible  ;  and  oven  in  the  rocumbeot  poM 
is  not  free  from  the  danger  of  being  thrust  ont  of 
clothes  and  linen  become  worn  out  by  oonstAat  mbbta 
the  skin  over  the  promineot  bones  beeomes  erythemsta 
may  ulcerate. 

On  the  patient  being  asked  to  sbow  the  tongue  be  pre 
it  with  a  jerk,  the  mouth  being  opened  to  an  imosi 
extent ;  the  tongue  is  immedistely  withdrawn,  white  ttw 
and  jaws  close  upon  it  with  viotence.  When  the  palie 
deavonrs  to  apeak  the  oouTulsire  action  of  the  facial 
becomes  aggravated ;  his  articalation  is  irregular,  jttkj, 
ing,  or  Btamm^ing ;  his  voice  is  moootonotis ;  and  in 
vated  coses  his  speech  ie  so  disordered  as  to  bo  oIi 
entirely  unintelligible,  Spasmodic  contractioa  extend 
muscles  of  mastication  and  deglutition,  and  oouseqaeoCl 
fuQCtions  are  performed  imperfectly  and  with  difficulty. 

Hemkkorca. — The    spasmodic  phenomena   are 
limited  to  the  roascles  of  onc-bolf  the  body,   the  as 
variety  occurring  in  about  one-fifth  of  all  cases.    SocM 
state  that  the  left  and  others  that  tbe  right  is  more 


CHOREA. 


819 


ifiected,  bnt  there  does  not  appear  to  be  a  great  ditTerence 
between  their  relative  liability.  Broadbont  asserts  that  tbe 
IDtucles  bilaterally  associated  in  tbeir  actions,  aud  which  are 
Mimparativcly  spared  io  hemiplegia,  are  affecbeJ  toitoiU'C  extent 

I  both  sides  in  hemichorea. 

The  other  symptoms  of  hemichorea  are  the  same  as  those  of 

BDcral  chorea,  and  do  not  require  separate  descriptioo. 
Althongh  HpaAtnodic  motor  diattirbaDce  constitutes  the  most 
ftaracterislic  feature  of  chorea,  it  must  not  be  forgotten  that 

certain  degree  of  rau&cular  weaknciss  is  always  present,  this 
wing  easy  of  recog&itloD  m  cases  of  hemichorea.  Indeed, 
owards  the  termination  of  the  atFootioD  or  duriog  ita  course, 
ho  choreic  movements  may  be  replaced  by  a  more  or  less 

<iup]i>to  heiotplegta  or  paraplegia,  and  we  have  already  seen 

lat  paralytic  aymptoms  may  precede  the  development  of  the 
ibaractoristic  luovementH. 
The  electric  excitability  of  the  nerves  and  rausclea  is  aaid  to 

I  increased  to  both  currents,  a  fact  more  readily  proved  in 
iwnichorea  than  lu  the  bilateral  variety  (Rosenthal,  Gowers). 

The  reflex  excitability  is  said  by  some  autbom  to  be  iocreasod 

Dd  by  others  to  be  dimiuuhed. 

Senwry  disturbances  are  not  frequently  observed  ic  chorea. 

'ainful  poiiita  have  been  found  at  times  in  the  course  of  the 
lerre  trunks  of  the  affected  region,  while  tendemeM  on  pressure 
vrer  the  spinous  processes  of  some  of  the  vertebree  is  occasionaUy 

let  viih.  At  other  times  cutauooua  hypertbsilhesia  or  byperaU 
BBta  distributed  over  half  or  the  whole  of  the  body  has  been 
bserved,  but  aofesthesia  of  like  distribution  is  more  common. 

VaBO-tnotur  and  secretory  diaturhancee  arc  waDting.  there  arc 

t  special  trophic  changes,  and  the  general  health  does  Dot 
aCer,  except  in  aggravated  and  chronic  cases,  in  which  the  ooq- 
Caot  agitation  and  waot  of  sleep  induces  a  condition  of  aascmia 

id  general  marasmus. 

Pgyckleal  disturbances  are  invariably  observed  in  chorea. 
3wilieDt.ll  depression  and  irritability  with  which  the  diseofle 

g^OS  QSaalty  increase  during  its  course.     The  patient  is  obeti- 

.te,  taciturn,  and  even  violent  towards  parents  and  atteDdnnts. 

e  suifers  from  impairment  of  memory,  ineapatity  for  thinking, 
ad  general  intellectual  weakneus.      At  times  there  mny  bo 


taaj~, 


■UUU   UIUID*1U^~1 


from  disease  of  the  valves  or  of  functional 
not  usually  uccompaoied  by  pyrexia,  bat  in 
lliere  is  violent  muscular  action,  elevation  of 
ODCommoo.   Wbeo  it  ia  as»ociat<,il  with  acuta  liiwu 
or  less  fevM  is  necessarily  present. 


al  ongu 
1  MVifl 

ifteoji 
taibwu 

r.— Clfl 


§  dOO.  Course,  DaratiotL,  ami  BemtUa.- 
ruus  a  cbronic  course,  lasting  in  the  majority  of  a 
to  eight  weeka ;  while  aggravated  caoea  awy  ooDti 
to  five  mouths.  The  disease  may,  indeed,  bat  iu| 
it  is  probablv  that  such  coaea  are  the  result  of  |fl 
tomicft]  lesions  in  the  nervous  eystetn. 

The  course  of  the  disease  is  seldom  uniform, 
are  fr^uent;  alight  Giaotiooal  disturbancasoftCD  a 
symptoms  or  induce  a  relapse  during  convaletceuD 

Chorea  frequently  recurs  at  varying  intervals  1 
attack  may  be  induced  by  emotional  dtsturfooaee,  b 
or  by  the  pr&.'tencc  of  ad  acute  disease.  Mostfl 
occur  during  puberty,  but  among  pereons  who  iH 
or  before  thin  period  they  may  appear  at  from  tl 
years  oF  age  or  later. 

The  disease  generally  terminates  in  complet 
a  nervous  6ilgelty  manner,  exhibiting  itself  to 
needless  baste,  and  want  of  precision  iu  executii 


-__:—  c- -. 


CHOREA. 


821 


tofreqiicotly  fatal  S^  founcl  a  mortality  of  57  per  cent 
cboreu  of  clildren;  whilst  the  statistics  of  Wenze!  givo 
ality  of  S7'3  per  cent  in  the  cliorea  of  pregnant  women. 
Luse  of  death  in  chorea  is  genemlly  to  1>e  assigned  to 
I  oanapticationK,  but  occafioually  to  the  iatentiity  of  the 
P  itself.  la  the  latter  cases  the  symptoms  are  UDusually 
uid  violeul  from  ibe  first,  aod  attain  excee»ive  severity 
w  days  ;  the  choreic  movements  cease  either  guddenly  or 
lly  and  cuUapse  seta  in,  along  wit-h  complete  muscular 
ion  and  iuvoluntary  erocuatious,  and  death  fallows 
ad  by  coma. 


)I.  Morbid  Anatomy.  —  In  the  old  obnorvationa  of 
Ibier,  Romberg,  and  others,  foci  of  BoftL^ning  were  found 
Loas  parts  of  the  braio,  but  tbe  absence  of  a  careful 
Wpical  examination  grc«11y  diminishes  the  value  of  these 
I.  BrowD-S^quard  and  tieiidrou  ubBervod  ftoftening  of 
nal  cord.  Tuckwell  in  1867  found,  at  the  post-mortem 
taCion  of  a  patient  dead  of  chorea,  fibrinous  vegetationa 

Talvee  of  the  heatl.  a  branch  uf  the  middle  cerebral  and 
t  of  the  posterior  cerebral  artery  occluded  Iiy  emboli,  and 
rod  softening  in  the  cortex  of  the  brain  corre-s ponding  to 
tributiuu  of  tbe  occluded  vetutels.  It  may  be  noticed  in 
f  that  Kirkea  ha>l  suggested  in  1850  and  again  In  1863 
le  well-known  relation  between  rheumatism  and  chorea 
be  found  in  the  endocanlitis  caused  by  the  former,  giving 
tta  turn  to  multiple  emboliem  of  tbe  vensels  of  the  braiu. 
ublinhed  in  1868  au  analyttis  of  uinety-six  caae»  of  chorea, 
I  of  th^se  were  fatal,  and  a  porit-inortcm  examination 
b  waa  ubtuintxl.  Cardiac  Ictioud,  consiatiog  of  fibrinous 
li  OD  the  Talves,  vera  fouod  ia  tea  cases  only.  lo  six 
tioD  of  the  nervcas  centres  was  noted.  In  a  girl  of 
^n  who  died  from  maniacal  chorea  during  pregnancy, 
tmia  of  the  surface  and  softening  of  other  part«  of  tbe 
(rare  observed.     The  anterior  culunm  of  the  spinal  ccrd 

lower  dorsal  region,  on  a  tevel  with  the  ninth  clorRal 
,  was  swollen  and  softened.  A  microscopical  oxaminatioo, 
ited  by  Loclthart  Claike,  reveaUd  eoftening  of  the  white 
jtce  and  extravasations  of  blood,  with  granular  exud&ttou. 


£vid«Dee8  of  endocarditis  were  round  ooly  in  one  of 
Fatal  ca»es  of  the  chorea  of  pregnancy,  io  wln( 
of  eodocarditis  were  obMrved,  have  boon  recorded 
LawBOD  Tait,  and  BamoB.  Aitkeu  found  ihe 
tho  corpora  striata  and  optic  thaluni  of  a  person 
mucli  less  tlian  that  of  otlier  parts  of  the  mne 
saiuti  parts  ia  hcaltbj'  brains.  Numerooa 
in  the  brain  and  spinal  cord  b/  Meynert  in  chom. 
changes  consisted  of  hyaline  swelling  with  molecnlji 
tion  of  the  protoplaBm  of  the  cells  of  the  cortex 
partial  sclerosis  of  the  cells  of  the  cortex  of  tho 
and  of  the  ha»al  ganglia,  and  multiplication  of  the 
nerve  cells.  He  also  found  great  multiplication  oU 
the  neuroglia  and  swelling  of  Deiter's  celta  in  tlQ 
Eliflcber  found,  in  a  pregnant  woman  dead  of  ohOI 
proIifenitLOo,  hyperplasia  of  the  connective  ttasue, 
of  tho  tunica  odventitia  of  the  smalt  veaaeb 
striatum,  and  dirision  of  the  ouolei  of  the  m 
clauatrum.  The  spinal  cord  presented  tbick«ai 
proliferation  in  the  walla  of  the  vessels,  tbickenin, 
dyma  of  the  central  canal,  and  nuclear  prt^fi 
nective  tissue  around  the  nervo  celts  of  the  grey 
cells  themselves  preeented  a  duU  appoaraoee,  were 
nuclei,  and  611ed  with   pigment     The  white  cut 


II  ohoi 
ie.M| 

miaP 
fceninjM 
feratd| 
eroy  ml 


CHOOEi. 


ftSS 


bnua  anil  spioal  cord,  exudatioDs  or  small  bieoiorrliagM 
*t«d  sometimea  1>y  tbc  presence  of  blood  crystals,  iato  the 
Bia  surroQDding  the  distODdcd  voimIb,  and  in  chronic  cu«a 
\m  of  sclerosis  in  tbe  neigttbourliood  of  the  vc^seli).  Tbeto 
fUBB  were  most  pronounced  in  th«  corpora  Rtriata  and  opUc 
mii,  the  anterior  perforated  apacos,  and  at  tlia  junction  of 
KMtdrior  grey  lioms  aud  ceotnil  cuLumus  of  the  apiual  cord, 
lially  in  the  upper  domal  and  cervical  regions.  In  one  cnse 
lentral  canal  of  tbe  dorsal  region  of  the  spinal  canal  was 
Jy  dutAoded  by  bloody  Berum.  "Speaking  generally," 
Dr.  DickiQiiOD,  "  the  chosen  seats  of  tke  choreic  changes 
be  parts  of  tbe  brain  which  lie  between  the  beginning  of 
Diddle  cerebral  arterien  and  tbc  corpora  striata— the  partes 
iratw! ;  and  in  the  oord  tbe  central  portion  of  each  lateral 
1  of  grey  matter  compriBing  tbe  root  of  each  posterior  horn." 
ill  bv  cvidi-nt  how  tbeee  ohsorrations  of  Dr.  Dickinson  hear 
the  theory  advanced  in  these  pf^es  as  to  tbu  groat  patho- 
ol  itaportaucc  of  tbe  ports  of  tbe  nervous  system  which  I 
termed  accessory. 

epical  examination  of  tbe  ncrrous  system  io  a  cas« 

Fia.  2S3. 


r~^ 


OV 


mnM. 


(Yrnins).    SntMn  iff  U(  Ctiyital  Rigvm  of  the  Spiniti  Oordfrum  a  asM  «/ 
■.— «;  Cenlnl  caaal ;  A.  BDcl  P,  Anlcrior  «Di' " 


:  *Dd  Potterior  horvM  n*p»otxwe\j. 


SSi 


CHOmUL 


of  fatal  chorea,  which  I  had  the  opportunity  of  mskin^  tnj 
I  me  to  ooafirm  to  a  large  exl«at  the  statements  of  Dr.  Didcu 
In  the  cases  he  de«cribw  periarterial  «rMioas  aod  lueawnlri 
occurred  arauod  tbo  ceotrol  artery  and  its  prinuij 
while  iti  ray  case  the  moat  pronotmoed  cbaogM  were 
the  anterior  and  antcro-lotenl  arteriei.  All  the  veneU  tf 
cord  wore  more  or  less  disteodod  with  red  Uood  coqmsdai, 
ia  some  sections  a  fihrinous  plug  was  obsprred  in  the 
or  autero-kt«ral  artvrics,  tho  vo^ul  being  distuodod  by  it  (, 
283).  Spots  of  necrotic  softening  wer«  observed  in  tbc 
atriata.  A  section  of  the  spinal  cord  from  a  cue  of  choni 
exhibited  by  Dr.  Buiy  at  the  UanchcBtcr  Microsoopical 
Ln  which  the  periarterial  exudntioos  and  biemwrbagci  nmi 
hranchea  of  the  central  artery  were  distinctly  afaown  {Fi^ 


Fio.  384. 


N}  V 


f 


■^•\' 


Flo.  SU  (Dvnr).    ANfMMt/UU  JnlcrwrOMirS'tnitrbUCtoMMl 

Fmr,~cc  OntUal  can) ;  ac;  Aatvior  muaiheiai ;  A,  Aalmor  ma 


and  corresponded  accurately  to  Iho  doacriptton  and  dnwia 
Dr.  DickioMO.  But  although  do  decided  cbaogea  ven 
in  the  tissues  near  the  central  artery  of  Ibe  !<pina]  oetd 
cagoeiaminod  byme.l  was  struck  with  thcaltemtioiw, 
by  the  aoceosury  oelU  of  the  anterior  grey  bonu  in  oompai 
with  the  fundamental  cells. 


The  aooessory  celU  could 


CHOBBA. 


82d 


[with  a  low  powfif,  and  arc  therefore  not  represonte^  in 

;  but  with  a  higher  power  they  appeared  ahrivelied, 

plasm  was  gniaular,  tbo  nucloi  were  obHctir«,  and 

of  the  prooeasea  were  indistiDCt  or  ahsent.     The  lai^er 

lental  celU  did  not  appear  much  altered.     Of  tweuty- 

■tal  cases  of  chorea  collected  by  Dr.  Dickinson  the  heart 

und  healthy  in  ftve  only,  an<3  of  thene  one  only  vra»  a 

i    As  Dr.  Dickinson  remarks,  endocarditis  appeara  lobe  an 

at  invariable  accompaniment  of  fatal  chorea  in  children, 

t  bcaJiag   of  the  initrai    valve  with   lymph  ta  probably 

t  in  every  ioHtance  of  cardiac  complication.     In  the  case 

ed  by  me  the  free  t-dges  of  tho  mitral  valve  wei'e  fringed 

ff  of  fihriuouH  beads. 


Morbid  Physiology.  —  In  1868,  Broadbeiit  nud 
iags-Jackson  almost  simultaneously  advanced  the  hypo- 
I  that  the  corpus  striatum  and  optic  tbalanitis  are  the 
I  centroH  in  which  the  Icsione  in  chorea  are  localiRcd. 
ilings-JacltsoD  surmised  that  the  convolulioDs  oF  the  cortex 
ted  uear  the  eorpiia  slriainm  were  also  involved  in  the 
<e.  The  observations  of  Meynert,  Dickinson,  and  others 
toed  by  the  c&ae  examined  by  myself,  prove  that  the 
s  are  widely  distributed  throughout  tho  brain  and  spinal 


Bndegivoiir  hii»  hwn  mode  to  dctenniiie  tho  Incaliioition  of  the 
in  rfuiiva  liy  «i|ii-nniviit»l  iiivestigatinn.  Chauveau  liirided  the 
I«or1  cloM  to  tho  skull  in  a  <l()^  uuflunn^  fmui  gciK^ml  ^-lii>r«a,  ujid 
that  th«  choreio  moroinentK  cotiiimo'it  iitmliiitrcl  (iniil  !>»■  ilcftth  of 
Inalsftvornl  hoiira  nEl«r  the  M|..  rili-'ii.     TIm' ..■■ir. -il -i'-'  ■     'its 

tailuHl  poBtcrior  eitreiiiitu-.'  '-.■.i-.nl  luiiiin'iiiii'i.'l.v  f-ii  tin   -_ iinl 

lividcd  in  th«  •tnraal  region.  Fr»m  the  roeiilta  of  tlwjso  «xi>«riment«, 
JBou  cundiiiW  UiAt  tlm  HgricDil  conl  in  tho  seat  of  the  Imion.  Similsr 
Donttt  vvK  <y<ii4ttoUi<l  hy  Longot,  Borh,  tuid  Cnrvillo,  anil  the  Mino 
■Ion  arriviirl  nt. 

and  Oiiimmi  fnimd  that  irritation  of  tha  posterior  cntamns  of 

:1  MTd  vitb  th»  ftcalpel  increoaed  lii«  twitchiiigfi.     The  chnTvio 

its  ccosud  uu  tlie  mnl  beinj?  exprawil  In  a  inirroiit  of  L-old  lur, 

ipearcd  on  it^  Iwitig  KiiW>qu«nt1v  roojati'-nitd  wiltt  warm  water. 

of  tlic  iKKftcrior  rocita  did  not  pxi-rt  any  iiiilurucn  mi  the  cliunejc 

ats.      PartiiiJ    n.'iii(tv»]    of   tlin   jioKU-rior  oonmu  and   coliimnH 

I,  and  uomploto  excision  »f  tbcni  aboUahod  the  iiici\c«Q£aW    Kn 


820 


CBOllEA. 


oHCondiug  galvaiuo  cun«ut  thnnigh  the  cord  inorawwd  tliB  JalMAy  i 
bvqiwacr  of  tbo  oontuK^ioos ;  wbila  b  iloaocnding  vaamA  ^mim 
than  oontiiderMbljr.     Th«  authora  coududfl  from  Umm  «i|Hniimai( 
the  morbid  procow  in  chvrva  )mi^i»t«a  tbo  oam  c«lU  of  tW  | 
grey  OMnua  of  the  spina]  oard,  or  the  nerre  Sbrm  wliidi  ontta  tibtm  < 
tbe  oolb  of  tbo  oDterior  ooniu&    BoMntfattl  uywted  fino  Aowct  i 
the  left  c»n>tiiJ  srt«i7  of  a  dog  mittnia^  ttam  ofaonio  mamaMIt  tt  t 
liglit  Tore-kg.    All  rDluntary  raoTcoMott  wgn  tnataatly 
dioroic  iiiuvoDienU  becanie  much  stronger  tn  tba  aSiwCad  csUmAf,! 
involvo.1  tho  «7«Iids  and  tail,  laitiiig  mtit  tlM  muomI  i&tA  h»  < 
nitWquoiitly.    Tbe  aato])^  revealad  floopbalitia  of  tba  left  mtwiorl 
Mftftning  of  the  left  oorpus  stristuUi  aikd  «inbolism  of  lb*  Ml 
aitoy.    A  Diicroaoc^c  gmniinatioo  ooaductad  by  Dr.  ScbriW 
spots  of  iiKliftrated  ooaiwctiv«  tlum  in  muijr  parts  of  tti«  Uslb  i 
stance.    Ciuiine  cJiorea  in  by  no  moonit  the  amae  diauwe  aa  tint  «^  < 
same  naiiu  in  man,  and  it  waulil  be  hasardoua  to  attaeb  muel) 
to  any  of  tluM  etperifflaita. 

The  uftturc  of  tlio  Icstoo  \a  chorea  haa  beea  a  cubji^tcf  i 
much  coDtrovtiray  as  its  localUatioQ.  Tbe  r«latif>a  bet* 
rheumatistn  aad  chorea  bad  beoo  kaown  for  a  long  tioM^ 
Bright  went  ao  far  aa  to  aasert  tbat  thflumatic  pericardhb  w 
the  most  ftvquent  cauM  of  chorea.  la  1850,  and  aguQ  in  IMl 
Rirkeft  suggeated  that  endocarditis  was  tlie  ouual  link  betma 
rfaounatism  and  chorea.  Aooordlog  to  tbia  opinioD,  cbocv 
was  caused  by  embolic  particles  washed  off  from  the  inflaaed 
flodocardiiim  and  Arrested  in  the  vessels  of  tbe  brun  and  sfwl 
cord.  Hughting9-Ja(^flOD  adopted  this  view,  and  ia  1S$8  ht 
advanced  the  opinion  tbat  cborea  wa«  caused  b^  iiinhi|ii 
emboliBtn  of  tbe  nutritive  arteriea  of  the  basal  gatiglift  wtA 
couvolutioDS  of  the  cortex  of  tbe  brain  situated  near  to  dui 
corpus  striatum.  It  cannot  ba  doubted  that  omboUim  of  (ki 
veaids  of  the  nervous  centres  does  occur  at  timea  in  cfaoiM 
ioaamuch  as  some  of  the  vessels  of  tbe  brain  have  been  taoak 
actutilly  occluded  by  an  embolus  in  fatal  tosea,  wfatle  fcba  vm- 
ilitiou  liable  to  oocaaion  embolism  is  praaeot  in  &  very  Ia9 
proportion  of  fatal  caaee.  On  the  other  band,  ia  some  &b1 
cases  there  has  beeo  an  entire  abeonco  of  cwdiic  oomplieatiift 
Again,  of  the  lai^e  majority  of  cases  which  recover,  allhoigit 
cardiac  complicatioQ  is  frequently  present,  yet  this  is  by  no  matm 
iuvariablo.  It  may,  therefore,  be  coaclud«d  that  although  dMm 
may  be  caused  by  multiple  cmbolium  of  tbe  Teaaets  of  the  i 


CHOBBA. 


827 


Item,  yet  the  ofTectiaD  mEty  occnr  in  tlio  nhaenoe  of  embolism, 
ftnd  it  is  Dot,  therefore,  tho  easeatial  conditioa  upou  wtiicb  the 
dlMOBo  depends.  Similar  roasotiing  applies  to  tho  opiDion  of 
the  humoral  pathologists,  who  believe  that  chorea  is  caused 
by  the  rheumatic  diathesis,  or  by  the  poinoa  of  rhoumfttiBm 
ciicolatiDg  ID  the  blood,  produciag  initatioD  of  the  tissues 
of  tho  oerrous  oyBtem.  Chorea  may  occur  in  the  abaeooe 
of  a  history  of  acLivo  rhtiumati;^m.  "  We  see  in  chnrftft," 
says  Br.  Dickinson,  "a  widely  dietributed  byponomia  of  tbe 
nerrops  centrea.  not  due  to  any  mechanical  miachanco,  but 
produced  mainly  by  causes  of  two  kinds— one  a  mortid,  pro- 
bably a  humoral,  influence,  which  may  affect  the  nervous  centres 
aa  it  affects  other  or^ns  an<I  tissues  ;  the  other,  irritation  in 
some  mode,  UBually  mental,  hut  sometimes  what  is  called  reflex, 
which  especially  beloogu  to  and  disturbs  the  nervous  system, 
and  affects  persona  differently,  according  to  the  inherent 
mobility  of  their  nature." 

To  tarn  to  tho  fintt  factor,  it  must  be  remembered  that  dis- 
tension of  the  blood  vessels  of  tbe  nervous  system  after  death 
by  no  means  proves  the  existence  of  an  active  hyperiHmia  during 
life.  The  conditions  usimtly  proaont,  such  as  cardiac  disease, 
are  such  as  to  cause  aniemia  of  tbe  nervous  system,  and  the 
pbenomena  of  chorea  are  best  explained  on  the  supposition 
that  the  excess  of  irritability  of  tbe  nervous  centres  is  caused 
by  defective  nutrition  of  tbeir  tissues. 

With  regard  to  the  second  factor,  tbe  profound  mental  im- 
preeeion  causing  chorea  is  usually  frij^ht,  one  of  the  depressing 
passions,  which  is  oertoiDly  more  calculated  to  exhaust  the  irri- 
tkbility  of  the  nervous  system  than  to  maintain  it  in  a  state  of 
continuous  activity  through  irritation.  Reflex  irritation  is  also 
more  likely  to  act  by  causing  anoimia  rather  than  hypersemia- 

The  third  co-operating  factor — inherent  instability  of  tbe 
nervous  centres — is  a  very  important  one.  It  is  probable  that 
the  children  io  some  families  inherit  an  unstable  nervous  sys- 
torn,  which  renders  them  liable  to  bo  directly  affected  by  chorea, 
hot  this  has  not  been  definitely  proved  aa  yet.  It  is  not  doubled, 
however,  tliat  an  inherent  tendency  to  develop  tbe  disease 
at  a  certain  age  exists.  As  Dr.  Dickinson  remarks,  "Every 
period  of  life  baa  its  own  regions  of  nervous  susoeptihility :  in 


830 


HEHIEBB'S    DtSE&SB. 


may  be  given  at  iirst  three  times  a  day,  bot  thia  doae  aiut  k 
gTa<laally  Jncrcastxl  daily ;  if  nausea  or  vomitiag  be  {wudwcd 
the  dose  (should  bo  slightly  dimiQished  for  a  few  day*  nai 
tolerance  is  eatabliahed.  After  this  it  Bbould  bo  agmio  g\ aiUJj 
incri»svd  uutil  the  symptoms  bogia  to  ini|miTe,  aiHl  tbeooa- 
linued  without  alteiatiou  uutU  iniprovemeDt  oeasea  of  tW 
disease  subsides.  The  tolerance  for  tlio  drug  beooma  m  glHt 
after  a  short  time  tbat  16  to  20  giaiofl  may  be  gif<u  tlim 
times  a  day  to  a  patieot  15  yean  of  age,  without  naus«&  or  or 
other  ill  effects  being  produced.  1  hnvo  made  a  fur  tml  4 
the  valarianato  and  the  bromide  of  suae,  but  bare  not  bul 
these  salLq  to  be  in  any  way  Ruperior  to  the  sulphnta  BnnD^ 
of  potawiiiim  does  not  appear  to  me  to  exert  any  fKVounbli 
influence  ou  the  progress  of  the  disease,  but  it  may  be  usA^ 
administered  with  or  without  chloral  when  psychical  diffiD* 
bsnce  and  sleeplessiiess  are  promioetit  syniptoma 

in.)   HiMI^Ra-S  DISEASE. 
r/mdttwv  VtrUffoJ 

§  906.  DfJinitimL—yiimhre'ii  disease  ifl  cb&raoterusd  If 
uttncks  of  vertigo,  auodated  with  noises  in  one  or  both  SM 
and  partial  deafoeas. 

§  907.  Etiology. — All  the  causes  which  produce  diwMS  4 
the  peripheral  organ  of  bearing  may  occasion  auditoiy  nrtigl 
and  they  need  not,  therefore,  be  eoumerated  here. 


§  908.  Synptom*.— The  characteristic  symptoms  of  IMsili^i 
disease  are  sometimes  preceded  by  partial  deafneas,  «*iikH 
and  other  indications  of  a  local  lesion  of  th«  poripberal  of^ 
of  hearing.  In  other  csms  the  patient  is  snddealy  sUKfcai 
with  noises  in  one  ear,  and  a  feeling  of  giddineaa,  uXtenAti  fcy 
faintneas,  nausea,  and  vomiting.  The  attack  paswa  off  b  a 
few  seconds  or  minat«s,  but  recurs  aftor  a  variaUe  pariad,  dw 
paroxysms  becoming  more  aggravated  and  mora 
repeated  as  the  disease  advanoes. 

The  noise  is  sometimes  heard  in  both  ears,  but  it  iji 
always  mgre  proooonoed  oa  one  side  than   the  other 


CHOREA.  829 

telj  to  be  misUkeD  for  cborea  Ihao  is  Ibe  tremor  associatei 

ith  old  ago,  and  with  clironic  poisoning  by  alcohol,  lead,  or 

ercary.     The  spasmodic  movemetita   occurring  iu  groujis  of 

Ivselcs  supplied  by  ccrtmo  oerves,  such  u  convulsire  tic,  and 

koae  occiimng  in  dehnito  groaps  of  muscles  eogaged  iu  per- 

ling  certain  actions,  as  in  the  case  of  writer's  cramp,  are 

Mparated  from  the  movements  of  chorea  by  broad  lines  of 

itiou. 

{^  904.  Pi-og-no»i.8. — The  prognosis  of  chorea  is,  as  a  rule, 

ITOurable.     Jt  becomes  grave,  however,  when  t!ie  movements 

so  violent  as  to  exhaust  the  patient,  cau.se  sleeplesKineiiB,  aad 

went  sufficient  food  being  taken,  or  when  there  is  delirium. 

chorea  of  pruguaucy  is  much  more  fatal  than  that  which 

in  about  and  before  puberty. 

§  BOiS.   TTCutnietit.—  In   the  treatment  of  chorea   the  diet 
iould  be  carefully  regulated ;  and  any  source  of  reflex  irritation. 
icb  as  iatestiual  worms,  should  be  removed.     If  aiia;mia  be 
:nt,  iron  may  be  given,  cither  alone  or  along  with  cod  liver 
irbile  if  rheumatism  complicate  the  case,  salicylate  of  soda 
initt  be  administered.    The  use  of  the  hot  vapour  bath  bos 
iB  much  pruisud  m  thctruutmcut  of  chorea,  and  it  is  worth  a 
ial  in  cases  in  which  a  rheumatic  diathesis  can  be  tiaced,  evea 
there  be  no  active  rheumatism  at  the  time  of  the  attack. 
fhc  child  should  be  immediatoiy  removed  from  school,  all  in- 
allectual  work  suspended,  aad  even  bodily  exertion  avoided  io 
the  early  stage  of  the  diseane. 

The  mediciues  which  appear  to  do  mwit  good  arc  the  nervine 
tOQica.  and  of  these  anionic  in  probably  the  best.  Ziemssen 
recommends  a.  dose  of  from  fivfi  to  eight  drops  of  Fowler's 
solution  for  children,  and  eight  to  twelve  drops  for  adults. 
Uoftt  practitionem  will  be  inclined  to  begin  with  a  smaller 
dose  and  gradually  increase  it.  Iron  may  be  combined  with 
arMnic  if  the  patient  be  aniemic  and  the  stomach  bears  it  well. 
If  the  arsenic  lia!;  not  produced  a  decided  improvement  in  the 
symptoms  withiu  a  period  of  a  week  or  leu  duys,  zinc  may  be 
nibstitated,  the  nulphate  being  the  most  convenient  preparation 
aod  as  suoceasful  m  any  other.    A  dose  of  two  or  three  grains 


83S  MKNIKRE'S    DISEASK. 

left,  to  right,  or  Id  the  same  direction  u  Ute  roUtioo  of  d* 
eyes.     Am  instructive  cue  of  thia  disease  is  reconiod  hflk. 
Lewia  Mackenzie  and  quoted  by  Qughlic^-Jaduoa,  in  vU 
the  patient — a  medical  raao — vra*  mncb   diatreased  by  i» 
tiouous  noises  in  tbe  ngfat  ear,  roliowiog  tlie  diKbugv^i 
heavily- loHdcd  gun   near  it^  artd,  aluag  with   ibc  «tli-:r 
usual  sympuitus  of  auditory  vertigo,  there  wu  maaifct;,v 
constant  teDdeocy  to  walk  tu  the  left 

§  909.  Courge, Duration,  and  TerminattonM. — ^Tlie  | 
of  vertigo  come  on  at  5i8t  at  irregular  iutervals ;  ihoy  ii 
gradually  in  frequency  and  intensity,  and  in  aggtanudi 
[he  patieut  suffers  coDtiououaly  from  some  degree  of 
while  tiu  is  liable  to  paroxysmal  exacerbations  of  great  i 
Tbe  Doises  ia  the  earn  oiay  ceaae  at  finit  during  the  in 
but  after  a   time   become   cuustanL      Tbe   sense   of 
becomes  gradually  diminished,  and  ultimately  complete 
uesB  of  tho  affected  eur  is  estabtished,  when.  fortDQAieij.  i 
paroiysma  of  vertigo  and  all  the  distreaaiog  aymfAocneift 
disease  cooaa 

tj  !tIO.  lUtnhid   Anaiomy  attd  Pkyaiolagy. — Seven! 
mortem  examinations  have  revealed  the  presence 
matory  uxudution  in  tho  semicircular  canal&     The  sj 
under  couaideratioa  are,  however,  often  associated  vith^ 
of  tho  middle  or  cxterual  car,  but  iu  such  casui  some 
intliience  is  probably  exerted  on  the  labyrtDtb. 

§  911.  Diagncm*  and  Prognoai*. — Auditory  veitig»i»' 
to  b«  mistaken  for  the  vertigo  associated  with  gfeftric  (ltw>< 
oexual  excess,  tbe  diagnosis  being  rendered  more 
the  fact  that  a  couHiderable  degree  of  deafnemi  and 
the  ears  may  be  prcsout  in  tho  latter.     In  auditory 
nwses  are  unilateral,  the  feeling  of  vertigo  is  very  int««>'.i 
if  accompanied  by  a  iiensalion  as  if  the  body  bad  ui 
actual  displacemeut ;  these  symptums  never  occor  to  tlici 
degree  in  the  vertigo  of  dyspepsia  or  seiusJ  exoesiL 
of   auditory   vertigo  may   be  niistaken    for   epitaptic 
axL^  c&n  ctnV'j  Nn^  diauu^utshud  by  a  careful  examipatwarf' 


HBNIEHBK    omiOSIC 


833 


Bjnnptoma.  The  progoDsis  is  grave  as  far  as  ultimate  recover;  U 
poQceroed,  but  the  symptoms  disappc'ar  wliea  complete  deafness 
eetablifhed. 

§  91S.  TTwUment. — IT  ibe  symptoms  depend  upou  disease 
dT  tb«  exterual  or  middle  ear,  tUe  patieat  should   be  pUiced 
ider  th(f  cure  of  the  speeiulist,  and  wbCD  Ibc  lucat  disease 
Qot  aceesuble  to  treatmeot,  relief  may  be  obiaioed  by  rest  iu 
le  recumb(>ut  posture.     Tb«  admintstmtion  of  four  or  tive 
ins  of  quinioe  three  times  a  dav  appears  to  have  produced 
I  amelioratioD  of  the  symptoms  ia  several  caaea  (Charcot. 
!ngh  li  DgH-JacksoD). 


EPIDEMIC   CBREBRO-SPISAL    MEMN0IT18, 
HYUIiOPUOBU. 


(L)   KPtnSSaO   ORBEBRO.SPINAI' 

§  913.  Definition. — Epidemic  oer«bro-BpiDaI   i 
ao  acute  epidemk:  fever,  chnracterinic  symptoma 
CAUBcd  by  a  parulent  iDflanun&tioQ  of  th« 
pia  mator. 


(914.  IfittotTf. —  IhJm  diwate  pcobabl;  lacrailed 
but  wft  have  no  nliable  aooooato  of  it  before  Um 
Tb*  fint  cpideznio  prendlail  In  Oenerft,  io  the  tuiyT 
Then  foUotfwd  epidemic*  in  Grcsoble  (1814},  Tecool  (181 
on  the  Ui>pe  (1^3).  The  Aiwm  appMrnd  fat  SouUwm  i 
and  rMAAinod  oonAncd  for  mitaj  jonn  to  tfa«  bMrfoeki.  J 
that  it  attAiaod  ita  hi^irat  dwdofHucnt  in  FVvooe  (he  wfi 
to  Italy,  ciDil  proinuW  ifaoic  from  1839  to  the  •priog  of  19 

Io  1&44  a  tnnaient  epidemic  oocuired  in  Oibtaltw,  tb 
in  DensuriG,  aad  in  1846  it  kppeand  in  the  wnrkbomM  ol 
a  lew  cam  wen  ubwrved  in  UTacpooL  Tbe  ftJ^ttr  i 
ia  ISM  And  reApjieered  Ld  1801 ;  there  wm  ■: 
I8&9— I8G0. 

Ite  disease  may  bo  tnuod  hock  in  the  Daitad 


EPIDEBCIC  CEBKBBO-SPINAL  MKMISOITIS.  833 

§  915.  Etiology, 
^mdisposing  Oauaea. — When  the  disease  was  first  Doticed  io 
onthero  Fnuice  ia  1837,  aud  in  tbo  subeequeat  outbreaks  up 
>  IMS,  it  fras  almost  eotirely  confined  to  fiddlers.  Raw 
acniits  were  Bpecially  liable  to  be  affected,  anil  this  liability 
ras  probably  largely  due  to  great  physical  exertion  aud  an 
Wercrowdcd  condition  uf  the  garnsona.  In  subsequent  out- 
^■noks,  bowfiver,  in  France  and  elsewhere  no  special  liability  to 
the  disease  has  been  manifeatud  amou^'ul  tboae  euj^aged  in 
particular  employmCDt^. 

In  the  earlier  epidemics  males  were  almost  eiclusively 
Utacked ;  aud,  although  Kubaequunt  observation  hoe  not  con- 
irmed  the  idea  that  the  disease  is  peculiar  to  men,  it  is  tnucb 
Bore  common  to  them.  Age  does  not  appear  to  have  any 
Articular  influence  in  the  production  of  thu  discaso.  In  some 
pidemtcs  children,  in  otberii  youug  people,  aud  still  in  others 
duJts  of  from  thirty  to  thirty-Bve  have  been  attacked  la 
r«ate0t  proportion. 

diauase  U  especially  prevaUnt  in  the  cold  months  of  the 
and,  notwithstanding  some  apparent  exceptioas,  it  is 
oaoubtcdly  more  prevalent  amongst  the  poor  and  ill-fe<]  than 
3e  afHuent  classes.  In  a  large  number  of  epidemics  it  almost 
Eclusively  prevailed  amougst  the  inmates  of  prisons,  work- 
ODsas,  and  overcrowded  garrisons. 

§  916.  Spiiptoms. — Epidemic  cerebro-spinal  meningitis  may 
e  divided  into  four  varieties :  (1),  the  aimpU  ;  (2)  lho,/Ttimi- 
WtU;  (3),  the  par^jttric;  and  (4),  the  abortive  forms. 

(1)  Simple  Epidemic  Cei-ebro-Spinal  ^feninffitia. — Prc- 
BOnitoiy  symptoms  are  sometimes  observed,  consisting  of  Iocs 
f  appetite,  Ukssitudc,  and  neuralgic  pains  in  the  back  and 
tbdomoa.  Ab  a  rule,  however,  the  patient  is  suddenly  seized, 
rhile  following  bis  ordinary  occupations,  or  at  play,  with  sbivor- 
tig,  vomiting,  and  headache  (Burdon-Sanderson).  Profuse  and 
meontrollablfl  vomiting  is  almost  a  constant  symptom,  the 
gecteJ  maltera  consisting  at  first  of  half-digested  food  and 
abaequently  of  roucus  stnined  with  bile.  Delirium  now  auper- 
matee,  BomstimM  so  violent  in  charact«r  that  it  is  necessary  to 


899 


tiPIDEMlC  CEB.£BEO-SPIKXL  UEXtSGITU. 


pUc«  tlio  patioitt  under  restmiat,  bui  hu  »  uaoaliy 
Bod  drowsy,  aad  only  talks  uf  imojjtiuu-j  objecU  when 

The  pfttieat  soou  complains  of  an  agoouiag  pais  ia 
occiput  and  oape  of  the  neck,  which  may  extend  aloBf 
spine  aoJ  is  aggra7al«d  by  movement  and  preawn. 
abdomiaal  muscles,  as  well  as  those  of  the  back  and 
are  acutely  pAinrul,  and  aov  moTemoot  rendoriog  tbmi 
occasions  groal  pain.  The  ttkin  becomes  extremely 
and  severe  puia  is  felt  in  the  limbs,  but  It  '%*  difBciih  todAiv- 
mine  bow  much  is  due  to  cutaocouii  or  muscular  hypeivaUiaa 
The  head  is  retracted,  partly  from  spaeim  of  the  mucdet  of  At 
nape  of  ttie  neck,  but  mainly  as  an  instiDctive  means  of 
the  miucles  iu  order  to  reliere  pain.  In  no  case  coming 
the  observation  of  Dr.  Bunloo-SauderMU  vrera  the  con' 
of  the  muscles  of  the  back  of  the  neck  of  such  a  charictct 
be  correctly  calleil  tetanic.  *'  The  patienla."*  says  Dr. 
"  invariably  Uy  on  their  sides,  with  ibeir  koces  drawn  sp 
to  relieve  lite  abdominal  muscles,  and  with  tha  fftcr 
towards  the  huad  of  the  bod,  and  excessive  pain  i 
wheuever  the  body  was  morexl  in  nucfa  a  way  as  to  exlsad 
painful  miuKitcs,  and  more  particularly  when  ibe  pali— I  W 
lifted  in  bed."  Tho  period  of  invasion  lasts  front  ooa  to  tin 
daya,  and  in  tbcn  foUowed  by  the  stage  of  depmsioa. 

Tbe  menial  confusion  and  low-mutterJDg  delirittni,  wladlt 
preseut  iu  the  stage  of  iuvaeioD,  now  gives  place  to  stupor,  «M 
in  fifttal  cases  ends  in  profound  coma.  The  pkUetit  ties  it  > 
somnolent  condition,  although  often  able  to  answer  qasstisv 
when  roused.  Tbe  symptoms  are  liable  to  undor^  couidcnllt 
Huctustions ;  at  timee  the  sopor  prodominate*,  at  vUicr 
there  ore  restleRiineas  and  noottunal  delirium,  and  tbs 
ooutinues  to  complain  of  paiaa  in  the  back  of  the  oeckaaJa 
the  loina  Tremors  are  observed  in  the  extremities,  tfas  psl» 
is  slow,  tbe  face  is  livid,  the  pupils  dilated  or  coatoilsi 
and  strabismus,  amlilyopia,  or  desfaess  is  not  unusnalty  ft- 
sent.  In  several  children  iie«u  by  Dr.  Burdoo-SandeaieB  iks 
symptoms,  shortly  after  the  cessation  of  the  initial  period,  en 
Very  similar  to  tbose  of  tubercular  meoinifitis.  An  eniHW- 
loaious  eruption  appears  about  the  moulb,  estber  hke  thftii^ 
measles  or  scarlet  fever,  and  occasiooally  herpetic  la  disncW' 


KPIDEHIC  CEREBRO-SPINAI,  MESISOITTS. 


837 


ipreads  opwards  over  the  eyelids  and  ears,  aud  downwards 

the  chin  and  neck. 

|The  degree  of  pyrexia  varies  greatly  in  different  cases,  but 

temperature  usually  rftnges  from  100^' F.  to  108"  F.,  or  in 

cases  to  105^  F.  or  biglicr.     The  tongue  may  be  cltan,  the 

els  are  usually  constipated,  and  the  abdomea  is  retracted, 

urine  is  fretjuently  uibuminous,  destitute  of  chloriilea,  and 

tains  a  relatively  large  pruportiou  of  urates,  while  polyuria 

sacchariDe  urine  have  occaeionally  been  observed. 

n  unfavoiirable  cases  the  coma  increased  and  IwcomeH  lutso* 

,te<i  nritb  more  pronowncei!  paralytic  symptoms,  such  as  ptosis, 

kbiamuB,and  paresis  of  the  eztreinitie!).    The  pulite  is  feeble, 

irregular  or  intettnittent;  the  respiration  ia  embarraxsed,  a 

and  laboured  inspiration  being  followed  by  a  quick  expira- 

nnd  a  long  pauSL-  (Burdon-SandersonJ ;  the  skin  is  cyanotic, 

covered  with  a  cold  nweai  as  in  the  algide  stage  of  cholera; 

the  patient  soon  sinks. 

le  disease  frequently  terminates  favourably,  the  amend- 
it  being  indicated  by  a  gradual  subsidence  of  the  nervous 
euomena,  restoration  of  the  mental  faculties,  and  a  steady 
fall  in  temperature.  If  the  progress  towards  recovery  be  un- 
iDtermpted,  health  is  re-established  in  from  three  to  four  weeks. 
CoDvaleecence  U,  however,  often  delayed  for  a  long  time  by 
pses,  and  in  such  cases  recovery  is  often  incomplete. 

(2)  Fuiminaiit  Epiilemic  Certbro-Spinal  MeningUis.~ln 
this  variety  tho  patient  falls  without  any  premonitory  symptom 
ioto  a  state  of  collapse,  drowsiness  rapidly  hiiperveites,  and  is 
quickly  followed  by  coma.  Purpuric  spots  appear  over  the 
•urfikce  of  the  body  generally;  these  soon  change  from  a  puiplc 
to  a  black  colour,  and  arc  often  conHucnt  so  as  to  form  irregular 
patcbea,  Death  may  ensue  in  less  than  live  hours,  or  life  may 
be  prolonged  for  two  or  three  (iay.<t;  recovery  is  not  unknown 
even  iu  this  forai. 

(3)  Purpiinc  Epidemic  Certbro- Spinal  Meningitis. — ^In 
this  variety  the  symptoms  which  charncterise  the  simple  and 
fulminant  varietiea  are  combined  in  various  proportions.  In 
the  great  majority   of  cases  the  disease  follows  at   first  the 

uf  the  Nmple  variety ;  but  in  from  one  to  four  days  from 


EPIDEMIC  CGUESaO-SPINAL   MCSIHOITIS. 


the  beginniog  potechi»}  or  purpuric  spots  am  derdopod 
or  less  copiousljr,  aod  sometimea  tuamorrluge  occurs  fnn  I 
uiucous  tracU, 

(4)  Abortive  CerdmhSpvrud  MtningUta. — Duriog  tbe  bofta 
of  an  epidemic  cases  an  obMrved  in  which  the  pUuAtiOM- 
plain  of  severe  headache,  Btifibeu  of  the  ueck  or  evea  ilifh) 
retractiou  of  the  Lead,  and  cnalaise  without  being  compU 
to  deiiist  from  work.  Such  etaea  are  jusU/  regarded  u  a  niU 
form  of  the  disease,  conespoDding  to  the  acut«  toonUttti^  «litk 
is  ao  coiumoa  an  acoompauimeDt  of  epidemics  of  soarlei  font , 

Cases  bare  beon  obtsorvod  iu  varioua  cpidumics  in  vbicki 
symptoms  resembled  thoM  of  iat«rmitteDt  fever  of  the 
diaa  or  tertian  tjpo ;  other  cases  Lave  been  noticed  in 
tbe  patieat  falls  into  a  "  tjpboid  condition." 

C<wrM  and  Dur<Uion.~la  very  acute  cues  tbe 
t«rmiDate  fatally  in  from  one  to  &ve  days,  wliile  abortiTe  i 
may  end  in  recovery  in  tbe  Bame  time.  Caaw  of  frmhrr** 
severity  usually  begin  to  eoDvaloece  after  one  or  two  wodo.  bu 
ftomotitiies  they  last  much  loDger.  In  the  more  protracted  t 
live  to  eight  weokfl  olapso  before  the  patieot  begins  to 
vatesco,  and,  if  fatal,  death  takes  place  in  the  sixth  or  i 
week.  The  course  of  tbe  disease  towards  reeoveij  is  sAm 
iuierruptcd  by  relapses. 

In  the  fulmiaaat  variety  death  is  tbe  usual  result,  aod  asa 
iu  miUl  canefl  the  mortality  is  high  owing  to  complicatiou.  Tk 
rate  of  mortality  varies  very  much  in  difFert.-Dt  epidemica  b 
tbo  mitdcab  the  mortality  is  tltirty  per  cent;  in  tbe  svrsn* 
over  suvc'Dty  per  cent ;  the  average  being  about  forty  per  ott 

Compiicaiions  arid  SeqwddB. — The  course  of  tbe  dtssaie  ii 
liable  to  be  oompltcated  by  intercurrent  affections.  Tbe  wat 
important  complications  are  pleurisy,  pneumonia,  brooctaak 
pericarditis,  parotitis,  inflammation  of  tbo  large  joiati^  W- 
sores,  affections  of  tbe  special  senses,  parBlyseai,  pcyduosl  4» 
turbancos,  and  chronic  diseases  of  tbe  braiu  and  spinal  Mi 
The  organs  of  hearing  and  sight  are  specially  Ui^  la  k 
a0eet«d. 

Tbe  auditory  lesions  may  occur  in  the  middle  ear  or  is  i^ 
labyrinth.  When  tbe  loeioD  is  in  tbo  middle  ear  it  tMUsU; 
leads  to  perforation  of  tbe  membraoa  tympani,  and  purfaW 


KPIDEJOC  CKBEBRO-SPINAL  MENINaWIS.  839 

-e  or  leas  deafDau.    Suppuration  in  the  labynoth  affects,  as 

lie,  botb  ears,  aad  ends  in  complete  deafness.     Complete 

Fness  in  children  under  one  year  of  age  resultH  iu  deaf- 

and,  in  older  children,  speecb,  although    previoualy 

luircd,  becomes  inarticalateand  unintelligible.    Aphasia  may 

caused  by  the  mcritngitia,  but  recovery  generally  takes  placa 

lO  chief  aflfectioos  of  the  eye.  irhich  accompuny  or  follow 

;inic  cerebro-spioal  meningitis,  are  keratitis,   iritis  with 

trior  synechia,  choroiditis  with  detctchtucn.t  of  the  retina 

amauro-^s,  and  optic  oeuritia  with  subsequent  atropby  of 

nerve. 

Ajm  of  single  oerres,  oepecially  of  the  cranial  nerves  or 
supplying  a  ainfjie  extremity,  or  general  motor  weakness, 
■M  not  unfrec^uent  Hequelie ;  but  recovery  from  tbeee  usually 
takee  place. 

Meotal  reebleoeM  and  impairment  of  memory,  aphasia,  and 
uiartbriA  have  been  observed  as  sequels;  but  in  them  also  the 
proj^oeuK  is,  as  a  rule,  favourable 

Permaneat  lesion-s  of  the  bmin  and  cord,  and  their  mcm- 
bmnefl,  are  ofbea  observed,  dironic  hydTocephalua  being  the 
moat  frequent. 

"§  917.  Morbid  Anatomif. — The  easeutial  changes  found  on 
dissection  arc  hypursemia  of  the  pia  mater  of  the  brain  and 
spinal  cord,  with  more  or  less  abundant  suharachuoid  and 
tnieretittal  cffutsion  into  the  mcshea  of  tbe  congested  mem* 
bnme,  couaisting  either  of  serum  or  a  transparent  gelatinous 
material,  or  purulent  matter.  The  more  acute  the  counts  of  the 
dJMwe  the  less  abundant  is  the  exudation  found  between  tbe 
pia  mator  and  arachnoid.  In  the  fulminant  casee  exudation  is 
entirely  ahjeut ;  but  the  pta  mater  is  found  densely  infiltrated 
with  cells,  especially  in  the  neighbourhood  of  the  vessels.  If 
the  disease  have  laslod  for  two  or  three  daya,  tbe  exudation  is 
dtatinctly  purulent,  of  a  greasy,  gelatinous,  or  firmer  conuUtence, 
sometimes  tinged  with  blood,  and  s&vcral  lines  iu  thickness.  It 
is  deposited  ou  the  convexity  aud  at  the  baae,  especially  along 
tbecourM>  of  the  great  vessels  in  the  Sylvian  Bssure,  aud  along 
the  sulci,  between  the  pons  aud  chiasma,  and  on  the  pons  and 
cerebellum.    Tbe  exudation  conslata  of  pus  cells,  fi^e  granules, 


fuo  oases  In  which  hyperpyrexia  U  pr«s«iit  dosee  d 
to  thirty  grains  may  be  odtntoistercd.  Kiffot  oqj 
have  btien  employed,  but  with  douWul  reeuliA     I 

Id  the  later  periods  of  the  diaeaBe,  and  eHpecialln 
oases,  iodide  of  potassium  may  be  employed  with  tb 
curing  ahtiorptiou  of  the  exudation.    The  complia 
from  afFectiona  of  the  ears  and  eyes  must  be  nibjac 
treatmeut,  which  need  not  be  entered  into  hen 
should  be  n^ulated  aocordiog  to  the  titate  of 
general  symptoms. 

Tiie  other  setiuelie,  such  as  general   motor 
various  pareees,  may  be  treated  by  the  use  of 
cbaogo  of  air  to  a  mountainous  diittrict  or  Um 

(IL)  TKTANTJS. 

§  921.  Dejmiiian. — Tetanus  is  ao  acute  affi 
teriited  by  a  more  or  less  oootinnous  tooio  spasm 
tary  muscles  with  paroxysmal  exaoerbatiooa  of 
during  which  the  head,  trunk,  and  lower  sxtroauti 

taioed  in  an  arched  poaltion  owing  to  the  predoQ 
acUoQ  of  the  extemor  over  the  flexor  tnusclea.      J 

§  932.  Stiotogy. — The  disease  may  be.  aocordiq 


TETANtja  843 

led  and  forgotten  vrheo  the  Bymptoms  of  tetanus  make 
their  Appoinincc.  In  tome  cases  a  nerve  is  involved  in  the 
eiestrix,  while  in  olhere  a  foreign  body  has  been  found  embedded 
ID  it,  but  this  i»  oxceptionnl. 

Wounds  of  tho  extreniitioa  aro  said  to  be  more  freiiuently 
followed  by  tetAoua  than  those  of  the  head,  neck,  or  truok;  but 
the  condition  of  the  woand,  whether  it  be  healthy,  inflamed,  or 
fltougliiug,  does  not  appear  to  exert  much  influeuce  on  the 
production  of  the  affection.  The  inton-al  between  the  injury 
and  the  development  of  tetanus  varieH  greatly;  the  average 
duration  is  from  four  to  fourteen  days,  but  the  xympbonis 
may  begin  a  fuw  boura  or  bo  delayed  many  weeks  after  the 
iojury,  New-bom  children  are  liable  to  suffer  from  tetanus  the 
6ni  nine  days  after  birth  ;  it  appears  to  be  connected  with  the 
separation  of  the  umbilical  cord,  and  in  therefore  of  traumatic 
origin. 

The  idiopathic  ia  much  le»s  fre«|U«Qt  than  the  traumatic 
form.  The  moot  usual  cause  of  idiopathic  tetanus  is  exposure 
to  cold  and  damp,  more  especially  when  the  patient  is  warm 
and  perspiring. 

A  caae  of  tetanus  wa«  observed  by  Bright,  which  developed 
daring  the  course  of  acuto  rheumatism  with  pleurisy  and 
pericarditis.  At  other  times  the  disease  develops  after  abor- 
tion, but  the  condition  of  the  uterus  is  then  more  or  less 
like  that  of  an  open  wound.  In  some  cases,  where  tetanus  is 
reported  to  have  nuperveued  as  a  consequence  of  acute  internal 
diMiiue.  a  careful  search  might  have  discovered  the  exiRtence  of 
a  wound.  In  a  case  of  pneumonia  reported  by  Rottenthal  an 
enema  iiad  been  administered,  tlio  patient  complained  of  feeling 
pain  iu  the  anus,  and  »ymptomft  of  tetanus  xoou  appeared. 
At  Uie  autopoy  an  ulcer  of  the  rectum  was  found,  which  was 
probably  the  cause  of  the  tetanus.  UulariiL  appeals  to  give  rise 
to  an  intermittent  tetanus,  which  may  be  cured  by  tho  Ewlmiuis- 
tration  of  quinine  (Ooural).  Stiycboine  and  other  toxic  agents 
oMUe  symptoms  reeembliug  tetanus. 

Variotis  iofiuences  may  co-operate  witb  external  injury  in  the 
production  of  tetanus,  and  of  those  oxposuro  to  cold  and  damp 
is  the  most  frequent  and  impi>rtaot.  Tetanus,  indeed,  occurs 
with  the  grsatesC  frequency  during  military  campaigns,  when 


"wrtner,  fiiHwy  a 

Rose  has  eadeavowred  to  ftliow  that  improper  t 
tlio  wounded  iDCreuea  tbo  proportion  of  tetaou^  l 
no  doubt  that  the  proportion  of  cues  of  tetAoaii 
woonded  is  much  less  in  the  present  day  tfi»n  in  for 

The  mnio  i«  moro  freqnently  effected  vith  tetaa^ 
female  box  ;  it  is  mor*  frequpnt  in  youth  and  inid«l 
in  advanced  life,  and  the  robust  and  miuicnlar 
more  frequently  attacked  than  the  feebla 


I 


U! ! L 


§  9?3.  Symptoms. — Premonitwy  symptoma 
observed  in  tetanus  cooitiitting  of  shivering  or  a  ds 
a«naatton  of  dragging  in  the  neck,  stiSneM  in  certi 
difficulty  of  articulation  and  deglutition,  and  ja 
matic  cftRes  the  wound  may  become  sensitive, 
coDiplfLin  or  shooting  pains  radiating  from  iL 
may  occur  a  few  hoiin  or  e/en  a  few  days  befi 
teristic  tonic  spasms  make  their  appearance: 

The  spaams,  as  a  rule,  be^o  in  the  muoctes 
6rst  the  jawt  cfln  bo  separated,  and  the  movcmo: 
and  BwaUowing  be  accomplished,  although  mtl 
Soon,  however,  the  jaws  become  firmly  clenched,  i 
the  condition  enllod  triamiu;  nputn  of  the  rT<M>pba 
swallowing  of  even  a  amatl  quaatity  of  fluid  d 
fatiguing;  urticulntion  is  indistinct;  and  thp  voice 


TBTAKU8. 


846 


and  motiouIeM  ;  the  pupUs  are  generally  contracted  ;  the  brows 
■re  writikleil ;  and  all  the  Utititi  o(  the  f&ca  become  KlroDgly 
marked,  and  give  to  the  patient  an  nged  appearance. 

The  spuaro  rapidly  extcuda  to  the  muscles  uf  the  back  of  the 
aeck,  causiog  rcintction  of  tbu  head ;  while  the  erectores  spine 
Mxm  become  implicated,  and  the  vertebral  cohimn  is  ihca 
»rched  backwards  ;  the  chest  is  projected  forwards  ujid  reudt-red 
V«rj  bruEtd,  and  the  [tmiy  rcsta  on  the  hiick  uf  the  head 
and  sacrum,  coustitutiog  the  conditioD  called  opisthotonoa. 
The  epigastrium  is  sunk,  aud  the  ubUomci)  tlattcncd,  while  the 
hardness  aasuraed  by  the  ubdomiua)  muscleti  ia  characteristic 
On  rare  occaAioos  the  body  is  said  to  be  bent  forwards,  the 
oouvexity  of  the  arch  being  directed  backwards,  a  conditioa 
uamef]  eniprostfioUmoa.  lu  a  few  caBes  the  buxly  ia  inaintaioed 
in  a  rigid  attitude  without  being  curved  ia  any  direction,  a 
ooDdition  named  orthotonoH ;  and  in  some  rare  ca^ea  it  hi 
curved  laterally — pleuroatJiotonos. 

The  oiiiscles  of  the  extremiiies  are  usually  not  affected  to  so 
great  ac  extent  as  ihoHe  of  the  trunk,  ueck,  face,  and  jaws. 

Fjc  S86. 


N' 


.■■.■  /, 


v^ 


^ 


V:^ 


FlO.  SSS  (Frooi  S{Mti<«'*  Stir^m).— Tolim  fmm  thu  firifiiiAl  {Muntinf  iy 
ail  lIutIm  I1«I1. 

The  muscles  of  the  lower  extremities  are>  however,  generally  im- 
plicated to  a  greater  or  lesser  extent ;  aud  during  the  apaamodic 
attack  extension,  as  a  rule,  predominates  over  flexloo,  although 
flexion   at  individual  joints  htu)   occasioually   be«u   uUervcd 


U  Kftdily  perceived.     When  the  spasm  ezLends  to 
of  the  upper  extremitiefi,  flexion  prcdominatM 
and  during  tlia  paroxysms  the  arms  are  drawn 
chest,  the  forearm  is  flexed  upon  the  ann,  the  b« 
at  the  wrist,  and  the  fist  is  closed,  the  palm 
towards  the  upper  arm  (^Fig.  285). 

Iq  some  caneB  the  spasm  pernista  coDtiouou: 
b^inning  to  the  termiDatitKi  of  the  disease;  bat, 
qjasiDodic  rigidity  of  tbo  nmsdca  oocurn  in  parox 
tervala  of  comparatire,  but  never  complete  rauscu 
t^b  paroxysm  lasts  from  a  few  seconds  to  se 
wilh  slight  remissions  for  hours;  while  the  duraU 
interval  varies  from  ten  minutes  to  hooTB,  but 
the  ttpHfiiDS  recur  and  remit  with  such  fireqaei 
assume  a  more  or  less  clonic  character.  As  tha 
gresse^,  the  paroxysms  of  spaiim  recur  with  gre*b 
and  Diuticular  contraction  is  sometimoa  so  riolaa 
are  broken,  long  bonea,  like  those  of  tbo  thigh,  U 
large  muscles,  like  the  psoas  and  rectus  femoria^ 
The  paroxysms  recur  spontaneously,  but  tlioy 
the  most  triTial  external  cause,  such  as  a  drau, 
Budde-n  noise,  or  an  attempt  to  swallow  or  to 
injection.  Attempts  at  swallowing  may,  imlei 
attack  so  readily  that  the  diaeaaa  may  bear  > 


TEXAN  vs. 


847 


of  tbe  expiratory  muacleR,  so  that  tbe  act  of  coughing  is  ren- 
dered imposttible,  and  mucus  accumulateH  iu  the  biODchi.  In 
•srera  pmoxysms  the  chest  becomes  fixed  ;  the  countenance  is 
livid;  the  eyes  are  auflFused;  the  patient  foams  at  the  mouth; 
and  in  tormented  with  a  feeling  of  dreud  and  8U0bcatioa. 
Arrest  of  renpration  may  sometimex  be  caused  by  spasm  of  the 
glottis  ;  but,  as  a  rule,  it  is  the  result  of  spasm  of  the  thoracic 
mueclcii  and  diaphragm.  In  the  intervals  leMpiratioa  is  only 
slightly  changed  in  frequency,  from  twenty  to  twenty-four  in 
the  minute,  but  it  is  accompanied  by  a  painful  BenisatioD  of 
increased  rceuitauce,  reiiuiniig  effort.  Motor  paralysis  is  a  rare 
•ymptom  of  tetanus.  Koee  obeerred  pftratysis  of  the  muscles  of 
OB*  tide  of  tbe  face  in  a  case  in  which  th^  primary  lesion  mta 
ia  the  area  of  distribution  of  the  facial  itcrvc.  Qcneral  mos- 
oolar  weakness,  and  paralysis  of  certain  groups  of  muscles  aro 
observed  as  terminal  phenomena;  strabismus  is,  according  to 
Wunderlicb,  a  precursor  of  death. 

The  tenaory  disturbances  in  tetauus  are  such  as  are  usually 
produced  by  intense  muscular  cramp  in  the  muscIeB  of  thu  calf. 
Some  observem  have  noticed  au  iucrease  of  the  seuiiibiEity  to 
pain  independently  of  tbe  spaara?,  while  at  other  times  the 
aeateness  of  tbe  senses  of  touch  and  temperature  may  be 
diminished.  ParawtheaiaB,  such  as  numbuees  and  titigling, 
hAve  occasionally  been  obfierved.  Paiu  is  sometimei)  absent 
daring  the  tetanic  seisures;  and  Blane  mentions  the  caxe  of  a 
patient  who  only  felt  a  pleasant  sensation  of  tickling  during 
tbe  severest  spasms.  Fain  at  the  epigastrium,  piercing  through 
the  bock,  ia,  according  to  some  authors,  »  pathognomonic 
symptom  of  tetanus.  It  m  present  during  both  the  tetanic 
paroxyaiQs  and  the  intorrals,  and  depends  most  probably  upon 
spaam  of  the  diaphragm. 

F»fihi^  disturbacco  is  generally  absent  in  tetanus.  The 
mind  is  almoet  always  clear  from  tbe  beginning  to  the  end  of 
the  diseaiie,  although  doUriam  or  coma,  may  supervene  a  abort 
time  before  death,  often  due  to  the  remedies  used.  Sle^ptess- 
neaa  is  one  of  tbe  most  troublesome  Hymptoms  of  acute  caaet 
of  tetanus,  and  even  in  subacute  coses  sleep  is  only  obtained  at 
brokeo  intervals.  The  apasms  cease  during  sleep  and  the 
narcosis  of  opium  or  chloroform.    Tbe  skin,  in  the  paroxysms 


843 


TITAHOB. 


and  even  intervals,  is  hot  and  batted  in  perspimltao,  liaiii 
a  peculiar  pungent  smuU,  while  the  surface  may  be 
by  sudumina  as  in  other  casea  of  profuse  sweatiDg.     la 
majorily  of  ca/sva  ibe  teiaperatur«  rangea  irom  lOl'F.  to  lOTI 
ami  may  even  rise  auddooly  to  105*  F.  in  caaea  which 
nlthouj^b  il  13  DOt  maintained  loDfif  '^^  this  level  only  is : 
coses.    Id  many  coseft  Ibere  is  hyperpyrexia  immediately 
death,  the  temperature  rising  to  lOS'F.  or  even  110"  F..I 
may  continue  to  rise  for  some  hours  afler  death. 

The  puieo    mny    remain  normal    during  the   first  sUfi 
tetanus,  but  there  is  a  oousiderable  increase  ia  its 
during   the  telauic  seizure,  aud  iu   iba   last  stage, 
wheu  there  is  elevation  of  temperature,  it  may  beat  aa 
as  180  iu  a  minute.     Liiton  observed  in  a  caae  of  ampot 
during  tetanus  tba  vessehi  so  coQtruicti^  that  not  a  drop  uf  1 
bad  escaped. 

The  daily  quantity  of  urine  passed  in  tetanus  is  uaually  1 
Uie  average  in  health  ;  the  reaction  ia  sUongly  acid,  the  npedSt 
gravity  high,  and  there  ia  gencmlly  an  abandant  d^MUl  d 
urates  on  cooling.  Sugar  in  the  uriuc  in  letaDua  ««a  Cm  H^ 
covered  by  Demme,  and  its  presence  has  since  been  detscls^ 
by  otbeni.  Senator  fuund  that  Ibe  excretion  of  nitrt^u  wm  alt 
increoited  in  tetanus  as  compared  with  the  amount  excntai  bj 
a  ponsou  fasting.  He  alao  states  that  the  cnsatiaiae  u  •» 
increased.  There  may  be  retention  of  urine,  caused  pffataMf 
by  spasm  of  tho  sphincter,  while  at  other  times  dhbbli^Mf 
occur  during  the  paroxysm.  The  bhidder  is,  howcrar,  osw 
affected  to  so  great  on  extent  as  in  acute  spinal  meaiaciiii 
Spasm  of  the  Rphiocter  ani  is  often  preseut,  ua'is  proved  )fj 
the  difficulty  of  introducing  an  enema  pipe. 

The  general  health  of  the  patient  suffers  greatly  dutiaf  tk 
course  of  the  diseasa  Thu  distorted  poailioo  of  the  body,  lk< 
perBistent  sleeplessness  the  difliculty  of  respir«tioa,  and  tbt 
impossihility  of  siirallowiog  combine  to  render  tb«  stale  ot  lU 
palivut  extremely  distressing.  The  bowela  are  eonsupatad,  th 
tungue  is  generally  coated,  a  tenacious  viscid  salivm  aeeosanl^H 
in  the  mouth,  and  the  patient  may  be  excassivelj  haagTyal 
tormented  with  thirst,  yet  can  neither  swallow  food  nor  driak. 


TETAsna 


8W 


§  92*.  Courm,  Duration,  and  Tm-minati'Ons. — The  timo 
vliich  elapses  betweea  the  oocurrence  of  &n  injury  and  tbe  oul- 
;W9ak  of  totjuius  varieH  greatly.  The  average  interval  la  from 
fife  to  teu  (Isjft,  but  tlie  spa»tnii  may  begin  a  few  liours  after 
die  injury,  or  wtfelts  may  intervene.  Mr.  Ward,  of  Muucliiister, 
hM  reported  a.  case  wli«rc  the  aymptoms  appeared  ten  weeks 
After  the  injury-. 

In  tetanus  neouaturura  the  disease  appears  from  four  to  eight 
days  after  birth,  but  it  may  sometimes  be  delayed  until  tbe 
ftwrteenth  day, 

The  ioteusity  of  the  disease  is  liable  to  vary  consideiabty. 
Tbe  syroptoras  iu  slight  coses  may  cousl&t  only  of  triomus  and 
some  stiffness  of  tbe  neck  ;  in  others  they  develop  rapidly  and 
prove  fatnl  in  a  few  days,  or  occasionally  in  a  few  hours  from 
tbe  comRicnccment. 

Deatli  takps  plnce  in  several  ways.  It  frwiuently  occurs 
daring  a  paroxysm  from  asphyxia,  caueod  by  rigidity  of  the 
requratory  muscles.  Iu  other  cases  tlieapusms  cease,  and  death 
loUoK's  during  mild  detirium  nesoeiatcd  with  quick  puliie, 
high  tcmperalurc,  nod  Hytnptoms  of  aKlbeuia.  At  other  times 
the  heart  suddenly  ceai^s  to  beat. 

In  cases  of  recovery  the  couvuluive  attacks  become  lighter 
and  less  frequent,  aud  after  a  time  entirely  cease;  if  sleep 
return,  it  ia  u  favourable  sign.  The  rigidity  continues  for  Kome 
tiioe  after  the  paroxysms  cease  and  then  gradually  disappears, 
ihoQgh  not  in  dutluitc  order.  Rticovery  takes  place  in  from 
one  to  eight  weeks  or  even  longer,  and  a  certain  degree  of 
weakueBs  and  stiffness  may  remaiu  in  Uiu  muscles  for  a 
long  time. 

§  925,  Aforfrid  Anatomy. — Rigor  mortis  sets  in  almost  im- 
mediately after  dt-ath,  probably  caused  by  tbe  strongly  acid 
reaction  iu  the  prcviouely  active  musclcH,  It  has  long  been 
suspected  that  the  morbid  changes  in  tetanus  arc  to  be  found 
in  the  central  uer^■0U8  system,  and  more  especially  in  tbe  spinal 
oord.  In  the  earlier  records,  the  changes  most  frcquentfy  men- 
tioned are  congeatioa  and  extravasations  of  blood  into  tbe  curd 
and  its  membranes,  and  occasionally  softening  of  the  former. 
Rokitansky  waa  the  tir&t  to  subject  the  spinal  cord  to  niicro- 
ccc 


and  ito  mumbraues,  as  well  m  ccDtm  ofsoltciiii 
aad  wliite  substaoce.  aod  similar  cbaogee  bare 
by  Dickson,  Allbutt,  Coata,  and  other  obserrers. 

In  tlie  Bpinal  cord  of  a  patient  deaA  of  t«t 
mArkeil  sofleninj;  in  the  lumbar  region.  A 
miildlo  of  tbc  lumbar  region  is  shown  in  Plata 
vettsel  from  tbe  auterior  iisftuTe,  repreaeated  in  PI 
iTM  seen  to  be  surrouDcied  by  leucocytea,  and  ifae  ' 
grajand  white  subfltaDcaa  nas  dewtely  infittrated  i 
altbcn^b  not  usually  a^r^[at«d  in  tbe  perivamill 
arouod  the  rcMeln  an  in  hydrophobia.  Another  n 
grey  itubiitaoce.  ait  obliquely,  is  shown  in  Plal« 
lymph  sheath  of  which  is  filled  with  leiicocyiea 
terestiog  cliaoges  were  obseiTed  in  the  gaoglioi 
anterior  horns.  A  few  cells  of  Dormal  sise  wan 
purtiuQ  of  the  median  group  nvttreet  the  antenc 
greater  portion  of  the  cella  of  the  aDtero>later»l 
few  of  thoM  of  tbo  poBtero-lftteral  group  were 
size  i  but  most  of  the  oeUa  of  the  median  group, : 
ginal  cells  of  tbe  other  groups,  had  apparenilj 
when  the  section  was  cxamioed  with  a  low  powe 
pearance  of  ik«^  cclU  was,  however,  not  real ; 
power,  they  could  be  seen  ehruntt  in  their  cai 
changes,  although  less  in  extent,  were  found  in  at 


TETANUS. 


851 


suffer;  while  tbc  longitudiniU  vessel,  which  lies  in  the 
ieep«3t  part  of  the  floor  of  the  fourth  ventricle,  is,  as  remarked 
tj  Dr.  CoAt*,  nsunjly  suiTounded  by  red  blood  corpuscles,  The 
Qclens  of  the  facial,  the  motor  nucleus  of  the  fifth,  th«  nucleus 
of  the  abducens,  aud  that  of  tho  third  and  fourth  cranial 
Dorves  appeared  nonnaL  A  large  number  of  leucocjtai  were 
|bterv«d  ID  the  olivary  bntltes,  the  brachiutn  of  tho  pons,  and 
letweeo  the  fibres  of  the  seventh  ntrves. 

In  the  roots  of  the  fifth  oerve,  proceeding  from  the  cere- 
nllntn,  large  vessels  were  observed  which  were  distended  with 
red  blood  corpuscles,  and  the  whole  of  the  surrouudiog  tissue 
mi)  dvuiicly  iutiilrutcd  with  leucocytes.  The  corpnti  dcutatum 
if  tbe  cerebcltuin  and  the  white  substance  siibjaceot  to  the 
MHlex,  were  alao  densely  infiltrated  with  leucocytes  &nd  inter- 
ted  with  dlstotided  blood-ve^els  to  an  extent  which  it  is 
iDpo«>tbIe  to  regard  as  other  than  the  result  of  disease.  Tbe 
•lb  of  PurkiDJc  were  surrounded  with  leucocytea,  but  did  not 
heouelves  present  any  decided  morbid  appearances. 

in  trftuiaatie  tetanus  tbe  older  reports  elate  that  marked 
were  frequently  seen  at  tho  scat  of  the  wound.  Serves 
nre  enished  aad  torn,  foreign  bodies  buried  in  the  nerve  trunks, 
md  ioftammation  and  thickening  were  found  about  tbe  injury. 

ipelletier  was  the  first  I«  describe  the  occurrence  of  an  ascend- 
Dg  neuritis  in  a  [mtient  who  died  from  tetaniui,  Froricp  found 
ed  spots  and  swolUnge  of  the  nerves  alleruatiug  with  parts 
hicb  remained  healthy,  these  changes  extending  from  the 
At  of  injury  to  the  spinal  cord. 

Evidences  of  iufiaiumatioa  have  been  described  by  Aronttsohn, 
Kipuy,  and  Andral  in  the  sympathetic  nerves,  a>ip(H:ially  in  tbe 
lervical  and  semilunar  ganglia. 

The  voluntary  muscles  are  generally  of  a  pale  colour,  and 
optures  of  bundles  of  fibres  with  eitravasatioQa  of  blood  have 
eea  found.  Fatty  dcgt-ueration  of  tbe  tnuscles  bos  also  been 
baerved. 

§  926.  Pathology. — The  pathology  of  tetanus  is  not  very 
lar,  but  a  few  landmarks  for  future  researches  havo  been 
Kortaioed.  Uorbid  alterations  have  been  found  in  rarioua 
ortions  of  the  cord  and  medulla  oblongata.    Whatever  morbid 


H5S 


TETANUH. 


process  iheee  changes  may  indicate,  th«y  are  <JuubU< 
puiiod  by  br«Jkktag  down  of  the  structure  of  the 
during  the  difiintcgmtive  procoM  the  moleealM  of  Um. 
plasm  of  tlie  cells  or  of  tlie  axU-cylindare,  or  of 
from   an    unstable   t«   a   stable    position,    the    libtrat 
being  rendered   active.     During   this    proceH   tfav 
of  tlie  grey  mailer  auil  of  the  nerve  Bbree  is  ii 
there  is  a  decrease  of  tbeir  retiistanoe  to  coodactioD. 
setiuenc«  of  tbe  iocreaBed  irritability  and  dimioisbed 
tlie   (ilighl(«it    pprlpIieraJ    irritation    will    tletennine    mi 
spasms  by  »eMiiig  free  a  relatively  large  amoant  at 
Indeed,  Romberg  regards  tlie  incrmMd  rejUx  irritt 
the  chief  element  in  tetsnuH,  but  it  mnst  l>e 
spasms  may  be  caused  by  the  pattiologlcal  prooMB 
thu  cord  independently  of  peripheral  irritation. 

Ad  ascending  neurilis  has  been  found  in  some 
nerve  leading  from  the  wound  lo  the  corti ;  and  il  is 
that  in  all  cases  there  is  a  progreBsive  extennion  of  the  i 
process  from  the  external  wound  towards  the  ctotre. 
morbid  changes  in  tulauus  are  not  limited  to  tbe  parifM 
nerves,  spinal  cord,  and  medulla  oblongata,  but  pnM 
extend  to  the  cercbcUuiQ.  I  am  iocliDed  to  belieri  «|| 
Dr.  Hugh  lings- Jackson  that  discharges  of  nerve  enetgj  fel 
llie  cortex  of  thu  cerebellum  are  the  main  cause  of  tbe  parai)H 
of  ajmsm  in  tetanus,  although  these  dischargvs  may  10  m 
extent  be  delennined  by  tbe  instability  of  ceotras  ia  tb«  i 
oblongata  and  spinal  cord. 


§  937.  DiatjnosiA — Tbe  diagnosis  iu  well-inarlced 
neaU  i>o  difficulty,  but  tbe  obscure  symptoms  of  the  m 
nUge  may  be  overlooked  or  their  importance  uoder-cstioii 
Id  the  tetanus  of  stxj'chuia  ibe  masticatory  musdes  annM 
ttttocketl  first,  and  may  possibly  escapu  altogether;  tbe  ^ 
toms  are  well  marked  at  the  oommenceDieDl.  and  rvachlhl 
full  development  in  a  few  minutes;  opisthotonos  is  a  TCfjMl 
symptom  ;  there  are  usually  intervals  ofoantplete  iotcniuHl 
and  death  occurs  comm(Hily  in  less  than  three  houi%  m  i 
recovery  is  very  rapid. 

Masticatory    spasm    induced    by    decayed     teeth, 


TETAKUS. 


833 


other  causes,  and  xUGTnus  of  the  jawn  from  toDsillitis, 
)titi8,  and  disease  of  the  articulations  of  t.he  jaw,  may 
listakea  for  the  first  stage  of  tetuuus;  hut  uvea  m  slight 

;ortetan\i8  the  oervical  muscles  are  toHotne  extent  affected, 

if  altentioti  be  paid  to  the  Bymptoms  of  the  furmer  diseases, 

canotit  well  lie  mistakeu  foi  tbu  lat1«r. 
rysterical  hpat^m»  may  sometlmca  closely  simulate  tetanus, 

in  hysteria  an  interval  of  variable  duration  follows  the 
(xysoi.  in  which  the  muscles  arc  relaxed,  and  other  symplotns 

bUve  of  hysteria  are  present. 


928.  Prognosis. — The  prognosis  in  tetanus  is  always  grave, 
authors  rej^ani  idiopathic  tetanus  as  heiog  less  dangerous 
Chan  the  traumatic  variety. 

It  may  be  laid  duwo,  as  a  general  rule,  that  tlia  longer  the 
iult^rval  tv'hich  ehipses  hetwueu  tlie  injury  and  the  appenmnce 
of  tet.inus  the  more  likely  is  the  disease  to  become  chronic  and 
to  end  favourably.  Acute  cases,  in  which  the  ap&sms  Hupervene 
noon  after  tlie  injury,  and  recur  with  increasing  vinlptice  and 
at  decrea^ng  iuten-aU.  are  almost  always  fatal,  death  taking 
in  a  few  days,  oi  even  bourt,  from  the  commencement.  'Ilie 
ism  of  Hippocrates,  that  tetanus  ends  in  recovery  if  the 
i  Burvivir  tbi;  fourth  day  uf  the  distoac,  may  he  accepted 

ically  true,  although  there  are  many  exceptions, 
cial  symptomij  are  relied  upon  by  some  authors  in  forming 
osii'.  The  prognosis  is  said  to  be  grave  wiicn  attemptn 
to  swallow  during  the  first  few  days  induce  suffocative  attacks. 
Wundertich  regards  the  occurrence  of  strabismus  as  of  fatal 
ftOgary,  and  a  frequent  pulse  and  high  temperature  belong  to 

Pe  terminal  phenomena  of  the  affection. 
5  929.  Treaime7it. — At  one  time  tetanus  was  regarded  as  an 
inflammatory  diseafe,  and  treated  accordingly  by  su-called  antj- 
phlogtsticB,  blood'letting,  and  mercurials;  but  this  method  of 
treatment  hna  beea  abandoned  alung  with  tho  theory  upon 
which  it  was  founded.  It  is  needlesH  to  point  out  hore  how 
necessary  it  is  in  surgical  practice  to  protect  all  woiiods  from 
unfavourable  influences  hutli  iu  the  local  treatment  of  the  wound 
in  ihegeDeral  sarrouodings  of  the  patieoL 


the  card.     Cbloral  hydrate  Is  probably  saperior 
remedy  for  this  purpose. 

Cannabis  ImUcn  lias  been  used,  but  it  w  too 
results,  and  iIh  physiological  action  ut  not  yet  i 
Calabar  bean  or  phyHO^xgmin  baa  been  empto, 
sional  miccesa.  Tobacco  or  nicotiue  in  liigbly 
Curling,  but  the  depression  it  produces  is  Mmetil 
aod  may  be  daugeroua.  Bromide  of  potoasiui 
retlex  irritability,  and  may  bo  uMxl  cither  alooo  a 
tion  witl)  cbloral. 

Curara,  beltadoDDa,  and  prusaic  acid  bave  been 
the  treatment  of  tetanus  with  the  view  of  cN 
spoAma,  but  the  course  of  the  central  diMUWO  ts 
arreet  of  the  spasms. 

The  cold  bath  and  oold  douohe  may  be  used 
a  aaddon  dovation  of  temperature,  and  under  ti 
stances  the  patient  may  be  placed  in  a  bath  of  i 
the  tempernture  of  which  is  rapidly  reduced  to 
giadiiHl  atldition  of  cold  water. 

Id  ordinary  cases  the  warm  fnUh  Is  exoeedtng 
the  patient,  and  for  this  reason  it  forms  a  pleii 
to  other  treatment.  The  vapour  btUh  haa  beai 
inferior  to  the  warm  bath. 

The  patient  should  be  protected  from  e 


UYDUUPtJOBtA. 


8e« 


ition  ;  but  less  irritation  is  caused  by  the  contact  of  feeCM 
the  Iwwels  to  which  they  are  accuBtomed  than  by  the  irrita- 
proiluc^d  b;  powerful  cathartics. 

few  trials  have  bcsen  mode  with  electricity  in  the  trtatinciit 
stonu^  but  the  results  have  QOt  bceu  encouro^ag. 


lUl.)  HYDEOPHOBIA. 
930.  DtJinUwtL — Hydrupliobia  is  a  diseajte  caused  by  the 
culatioD  of  a  speclBc  animal  poison  contained  in  the  saliva 
If  aoiniala  uDdo'f  its  tuflueucc,  the  moat  obarocteriatic  clinical 
raalurea  in  man  being  ejicitemcut  and  spasms  induced  by 
Uempu  to  Kwallow  fluida 

{^1.  Etiology. — The  cause  of  bydropbohia  appears  to  be  in 
a  specific  virus  contained  in  the  secretions  of  the  mouth 
the  infected  animal,  and  the  disease  is  communicated  to  man, 
and  probably  toother  animals  ahio,  only  by  direct  iuoculatioa 
through  a  bite.  There  are  no  groiinda  for  believing  that  canine 
rebies  ever  arises  spontaneously,  and  it  is  probably  in  all  in- 
.atftooee  communicated  from  one  animal  to  another  by  means  of 
•  bite.  The  animals  which  are  capable  of  inoculating  man  are 
the  dog.  wolf,  fox,  badger,  marten,  cat,  horse,  sheep,  pig,  and 
goat  (Ganigec).  Only  a  Kmall  proportion  of  human  bcingH 
l)itten  by  rabid  animals  become  affected  with  hydrophobiii,  a 
proportion  which  has  bcou  variously  estimated  at  frvm  5  to  50 
per  cent,  The  number  which  become  8ubs.ec|uenUy  affected  with 
the  disease  is  greater  when  tbe  exposed  parts  of  the  body  are 
Utten.  It  is  probable  that  the  teeth  in  passing  through  the 
dothes  are  often  cleansed,  so  that  the  wound  escapes  inocula- 
tion. It  is  likely  that  a  considerable  proportion  of  those  bitten 
are  protectiHl  by  the  cauterisation  and  other  local  treatment  to 
which  the  wound  is  usually  subjected  at  the  time.  Some 
individuals  appear  to  possess  a  relative  or  complete  immunity 
from  the  disease,  and  it  is  transmitted  irrespectively  of  age,  sex* 
or  constitution. 

t!}  032:  Syniiiityma. — The  period  of  incubation  in  hydrophobia 
is  longer,  and  liable  to  greater  variations  in  tta  duration,  than 
that  of  any  other  8peci£c  diueaso.    In  the  majority  of  cases  the 


868 


BTDROPHOItlA. 


aud  all  bis  naovemeaU  are  cbaracterued  by  great  praci|Kt 
The  iaiellect  may  remaiQ  more  or  lew  cle&r  for  »  ttau^  I 
towards  lliu  end  he  begitu  to  wander,   anJ  hallucinaliaoi  i 
attacks  of  violeot  maniacal  excitemeot  8uperTeDe,dtinog  i 
tho  petieot  muy  lojuro  btmself  or  tbc  attcadanti.    In 
the  aymptoim  of  acute  mania  may  predominafae  rronil 
In  ihe  case  of  a  child  four  aod  a  half  ycani  of  age 
core  of  Mr.    Kwart,   in  St.   Uar/a  Hospital,  UanclieatBr,  I 
maniacal  Aymptoma  were  early  maDif«8t«d.  Duriog  tbc  i 
paroxyeou,  t«rror,  caused  probubly  by  batlucioatiooH  of  i 
appeared   to  be    the   predominaQt  symptom,  aod  Ui4 
screamed  to  bia  mother  tv  save  him  from  the  "  piu^  "  tl«< 
thraateDing  to  attack  him  (he  had  heea  bitt«n  five 
viously  in  the  face  by  a  rabid  eat),  aad  struggled 
eooape  from  biit  attendants. 

As  the  disease  progresseB  to  a  fotal   terminatim^ 
synaptomsare  aggravated, and  the  poise  becomes  rapid,] 
aDd  thready;  tenadous  mucus  aocumolatee  in  tJie 
in  expelled  with  difficulty,  the  Toice  becomes  hoane, 
spasmodic  paroxysms  increase  in  severity  and  freqw 
attack  of  couiruluons  or  profound  coma  may  pn;ci-(le  Um  I 
termination,  bat  it  is  rare  to  observe  a  case  anioflai 
narcotics.  Death  may  take  place  suddeoly  from  aspfaj 
a  couvuliiive  attack,  or  from  exhausUoD.     In  some 
spAsms  gradually  dimioish  and  may  ccaae  a  few 
death  ;  the  patient  may  even  become  able  to  dnalc,^ 
campomtivo  calm  is  deceptive,  and,  iosteatl  of  being  *a^ 
recovery,  is  only  the  precursor  of  death. 

§  933.  Coitree,  Duratwn,  T«rmi7iatvm*. — Wh«a  VM ' 
disuase  is  fully  establithed  it  pursues  a  rapid  ooorae,  t»i 
miDates  probably  always  fatally  iu  from  two  lo  foordsjii 

tho  commencement  of  the  symptoms. 


§  934  Morbid  Anatomy. — In   the  older  reoordi  of 
mortem  examiiiatious  in  cases  of  death  from  bydropboUal 
chief  alterations  of  the  nervous  system  mentioDed  are  oon 
of  the  brain,  medulla  oblougaUi.  and  spinal  cord  ami  <^  I 
nLQt£bi«LiL«a.    ^A-V^*^  \(£.'^\i&tt  toade  a  microscopic 


HYDROPHOBIA. 


8S9 


tion  o(  portioDS  of  the  brain  and  spinat  coril  of  two  patieiita 
who  had  died  of  hjrdrophobia ;  but  the  cliaogeH  ubserveJ  bjr 
bim,  in  addition  to  congestion  of  the  spiaai  cord  »nd  brain, 
were  somewhat  indefinite.  Soon  afterwards  Dr.  Ailbutt  made 
•ome  ioiportaut  observations.  "  Iq  the  cerebral  coQvolutioaii 
the  mesocephalon,  the  ponn,  mcdiilla,  and  Hpiuo,  tUe  vesseU,"  he 
kayH,  "  were  seen  in  variom  degrees  of  distension,  and  in  inaay 
pUoen  tbe  walls  were  obviously  thickened,  and  here  nod  tliere 
ia  them  were  patches  of  incipient  anclear  proliferatioa."  These 
observations  were  confirmed  by  Hammond,  wbo  also  found 
chau>;es  in  tbu  gau<;Uon  cclln  of  thu  nuclei  of  origin  of  tbe 
pnuumogastric  and  hypoglossal  nerves,  as  well  as  in  those  of 
"  the  first  and  aecoad"  layers  of  the  cortes  of  the  cerebrum.  The 
nuclear  prolifemtioo  doscribeJ  by  Dr.  AJlbult  as  oocumng  in 
the  walls  of  the  distended  rossels  coasista,  as  waft  ftubse- 
queotly  pointed  out  by  Benedikt,  of  migrated  white  blood 
corpuscles. 

Ia  the  brains  of  dogs  atfectod  with  rabies,  Bcnedikt  found  the 
white  blood  corpuscles  aggregated  around  the  vessels  to  sucb  an 
extent  as  to  form  what  he  termed  a  miliary  abHceB-i.  He  found 
similar  appearances  in  the  brain  of  a  human  subject  who  had 
died  of  hydrophobia  Tbe  spinal  curd  and  mwlulla  oblongata 
were  not  examined  in  these  cases.  TIimb  obKervations  have 
beeo  confinned  and  extended  by  Coats  and  Qowers,  who  found 
Accumulations  of  leucocytes  around  tbe  smaller  vessels  of  the 
medulla  oblongata,  spinal  cord,  basal  ganglia,  and  cortex  of  the 
brain.  Smalt  extravasatioas  of  blood  were  occasionally  observed 
ia  the  neighbourbood  of  tbe  distended  vessels,  while  Coat^ 
found  migrations  of  lencocytca  in  tbe  salivary  glands,  mucous 
glands  of  the  larynx,  aitd  kiduvys.  Uurochetti  observed  pustules 
OQ  the  freoum  linguie  during  tbo  first  few  days  of  the  period  of 
ineubation.  lo  the  case  of  a  dog  that  died  of  rabies  I  found 
miliary  abscesses  ezteauvely  distributed  through  the  spinal  cord, 
medulla  oblon^ta,  b«3al  ganglia,  and  cortex  of  tbe  brato.  In 
addition  to  the  aggregation  of  leucocytes  around  the  vessels, 
Qowen  deacriboa  intrava.?cidar  changes,  consisting  of  the  pre- 
sence of  clots  in  some  of  the  vessels,  which  he  thinks  must 
have  formed  during  life, 

Tbe  following  description  ia  derived  from  my  own  micro- 


■diirtiuma  py  taen.    iiw  TnmiaM  oi  ta«  nfpoit*''**' 
yaooajtem;   hnt  iU  cells  hrc  iii<pwTnitl]r   bmtlUir.      AluMb  I 
imi-ltnui  of  tliB   paou III' iitu trie  uorrn  liavr  diMpiaMml,   Midi 
qiinal  ttncumoTJ  nervB  wu  ■imilarir  affnetsd  Ii»w»r  dnwB  tlw  I 

FiQ.  S.  — PiMtiiin  tit  th«  raelMt  aT  tl>*  brpnylaaMl  n«fT«  I 
Vig.  1,  an<Ur  «  hiebar  nuwiri^nnc  rowra,    Tb*  gaa|l»a« 
•Ithooitb  ihay  tn  aanwuulnl  by  leuoncrtcL    The  col  cod*  i 

Via.  S.'-Portiun  of  grey  m*U«r  of  olivMr  baity  tntm  \ 
magtii6<kl,  ahniriDg  fnlQimli^  wltb  teoooryt**. 

Fill.  4  — ^MtioD  nf  tb»  uiUrriw  ban  ol  Ui*  irraf  aat 
ulM^cmont  «f  tho  Dpjul  cord  in  4  cm*  of  hjA«fhM^  m,  Mai 
1*Ural;  fj,  Foitteru-Utcnl  i  kod  t^  UmtnJ  fixiap  o(  (■•ctta 
inflltmUon  *(  the  Uhbm  nitk  haeocyU*,  and  ibv  cut  vtvel*  Mm* 
Thn  KaM|[Unn  oelli  luiva  aptwnntly  JhippwreJ  (rooi  ihv  acx*  all 
llie  mFcliiU]  ftiid  the  antcro-Ulcral  fmopa,  and  only  tvu  or  Uira 
tbr  oRDtnl  ttraaii  ar*  «««>a',  whUv  MBa  mU*  bar*  alu>  fpMH 
rnim  the  mantitui  at  Uia  aat«n>-kua»l  anil  paM«r»-UUnl 
group  m*  aI»o  iiililtnt«d  *itb  rvd  blood  «arpiMcAM. 

Fni.  ».— rflrlEon  ol  tli«  an*  frotn  wkick  tb»  mlU  bwl 
in  Flic  4,  inaeBifiml.    SlMin  tUt  Um  ocUa  an  atill  |«Maitt,i 
moeli  ahniok,  and  tome  of  UkIt  iwoccaae*  tUatroTtil     The  wal 
•uiruuDilinK  them  am  iaBltntod  wiili  \neaey1mt  <«  mvcnd  by  j 

Fio.  A.— TatantM.    RacUon  aftbo  aadvior  born  «t  ntvy  i 
niddta  of  th«   Inmbar  cfiUrgMtiMiL      Sbowiaf  inlUUathM 
leoaocf  t«a,  Mid  ajipuoDt  duappaarane*  at  thm  ga^lioa  e*Ila  ] 
b«lw««a  tba  Uw  maainLnf  calla  «f  tbo  mr'**"  kt»bp  aad 
labtnl  group  g  aln  ^pannt  diMppaknaoi  ol  a  eondteiUa 
n(  ib«  pM(art>-laMral  gnmp. 

Pia.  7.— T«Mal  trom  tba  antonor  nadkn  Canm 
Pic.  6,  ■uironndod  by  tiainHinn  Itnoa^tai: 


I 

IteiUaM 


n. 


?Ut6  V 


TH     i 


V 


Fii    3 


Fif!      * 


^ 


^  •  ■ 


■ . 


Fi? 


■:f: ,? 


-■'  J 


Fi4« 


1^ 


h 


Ji 


1  I  ■ 


^■'    '.'.■.-"  '- 


^;::Vv^4^ 


-1 


X 


N 


HYDROPHOBIA. 


SQl 


l)Kal  examioatian  of  the  Decvoua  syatem  bom  six  cases  of 
bydrophobi* ; — 

Tbo  cbnagca  obeervid  in  the  moJulU  oblongata  in  hydrophobia  oottd- 
i|mD<lo(l  cl(M^  to  the  careful  drawingB  and  aocunte  dessriiJlion  of  Dr. 
3owBn ;  Gxoqit,  [lortiapa,  with  rosi^ect  to  his  ilesuription  nf  thu  dot  within 
Iba  lilixil-vi-welM.  Tho  distrilmljon  of  these  riuoular  Rnd  perivwiciiW 
juutgcs  in  tbi:  molulla  oblongftlA  wati,  in  otiu  of  ni;  cosea,  olinrii^  n>uitcii- 
ijre  witii  the  dirtribution  of  the  vessels.  Tho  p«y  iiuLtl4>r  nii  tlm  floor  of 
ihu  fourth  vpotricki  wa»  dumI  iilTix-t«(l,  probubl^  bccuiuw  ti  is  tbo  moet 
raaculax ;  hut  similar  cbnng»i  were  fouti'l  in  tbt-  Jtmaatiu  tvticviariaf 
ilirary  UKlies,  imtifgnn  bwiicts  nnil  ton  lm»  «xt«iit  in  tho  anterior  pyrsr 
UidH.  Th«  concUtidti  of  thtt  tiinclullu  in  thin  oiuu:  i^  tttuiwii  in  ?lHtv  V.,  fig.  1. 
It  will  fc*  olwervCTi  tluit,  lUtlMiiigh  the  tiudcua  vf  the  hj'|xiglo«BiLl  is  infil- 
tnted  with  leucoeyteN,  itM  tiwii  ckIIx  iut  nut  oiiichiifftictw),  whilosciircelya 
trkoe  is  left  of  thoM  l-ieloiiging  to  the  K]>iiial  acceeaary  and  |ineumogMtnc 
Hiiclei.  Tlu!  nniiii'  <xiii<liti»Ti  insliowii  iindur  ii  lii^hrr  msjpifjriug  ponrer  in 
Kg.  S,  in  which  the  c«ll«  vf  the  uik^Iciii*  of  the  b^rpoglowwl  Ap|>Mir  boalthyi 
iHhough  ifav  tisHiic  hi  ilonscl)-  infiltrnU.il  with  lentmc^tmL  Itifiltraticm  of 
tlw  gtv-y  nintter  of  th«  olirarjr  hodioa  with  Icuoooytc*  it  shown  in  tig.  3. 
BimiLLT  viwculflr  hqJ  pcrivoaculnr  changes  were  ohecrvwl,  though  to  a, 
Imb  eztrnt,  throughout  thf>  whole  extent  of  thi>  jKina,  in  tha  grey  salv 
KUKe  MirroiintUiiit  tlii?  Higtidluct  of  8.vlviu?<,  ami  iu  the  oorpom  quanlri- 
pmina,  aa  ha*  alrcaily  l><»eii  diutcribod  by  Dr.  Oostii.  Tho  cort«s  of  tho 
hraiu  ami  nubjnccut  wbitu  substouoc  wvn:  infiltrated  with  louixxr^-tut,  and 
the  pgmunidAl  ocUs  of  tho  fourth  Uy«r  of  th«  oort«s  wore  ofltm  {uutially 
filled  with  hdjaII  ycUow  gnunilca^  The  cortex  of  the  cxTclx:Uun)  and 
aabjaoi'iit  vhtt«  MubHtanoiHi  wore  also  miich  iiitiltratwl  with  Iviicocytes, 
Uw  obaugoB  here  being  almnst,  if  not  quite,  as  morki^  in  cxtcni  as  iu 
the  bnoD,  nut  the  oella  of  Purldiije  were  very  gmDular.  It  would  SF-pear, 
thereCDrc,  that  bydrophfi'biiL  in  n  dioeaae  Ot  a  very  diSUaed  character. 

The  cbangda  found  in  tho  spinal  canl  in  hydrophobia  deserve  apodal 
msnUoD.  They  am  tint  jilwivyn  wuU  tuurlcod,  ajid  in  three  of  my  caaw 
tni^t  very  readily  be  ovfi-lijokud,  wlule  in  the  otlier  three,  tn&Hced 
atbeiatioiu  w«re  obtten-ed  in  Uiu  upix^r  dunuvl  region  and  in  the  corneal 
ralai^gement  One  of  thi.'  anti-riur  hi>nis,  from  a  lioctian  of  the  oervioal 
anlar)Ci!aieDt>  it>  rB[)rtsciit«d  by  Dr.  Vouu^  in  fig.  -1.  The  wholo  of 
the  grey  mbotanoe  is  itillltratvd  with  Icuoucytea,  and  the  vessels  on  ea«h 
■■d«  ot  tho  i;«Dtrul  conid  aro  surroondod  by  Ihtuu.  Tho  brancbee  of  the 
anterior  tiitenLiI  ;itid  iiiiti^hur  IaIcteiI  arteriett  di!ttribiit«d  to  the  grvy 
mbataooe  aiv  •urroiiudod  by  louoocytcs.  Time  dttttiti<.'t  uiliiu-y  abeoeaees 
ware  obmn-i-ed  in  the  ex1j.TDHl  margin  of  tho  uEilen>litt«ral  ^roiip  of  oelk 
tn  the  ooril  talicn  front  the  child,  who  died  of  hyilrophobia,  under  the  care 
of  Mr.  Kwart. 

The  moat  intenseitiiig  obau|^  probably  have  occurred  iu  Has  ganglion 
ocQs  thcniselTes.    IVo  or  thre«  oella,  of  normal  aim,  luay  be  observed  in 


HTDUOPHODIA. 


863 


group  and  the  marginal  cells  of  the  other  groups  of  ganglioD 
mIU  of  the  aDlerior  borofl  were  iurariably  alt«r«i],  while  the 
ganglion  cells  of  the  centres  of  the  groups  were  appaientlj 
ODaffected  It  waa  in  my  power  to  take  refugti  in  the  siippoHi- 
lioo  of  a  special  affidiiy  between  the  poison  and  these  cells, 
but  I  waa  met  by  a  nimilor  vulnerability  of  the  mmc  oclla  in 
tetanus,  in  all  cedtral  inBfiramaCioDB  of  the  spinal  cord,  whether 
toute  or  chrouic,  and  even  in  chorea.  It  was  ia  this  state  of  doubt 
that  1  came  to  recognise  the  significance  of  two  other  facts  with 
regard  to  the  cells  in  qiieetion.  The  ganglion  cells  which  are  most 
valnerable  in  all  afToclionH  of  the  grey  substance  of  the  spinal 
oord  are,  upoftking  broadly,  smaller  than  those  which  aro  nio«t 
rcsiAliog,  and  the  former  are  developed  at  a  much  later  periwl 
than  the  latter.  The  Binall  siie  of  the.  cells  enables  them  to 
{tfeeent  a  targe  surface  to  their  environment  in  comparieon  with 
their  bulk,  and  consetpieotly  they  must  absorb  a  proportionably 
larger  tiuanlity  of  nourishment.  The  cell-membranes  of  the 
bM  &re  also  likely  to  be  thinner  than  those  of  the  first 
developed  cells,  and  this  will  iacreasv  still  furtlier  the  capacity 
of  the  former  for  the  absorption  of  uourishment.  The  ganglion 
oelli  which  abaorb  alargc  quantity  of  aouriahraent  in  a  rela- 
tively short  time  must  necessanly  siilfer  at  an  earlier  period  in 
states  of  active  byp^raemia  than  the  cells  which  absorb  a  leati 
quantity,  while  they  will  be  equally  the  first  to  euficr  in  condi- 
tions of  aufflmia,  inasmuch  as  the  want  of  nourishment  must  be 
6nt  Ml  in  those  celts  which  are  uudergoicg  tUe  most  active 
cb&Dgcs.  There  arc  no  grounds,  therefore,  for  believing  that 
the  accessoiy  maDtfest  a  greater  affinity  than  the  fundamental 
oells  for  the  virus  of  hydrophobia,  but  the  conditions  under 
'which  nutrition  is  normally  carried  on  in  both  are  «uch  that 
tb«  former  saiTer  in  this  dineaae  to  a  greater  degree  than  the 
l»tt«r 

§  9iG.  Liagnoais. — The  history  of  a  bite  from  a  rabid  animal 
U  generally  sufficient  to  direct  attention  to  the  true  nature  of 
the  diseasa  But  inasmuch  as  the  animal  is  generally  killed 
•oon  aft«r  inHictiog  the  injury,  we  often  cannot  be  sure  tliat  it 
was  the  subject  of  rabies.  On  the  other  hand,  those  who  have 
be«n  bittcu  by  dogs  ur  other  animals  lire  often  huuuted  by  the 


that  tetaov^^^Hboar  after  the  bit«  of  an  ■ 
Aft«r  other  injtineff,  and  it  is  not  impossible  tbkt  CM) 
recovery  from  hyilrophobiiL  have  been  of  the  tataa 
In  tetaDus  tbo  patient  is  usoalty  calm  aa<l  tbe  d 


are  clear  to  the  last;  while  there  ia 
the  einotioiuU  excitemeDt,  horror,  and 
hydrophobia. 


complete 
iletirit 


1 


1 


§  937.  TVcttimeiK  — .Erery  effort  should  be 
the  developmeut  of  the  disease.  The  tlsiQes  ran 
wouDil  Khoiild  be  at  once  excised  with  the  katfe,  or,  i 
possible.  Jestroyed  by  tbe  actual  cautery  oc  powerli 
p.)laKiia  fiisa  or  nitric  ai-id.  Youatt  placed  the 
oa  the  cauterisation  of  the  wound  nitli  the 
silver. 

When  the  disease  15  ert&blbhed,  every 
directed  to  soothe  tbe  sufferings  of  the  pattonL 
coming    nndur    niy    otwervatioo.    eiibcutoaeous    i 
morphia  and  chloral  appeared  tu  be  produotive  tA 
inasmach  as  several  boura  of  quiet  sleep  were  pnx 
unfortunate  patient.     Hot-air  and    vapour   batbs 
recuuuuendvd,  and  the  latter  is  very  soothing 
but  there  are  no  grounds  for  belieriog  that  it 
virus. 


r    uvkua 
ling  ^ 


805 


CHAPTEK  IV. 


HYSTERIA. 

TSTEElA  i«  a  functional  disease  of  the  nervous  sptem  cliarac- 
ri»eJ  by  paroxysms  of  couvulBions  witU  appareul  loaa  ol  eou- 
toiisne-M,  along  witb  various  sensory,  motor,  vwo-motor,  auU 
ijcbical  disturbances,  which  may  be  combined  iu  eucb  maoi- 
ways  Ibat  the  ^roupiiig  of  the  symptoms  may  simulnte  anj 
«  of  the  Dumerous  or^&ic  disetiAcs  to  which  the  ncn-ous 
Ifvteto  is  liabla 

§  93S.  Etioloijy. — Hereditary  preJiaposition  exerts  a  power- 
1  intliiencc  in  the  proiiuciion  of  hyatcrio.    The  trnDsmiiisnon  of 

he  disease  is  sometimes  direct,  ihe  motlier  tmnsmittiug  it  lo 

b«  daugbter,  aud  at  otber  timeti  indirect,  the  patient  inboriliiig 
neurotic  con«titutioQ  which  mnQift!«tii  iteelf  in  one  member  of 
bmily  *&  by^tteria,  and  in  the  others  as  neuralgia,  epilepsy 

lliorea,  or  insanity. 

Hjreteria  occurs  with  prepon<lerating  frequency,  although  by 

>  means  exclusively  in  the  fL-timle  sux.     Uriquet  stales  that 

A  oat  of  fonrof  nil  females  are  affected  with  decided  hysteria, 

d  tbab  one-half  present  an  undue  imprcttsionability  which 

liffers  very  little  from  it,  a  pr<i[)orliun  much  too  itigh  for  this 
antry.     Out  of  1,000  cases  colk-cted  by  Briquet,  one  male 

affected  with  bysteria  in  proportion  to  twenty  females. 
The   disease    unually  begins  in  fumalcs  about   the   Bge  of 
.berty,  the  first  symptoms  being  manifested  in  more  than  half 
cues  collected  by  Briquet  between  twelve  and  twenty,  and 

in  a  third  of  them  between  fifteen  and  twenty  yenr»  of  age. 
le  eslablishment  of  menstruation  does  not  appear  lo  favour 


TIM  neuralgilonn  paumi  wbich  occur  la  vsnoa 
body  are  described  as  of  extreme  Kverity.  Nd 
mammary  glaad  is  somelimes  oompUined  oC  M 
menstrual  pcriotls;  while  a  6sod  and  sercre  pi 
infFa-Tnammary  r^oo — probably  an  intercostat 
au  all  but  ouDstant  symplom  of  byateria.  Tb« 
maminui  may  bucomo  ao  aciutiltve  Uiat  tbo 
the  coQtoct  of  the  dreaa  may  be  unbearable, 
tivcneea  to  pain  is  oftea  obwnred  in  tbe  acigbl 
eosiform  cartilage;  while  pains  of  &  dull,  b 
accompanied  by  a  feelio);  of  oppresaton  aod  anxii 
times  cxpmcQCcd  at  different  parts  of  the  stornti 

Severe  pain  dlH'used  over  the  whole  surface  of 
is  a  not  uncommon  symptom  of  byAteria.  T| 
pain  is  asoally  associatod  with  tympaoiles,  and  Ih 
to  touch  is  80  great  that  the  patient  cannot  bear 
the  bcfl-clothes;  while  deep  and  continuous  pn 
other  hand,  may  cause  little  or  no  discomfort 
the  atteotioQ  of  the  patient  bo  diverted.  Hyi( 
suffer  greatly  from  cardialgia.  and  when  it  is  ai 
frequently  the  case,  with  per&isu^ot  vomiUDg 
may  be  miataken  for  those  of  perforating  ulcer 
Many  hysterical  patieats  suffer  from  a  great 
leadin<;  them  to  cat  largo  quaatiLiea ;  this  oondii 
_^us«d  bv  a  hTDertesthetie  oondition  of  the  ma' 


HTSTEBU. 


BUd 


latgia  is  not  an  unfr«qii«gt  symptom  of  hysteria,  inde- 
itly  of  aoy  local  disease;  coccygodynia  without  local 
)  is  exceptional 

terical  patients  suffer  from  various  mare  or  lef^s  painful 
ins  of  the  back.  Cutaneous  hyperteathesia  i*  sometimes 
t,  it«  bTourtt«  «ite8  boiug  circunutcnbcd  portions  of  Ekia 
id  between  the  scapulaj.  Tenderness  of  the  yertebne  and 
Ddiog  structucea  is,  however,  a  more  frequent  nymptora, 
nmtivenus  being  fiometimes  limited  to  the  Apinoua  pro- 
and  at  other  times  distributed  laterally  in  the  muscles  of 
iTtcbra)  column ;  this  spinal  tcndcmcss  is  frequently 
pukied  by  genuine  neuralgia.  The  affection  already 
Ad  under  the  name  of  spinal  irritation  consiats  of 
teodemoat  in  association  with  other  nggravated  K^inptoma 
beiia.     Increased  sensitiveness  of  the  nauscular  afferent 

probably  cause  the  restleBntess  frequently  experienced 
terical  patients. 

'  pains  and  hyperesthesia  frequently  occurring  in  and 
,'  the  joiiitJtare  rleservingof  particular  attention,  inu»muck 
r  are  often  mistaken  for  chronic  articular  dieeaxe.  Sir 
kin  Brodic  was  the  first  to  direct  attention  to  the  fre- 
'  of  these  affections,  and  he  asserted  that  four-fifths  at 
f  the  Joint  diseiues  met  with  in  women  of  the  higher 

of  society  are  purely  hysterical.  The  hip  and  knee 
ire  most  frequeiilly  affected;  but  the  ankles,  wriata,  and 
Dger  Joints  may  be  attacked.  In  the  hysterical  affection 
«  upon  the  joint  produces  pain,  but  little  or  no  pain  is 

by  forcible  apposition  of  the  articular  Hurfaces,  eapeeially 

attention  of  the  patient  be  otherwise  engaged.  The 
I  may  continue  for  years,  and  in  chTonic  cases  the  Joint 
Bcome  slightly  swollen  from  oedema  of  the  surrounding 
rt& 

senses  of  smell  and  taste  are  frequently  increased  in 
ew,  the  patients  recogniidng  tastes  and  odouni  wbich  are 
k:iablc  to  most  people.  At  other  times  there  is  a  per- 
1  of  these  seuaes,  had  the  patient  mauifcHta  a  preference 
tain  tnstea  and  odours  which  are  disagreeable  or  in- 
at  to  others.  In  obudieiicc  to  this  morbid  craving 
eal  patients  Humctimes  devour  chalk,  cinders,  or  erren 


creoMd  in  1 


auditory  h&Uuoinations. 

The  BCQBO  of  aight  \i  soroetimeH  inci 
iatolerance  of  ligbt  ia  more  frequoDt.     Under  It 
Mtaocee  tbe  patient  vhiins  the  light,  and  tho 
obj«Gt«  in  the  dark  in  increased.     At  times  tt 
only  exists  with  respect  to  a  particular  colour,  j 
red.     SparlcH  and  flashes  of  light  are  itometimc 
while  at  other  times  there  are  hall nci nations  of  si{ 
seen  being  oflea  productive  of  disgust  aud  boTTor. 

AiKEiftJiMin. — DimiDution  or  complete  loss  of  m 
very  freqiieat  symptom  of  hysteria.  It  may  exia 
portion  of  the  surface  of  the  body,  aud  maj^  j 
muiiclcit  aud  dMpcr  liasaes  as  well  aa  the  nerree  of 
AQieatbcfiia,  in  some  form  or  auotbcr,  occurs  fieqi 
hyslcriail  attack,  and  the  more  severe  tbo  atta 
likely  is  aniestbeeia  to  ensuo;  as  a  rule,  it  dinij 
interval.  Sometimes,  bovever,  an  exteoslvel 
ana^sthcRia  may  disappear  after  «  fr«$b 
gcD<;ibility  of  tbe  previously  affected  part  ma] 
or  eiaggerated,  or  the  aQa3stbeMia  become 
portion  of  the  body. 

lu  the  majority  of  caaes  aensibilitj  to  pajn> 
while  the  other  forms  of  cutaneous  senstbilitj 
In  some  cases  tactile  seosibility  is  loAt,  whil^ 
temTwrntnrA  am  mrmndv  iiBnrM!m£Ml  •  i»  ^tAat 


BVSTEftU. 


S7l 


□ctiva,  nor  sneeziag  by  the  inbalation  of  irritating  tub- 
's vhea  the  nasal  moeous  membraoe  is  implicatod.  SeDSa- 
Day  be  abolished  in  the  mucous  membraacfl  of  the  pharynx, 
I,  and  respiratory  tract  generally,  and  the  occasional 
tion  of  urine  and  fa-ccs  in  hysterica]  patiouU  ia  probably 
li  by  aciBstheaia  of  the  mncoua  membraneH  of  the  bladder 
ectum,  iaaHtnuch  as  iu  such  cases  the  bladder  or  rectum 
loraelimes  be  found  enormouiily  disbended  witbout  having 
i  more  than  a  trifling  amount  of  discomfort  The  raucous 
>raae  of  the  gouitui  orgaus  and  of  the  urinary  passages 
letimes  found  Insonsiblo,  The  laucous  mcmbrano  of  the 
and  vagina  may  be  completely  aosBstbetie.  This  «oq- 
is  found  in  highly  liystcricAl  married  women,  and  in  tbetn 
is  an  entire  abi^euce  of  sexual  desire  or  pioasuru. 
i  special  scnites  are  not  unfrequcntly  affected  by  nnaw- 
t  in  hysteria,  more  especially  after  severe  hysterical 
Bl  The  senieH  of  taate  and  suihH  may  be  tcwt,  the  Io>» 
aometimeK  unilateral,  at  other  times  bilateral.  Deafoess 
rvous  origin  is  also  occasionally  observed,  and  it  may  be 
td  to  one  ear  or  aSect  lioth. 

ere  may  be  amblyopia  or  complete  amaurosis  of  one  or 
eyes,  unilateral  amblyopia  being  the  most  frequent 
btoa  Hynterical  amblyopia  conAi-sts  of  diminution  of  the 
aefls  of  vision,  restriction  of  the  6eld  of  vision  and  achroma- 
i,  while  isomutimi^i  a  condition  simulating  hcmiopia  may 
teent.  An  ophthalmoscopic  examination  does  not  reveal 
hanger  in  the  optic  discs. 

e  distribution  of  theditfcrent  forms  of  hysterical  anesthesia 
ry  variable.  Cutaneous  aoEesthesia  is  often  limited  to 
p  circumscribed  portions  of  the  surface  of  the  trunk  and 
nities ;  it  may  be  obiierved  in  the  region  of  distributiea 
i  or  more  nerve  trunkH,  be  limiti>d  to  one  or  more  extremi- 
ir  be  accurately  confined  to  Imlf  the  body, 
hysterical  Itemitina^Jteaia  the  loss  of  feeling  mi  the 
ilietic  side  fretjuently  afiectH  the  superBciat  parts  only; 
it  other  times  the  muscles,  bones,  and  articulations  are 
cated. 

taianolgesia  is  the  most  common  form  of  the  incomplete 
fj,  the  ioseosibiliby  to  pain  being  sometimes  assooiited 


ft7S 


UTSTEAIA. 


with  tbetmo-ana^stbcsio.    la  complcto  hemUnfoetb«Mk  a»t< 
ihc  skin,  but  ttie  muscles,  booes,  articulations,  and  Um 
aeoseB,  anil  otod  the  acoeasiblo  mucous  membtBDM  M 
same  side  of  the  body  are  implicated.     Taate  ti  aboUAaJ  j 
the  corresponding  half  of  tho  tongue,  tbo  eenw  of 
less  acute  in  the  corresponding  nOAtril,  and  partial  daafaewj 
amblyopia  exist  on  the  samo  side.    The  «iUL<stbesia, 
does  not  appear  to  extend  to  the  Tiseeta,  and  ooraplelO  I 
aniestberia  is  usually  aisociatcd  with  ovarian  hjrpontithiMfc  | 

{b)  Motor  Diaturbaruses. — Spasms,  either  tooic  or  doai^  I 
occur  in  hysteria  in  every  muscle  or  group  of  matdw  of  iIb 
bead,  trunk,  and  extremitiea.  Zvcry  ooe  of  tbo  ■paEmi  alimdf 
described  as  occurriog  in  the  area  of  diatribotioti  of 
several  of  the  peripheral  motor  nerves  may  appear  in  hj 
in  the  form  of  a  more  or  less  persistent  or  of  recurring 
lions.  It  is  imnccessary  to  describe  them  in  detail 
musdes  are  incessantly  active  in  many  hysterical  patieati^l 
that  the  oouutenance  has  a  refltless  and  unsettled  e^] 
constituting  one  of  the  main  ebaraoteriftios  by  meaoa  cf 
the  practiaed  physician  in  enabled  to  dia^osticate  tbe  i 

Spasmodic  closure  of  the  glottis  may  produce 
dyspccfta,  and  tho  patients  an  liable  to  attodca  of  ooei 
laughter  and  weeping,  which  often  arise  apparently  ta 
abftenDc  of  any  emotional  disturbancow  Duriag  byrteneri 
attacks  loud  scroama  are  commonly  emitted,  and  id  tbst  fe(B 
of  hysteria  named  chorea  major  the  patients  oft«n  imttat*  lit 
cries  of  animals  by  mewing,  barbingj  or  bowling,  Hysccnul 
patients  often  suffer  from  a  tcmpomry  aceelezation  and  Olf' 
geration  of  breath  injf  without  there  being  any  feeling  of  eoihsf* 
nused  respiration,  and  at  other  times  tbeynifferCromtMifaaif 
spasmodic  pauses  in  tbe  respiratory  rhythm.  Bioooogh  mi 
yawning  are  frequent  and  sometimes  Tery  distrasnng  ajraptMa 

The  pharyngeal  muscles  are  sometimee  spRBinodicaUy  cob- 
tracted,  so  that  swallowing  becomes  difficult  or  impiMsiWa 
Spasm  of  the  tongue  ia  not  anfre(]uootiy  associatad  with  i 
of  the  pharyngeal  muscles.  At  every  attempt  to  mava 
tODguo  it  liecomcs  distorted  in  vsjious  directioas.  a» 
articulation  and  swallowing  become  greatly  impeded. 
sensatiou  of  choking  in  the  throat,  named  gtobwi  Aj 


HYSTERIA. 


873 


BUppoaed  by  some  to  be  caused  by  n  apasm  of  the 
The  senBation  of  a  foreign  body  lu  the  throat  is 
Imes  BO  real  chat  the  patient,  after  making  xtrenuous 
B  to  remove  it  by  swallowiufj,  put«  her  fingers  into  her 
it  ID  order  to  induce  vomiting,  by  which  she  Iiopps  to  eject 
&ctua]  Bpaam  of  the  (Beopbagus  may  sometimes  be  so 
Itenl  as  to  resemble  organic  stricture, 
e  Rtomach  is  liable  to  undergo  Hpafimadic  contractions. 
^  rise  to  persistent  and  distressing  vomiting.  The  patient 
tealnooftt  immediately  after  food  is  taken,  so  tlat  the  latter 
tally  cjeoLcd  in  an  no'l  igettted  condition.  Some  of  the  food 
4rever,  probably  retained,  as  the  nutrition  of  the  patient 
'  sulfcrs  in  proportion  to  the  apparent  violence  and  per- 
(cy  of  the  vomiting. 

ignlar  pcristallte  roovementi  occur  in  rarious  parts  of  the 
inee,  and  these  may  he  tio  energetic  that  they  can  be  felt 
gh  tlie  aMominal  wall.  The  rolliug  of  the  intestines  may 
■08  tbe  patient  that  a  movable  body  is  present  in  the 
Ben.  Spagm  of  certain  portions  of  the  intestines  may 
»  persistent  as  to  cause  temporary  stricture,  and  tb^ 
8  above  ibe  con-Htncteil  portion  become  greatly  diiitended 

Bfc  giving  rise  to  what  has  been  called  a  "  phantom 
;  or  a  real  obstruction  of  tlie  bowels  may  sometimes 
used  by  accumulation  of  faeces  behind  the  constricted 
ta.  Enictations,  borborygmi,  and  griping  pain-i  may  also 
t»«l  by  irregular  peristaltic  movemcntH  of  various  portions 
f  digestive  canal. 

uraodic  retention  of  urine,  generally  combined  with  in- 
id  iuclinatiou  to  micturate,  occurs  in  many  hysterical 
|t«;  and  this  condition  is  sometimes,  but  not  always, 
feted  with  a  paiuful  condition  of  the  genitok 
^Dismus,  cnuRcd  by  spasm  of  the  constrictor  va^DED,  aocne- 
renders  coitus  difficult  or  impossible;  it  is  generally  asso- 
}  with  bypurdaithesia  of  tlie  vaginal  orifice,  the  spusm 
induced  by  reflex  action. 

mlyaea. — Partial  or  complete  loss  of  muscular  power  is  a 
mt  symptom  of  hysteria.  Briquet  found  that  out  of  430 
c(  hysteria  ISO  suffered  from  paresis  or  paralysis ;  and 
mzy,  out  of  370  caacs,  found  40  similarly  affected. 


874 


nrsTEniA. 


The  lose  of  motor  power  may  be^n  with  mere  wetkMti  mi 
hcftvioess  of  the  liro1}  or  Imhi,  wbicb  graduaUy  ioereMi  b 
oompUte  puralysis.  At  other  times  th«  oomneanoLVt  ■ 
Roddon,  tbo  paralysis  becoming  fiiltj  d«Talo|nd  mAk  a  ^mnol 
attack. 

The  HtBtrihntion  of  the  piwralyRis  in  very  TanaUe.  It  nt 
assume  the  bemiptcgic  form,  and  in  these  eftaea  the  panJfw 
often  Biipervenes  after  ao  attack  of  bysterical  ooonloHik 
att«Q<led  with  partial  lo&s  of  consciousneM,  which  maj  hri 
for  several  days,  m  that  the  hemiplegia  reaemblea  i1m  mk 
of  organic  lesion  of  the  brain.  Id  hysterical  bemipl«^  tin 
is  no  diiitortioa  of  the  face,  nor  'deviation  of  the  tongot  m 
protrusion,  pheuometia  wbicb  are  almost  alwava  pnawtt  * 
Brat  in  hemiplf^ia,  due  to  cerebral  leaion.  In  hyaterical  haai' 
plegia  the  paralysis  ia  seldom  oomplete;  io  tbe  majorilT  W 
cases  tbe  leg  is  more  profoundly  affected  than  the  ana.  ut 
the  loss  of  motor  power  in  liable  to  con.sidemble  Tariatiau  it 
intensity,  especially  under  tbe  influence  of  emotional 
mnnt  Hystctical  hemiplegia  ia,  morooTor,  generally 
with  the  hemianoBstkesia  already  deeoribed,  as  well  ai 
orarian  hypcraiathosia,  retentioa  of  uriac.  tympanites,  ami 
symptoma  of  a^ravatod  hysteria.  Aootbar  fe&ture 
attention  i«  that  tlie  oooTulsire  attack  wbioh 
pualysid  is  always  produced  by  a  profonnd  moral  sb 

One  extremity  only  is  affeet«d,  or  the  apper  ex 
one  side  and  the  lover  oxtrcmity  on  the  other,  aod 
paralytis  of  all  tbe  extremities  is  not  unkoown.  Tbo  paialjn 
may  l>e  limited  to  one  or  more  motor  nervoa,  or  to  mm  of  As 
branches  of  a  nerve.  Hysterical  poralyus  of  the  ocular  mamim 
m  rare,  but  pamlysis  of  one  or  botli  tbe  levator  palpehn 
suporioris  mnsclos  is  not  unfrwiuent.  ^d  tbe  well-knim 
hysterical  expression  U  probably  partly  due  to  the  droopi^ 
of  the  upper  eyetidit,  caused  by  imperfect  oontrnctioo  ol 
musclea 

The  Gxciubiliiy  of  the  paralysed  musolaa  to  both  the 
and   galvanic   currenta   remains   unchanged    even    whea 
paralysis  baa  existed  for  years,  a  circumstance  of  icn»t  m-' 
portanco    in    ctttHbtisliing   a    correct    dis^oaia.      After    iMf 
diauaa  the  muaclea  may  indeed  undergo  a  oertua  MMwat^ 


ea  ^M 


HTSTERIA. 


876 


atrophy,  in  which  caae  tiieie  may  be  a  slight  diininution  of 
electric  excitability,  but  the  "  reaction  of  degeneration"  h  never 
established. 

Aua.-sthe«iu  is  frequently  associated  with  paralysis  in  hyste- 
rical patients,  although  each  of  these  conditions,  may  be  present 
witbotit  ibe  other.  Wlieu  both  condttioua  arc  combined  tbe 
aDa»ihcsia  is  generally  not  couftned  to  the  skin,  hut  cxteuds 
to  tho  miiscles,  and  then  "electro-miiscnlar  geosibility"  is 
diminished  or  abolished.  Duchcuuc  r^giu'ded  this  cooditioii 
aa  a  very  valuable  sigu  of  hysterical  paralyaia,  but  it  must  be 
remembered  tbat  muscular  anesthesia  is  soraetimea  ab^^ent  id 
hyMtericftl,  and  occasionally  present  in  paralysis  of  apoplectic 
erigiu.  Hysterical  paralysis  is  alwaya  aocompaniod  by  other 
manitestatiuus  uf  the  di<teaae,  such  as  spasm,  hyperujtilbe»ia, 
and  particularly  by  the  characteristic  peycbical  condition. 

In  doubtful  cases  a  careful  observation  of  the  course  and 
progress  of  the  diaeaso  will  aid  in  clearing  up  the  diagnosia 
Hysterical  paralyfiis  is  generally  variable  in  its  duration,  con- 
tinuiug  for  a  few  hours,  days,  or  weeks,  and  then  completely 
diMppeariDg,  perhaps  to  return  after  subsequent  attacks  of 
hysteria.  The  mode  of  extension  of  tho  paralysis  is  sometimes 
charB<?terisitic,  It  may  be  prououueed  at  first  on  one-half  of 
tbe  body,  then  quickly  disappear  from  that  side  and  present 
itself  on  the  opposite  side,  or  it  may  be  crossed.  In  some 
cases  the  paralysis  continues  for  years  unchanged  In  extent ; 
in  these  cases  hysteria  may  be  ditHciilt  to  distinguish  from 
licmiplegia  caused  by  circumscribed  ksiou  of  the  brain,  or  from 
cerebro-spinal  scleroais  and  spinal  paraplegia 

ContTiictitre  not  unfreqneotly  becomes  developed  in  tbe 
paralysed  extremities.  In  some  cu^es  the  contracture  appears 
simaltaoeously  with  the  paralysis,  while  in  other  cases  the 
panlysis  coDtioues  for  some  time  and  then  contracture  stipcr- 
ven«8  gradually  or  suddenly  after  a  fresh  attack.  In  the 
upper  estremitioR  there  is  spasmodic  Hcxion  of  the  forearm, 
band,  and  fingers ;  the  muscles  are  in  a  state  of  considernhlc 
rigidity,  »o  tliat  it  is  impossible  to  obtain  complete  exteuaion, 
or  to  increase  the  flexion. 

The  lower  extremity  is  strongly  extended  upon  the  pelvis,  ard 
the  leg  upon  tbe  tbigb ;  the  foot  generally  assumes  the  poBLtioD 


878 


HynnuA. 


face  IB  often  accompanied  bj  profiwe  perspiratioo.  Btn  tb 
alternale  conUoctioD  and  dilatatioQ  oT  the  vetseU  a  not  oooEnat 
to  tbe  fsca  In  hynterical  joint  BffecLiotu  Brodie  ohiaTod  tb 
coldoess  and  pallor  of  tbe  aifected  extremity  existad  fix  mm 
bours  duily,  to  be  succeeded  b;  redness,  beat,  and  Bwsaliagfi* 
a  aiinil&r  pi>riod,  tbe  luttcr  symptoma  id  tbeir  lam  giviBf  fhtt 
to  tbe  Dormal  condition.  The  bands,  which  are  dry  asd  aU 
when  at  rest,  often  become  warm  and  moist  on  the  tijf^im 
attempt  aX  manual  «xcrcis«,  such  aa  writing,  and  cvea  thtfliM 
faaoiis  of  hysterical  patients  are  often  covered  by  a  clammynrMi. 
Tbe  whole  body  is  ftometimes  prone  to  perspire,  while  oat- 
lateral  sweating  is  occasiooiUly  obaerved.  Nearalgio  afftetioaa 
somotimea  accompanied  by  herpea,  ore  frequently  auoaiMl 
witii  local  hypenrmiaof  tbe  skin  in  hysterical  Huhjocta. 

Charcot  has  drawn  attention  to  tbe  fact  that  in  thv  eomfktt 
form  of  bygterical  bemiaovtttbe«ia  tbe  axussthetic  nde  Dot  pa^ 
sudent  from  comparative  pallor  and  coldoeu,  but  ble«dx  IHtkm 
not  at  all  on  being  pricked  with  a  pin.  His  attentJoo  wacfial 
drawn  to  Ibis  peculiarity  by  obsuerving,  on  teecbea  beiDg  Bf|M 
to  a  patient  affected  with  hystorioU  bemiansBstlMna,  Hm 
their  bites  yielded  very  little  blood  on  tbe  aiuntlictic  li^; 
while  the  healthy  side  bled  as  usual.  Cfaarcot  balimi  tkal 
hysterical  iscbiumia  may  furnish  an  explaoBlioo  of  cntia 
reputed  miraculoiia  occurrenccx,  as,  for  iDstanoe,  of  tbe  ttste- 
ment  made  on  good  authority  that  in  tbe  epidemic  ol  ^^*':' 
Uedord  the  sword  blows  given  to  the  "cunvulaionDairM"  -^ 
not  cause  bleeding.  The  amenorrbcea,  bo  frequcntlj  asaocnld 
with  hysteria,  is  probably  often  caused  by  local  lach'  ^  *■ 
although  it  sometimes  reeults  from  tbe  general  auannta  «W& 
uudcrlics  both  afTeclions. 

Not  less  remarkable  than  bysterieal  ucAtptnia  ia  what  mij 
bo  termed  hyeterical  kyperatnieu  Hysterical  bypenenu*  mm- 
times  loads  to  profnso  and  frequently  repeated  roeoatnialisa 
although,  no  doubt,  both  the  menorrhagia  and  hysteria  i 
times  result  from  ovarian  disorder.  Id  hysterical 
ameoorrbcea  bfemorrbages  may  take  place  from  other 
and  these  are  generally  regarded  as  vicarious  of  mensinuaa 
The  rnocoUH  membranes  of  the  nose,  tbrost,  stomach,  and 
are  the  favourite  sites  of  these  hnmorrbagci;  but  is  rare 


HTSTEltlA. 


877 


not  an  uncommon  symptom  of  liyeterift,  and  swftllowtng  may 
consequently  bo  rendered  difficult  or  impossible.  In  such  a 
owe  th«  ojsophageal  tube  pmtsea  iutu  tbe  stomacli  witliout  any 
olMlruction.  Retention  of  urine  m  common,  and  often  paralytic 
in  origin. 

pATalysia  of  the  muitcular  coat  of  the  xtomucli  lit  partly  cause, 
jiArtly  effect  of  the  general  tympanites  which  is  so  frequently 
met  with  in  hysterical  p&tieiits.     Tympanites  may  come  ou 

I  anddenly,  in  consequence  of  mental  agitation  or  at  tlie  cloae  of 
a  hysterical  attack,  and  sometimes  reacben  such  a  degree  that 
tbe  patients  may  be  kept  afloat  in  a  liatb  by  means  of  the 
gM«ouii  disteotioQ.  Tlic  obstinate  conistipation  which  ia  bo 
frequent  in  hysteria  is  probably  due  to  paralysis  of  (bo  muacular 
coat  of  tbe  bowela  ' 

(c)  Vaachmotor  and  Secretory  Disturbance. — In  the  inter- 
vals between  the  uitackii  of  liysjti^ria  the  action  of  the  L^art 
aud  the  puW  may  be  normail,  unle^i  iudued  some  general 
dueaae,  like  chlorosis,  be  present.  Jlynterical  patienta  are, 
however,  liable  to  suffer  from  paroxysms  of  palpitatioo.     During 

,  ihese  attacks  tbe  puliie  in  at  limt  fretjuent,  iimail,  aud  bard ; 

;  the  akin  in  pale  and  cold ;  there  is  a  feeling  of  fulnetis  and 
oppresiiion  in  the  chest;  aiid  there  may  be  a  degree  of  menuil 
confiuiou.  After  a  time  the  cutaoeous  vuHsulu  relax  and  the 
maHace  is  reddened  »nd  covered  with  perspiration;  tbe  pulse 
then  becomes  slow,  full,  and  compretaible.  Uyntericai  patit-nts 
ant  liable  to  fainting  titK,  caused  doubtless  by  sudden  auoimia 
of  the  brain.  The  cerebral  anu^tiiia  may  in  its  turn  be  produced 
•iAher  by  vaso-motor  contraction  ol'  the  iulrucruuial  arterioles, 
or  by  sudden  dilatation  of  tho  arteries  of  Cbo  body,  capccially 
of  the  abdominal  arteries,  permitting  the  blood  to  accumulate 
in  tbe  dependent  p<Lrt«. 

Various  other  alterations  of  the  vascular  tonus  may  occur 
in  hysteria,  indepeudeutly  of  the  state  of  the  cardiac  action. 
Patients  frequently  cutuplain  of  "  rushing  of  the  blood  to  tbe 
bead"  and  Hushing  of  tbe  faoe,  which  may  assume  an 
inteosely  red  colour ;  the  hands  and  feel  are  at  the  same  time 
pale  and  iij  cold,  aud  the  mucous  membrunes,  especially  of  the 
conjuoctivai  aud  UpH,  are  amumic.  Uyslerical  subjects  are  liable 
to  become  pale  and  to  blush  aLteniately,  and  the  duahiug  of  iho 


affected,  these  vou]d  not  bleed  at  ftr^,  bat  oiig 
ci  short  time  aftervrarJs  wheu  the  hvpersetntc  8t 

Sudden  elevation  of  tempemtore  of  the  bodj 
most  remarkAblo  phoDOmona  of  byflt«m.  In 
Indy  who  8ufier«d  from  anomaloas  nervous  tjra] 
from  a  horse,  under  the  cnre  of  Afr.  J.  Teak*,  a 
1S2*F.  was  recorded.  Uore  or  lesa  aimilar  cm 
tib»erred  by  Dr.  Donkin.  The  following  case,  n 
Sleell,  is  a  good  example  : — 

M.  M ,30  j-imn  of  tkgn,  u  mint  in  the  MMnchwrtw 

tint  vomo  uii'lcr  tiiixticvil  trvattunit  on  th«  S4tl]  of  Octob4 
tieeii  i>iit  iiiimiig  a  caw  of  erTsijjeloa,  oaA  weiuod  inipna 
that  abv  luul  ooatnict«d  Uu  dboue.  A  alight  ii\uii  aint 
tt  tmwibur^r  aud  uVmht  {>ynt\u  wviv,  hinrovcr.  all  tlw  t>v 
■be  thcti  i>R0L-iito(l.  A  few  (Ia7«  after  lulnuMioa,  w! 
«i^-sipeLw  tuu)  I'titirDi)  suWulutl,  ralmtiun  or  iiriiie  « 
and  it  nw*  kitruod  tliiit  ubout  s  jmu-  jirvninMlj  sbr 
Hflbcted,  but  IihiI  not  unwi  under  mMlicul  soperriflluo. 
drawn  oS  twios  daily,  attd  rariouA  renwdiw  wrcow 
reatoiijii;  Toluntac;  micturition.  Aa  the  ewe  waa 
hysterical  in  nntiiro,  Bh«  was  allowed  to  p>  on  dety*  ean 
no  otuluo  diltteDaion  of  the  liloddcr  occiirraL  Her  polM 
at  tjiis  time  wen  always  fouud  to  bo  DomuL  A 
occasioDalljr  proeent,  and,  perbaiM  wrouglj,  wiiti  attri 
of  eba  Uiklder.  Henstrtmtiuii  did  not  deviate  uuiteriullr 
Other  reiuiidiBs  haviuj-  faiW,  fuwlioutipn  wan  craploy 
hrtliijf  iitLii-hfld  to  tlie  Btik-tta  of  a  iriitn.»Liid.ic  entturtiir. 


HYSTEBU. 


881 


laft  iliac  regknit  where  thura  wan  iil»o  tcudpnieas  on  preasure,  but  not 
iiod  entirely  to  that  spot.  Her  temperature  at  thiu  tiaiu  btHuuue 
It,  oa  sbowD  by  the  following  obsen'atiniw:  Doceniber  Hcli,  oveuiiig, 
W-Q';  9lli,  i-veuiug,  98-S°;  averagiiii;  101°  frum  tlio  lltb  tUl  tbu  SMtli, 
lieu  it  notched  1li3'2°  ill  the  moriiiii({.  Tliw  kicnpemtiin.'!  vn»  not 
■iatiit<uui.>l,  uitJ  thiif  tLertui>mettfr  n^isturvd  ICXJ'4''  qu  tho  wcniag  of  tbu 
lOth.  The  tMiiiJUiatiim  reauiiui^il  alxmt  101"  (nsM'^biiiiii;  tlie  uonnal, 
lowerer,  on  tlio  moruin;;  of  tbe  SBtb)  till  thu  30tb,  whuu  the  ivmariublo 
Jiiiiiniiil.y  which  it  is  the  oly'eot  uf  tliL'.-tc  Wiks  Uj  rcainl  bv^ii  U>  luntiifost 
tiwif,  tvinperotiiraa  of  lOA'  and  dK'C  (the  foniicr  oocuiring  iluring  a  rigor) 
aing  obeerveil  Uie  miaa  eveiiiujc.  Tho  tvuijioratiirt:  aHer  tliia  conticiuod 
RVguUr,  on  bcfuiv,  till  the  3td  of  Jiuitiiuy,  wli«n  th^  thormomutor  in  the 
ijdUa  r^intcreol  10l}'3°  »t  10  [i.iii.  diiriug  h  rigor  (pulse  132).  On  tho  6tb, 
(W*?*  wiw  ruiti^l  umlei  Hii)iilu.r  circitmstonooa,  but  shortly  after  !)9'-l". 
'he  folliiwiiig  iwu  ilayj*  it  r^iuuiiieil  normal,  aiJij  dii  the  1 1th  nyaa  iiiily  ki 
iO^'C,  again  to  foil  to  nonu&l.  1  Kgrat  tluit  1  nm  iinAhli;  t^  funiiah  an 
Uibrukcii  curve  of  l«n|)emtuni  obewrvatiuiui,  Init  I  trutl  tiw  fnctt  I  can 
lutM(tat)tiat<  will  iaxc  nono  of  tiioir  vnixus  od  thftt  aoooiint  Klgon  iww 
legsa  to  occur  with  iaivuuuiig  frcquoiicy,  each  being  nccoinpfuikil  by  a 
Kpul  nnij  giMat  ma  of  tempen(tim>.  Thay  w«ro  irrDgiiliLr  in  rwciinviiov, 
jkI  diJ  HOC  oonfonn  to  aay  dcHnite  type,  Porspiratioo  usually  followed, 
t  will  be  «eoD  that  tho  ^-^n^ml  form  of  tho  tom^icraturd  curve  would  tuojit 
toeely  Ksenbla  that  of  pyaimia,  and  tho  poa«iblc  cxiatcnoc  nf  oil  absocas 
or  atwut  the  orary  oould  m^t  but  suggest  itsulf.  The  geQ&nd  ooiidittoa 
f  the  patKsiit  vaa  at  v)kriaii<»:  -wiUi  thia  liyiK^thesiu,  tho  wcU-kuowu 
ntnrwi  of  iiit»n>w  iilue-Hit  l>uiiig  ulineiiL  I  whall  meri'ly  mention  Nome 
Engle  obaon'stioua  of  tenificnkture,  giviug  the  date  lui'l  time.  It  may  ba 
aken  for  gmntwl  that  tlio  high  t^'inixtrstuiui  wore  thiwu  i>l*terv©d  duhiifj 
r  immoliatcly  after  a  rigor. 


'•nuary  34th,  11  ajn lOT'S* 

24th,  liajn.  I02-i" 

24th,  9]i.ia     ......  101* 

•Ihth,  in-cniiig 98-4° 

Siltti,       „         100-8° 

3(tth,  moniing SIS' 

Si^itli,  evaniDg 901^ 

Pcbruanr  4th,      „       lOfi" 

6th,       „        105-r 

(ith,  BoamiDg 9&-8* 

lOlb,       „         106-4' 

16th,        „         99-4' 

16th,  livening  10B"«* 

a^tli,  moniing 9K» 

24th,  5-36  p.ni.    ...  1U8-B' 
a4th,  \0\i.m.  (J)...  88-4' 

»Bth,  «p.ni US' 

SSth,  4-3Upia.    ...  U3» 

Har«fa  txt,  morning  , 9fl*2* 

Ut,  evening totf* 

EEB 


Mareh  Srd,  8-45  a-BO.    Ill" 

„       3rd.  10-30  a.m lO&-r 

„       3rI,  11-30  a.iu. 90-2° 

„       4th,  6-15  a-tn.    107-4'' 

„       4th,  8-43  a.m.    108* 

„       4th,  4  luin Iia'4» 

„       5th,  8-50  n-ni.    108-«* 

„       5th,  2-30  p.™.    106* 

„       ath,  3-45  p.ni I07-4'' 

„       7th,  10a.iu 109° 

„        7th,  8-30  p-ni IMC* 

„       8th,  fl  [xni Illi" 

„       11th,  4-30p.m. 111-2= 

„       12th,  10  am. 108* 

„  '    I7th,  evening    100*1" 

„       18th,  3-30|i.ni 110-4" 

„       IKth,  4a.ni 118°+ 

„       Iftth,  H  p.m flS-H" 

„       2lrt,  9-30aJii lll'-H 

„       23k1,  9-30  aja. 106' 


uii)  wh^ro,  by  the  n)Mv«  fifiru'^T  i^  pnltMigetl  higb  Itfniperall 
it  u  only  ajipnRntljr  ws  the  olsmitioiM  hnrinc  bwD  n, 
ngpn.  AH  were  made  )o  tlw  udUo,  latA  dUEHVOt  llM 
used,  acTeral  of  wliioh  h»A  bhoir  mgiiitvrinK  culumas  Mr 
Bt  the  top  (indiMtMl  kIkpto  by  the  i^Tuboi  +).  l_ 
ibc  rvtrntion  of  urini:  noted  nt  the  cuinii 
ooonKciiut]  iiitcmitwiAiiH  uf  vmrying  iltimtiun. 

Tlieai:  lines  wcru  wnttco  hnroids  the  vntl  of  >tarct 
ma  in  a  tbw  sonfanicm  to  namto  tJie  ■ibMqtmt  i 
•ttockB  <if  hjimpyresi*  DMoecl  (thon^  tnaaieot  jtymii 
tiiiw  to  tinu)  on  the  >dT«ot  of  o  new  wraa  of  plMBOi 
gaMml  coUTulaiooB  of  extreme  vmImioci,  aoooiniaiMBd  ( 
Icoa  of  DOtUGtouBDen,  Uridity,  Sol,  and  IbUovol  liy  poi 
nmaUtuig  ta  a  remukable  way  the  tramaatjc  funu  d 
Theae  wreiv  aymptom*  grnduolly  dimiiiiKhed  in  iittaMty 
wbOo  gCDcnil  umcliomtion  in  Ube  pAtientW  oondHioa  art  fa 
IStb  of  Aimt  nhn  wtut  ntilo  to  ho  nmuxred  to  tb»  CbMd 
Ilospttal.  There  licroGovaleMNMoeoittioucdwitli  but  rii^ 
anil  she  i»  now  on  fiill  duty  u  a  Dune  in  tbo  lutitiitkni,  : 

Hysterical  pitieatA  suffer  frxHD  various  aoomalit 
aod  excretioD.  Increaseil  flow  of  salint  is  noi 
symptom  aricr  a  hyatencal  attach,  and  it  oeeui 
indcpenikntly  of  the  fita  At  other  ticMs  an  aim 
of  the  mouth,  aloag  vrith  great  thirst,  u  preMOt, 
patisDts  to  driak  large  qnaatitiee  of  fiukL 

The  gutric  seei«ti«ti  is  aometimu  Iwgdjr  iocm 
take  place  iodepcDdeotly  of  the  iogeetJ&n  of  fiwl 


IITKTKHIA. 


883 


Hysterical  vomiting  ia  not  often  accompanJecl  by  much  loss 
f  flesh,  but  great  emaciatiun  may  take  place  in  hpteria  in 
W  abaeace  of  vomiting  or  any  recogDisable  ]e<iiou  to  account 
ir  it.  TIiIh  condition  baa  been  describc^d  by  Liut^ne  under 
IB  name  of  hysto-iaU  anorexia,  anil  by  Sir  W.  OuU  as  aptjma 
j/attrica.  "These  patients,"  says  Dr.  Wilks,  "declare  that 
bey  Ho  not  care  for  food,  and  so  they  take  leH  and  less  until 
U  appetite  ha:^  gone,  and  then,  indeed,  a  loalhiiig  may  come 
nJ*  la  a  case  of  ibU  kind,  tbat  of  a  girl  aged  18  years,  which 
uoe  under  my  observation,  the  emaciation  waa  extreme,  the 
luD  being  stretclied  over  the  face  so  as  to  reveal  all  tbo 
q>re88ioDs  and  prominences  of  the  jaws  and  malar  bones, 
"be  condition  of  the  patient  ruToindcd  me  forcibly  of  the 
ippeaiaoce  presented  by  those  auffonng  from  chronic  starvatiOB, 
loe  to  organic  stricture  of  the  cesophagaa.  Some  months  subse- 
oeot  to  my  Mcicg  the  patient  her  parents  changed  their 
Midence ;  she  almost  immediately  began  to  eat,  and  became 
uite  plump  in  a  few  weeks. 

Hysterical  vomiting  ta  sometimes  ttio  complement  of  hya- 
erical  suppresBion  i>f  urine.  In  attcb  caam,  when  the  smpprefHiioa 
tf  uriuQ  is  complete  and  of  long  continuance,  the  quantity 
pomited  ig  large,  and  in  a  case  observed  by  Charcot  a  ouasider- 
ibte  quantity  of  urea  was  detected  in  the  vomited  mattera 
^eroct  also  found  urea  in  the  vomited  matters  in  a  case  of 
hii  kind.  It  in  therefore  probable  that  the  vomiting  is  caused 
ly  the  supplemental  elimination  of  urea  by  the  stomach. 

The  renal  secretion  undergoea  fre<iuen[  alterationa  in  hysteria 
Hysterical  polyuria  ia  avery  conBtant  symptom  after  conralsive 
kttocka,  tbenrioe  under  such  circumstances  being  pale  and  of 
DW  specific  gravity. 

Hysterical  anuria,  although  seldom  met  with,  is  a  more 
nteresting  phenonienou  than  polyuria.  Almost  total  Aiippree- 
noD  of  urine  may  exist  for  a  period  of  vrcckb  or  months  without 
giving  rise  to  serious  aymptoms  besides  the  constant  vomiting. 
Charcot  bas  sbowa  that  this  curious  phenomenoa  depends,  not 
upon  a  spasmodic  coadition  of  the  ureter,  but  upon  some  dis- 
Bntw  of  the  kidneys  cbemBelves,  probably  vaso-motor  contrao- 
tbn  of  the  renal  arteries  analogous  to  the  hysterical  iscbaemia 
already  described  as  occurring  on  ibe  surface  of  the  body. 


wrviiic  VI  ujrvunvsi  pnuutis  u  nir 

bility,  unchecked  by  Toluotary  effort,  whiob  fit 
in  various  ways.  Both  pleosanl  and  UDpleafli^| 
excited  in  ttiem  with  unwontoil  ease,  bo  th«| 
remarks,  "  the  piLtaeat  ia  hurried  froui  oue  ext 
vith  ludicrous  mpidity ;  and  often  she  walks, 
narrow  line  where  tears  and  laughter  meeLJ 
sdbbiuti;  not  oaly  alteriuita  but  ccHi^xisi,  and 
obvious  and  suBident  reaaoa  for  eilber," 
tlonal  activity  nece!i»rily  iodnces  exhauatJoo.i 
iicrvoiu  nyatcm  is  adapted  for  the  retention 
emotions,  so  that,  as  a  rule,  bystericsl  pstic 
gloomy,  and  not  ouly  exaggerate  bodily  aili 
but  imagine  those  which  bare  no  existence. 

Another  mental  peculiarity  of  byflterical  patti 
liarity  which  lius  at  the  root  of  almust  nil  tiwj 
derangements — it  eraving  for  Bynipathif.  i^ 
quality  of  miad  which  adapts  man  for  the  todal 
the  foundation  of  all  his  moral  octians ;  tbo  lii| 
must  necoiwarily  crave  for  the  sympathy  of  their 
the  more  highly  the  mind  ts  developed  the  more 
will  the  craving  for  sympathy  probably  beoomei 
well-regiilated  minds,  however,  perceive  that  tl 
right  to  claim  the  regard,  esteem,  and  symf 
irho  refuse  to  be  srmpatbetic  in  their  turn 


ionj 

tiefl 

'■1 


UVSTERU. 


8S5 


small  To  tliiok  of  others  becomes  a  second  nature,  iidiI  tbe 
tnie  method  b;  whtcb  to  purchoae  tbo  iaeatimablv  boon  of 
Inman  eympatby.  Sympathetic  aaturea  of  this  class  are  necee- 
Buity  deeply  cmotioual,  but  tbo  life  of  active  bencvolcaee 
vbicb  they  lead  teDiiers  it  aecessory  for  tbem  to  develop  the 
intellect  in  odaptiag  means  to  endii  and  tbe  will  by  tbe  daily 
SKerdM  of  (clf>contro!.  Siirh  natures  nro  emotional,  but  they 
«»  also  Btroug-willed  und  of  vigorous  iutoUecl ;  in  one  word, 
tbeir  minds  are  well-balanced  and  healthy. 

Conlrut  these  individuals  with  the  habitually  hysterical. 
Both  are  emotional,  and  both  crave  for  sympathy;  but  while 
IIm  furraer  purchase  nympathy  by  actively  bestowing  it,  the 
latter  would  like  to  be  itg  recipietils  while  refuaing  it  to  others. 
Tbe  former  ace  unselliah  anil  ilevutcd  to  tbe  interests  of  otherx, 
white  the  latter  are  RelHsh  and  regard  theinselveit  as  tbe  centre 
of  tbe  whole  world  of  feeling,  thought,  and  action. 

It  is  this  morbid  desire  for  sympathy  that  prompts  hysterical 
|lftUents  cither  to  exaggerate  a  real  nilment  or  to  feign  illncsti 
when  they  are  free  from  it,  or  erea  to  iafllcb  bodily  iLJury  upon 
themselves  for  the  purpose  of  arousing  compassion  and  attention. 
Scarcely  a  diseaeo  can  be  montioned  which  may  not  be  simu- 
lated by  tbe  hyaterical,  and  the  methods  tbey  adopt  to  effect 
llieir  object  arc  truly  marvellous,  and  would  he  utterly  incredible 
UDle«  atte.stcd  upon  uudeulable  ovidcnca  In  order  to  excite 
compassion,  some  injure  and  burn  themselves,  induce  purulent 
cutaneou!!  eruptions  by  the  use  of  irritating  ointments,  sffallow 
needles,  or  even  pretoad  that  they  are  about  to  commit  suicide, 
althougb  real  attempu  at  suicide  are  rare. 

The  depraved  ideas  formed  by  hj'sterical  p&tients,  and  the 
derailing  actions  resulting  from  them,  defy  all  dencriptJoa. 
Sotne  havu  druuk  urine  and  eaten  excrement  in  order  tbey 
may  vomit  them  ;  others  have  led  their  too  credulous  attendants 
to  believe  that  urine  issued  from  tbeir  navels,  breasts,  ears,  or 
•jres;  othors,  again,  have  introduced  living  aaiaials,  such  as 
frogs  and  worms,  into  the  aiiUK  or  vagina,  so  that  thuy  might, 
1^  reproduciag  tbem,  excite  wonder,  and  become  objects  of 
sympathy  to  thoir  fricndB. 

But  there  are  lower  depth?  of  human  degradation  which 
hysterical    females    do    nut    fail    to  reach.     TUuy    sometimes 


fi    I  t — :: a 


^tma: — -  wiun  ;khi  mo  &  ptnignpii"  uy»uti 
'  cxtraoriltDary  occurrence,'  ami  jou  read  bow  c 
rapping  is  heard  in  Bomo  part  of  tbe  bouae,  or 
ar«  being  ooostautly  Kt  on  fire,  or  bovr  all  tb< 
house  oro  bung  devoured  b;  rats,  you  may  be  q 
iR  a  young  girl  on  tlie  premiaes," 

I  hftvo  known  a  young  Imly  at  a  bo&rding 
Hb«eU  aoMl  ber  own  uoderctoiliuig  into  sbreds, 
vour  to  fasUia  the  guilt  upon  a  achoolmata 
a  carving-kuife  undor  her  pillow,  and  wheu  it 
as  was  doubtless  intended,  sbe  confesBod   to  l 
committing  guicide. 

Tbeso,  however,  are  only  a  few  of  the  minor 
may  be  committeil  by  hyBterical  girls.  A  ymuid 
not  uafri.x)ueiilly  been  known  to  poi«OD  tbe  cbiU 
charge,  at  other  timeft  the  attempt  is  direct^ 
mistress,  and  it  is  so  clamsily  carried  out  that  i 
whole  family  may  be  oodaogered.  At  timoa  m  ^ 
ooal  may  be  placed  under  tbe  infant  in  the  cradl 
attempts  be  made  to  set  the  house  on  firo.  all 
wbile  tbe  girl  ia  treated  with  tbo  utmtnt  cog 
kindness  by  her  omployoraL 

The  well-knowD  ca^e  of  Constance   K«at 
frightful  crimes  which  may  be  perp«lr«tod  by 
fchifl  fltfniura  oanditinn_     T>r_   Wll^  in  sUiuyi 


UVSTEllU. 


887 


olessness  of  the  act  (except,  perhaps,  for  revenge)  con- 

me  that  It  wu  perpetrated  by  a  young  womau.     I  felt 

ita  sure  io  my  own  mind  a^  to  the  real  criniinal,  who,  even 

hor  own  ooaressioD,  was  considered  by  many  incapable  of 

a  deed." 

[t  U  not  umisiial  for  the  psychical  diatiirbaoce  of  hysteria  to 

tmc  an  erotic  character.     GirU  may  then  ajwert  that  they 

t?e  been  ravished,  and  usually  maintain  that  the  most  out* 

JUS  violence  wan  used  by  the  perpetrator  of  the  crime,  or 

kt  they  themselves  were  previously  drugged.     The  notes  of 

te  foUowiug  case  hare  beea  kindly  supplied  to  mc  by  Mr. 

Culliogwortb,  who  was  the  medical  witness  called  in  by  the 

police  to  iaveetigate  the  case  after  her  supposed  dying  state- 

L^MDt  bad  be«i  taken  : — 

^^■In  Deeember,  1876,  n  girl  of  ei^teon  was  fcninil  niio  oruiiirig  tt-in'f'nfc 
^H|Ui  her  cioLtiiiix  wet  ainl  nniddj'i  luiil  in  an  n|>|HUviitlir  atup«Jted  eoii- 
^thw,  In  llie  doMid  dmirHay  uf  a  n»Utiimut  in  tita  cciitiv  iti  Manolic'st«r, 
■  ftnr  yank  ftnta  vrhuv  hUd  wwt  lud^ti^  She  vrita  Inkcn  home  otul  to 
twd,  and  a  medical  man  vnw  seiit  Tor.  H«  foiiud  livr  to  uli  sppiHiranoe 
unaoiiscioua  of  vbat  wu  going  on  aronnd  hor,  and  uttoriug  some  die- 
juLuled  Bwl  inootKiviit  comjiliiiDtH  uf  liaving  been  drugged  and  threatened. 
He  thought  aba  was  raooreiing  ham  the  eSbcts  of  some  nanxilic^  aud  did 
not  at  Ant  [lay  much  atteuticHi  to  her  story.  The  foHowiDg  day,  however, 
abe  aiPiwAKd  w<>nic,  ajid  in  ihe  evcuiuK  Ucr  wiiditiou  wtw  oooaidoicd  do 
«nti(sU  that  iIk'  lulice  were  oominuuioated  with,  with  a  view  to  har  st*t»- 
BMot  hctng  Uikva  dowu.  She  waa  viHitvd  hy  iw  «xpericiicod  dotoctivoe, 
wbo,  mKuii  buw  nutters  irtond,  and  fajiTtiig  tho  doctor'^  aanuonce  that  she 
vna  in  a  dying  itate,  sent  at  once  for  a  nii^UtratD,  bcfure  whom  shs  made 
a  aoleoui  divhuntion  to  the  fnllowinx  eSooL:  .Slii-  MievW  hnwlT  to  be 
dying.  On  the  jtrenoUB  evening  a  aoltoitor,  at  whone  ofRo:  sho  bad  called 
an  buainetSK.  told  Iut  thjtt  nliu  uiimt  go  iiiUi  iiixinvcut.audgave  her  "some 
nort  of  dart;,  Kwcct  drink,''  which  rciiderml  her  mnRolom.  On  going  down- 
stain  tnm  the  office  she  mot  a  Josuit  (athur,  whom  aho  had  seen  onoe 
befoTEi.  Tbis  g<-iitl<.fiiinn  tt»\\t  liold  or  hirr  mid  pulled  hor  along  the  street 
to  a  Utth;  houHc  In  a  ooiirt,  wbcro  tlii'tv  won  mi  up]jcr  room  with  a  bed  in 
it  aud  a  erom  on  thii  wall.  Hnviiig  got  her  into  this  room,  be  said  im- 
pit)|N:r  thtnga  to  bor,  niul  gnvc  hcra  little  cake  which  afllbcted  her  diKcUy. 
Tbe  woman  of  the  house  rnmt!  itilo  thu  njum  and  found  her  on  the  floor, 
after  which  she  aonichow  got  outside,  tho  priost  fallowing.  He  again 
iliagged  her  along  in  the  dirt  to  tbustrvut  oomm*,  when  be  ran  away. 

Tlio  Moliratur  imd  tli«  priest,  both  of  tbeni  well-known  and  liiglilv- 
I,  were  UuTdupou  pluoed  under  anwt  iu  tU»  uiiddlu  u(  IIk  night 


888 


UTSrtEBIX. 


umnlor.  The  story  vnn  proviirl  to  be  pimly  hnngiiMfy.  wbI  Um  i 

It  U  not  oaly  the  actiooa  wUicb  are  in  immedtsto  raJatMi 
vritb  the  emoLionH  that  are  so  profoundly  JUturbe*]  II  britek 
but  grave  disordars  of  the  representative  feelings  and  mpJTifi 
occur.  Illunona  of  sight  are  common  In  the  earlj  itigei  4 
i4cvcre  hysterical  attacks.  Charcot  has  drawn  att«Dtioa  talk 
fact  that  in  the  grare  Goaee  of  hysteria  MBOoiated  with 
hypenesthesia  and  hemiansoatheaia  the  patieute  Ixeqaeotlyi 
rets  and  othor  odious  animals  oo  the  aocsthtttic  tide  «f 
body,  or  with  the  eye  suffering  from  amblyopia.  At 
times  they  biivc  hallucinations  with  crroneou*  idoa* 
some  of  the  imager  that  have  appeared  duriDgthcpanHcywii 
subsequcDlly  cotiaidercd  r«aL  The  entire  hysterical 
may  cousist  of  a  euccesAioo  of  images  like  that  o<ciimB| 
TJvid  dreams,  a  condition  genenUly  dc«crih«d  ai  byitedal 
deliriuni. 

If  the  attacks  be  tntDSioat  and  occur  rarely,  the  patjeat  nn 
recover  comptotoly  from  their  ctfectt ;  but  if  they  teoor  f» 
quently,  perastent  mental  aberration  is  after  a  timfi  TT^«Wir4i  i"* 
'File  delirium  frequeotty  makes  its  appearance  in  a  psHsetl; 
periudical  maiiDer  aud  without  any  recognisable  oauss,  haaf 
regularly  preceded  by  a  condition  of  ill-humour  or  mentst  tni* 
luLility.  Td  other  casea  a  ehrunic  and  continuotu  fora  <^ 
menial  disturbance  is  eHtabltsh(>d,  which  la  liul«  affectaj  W 
the  fiU. 

One  variety  of  this  mental  condition  assumes  iheiurtDirfpGiv 
melancholy.  The  patients  are  anxions,  wretched,  and  tocapUi 
of  eujoying  the  society  of  others,  and  under  such  cinntautaaaM 
they  are  subject  to  uncontrollable  impulses  which  urge  th«B  la 
commit  outrageous  nctioos. 

A  second  form  of  chronic  oontiauous  hysterical  mental  At 
turbonce  oorresponds  closely  to  the  dinical  deecriptioo  of  \ht 
so-called  /olie-raUonnaytU.  Patieota  affected  in  tbii  vsj 
pursue  their  own  selfish  aims  with  the  graataat  penereraMk 
although  they  are  unfit  for  any  useful  employmeDt;  the  •etitkl 
appetite  is  ofton  strongly  dorclupeJ,  and  not  rarely  they  us 
given  to  drunkeDDeea.    There  is  complete  abeaftc*  of  the  idooI 


m 


HYSTEBU. 


SS9 


they  are  quite  unable  to  curb  tbeir  iDcIin&tioiis  and 
impulsed  i  tbvjr  are  linrf,  aud  cbcat  and  ateal  wit-h  tbe  greatest 
lOUnniog  aod  dexterity ;  and  are  always  ready  witb  plaiuible 
Ireosons  to  cloak  tbe  perversity  of  their  aetioD».  while  tbcy 
Ima&ifeet  tbe  utmost  centidcnco  ia  the  iDCOQtrovortiblc  nature  of 
|th«ir  arguments.  In  tbeae  caaes  tbe  intelligence  ta  profouudiy 
disturbeJ,  for  it  is  pvident  tbat  the  statement  which  was  at  one 
time  u  cdD9ciou8  fabrioitioii  to  meet  an  emorgcucy  is  afterwards 
Ireprwluced  by  tbem  witb  a  full  belief  in  its  trutb.  Tbuy  fre- 
'queotly  MitTt^r  from  balliicinatlotis,  wbicb  may  gradually  become 
itraosformed  iuto  established  erroneous  ideas.  They  are  besides 
fUibject  to  occasional  outbursts  of  excitement,  which  aft«r  a, 
'time  pass  into  pronounced  miiniacod  daUs. 

^^k  (Z)  Hnmic&t.  AnicKiL 

^^Sjsterical  fits  arc  exceedingly  variable  ia  the  combioatioit  of 
.their  symptODU  and  tbe  degree  of  their  intensity,  so  that  it  is 
linpoeMble  to  oomprifte  nil  the  various  forms  under  one  geacnl 
descnptioo.  Tbe  attacks  occur  sometimes  without  any  recog- 
nisable cause,  while  at  other  times  they  are  provoked  by 
lorer-excitomen t  or  some  slight  emotional  disturbance.  Tbe 
i^pAioxysm  at  wavB  takes  place  when  someone  is  present  to  uritneai 
lit,  and  never  during  sleep,  nor  when  the  patient  is  alone. 

(a)  SimpU  Hjfsterical  Attack. — ^Tbe  attack  ia  preceded  by 
the  aensttion  of  globus  along  witb  a  feeling  of  suffocation,  a 
painful  dragging  in  the  extremities,  pain  and  giddiness  in  the 
laead,  singing  in  tbe  ears,  or  daikeoiag  of  tbe  6«ld  of  vision. 
lit  is  often  preceded  by  a  6t  of  crying  or  laughing,  or  a 
cooibination  of  t>oth;  the  patient  suddenly  screams  or  toaJEca 
a  spluttering  noise,  and  lalU  down  in  a  state  uf  apparent 
UDCODacioMDCM.  Tfac  bcsd  and  extremities  becocDe  aaiccted 
witb  geneml  rbythmieal  etooie  ooBvulaioos,  tbe  t»re*thii«  is 
Accelerated  and  exaggerated,  incgular,  or  temporarily  ancMcd. 
'The  loaa  of  eoBScioimeaa  is  more  appanot  than  real  Tbe 
ibystctical  paUeot  gcDermDy  bean  what  is  md  by  thoee  anmad 
b«r,  and  she  baa  almeet  always  time  to  fiod  a  aoitable  plaea 
upon  wbicb  to  &II;  sb*  often  ttrowi  benelf  on  a  eooefa  or 
redioeA  oe  a  ao^  and  aot  aafreqaeatly  appean  U>  bestow  some 
degree  of  atteatioa  npoa  tbe  ptoprietj  aad  gitwfiiliicM  of  bcr 
.  attitodcL 


890 


uysrreiiiA. 


Another  peculiarity  of  Ui«  hycteric  attack  is  tbat  lb* 
expresgtOQS  and  attitudes  amumed  are  not  devoid  of 
but  are  ropetitions  of  those  occurring  io  baaltb  uoder 
emotJoDa    Sometimes  the  eipression  is  that  of  great 
other  limeB  there  in  a  frown  as  if  nf  anger,  and  at  atill 
times  it  becomes  Imploring  or  beseeching. 

Hysterical  attacks  larclj  last  more  tban  a  few  mioutea 
they  may  recur  in  quick  giiccession,  so  that  they  aeem  la  I 
an  almuat  continuous  parozystu,  extending  orer  a  ooaudcnUi' 
period.    Tbo  liynborical  seizure  frequently  ends  in  a  fit  of  ayii| 
and  Bobbing,  there  is  no  subaeqaent  coma,  and  ou  reoontytks 
patient  generally  passea  a  lai^  quantity  of  clear  and  fiaqM 
urine  of  low  speciBc  gravity. 

(6)  CcUaUtptic  att<tck3  are  liable  io  oocur  to  b) 
patients;  they  arc  of  variable  duration,  disappearing 
times  in  the  course  of  a  few  hours,  and  being  pruloufvl  H 
other  timeK,  with  Blight  intermisaions,  fur  a  period  of  BMdha 
Cataleptic  rigidity  is  sometimes  limited  to  particular  Itutlai 
hut.  as  a  rule,  the  whole  body  is  implicated,  and  tben  sfl 
voluntary  movements  arc  suspended  and  reflex  aciioa  is&Bi- 
nished.  All  the  formit  of  i^oeral  stmiiibiliLy  are  usuaOy  la<  h^ 
one  or  more  of  the  spedal  senses  may  he  retainnd.  Tb*  i 
of  heariag  ia  probably  the  one  most  generally  retained,  i 
which  should  be  borne  in  mind  by  the  attctidaau. 

Somottmes  every  form  of  seninbility  appears  to  bo  ooid{ 
abolished,  aad  in  such  cases  the  lirubs  retain  the  positk 
which  they  ore  placet).  This  condition  has  been  called  way 
rigidity,  because  the  limbs  can  be  as  it  weie  moulded  iaalvcit 
any  posttiou. 

There  are  cases  of  complete  general  rauscnlar  relaialioaa 
which  the  Action  of  the  heart  and  pulse  beoomo  almost  taf*r 
cepUbie,  while  renpiration  may  be  h  feeble  that  the  (atietf 
may  teem  to  be  dead.  ThoM  eases  have  been  deaeribsd  m 
"  hysterical  trance,"  and  it  is  possible  that  patienta  may  bsn 
been  buried  alive  tn  this  oouditioQ. 

(c)  Hytiei'M  in  Soy^.—Boyst,  at  the  approaefa  of  pabaty,  M< 
nofrcquontly  sutfer  from  hysterical  symptoms  resembltsf  tb« 
observed  in  the  Fi-male  sex  (Wilks,  Roberta).  SonstiiDM  At 
symptoms  may  assurao  the  form  of  globus  along  with  attach  rf 


ittcaH 


HTBnBU. 


891 


causelcm  weeping  and  soblnng;  nb  other  times  there  niAy  be 
partinl  »paam  of  the  glottis,  a  barking  congb,  attacks  of  dyapooea, 
or  some  local  Bcnsor/  or  motor  disturbsooe.  Psychical  pheno- 
meoa  often  ]>n<4loniit]Bte.  In  a  case  which  I  eaw  a  few  montha 
ago  the  boy  vas  sometimes  found  creeping  on  hia  hauds  and 
hneec*  and  harkiag  lilce  a  dog ;  another  time  he  jumped  like  a 
frog  Irom  the  floor  on  to  tho  tabic.  The  depraved  form  of 
hysteria,  named  chorea  major,  is  oft«a  met  with  in  hoys.  In 
thid  variety  of  the  diacaec  the  patieota  mo,  dance,  jump,  or- 
climb  with  macb  greater  readiness  and  dexterity  than  similar 
actions  could  be  performed  in  liealtti,  ur  they  may  sing  or  recite 
poetry,  even  in  a  foreign  langungc. 

The    paroxysm    of    h^t«i'0-epi(*'p9y   will    bo  subsequently 
ribed. 

[MO.  Courw,  Progre»$,  and  Terminationa.—Tho  giDti|dnf 
e  symptoms  in  hyatcria  in  exceedingly  variable,  not  only 
in  the  case  of  dilTereat  iadividuaU.  but  of  the  aaiuv  individual 
at  different  timen.  It  is  almost  always  a  chronic  diseastt,  which 
exista  for  year*,  and  disappears  only  at  an  advanced  age.  Those 
wbo  are  Btrongty  predisposed  to  hysteria  are  fre*mently  very 
irritable  and  pecviiih  diiriag  childhood,  although  convulsire 
attacks  do  not  generally  occur  until  the  period  of  puberty. 
When  pubvrty  is  ufttuhlishcd  the  cutivulsive  attacks  frequently 
disappear,  and  other  symptoms,  more  especially  emotional  dis- 
turbances, are  then  apt  to  become  promioent 

la  some  hysterical  putioots  sensory  and  motor  disturbances 
arc  well  marked  and  persistent,  and  psychical  only  present  to 
a  slight  extent,  while  at  other  times  the  ruvorso  is  the  cosa 
The  diiieniic  is  linble  to  undergo  many  rariatious  in  its  course. 
The  symptoms  may  disappear  for  comparatively  long  periods, 
but  are  liable  to  reoitr  on  exposure  to  the  slightest  excitemeoL 

Hysterical  symptoms  frequently  caajie  after  the  climacteric 
period,  but  the  higher  degrees  of  mental  disturbance  sometimes 
develop  at  this  age. 

Hysterical  symptoms  may  appear  at  puberty,  but  subse- 
quently become  latent  to  a  certain  extent,  reappearing  in  a 
very  pronounced  manner  at  the  climacteric  period.  Hysterical 
^rmptoms  may  be  of  every  degree  of  inteasity  from  simplo 


I 


893 


HTSTBRU. 


I 


mental  trritaliUity  up  to  the  profound  menUl  diaordan 
border  upon  iDeanity,  and  from  slight  seuiations  of  gtnbMaal 
iDfra-mainmary  neuralgia  to  attackx  of  general  conmUioa^ 
aod  wLJely  spread  paralysu  and  anaathesia.  Tbo  caaea  is  wUck 
oouvulstuu^.  poralysU,  anieatlicaU.and  coQtnM:tioiis  are  laiBdalei 
with  severe  petychical  disi>rden  ooustilule  the  n)06t  aiggnnu4 
forniB  of  the  diaeiase. 

Hysteria  aelJum  sbortena  life.  Kvea  cases  of  pcrHlMl 
vomitiag  uad  oopioua  htcmorrhoge  are  relatively  ianoeuMii  t» 
comparison  with  simiUr  symploma  ariniag  from  other 
Caaes,  however,  are  oocasionaUyobeerved  in  which  after  a 
moral  shock  violent  hyuteneal  aymptoms  become  tlevckipei, 
il^nth  luay  occur  within  a  few  dayii  or  weeks  in  the  atweow 
atiy  recognisable  organic  chaoga. 

In  a  case  of  hystero^pilepey  ob«orv«d  by  Wunderiioh,  tU 
patient  aiifferfKl  from  epileptiform  attacks,  not  attAoded  bf  anf 
increase  of  temperature,  for  more  than  eight  weeks,  wheeM^ 
denty,  without  known  cause,  the  patient  became  oollap«d.«D4 
tliu  temperalura  rose  to  109  4' F.  (43' C.)  befora  imuh,  b 
a  second  case,  related  by  the  same  author,  the  patient  saAnrf 
for  several  years  from  various  forms  of  paralysix,  hyperBsthaia 
loss  of  sight  and  smell;  ultimately  ilifGcalty  of  swallowing aoi 
vomiting  Miperveaed.  and  ^lo  died  with  febrile  symptoow  in  s 
state  of  marasmus  and  emaciation,  while  post-mort«ni  ezaaiak- 
tioii  rcvculed  no  changes  in  the  nervous  system. 

Sometimes  death  may  occur  indirectly  from  hysteria, 
the  cases  of  patients  who  mutilate  themselves^  with  or 
the  intention  of  committing  suidde.     Hysterical  patients  nnif 
attempt  to  commit  suicide  in  earnest',  but  feigned afctempta taad* 
in  order  to  attract  attention  have  sometimes  been  fai 
oocasiooaUy  suicide  bos  actually  beeu  committed. 


suniair^ 
nifsly' 

OOBSIM^H 


§  941.  Morbid  AruUcm^  and  Physiology. — No  ooi 
aoatomical  changes  liave  been  found  in  cases  that  hars  thai 
from  hysteria.  Charcot  discovered  symmetrical  idflrans  ef  iW 
lateral  columns  extending  nearly  the  whole  loogtll  of  the  SfJisl 
cord  in  the  case  of  a  bynterical  woman  who  safiered,  for  W 
years,  fi-om  paralysis  with  contracture  of  all  the  exireoiitMa 
It  w,  therefore,  probable  that  in  oases  of  hyataricsJ  cont 


HYSTERIA. 


898 


the  fibres  of  tbe  pyrnmidnl  tracts  undergo  morbid  cliaages, 
&t  first  lemporary,  allUuugU  ultimnt-ely  becoinitj^'  permauent. 
But  oven  if  this  be  so,  the  primaiy  change  probably  occur!  in 
the  motor  cuntres  of  the  cortex  of  the  cerebnim.  Indeed  alt 
tbe  pheaometia  of  hysteria  mny  be  exptatued  moat  rciuJily  ou 
the  aflsumptioD  that  the  irritability  of  the  cortex  of  the  braia 
IK  sometinnes  In  excess  aud  sometimes  diminished  or  abolishetl. 
Increased  irritability  of  the  cells  and  fibres  of  portionH  or  the 
wbole  of  the  cortex  of  the  cerebral  hemiBphere  supplied  by  the 
posterior  cerebral  artery  would  accouut  for  the  hypertuathcsia  of 
variable  distribution  a-nd  completeneea  on  tho  upptaite  side  of 
the  body;  aod,  conrersely,  dimiQutlon  or  loss  of  the  irritability 
of  those  same  cells  au<l  Sbrva  would  account  for  the  various 
forms  of  aDSMtbesia. 

Again  iacreased  irritability  of  the  cells  and  fibres  of  portions 
of  the  cortex  of  one  hemisphere  supplied  by  the  middle  ccro- 
bral  artery  would  account  for  spasms  of  groups  of  muscles  on 
the  opposite  side  of  the  body,  while  dimiaution  or  Iobs  of  the 
irritability  of  these  cella  and  fibres  would  account  for  the 
various  rormo  of  paralysis  observed.  Variatious  in  the  degree 
of  irritability  of  the  cells  and  fibres  of  the  cortex  supplied  by 
the  anterior  cerebral  artery  would  account  for  many  of  the 
psychical  dinturbances.  Even  tlie  uumerous  vaJo-motor  disorders 
observed  in  the  course  of  hysteria  are  best  explained  on  the 
sappoaition  that  they  are  determioed  by  rariationii  in  tbe 
iateoHtly  of  the  nervous  dischargeH  from  the  cortex  of  the  brain 
to  the  nerve  centres  in  the  medulla  oblongata. 

HemtaniuathesiB  from  organic  lesion  is  generally  cauaod  by 
diseaae  of  the  seasory  peduncular  fibres  and  of  Qratiolet'a  fibres 
in  their  ascent  through  the  iuterual  capsule;  and  hysterical 
bemiaDaMthcsia  might  result  from  a  losa  of  the  irritability  of 
fcbefle  fibres  withoub  recognisable  structural  change,  while 
bypenestheaia  of  half  the  body  might  be  caused  by  excessive 
irritability  of  them.  Muscular  spasm  or  paralysis,  oa  the  other 
hao'l,  might  be  cau»e<l  reepeclively  by  excess  or  abolition  of  the 
irritability  of  the  fibres  of  the  pyramidal  tract.  Tbe  fact  that 
anesthesia  is  sometimes  asaociaied  with  tosa  of  reflex  irrita- 
bility shows  that  the  irritability  of  the  nervous  tissues  is  modi- 
fied in  hysteria  in  more  than  one  JocaHty  at  the  tame  time: 


894 


HTSTERtA. 


§  943.  DiagriMit, —  When  bjateria  ia  folly  developed, 
tbv  physicUn  has  ao  opportunity  of  inquiring  into  tb«  IubUi| 
of  tho  cue  and  of  watcbiDg  its  progrccs,  the  dtogwma  pnMli 
no  great  difflcuUies,  Hysteria  may,  however,  «muUu  ilmMl 
every  possible  disease,  and  a  pbyHictsa  baa  to  be  oooMutlj 
oil  big  g\iard  if  he  would  not  at  »ome  time  1^1  a  victim  ba  tb> 
(leceptioiu  practised  by  the  hysterical. 

IndtviduaU  of  a  nervowt  temperament  aomotjmes  eiJubil 
the  minor  cbamcteristioi  of  hvsteria,  such  tu  great  iriitabili^ 
of  ttimp«r,  exaggerated  sensibility  to  physical  iupreasioiu^  uA 
«V6Q  occiuionally  alight  motor  disorders.  Gases  of  thi*  IebA 
bordering  upon  hysterin  demiind  the  same  Ireatmeot,  lo  tkl 
it  is  unaec&tsary  to  enter  upon  the  diagaoais  betve«D  tb 
affections. 

Hysterical  arthritic  aS«ctioti8  are  particularly  liable  taj 
mistaken  for  organic  disease  of  the  joints.     In  tbe  hy 
affection  the  paio  varies  in  degree  at  different  tinue 
Bucluatiug  in  character,  the  form  of  the  joint  ia  uae 
there  is  no  heat  or  rednese,  nod  tbe  pain,    like  toMt 
local  hysterical  paisR,  in  limited  to  the  surface,  ao  that 
contact  may  l>e  painful  while  deep  pressure   causai  ua  fr' 
comfort,  cepedatly  if  the  attention  of  the  patient  ba  otbvMt 
engaged. 

Pain  and  sensitivenesa  over  tbe  spinous   prooMBM  of  tW 
vertebne  in  bjntterical  sal^ecta  have  led  to  the  affeolio    ' 
mistaken  for  grave  organic  diaease  of  the  spinal  cord,  bi:  ^ 
symptuma,  indeed,  are  rarely  present  in  tbe  organic  diaatafc 
The  exciting  causes  of  hysteria  simulatiog  diaea^ie  of  the  mi 
are  usually  emotional  disturbances,  wbiob  rarely  indoee 
spinal  affcctiona. 

lo  hysterical  parapUffia  the  lower  extremitiua  are 
aud  give  way  under  the  weight  of  tbe  body,  while  tbe  feet  i 
OD  tbe  ground.    The  paral}'8is  is  seldom  complete,  the 
is  able  to  move  her  limbs  in  bed  with  comparative  eai^i 
may  even  be  able  to  get  out  of  bod ;  but  after  walking  ti 
threo  steps  tbe  limbs  give  way,  tbe  gait  becomes  totteria^J 
nnloas  supported  the  patient  falls.    The  oloctrio  excitabifil 
the  muscles  is  usually  unaffected  in  hysteria,  and  tbe  dm 
do  u<A  >&T:i^«st%«)  \.x(i^U.<^  «haja(^«<. 


HYSTBBIA.  895 

The  concomitsnb  sjmptunu  of  byeterical  paraplegia  are 
;Mitesthesia  of  the  itkin  and  mii-sclefi  of  the  lower  extretniticfl. 
tyiDpiiuil<*t.  const  i  patio  II,  dyatOL-uorrlia-a,  and  rctODtion  of  urine. 
Cerubro-spinul  mtiltiplu  sclcroRts  Hometimes  closely  rcsembies 
bysteria,  aad  tlie  iliagnoeiB  betneen  cbe  tiro  affectioDs  is  oc«a- 
Boiulty  only  prauticabtu  in  the  latvr  sta};eH. 

Bj/steruxU  hemipUgia  differs  from  hemiplegia  due  to  cerebral 
ffieauc,  iQ  tbc  following  respects : — It  ia  usually  accompanied 
by  w«ll<inarko<l  disorders  of  Bonsibility;  Chcro  is  no  facial  or 
lingual  paralysis;  the  paralysis  is  scarcely  ever  complete;  in 
the  brge  majority  of  ca»C9  it  is  worse  in  the  leg  than  tbo  arm  ; 
it  ift  liable  to  stidden  variatioua  in  intensity  uoder  the  infiuenc« 
of  emotions;  the  electric  excitability  is  dOchatigGd ;  and  the 
muscles  do  not  undergo  ntrophy. 

Uysleiical  convulsions  may  be  diritingitishei)  from  epilepsy 
byiiQgative  chamct^^rs  The  loss  of  consciousness  in  tbc  former 
is  not  complete,  nor  h  it  so  sudden  iu  its  onset ;  there  is  no 
asphyxia ;  the  tongue  is  not  bitten ;  the  attacks  last  longsr 
than  in  epilef»y  ;  the  patient  does  not  on  the  cessation  of  tho 
attack  fall  into  a  profound  Htiipor,  but  only  appears  exhausted  ; 
mad  there  is  much  sobbing  and  crying. 

It  is  sometimes  difBcult  to  distinguish  between  hysteria  and 
hypochondriasis.  Some,  indeed,  regard  hysteria  in  the  female, 
and  hypochondriasis  in  the  male,  &i  only  ditTcreat  manifesta- 
tioDB  of  the  same  disease.  The  psychical  symptomi  of  the  two 
diseases  are,  howerer,  different,  and  paralyses  and  convulsive 
attaclcs  never  occur  in  hypochondrirutiK. 

Sjf8lerie<il  aphonia  is  seldom  accompanied  by  a  cough  as  is 
laiyngitis,  the  loss  of  voice  is  sadden,  while  in  almost  all  other 
forms  of  aphonia  the  voice  becomes  gradually  extinct ;  a  laryngo- 
Boopic  examination  shows  a  total  absence  of  any  structural 
lesion . 

ff^erleal  Tieuralgia  bos  not  tho  intensity  of  the  genuine 
disease,  and  there  is  an  absence  of  "  painful  spots."  The  dis- 
tribution of  pains  in  hy»terin  is  more  diffused  than  in  trtte 
neuralgia,  and  often  not  limited  to  any  one  nerve  territory. 
I  In  lead  paralyiiis  the  affected  muscles  undergo  atrophy  and 
manifest  the  retiction  of  degeneration  at  an  early  period  of  tho 
disease,  phenomena  which  never  appear  in  hysterical  paralyaia 


896 


HTSTKRIA. 


iliihlh^ 

viMdM 


§  913.  ProgncsiA — So  far  as  life  is  oonoenied,  tbe 
is  always  favourable ;  it  should  not  be  fo^tottco,  bmrew,  < 
a  fatal  issue  is  poeable. 

But  altliougb  hysteria  rarely  eaiiMsdeath, it  isalmoAi 
ran  for  complete  recovery  to  take  ptace.  The  moM.  htf 
cases  are  those  in  which  a  predisposition  to  tho  diwaM  b 
berited,  aod  in  which  the  itymplonifi  coinmeace  in 
Id  Rtjch  cases  the  disea.<te  usually  beoooiei  exagggratcA^ 
puberty,  although  coDsideiable  remisiious  often  take 
this  period.  Many  palteotii  get  well  ax  age  sdvaoee*. 
timea  the  climacteric  produces  a  favourable  cbaoge ;  bat « 
other  times  this  period  induces  exaoerbationa,  auJ  leadi  totl* 
eetabtisbuK-ot  of  iuvctcrate  forms  of  mcatal  diatutbaoce. 

The  most  favourable  ca»eii  are  tboae  ia  which  the  divi* 
cau  be  traced  to  a  distioct  excittog  cause  that  can  be  raoMni 
rather  thau  to  rooted  moutal  prudispo&iUoD.  Vihvu  hyskiii 
baa  been  induced  by  aGteaiona  of  the  geaeratire  orgaoi 
chlorosis,  hopes  may  be  eotertaiDed  tliat  the  bystefical 
toms  will  vAoish  with  tho  rcmoral  of  these. 
howet'er,  the  altered  ooodittoii  of  the  aervou*  «y«tefa ' 
after  the  exciting  cause  is  romovcd. 

Remissions  fre<iuently  occur  in  the  course  of  the  di 
may  ht£t  for  yeara,  hut  the  symptoms  geacmUly  roeur  fn 
to  cirao  in  one  form  or  another. 

Sensory  and  motor  dixturbanoea,  however  severe 
tletily  disappear  temporarily;  but  the  symptoms  becdOMi 
obstinate  to  treatment  every  time   they  are  rapaate^ 
ultimately  become  persistent 

Transitory  psychical  disturbances,  even  when  they  an 
Tiolent.  may  not  exert  an  unfavourable  influenoa  apoa  A« 
progTL-ss  of  the  case;  and  evea  attacks  of  ordinary  invoi^ 
superreoiiig  in  the  course  of  hysteria  arc  capable  of  omnptiO 
recovery.  When  once  the  mental  distorbonoe  has  asDivds 
chronic  form  the  prognosis  beoomos  uttremely  unfaroanUa 
and  when  the  aigna  of  moral  depravity,  foiie-raimmiuuti*  ■ 
fixed  erroneous  ideas  have  become  estabUafaed.  compiof  n^t* , 
ration  seldom  occurs. 


§  9U.  Treatm«tit.—The  great  aim  of  trwlmeal  should, 


HTSTERU. 


897 


prevent  the  appeartuice  of  tbe  aggravated  form  of  hysteria. 

itb  this  view  the  greatest  attcatioD  sboalil  be  paid  to 
he  eirtj  e<liication  of  cliildren  who  inherit  a  nervous  tero- 
ineut,  or  who  are  congenitaUy  predisposed  to  bjsteriiL 
Sueb  cbildrcQ  should  b«  tmiueU  to  h&biis  of  UDselSshuess,  aud, 
under  judicious  maQagement,  considerable  progress  may  be 
made  before  tbe  child  leaves  tbe  arms  of  the  nurse.  Uae  great 
difficulty  is  oficQ  oxperieQced  in  such  owes.  When  the  ten- 
llency  to  the  disease  la  inheribed  tlirougb  the  mother,  she  herself 
s  often  irritable  and  explosive  in  disposition,  at  one  lime  un- 
ueceSKirily  bnr^h  to  her  children,  again  nndnly  indulgent  to 
ibem,  always  capricious  and  n^ver  firm;  while  the  father  is  too 

ucb  occupied  with  hnsiness  to  be  able  to  counteract  the  evil 
IDllueiice  of  tbe  motber. 

Tender  nicb  drciimstances  the  motber  abouM  l>e  advised  to 
ilace  tbe  management  of  her  children  as  much  »t  possible  ia 
tbe  bauds  ui  some  6rm  aud  judicious  woman,  be  she  nurse, 
relative,  or  govcmetss.  To  tmia  a  child  into  habits  of  self- 
renunciation  is  the  most  difficult  of  tasks  anyone  can  undertake, 
tad  can  ouly  be  accomplished  hy  tbe  babituni  excrcisi;  of  seK- 
Dontrol  on  the  part  of  the  teacher. 

During  ll"^  period  of  bodily  development  great  care  should 
l1>e  taken  of  the  health.  The  diet  should  be  plain,  uouriihtog 
;axid  abundant,  the  utmost  care  being  taken  that  the  child  is 
■Jiot  treated  as  aa  invalid,  inasmuch  as  the  observance  of  special 
rules  with  regard  to  diet  is  apt  to  foster  that  feeling  of  self- 
eooaciousncsis  which  it  h  so  desirable  to  suppress.  Regular 
hours  fur  meals,  going  to  bed  nud  getting  up,  should  be 
obaerved  as  part  of  general  discipline ;  plenty  of  outdoor 
exerdse  should  be  taken,  all  tbe  better  if  it  can  be  made 
agreeable,  or  subservient  to  some  useful  purpose  to  engage  the 
fcltentiou.  When  the  young  girl  passes  into  womanhood  she 
ought  to  be  taught  that  she  has  a  6etd  for  work  and  a  roisaion 
in  the  world,  and  that  she  is  surrounded  by  human  sufTering 
which  fthe  can  alleviate;  there  is  little  doubt  that  the  more 
^opportunities  of  uscfulnesa  are  mulliplie<i  for  young  hidics  the 
;taore  the  tendency  to  hysteria  will  diminisb. 

But  let  us  now  pass  to  the  treatment  of  the  fully  developed 
diseuJic.    The  exciting  cause  can  only  beremoved  in  a  few  caaes 
FFF 


HTSTERtA- 


ortoj 


itnd  even  when  tbat  U  posalble  the  modtficftUoD  of  the 
sjntcm  already  induced  may  persist.     Wban  uuenaia  eziiti  I 
usual  trenlmeut  with  iron  aod  other  tonics  should  be 
If  there  be  indigestion  with  flatulence,  bismuth,  charcod,! 
lies,  or  nUDeral  acids  may  be  administered  with  or  wiiboct »" 
better  infnsion ;  constipation   demands    the   admiDistiatici  d 
mild  aperients,  and  ntooy  of  tho  alimentiu7  canal  quiniM,! 
vomica,  or  strychnioe,  while  uterine  derangements  DtBK| 
Hubjcctcd  to  appropiiate  tieatmeDt.     Tho  tro»ttDcnt  of 
or  suspected  disease  of  the  genentire  org&os  in  caact  of  h} 
requires  tUe  greatest  tact  on  the  part  of  tb<i  medic*!  attcaJ 
The  intioduction  of  tho  catheter,  or  a  Taginal  as 
the  patient  be  uomarried,  nay  lead  to  an  agsraTmtioa 
symptoms.     On  the  other  hand,  if  real  disease  exiat,  local ' 
mont  mny  be  indispeuRablo  to  suooesL    Wh«a  the  oai 
hysteria  in  a  moral  oue  it  is  often  impoeribia  for  the ' 
to  rembve  it,  but  even  then  much  may  be  dooe  br  placiilf  I 
patient  under  conditions  as  much  as  possible  coDdodvelaj 
happinesx. 

The  drugs  which  have  boon  employed  In  the 
hysteria  are  characterised  by  &  pungent  and  often  dt 
odour.    Assaf(Ktida,  galbanum,  and  valerian  are  the  best 
and   most  commonly  used  of  this  cla^  and  many  b^ 
patients  come  to  litce  both  the  taste  and  smell  of  tbme  i 
aubstauces.     Tbey  do  not  appear  to  produce  a  pettnaoeali 
fluenoe  upon   the   disease,  although  tbey  may  be  of 
removing  flatulence  and  other  troubleeome  symptoms. 

When  general  hypeneathesia  and  sleeplessneaa  exist,  it 
be  necessary  to  administer  narcotics,  morphia  injected 
tauoously  being  the  best.  The  patients,  however,  sbevld 
bo  allowed  to  take  morphia  or  other  narcotic  at  their  owi  ^ 
cretion.  Bromide  of  potassium  is  a  valoablo  agent  is  sbhi 
cases,  and  where  there  is  much  sleeptcssDeas  M  efficaff  b 
iiMreased  by  being  combined  wiili  cbloraL 

The  electrical  treatment  of  particular  siymptotns  of  bysuds 
is  aometiraea  followed  by  improvement  of  Ibe  geiMtat  c*- 
dition.  Beard  and  Rockwell  have  recently  leoommendsJ  ill* 
the  entire  surface  of  the  body  be  treated,  in  suocesatee 
with  tolerably  strong  induced  currents,  nod  thia 


HTSTEBIA. 


899 


iMd  found  very  successful,  although  its  efficiency  depends  pro- 
kUy  on  the  mental  impression  produced  nitber  ihau  on  the 
(teal  action  of  the  cuitgdL  The  infliien>c«  exerted  hy  counter 
nitatioD  of  various  kinds  appears  also  to  be  largely  due  to  the 
nental  impression  made. 
The  must  important  part  of  the  treatment  of  hysteria  con- 
of  the  moral  oianatjeiiieDt  of  the  patient.  Oue  of  the 
requisites  for  treatment  is  that  the  phyaiciau  nhould 
KMMM  ihe  entire  conRdenco  of  the  patient  and  her  friends.  An 
ssoDtial  condition  for  succesa  is  that  the  physician  be  bimaelf 
iottrinced  that  hysteria  is  a  real  and  Dot  a  sham  disease,  and 
btt  the  treatment  prescribed  i»  a  real  and  not  a  sham  treat- 
antt  There  ia  probably  no  disease  which  a  medical  man 
i&S  to  treat  which  makes  so  many  demands  upon  bia  Brmneea, 
Klf-control,  and  ingenuity  as  hysteria.  He  must  be  able  to 
tyinpathise  with  th«  foelin^'s  of  the  patient  in  order  to  command 
ler  coulideuci},  but  if  bis  sympathy  degenerate  into  fals« 
ontimcnt  or  into  the  sligfateat  exaggeration  of  manner  lie  will 
loly  b«  adniiiiistering  to  the  morbid  craving  for  sympathy  which 
a  nt  the  root  of  the  di»en.se,  while  on  the  other  hnnd  the 
ilightesL  attempt  to  laugh  down  thu  patient's  fancies  may  be 
ital  to  Bucce&s.  EarneHtnesii  of  purpose,  determination,  and 
ertility  of  rcHource  are  all  called  into  requisition  in  the  treat- 
nent  of  hysteria.  The  instructions  given  to  the  patieut  abould 
ke  plain  and  eoob  as  can  bo  readily  earned  out;  they  ought 
kt  the  same  time  to  task  to  some  extent  her  voluntary  etTorta 
Vhea  once  instructions  are  ia&ued  the  moot  implicit  obedieooe 
B  them  should  be  insisted  upon,  for  laxity  in  enforcing 
bacrvance  of  rules  argues  want  of  confidence  in  their  efficacy. 
rhe  voluntary  efforts  of  the  patient  should  ho  daily  exercised 
ty  making  progressively  increasing  demands  upon  theco.  And 
ts  ibc  power  of  will  becomes  strengthened,  emotional  excite- 
neQt  will  diminish  in  corresponding  degree. 

lastead  of  exciting  the  dormant  will  into  activity  by 
taduated  exercisers,  Lhis  can  frequently  be  nccomplishcd  at 
Dce  by  anything  which  acts  poworfully  on  the  imagination. 
lystcrical  patieiitu,  wbu  have  been  bed-ridden  for  years,  have 
leeo  known  to  get  out  of  bed,  and  walk  under  the  indueoce  of 
I  strong  emotion,  or  after  having  the  imagination  powerfully 


=1 


Pftinful  rcmodics  ased  with  modontion  &n4  1 
aoiiietimea  very  useful,  partly  by  appealiag  to  the 
Of  these  reme^lieM,  the  faradic  cnrreot  m  profad 
generally  useful,  and  a  subcutaneous  injectiuo  o 
for  a  similar  reason  tnoro  efficacious  than  the  ioti 
atration.  Simple  vater  has  been  luoceMfiiUjr 
the  narcotic  ii\)ectioa,  so  great  is  the  inflai 
impression. 

It  is  Bomutimes  posaible  to  care  severe  hystccii| 
by  means  of  tlireats,  suddeo  flight,  or  tnonJ  abi 
c'xpccliHl  iibuvrcr  of  cold  water  may  hare  the  d 
and  at  other  timen  the  threat  of  the  actual  «aotery 
Charcot  meoUoiis  the  case  of  a  woman  who  bad 
more  tbnn  tvn>  years  from  permaneot  eoDtntcitt 
tho  lower  extremitiea,  which  suddenly  vaniabed 
of  the  moral  shock  caused  by  aa  accusatJon  of  i 
agaiDSt  her;  a  secoud  nlm  \u  whom  contracture  < 
atanding  suddenly  ditmppeared  id  cousequooce 
admonition  given  her;  and  a  third  in  whom  a  I 
vanlHticd  on  account  of  a  sudden  disappoiDtintcaL 
meut  musL  be  exerciaed  in  the  employmeDt 
inaNUiiicb  as  the  disease  may  be  aggravated  ini 
rated  by  them. 

Uystericat  patiento  are  treated  with    moch 
ia  the  rrards  uf  an  ho^itaL  thaa  in 


I 


HTSTSRIA. 


901 


in  all  directions,  but  to  hold  her  dowQ  gently  but  firmly,  and 
to  prevent  her  struggles.  The  beat  method  of  aecuring  the 
patient  is  to  ploix:  aa  attendant  oq  each  eidu  of  her,  and  to 
direct  each  to  grasp  one  wrist  with  ooe  haod  and  to  hold  the 
•houlder  lirmly  dowa  to  the  bed  or  floor  with  the  other;  if 
aoeeosary  tho  patient's  legs  must  be  held  down.  It  is  remark- 
able how  sooa  a  hysterical  patient  ceas<»  to  straggle  when  she 
finds  that  she  is  held  aa  ia  a  vice.  So  long  as  the  patient  can 
shake  herself  free  from  her  attendants,  so  long  is  the  etru^le 
apt  to  be  maintained,  but  when  oncu  she  feels  that  she  is 
thoroughly  restrained,  and  that  her  efforts  do  not  find  outward 
ezpreasioB,  she  generally  ceauoa  to  struggle.  The  must  uuual 
remedy  for  arreciting  the  attack  is  to  dash  cold  water  on  the 
face  and  neck;  although  this  is  a  useful  method  occasionally 
it  iii  by  DO  meana  the  best.  Tho  plan  suggested  by  Dr.  Hare 
of  forcibly  holding  the  mouth  and  nose  of  the  patient  so  as  to 
prevent  her  from  breathiug  is  very  effectual.  In  my  own  prac- 
tice the  admiuLBtratioo  of  an  cmotic  was  at  one  time  a  favourite 
method  of  arresting  an  attack.  Strong,  rigorouH  servant-maids 
■omotimes  suffer  from  violent  hysterical  convulsions,  uad  in 
them  I  was  in  the  habit  of  giving  an  emetic  dose  of  the 
tartrate  of  autimouy.     Id  most  cases,  however,  the  sulphate  of 

Eu  safer  if  loss  officiunt. 
tile  attack  be  caused  by  some  peripheral  irritation,  its 
.«»oval  may  arrest  it.  Severe  attacks  hare  sometimee  ceased 
•lUr  the  rectiticatloa  of  a  misplaced  uterus.  Id  cases  of  hjstcro- 
«pilep0y  Charcot  has  succeeded  in  anestiog  the  attacks  by  firm 
compFMsion  of  the  byponc-sthetic  ovary^  but  this  does  not 
appear  to  be  a  means  applicable  for  the  convulsive  attacks  of 
ordinary  hysteria.  Large  doaes  of  the  bromide  of  potassium 
«Z9rt  a  favourable  influenco  on  the  fits  of  hystoro-cpitepny,  bat 
this  romedy  is  not  of  much  value  in  the  common  form  of 
«onTul)iive  attack. 

limited  spasms  in  hysteria  are  best  removed  by  general 
tment  and  moral  management,  although  local  treatment  and 
.1  remedies  are  occasionally  found  useful.  In  the  case 
of  patients  suffering  from  obstinate  globus,  Brb  recommends 
the  repeated  application  of  the  constant  current,  the  anode 
placed  at  the  side  of  the  larynx. 


milk  cooked  in  variouH  fonnit,  but  this  method  | 
auocessrul.  Sometimes  the  patieots  rolala  highl^' 
better  tban  bbtDd  diet,  and  tbe  vomitiog  may  < 
am  allowed  bo  eat  raw  bam  or  raw  mloce-meat  m 
Ofure,  howcTer.  should  bjr  taken  that  the  oatare  < 
clear,  la  apaitic  as  well  as  in  paralytic  retentioa  c 
sitz-bstha  will  often  bring  relief;  wlieo  they 
the  catbetvr  nhould  bo  employed  in  caao  the 
distcQiJed. 

In  hyfit«ncal  paralysis  electricity  la  the  best : 
application  of  strong  faradic  currents  to  the 
muscles  is,  as  a  rule,  auccessfuL     GalratuMt 
cord  a  useful  in  hj-sterical  paraplegia.    Af 
treated  by  external  faradisation,  but  in  obctinata  o 
must  be  ba^I  to  the  intnUnryogcal  appticatioa. 

Passive  movements  and  frictions  of  the  linbs  wil 
embrocations  are  also  oseful  ai>  aids  in  treatment,  a 
strongly  leoommaods  the  npplicatiou  of  naim 
blister  passing  completely  round  the  affected 
presson  of  the  larynx  witli  the  liDgere  sometii 
reiitorea  lost  speech,  nod  a  similar  effect  may' 
paitsing  a  atrip  of  adhesive  plaster  acroia  the 
partially  surround  the  neck.  Hystericil  tymi 
times  be  dispersed  by  powerful  foradisatioa  at] 


nairq 

I 


HTSTBIUA- 


903 


aoAisthetic  coadittoa  is  ocly  tranarerred  from  tbe  aff«ct«<l  to 
the  opposite  side  of  tbe  body.  It  Is  somewhat  premature  to 
IMSB  ftny  oplQion  wicb  rospcct  to  the  success  of  this  practice 
So  loDg  as  certain  "  p&ss«B "  over  the  surface  of  the  body  can 
induce  a  coDtJitiou  of  general  auiusthcaia,  such  as  that  met  with 
in  the  mesroenc  state,  thero  is  uolbiog  absurd  iu  xuppociug 
tbat  similar  passes  and  the  application  of  cuitia  to  the  surface 
tuay  Itave  a  curative  etlect  in  conditionH  of  partial  aneestheaia. 

Hysterical  oeuralgia  aod  hyperfsstbesia  demantl  tbe  etaploy- 
nieut  of  narcotics  and  auiestbeticH.  Caffuiu,  guaraua,  anil 
chloride  of  ammonium  are  useful  in  hyKterical  ceplialalgia. 
Chloral  bydmte  given  in  scruple  and  half-dracbra  dosea  to 
procurt:  sluep  is  occaaionally  useful,  and  iobalatiuu  of  cblorg- 
form  may  be  necessary  id  oider  to  overcome  oonLracturea  of 
niusclca. 


CATALEPSTT,    TKANCE,  ECSTASV,  AND  Ol 
CONDITIOKS. 


(I.)    CATALEPSY. 

Cat&Lbpst  is  cbaracterUfd  by  atUtcks  of 
loss  of  coosciousQcas,  aoooinpa.ateJ  by  stifleiUDg  of  I 
moBcles,  having  the  pecaliarity  that   the   Umba 
relatively  long  period  tb«  poaitiomi  ia  which  th( 
by  posaive  motioa. 

§  943.  Etiology. — Catalepsy  oReu  occurs 
uiauifv^tatioos  of  hysteria,  whilo  at  other 
by  chronic  cerebnU  diseue,  sach  as  Bof 
meningitis,  and  tumourB.  In  some  cans  the 
dition  appears  to  ho  premonitory  of  true  «pU«^ 
Some  cases,  however,  canaot  be  traced  to  either  of  i 
and  then  catalepsy  may  bn  eallod  i/Uopnilne  c 
cases  of  the  hitter  form  are  obeerved  in  familii 
a  decided  neurotic  dtspoaition.  The  disease  is 
oKterved  about  the  age  of  paberty,  hot  it  hi 
as  early  as  live  years  of  age,  aod  occasionally 
3^e  two  aexes  appear  to  be  eiLoaUy  liable  Lgib 


.11  tic  « 
nili«^ 

10^ 


CATALBPSV. 


906 


ling  of  iuilividual  muscleB,  and  an  undeliQcd  seose  of 
ibrt.      Aa    a.    rule,    the    nttock   begius    abruptly ;    the 

>vemont8  of  tho  patient  ore  saddcoly  arreeted,  it  may  be 
Ibile  be  is  speaking  or  performiDg  some  action  ;  the  face 
becomes  deadly  pale;  Uie  respirations  are  stow  and  tranquil ; 
tbe  pulse  is  soft ;  and,  althougU  consciousness  is  lost,  tbe  atti- 
tude  of  the  patieut  at  the  time  of  the  iteizure  is  retained. 
Tbe  muKcles  in  action  at  tbo  begiooing  of  the  attack  appear  to 
bo  the  first  to  bucome  rigid,  but  the  spaAm  rapidly  extends,  om 
a  nile,  to  all  thn  voluntary  musclea.  although  ocoiHionatly  it  is 
partial  or  unilateral.  The  alTected  muscles  feel  firm,  and  offer 
rcsiittancc  to  pasHLve  movements  of  iho  timhs ;  wbun  oucu  this 
resistance  is  overcome,  the  limbs,  head,  and  neck,  or  features 
m&y  bo  placed  iu  cunstruincd  positions,  which  they  retain 
for  a  comparatively  long  period.  After  the  first  resistance  of 
tbe  muscles  has  been  overcome  the  Umba  possess  a  ilexibiUty 
And  pliability,  which  has  been  compared  to  that  of  soft  wax. 
It  has  consequently  been  named  JUxibiliUid  cerea.  This  con- 
dition of  the  muscles  enahl(>s  the  limbs  1o  be  moulded  in 
any  position  compatible  with  the  rigidity  of  bones  and  inex- 
tcnsibitity  of  ligaments,  and  the  constrwned  attitudes  in 
which  the  limbs  may  be  placed  are  maintained  without  cbaage 
during  tlie  whole  course  of  the  attack.  "  I  was  abuwn."  aays 
Dr.  Wilks,  "a  man  in  MorningKide  whom  they  could  mould  in 
aay  position.  Whilst  in  bed  on  bis  back  they  eould  arrange 
His  arms  and  legs  in  any  posture  and  there  his  Hrobs  would 
remain.  Dr.  Savage  has  a  case  in  Bcthlem  of  a  young  man 
who  will  keep  his  arm  stretched  out  for  two  hours,  and  stand 
oo  one  leg  for  a  great  length  of  time.  If  made  to  follow 
another  patient,  he  will  continue  to  do  so  until  he  is  stopped." 
But  even  during  tbe  cataleptic  condition  the  muscular  stifEaesa 
does  not  persist  in  its  full  intensity  for  a  lengthened  period. 
After  Borne  minutes  tbe  stifinou  diminisbea  somewhat,  so  that 
llie  arm,  for  instance,  when  raised  horizontally  falls  lower  by 
its  own  weight,  add  the  limb  uodergoca  a  slight  trembling, 
indicating  the  approaching  exhaostioo  of  tbe  muvdes. 

ConadonsDeM  is  nsvally  abdisbed,  but  not  in  all  caacm,  A 
certain  amount  of  oonseioiuneM  may  be  letuned  in  tbe  early 
stage  of  the  attack  or  be  prMent  throogbout,  lo  that  strong 


90S 


CJITALEPST. 


peripheral  irritation  may  cause  -paaa  which  will  be  romiuihia 
by  the  patioDt     RoOox  irritabUltjr  in  sometimes  UxA ;  at  oifca., 
times  certain  reflex  actions,  nuob  as  closure  of  the 
touching  the  conjuactira,  are  retained.    The  electric 
tilitj  of  the  muscteii  rem&iiu  ;  and,  aocofding  to  Cbe  i 
of  Beoedikt,  the  galvanic  irritability  of  the  nerves  U  ii 
during  the  attack,  but  becomes  rapidly  diminiihed  dt 
interralo.     In   one   case  observed  by  RoaeDthal  the 
reaction  of  the  nervea  to  both  current*  vras  perfectly 
in  another  it  was  tncreoBed. 

The  organic  functiooa  are  Dot  usually  seriously  int 
with.     The  n^piratiou  may  be  normal,  but  ifl  geDczally  ilie 
and  shallow.     The  puUc  is  slow,  soft,  and  compraatbUi 
temperature  is  goaerally  lovrered,  aud  at  times  the 
tbo  body  becomes  icy  cold.      Whoo  the  miriaoo  of  tbt 
ia  cold,  aud  the  pulse  at  the  wrist  and  reepiratioD  ant 
impCKOptilile,  the  conditioQ  may  be  mi«tak«D  for  rc*L 

The  attack  of  catalepsy  is  sometimes  very  brief, 
ocly  a  few  minutes,  at  other  times  several  boon  or 
Attacks  described  aa  being  very  protracted  arc  in  reali^ ' 
tip  of  a  successiou  of  these,  separated  from  one  aootber  1 
torvals  in  which  the  patients  recover  either  wholly  or 
The  seizures  sometimes  dimppear  quite  suddenly, 
patients  nt  ouce  recover  full  coosciousDees  and  imi 
resume  the  actions  which  bad  been  interrupted.  As  a  nla' 
however,  recovery  is  gradual,  patients  at  first  beii^  rtupefied  s* 
if  awaking  from  a  profound  sleep,  a  certain  aoMunt  of  : 
stiffness  remaining  for  some  time,  which  renders  motion ' 
aud  slow. 

In  simple  catalepsy  no  mental  disorder  is  obMrved  in 
intervals  between  the  attacks,  but  when  it  is  merely  a 
of  profound  nerroua  disi^ase  the  inlcnrals  may  be  cb 
by  the  oocurrenoe  of  kyslerical  coavulsioas.  deliriom, 
attacks,  and  hallucinations,  (H-tbe  catalopsy  may  be 
with  ecstasy  and  wtmnambulism. 

§  947.  Cov-rM. — The  course  of  catalepey  ia  usually 
extending  over  many  years.    Some  individuals  suffer  only 
a  small  number  of  attacks  separated  by  inlerrali  of  nsasy 


TltANCE — ECSTASY". 


907 


kbern,  again,  hare  frequent  periodical  attacks.    In  hysterical 

lepay  tbe  sliglitesl  extt^rnal  influence  nuy  Ruflac«  to  provoke 

paroxysm.     Catalepsy  of  malarial  origin  follows  the  regular 

>urs«  of  other  matatial  neuroseej  they  are  somelimes  accom- 

lied  by  fever  and  sweating,  and  generally  yield  to  the  usual 

itipcriodic  remcdieH,    Cases  cauied  by  sudden  fright  or  injury 

\j  also  run  an  acute  courae,  tlie  disea<ie  termiQating  after  a 

ttngle  attack  or  after  a  Heries  of  them.     Cataleptic  attucks  are 

banlly  over  fatal  of  themaelres. 

(It.)    TKANOK, 

§  018.  In  this  condition  the  patient  lica  for  daya  together 
aa  apparently  inseoBible  condition  without  eating  or  drinking. 
Cbe  state  of  complete  inscnaibility  is  not,  however,  continuous, 
laamuch  as  there  occur  periods  during  which  the  patient 
noticed  those  around  her,  and  may  partake  of  small  quantities 
of  food.  The  oonditioQ  of  the  patient  ia  not,  indeed,  unlike  that 
of  a  hibernating  animal.  In  tho  state  of  trance  the  patient 
usually  lies  ia  a  warm  room,  well  covered  with  clothing,  so 
that  little  heat  is  lost  by  rodiaUon ;  the  mental  functions  arc  in 
abeyance,  indicating  that  the  molecular  changes  which  are  the 
correlatives  of  mental  actiona  have  ceased ;  and  all  muscular 
movements  are  suspended  with  the  exception  of  the  cardiac 
contractions,  and  uUght  reBpirutory  muvem«>uts.  Under  such  cir- 
cumstances the  amount  of  waste  must  be  small.  If  Dr.  Tanner 
(and  there  are  no  grounds  for  believing  that  any  deception 
was  practised  by  him),  with  all  the  waste  implied  by  the 
podUDession  of  active  meutal  faculties,  outbursts  of  temper, 
walking  and  driving  in  the  open  air,  could  live  forty  days 
without  food,  it  may  be  inferred  that  persons  in  the  state  of 
trance  might  live  fasting  for  a  much  longer  period.  Tbe 
ptiysjcian  mutit.  of  course,  be  on  his  guard  against  deception  in 
cases  of  trance. 


(IlL)    ECSTASY. 

:  §  D49.  This  condition  is  clonely  allied  to  trance,  tho  patient 
nng  iimensible  to  outward  impreasiona  in  bath.     In  ecstasy 
tbe  mind  U  absorbed  with  some  fixed  idea,  generally  of  a 


908 


soim^uuusM  jiMD  nrriiOTiax. 


religious    characber,  and    the  patient    beoomM    obit 
sunoundiDg  ereotii  and  objects.    The  Umbt  u«  motiooloi^J 
ufteD  6xed  in  maiDtainiDg  a  particular  attitude;  Ui« 
is  slow  hoc]  feeble ;  the  pulse  in  almost  imperceptible ; 
are  often  bright  and  animated;  aad  the  oouateiuuii 
expression  of  rapture  (Maudsley). 


(IV.)    SOaiNAMBULISU  AND  KTPS0TI8W. 

§  950.  In  aomnambtdimti  the  patients  appear  to 
unconscious,  yet  they  walk,  climb,  and  aTold  oUstdclM,  and  sbt 
manifeet  greater  strength,  agility,  and  preoisiou  of 
adjustments  than  during  waking  houxa 

Bi/pnotimn  or  mtsmtrum  is,  as  Maudslcy  romariu,  a 
of  artificially  induced  somn&mbalism.  The  subject,  «ko  ii 
probably  always  of  a  neurotic  tcmporomeot.  is  iodaeed  toleifc 
steadily  at  the  operator,  the  latter  nttnicting  his  attvotiaa 
making  a  few  gentle  "passes"  with  bis  band.  Ur. 
Manchester,  directed  the  person  to  look  upon  a  dtae  or 
bright  object  held  in  front  of  and  a  little  above  the  lerel  of 
eyes.  After  a  short  time  there  is  a  slight  tremor  of  the 
of  tbo  Hubject,  his  pupils  dilate,  and  be  falls  into  the 
condition.  In  thiK  state  the  mental  functions  are  aboliabad, 
nil  the  actions  of  the  subject  are  afterwards  detamiiaad  bf 
the  tiuggestions  of  the  operator.  Under  the  influence  of  tiwst 
suggL-stiona  the  subject  may  sing,  recite  poetry,  and  ftafam 
the  most  absurd  and  outragcoua  actions.  He  may  be  aide  H 
eat  a  raw  cabbage  amidst  all  the  ontwanl  signs  of  apjaywl 
to  appeaw  a  suggested  hunger;  be  may  qnt  out  purv 
given  bim  to  drink  with  all  the  signs  of  diagnst,  on  tie 
tioQ  that  it  ia  bittor  and  nauseous,  or  drink  ittfoisaa 
wormwootl  witli  apparent  relish  on  bang  told  thai  it  ii 
agreeable  beverage  ;  or  be  may  be  made  to  aneeso  violaatly  ■« 
lieing  asked  to  take  a  pinch  of  soutf  from  an  empty  boi.  Uji*^ 
rical  patients  may  be  thrown  into  a  condition  of  tnoos  er  sf 
catalepey,  or  one  half  of  the  body  may  bo  thrown  into  tius> 
and  tbo  other  half  into  catalepsy,  by  being  made  to  look  npias 
bright  light  (Charcot).  A  condition  much  resembling  tbekj^ 
Dotic  state  is  sometimes  indnoed  by  disease.     A  curiou 


It  M  VT 


OM^ 


SOU^'AMUULtiiM    AND    BITPKOTISM. 


900 


this  kiad  is  triuificribed  by  Dr.  Wilks  from  Gatiffnani,  B-nd  as 
the  ease  is  a  remarkable  one  in  mnny  ways  I  quote  it  at  length. 

J  /.in'ny  AMtotiuUon. — A  curioiiH  pAti«ii.t  i»  JMt  uov  nn  iniuato  of  Dr. 
M«Mi«t'B  wanl  at  the  Udpital  St.  Antoiiin.  liiii  profeaiun  wus  thut  of  a 
nuga  st  tho  Cofua  Obouiauls.  l>uriiig  tbo  war  «f  I670-7t  ho  wm  hit 
orer  tbe  left  ear  by  a  miuiket  bullet,  wUtcb  carriwlofi'  about  2^  iuchcs  of 
lb«  fMnetttl  bone,  and  Iiiid  )»irv  thu  brain  on  the  left  side.  Thio  led  to  s 
tauiiorary  iianlyain  of  Ibu  rneulicrH  im  the  oiJ|NMittj  aide,  as  id  always  the 
eatM ;  but  he  iraa  ev<^Uially  curu<I  of  thia,  trhilo  the  trooiiiiKluiia  wouod 
DO  tbe  skull  began  to  Lcul,  »o  that  after  a  time;  lit  cuuld  imuiut;  lu«  i)n> 
CbWQMial  duticN  at  the  cnfb  to  th«  mtiitfactian  of  the  public.  Suddenly, 
bomrvrt  lie  wiw  seized  with  ucrromi  symptoDu,  lostiiig  fnim  24  to  43 
boon,  and  of  such  an  «ltrao^dinary  nnturv  that  it  wu  ooiujdorad  «aft  to 
tolcD  bait  to  tho  hoHpitoL  Ilia  laiUdy  is  oader  to  illiistrutc  hj  cxamplea 
tlian  to  dvfitio.  VVIicti  he  i^  in  his  tit  he  ha8nos6nHitivent>a8  of  tm  onrt, 
•ud  will  bear  physical  pain  without  bciug  annro  of  it ;  but  his  will  may 
be  influenootl  by  contact  with  exterior  objecta,  Set  bitn  on  hia  feet,  aitd, 
M  Boon  as  tboy  touch  tbvgrouDdf  they  awaken  in  him  tliedwureof  ^^-alkillg; 
ha  Iheu  oiomh^  atraighton  quite  Rrt«adi]y,  with  tksad  «yea,  without  uj^g 
•  want,  ur  kuowiiij;  what  in  ff^\ug  on  ahciut  him.  If  he  meets  with  an 
obstacle  on  his  way  he  will  touch  it,  atiJ  try  to  make  out  by  Caelittg  wluit 
it  is,  ood  then  attempt  to  got  out  of  its  way.  If  savoml  persona  jain 
hAQclH  aiul  form  a  rinjj  around  hira,  tie  will  tiy  to  hnH  an  ojwuiug  by 
repeatedly  crasaing  over  tnm  oox:  nido  bo  tho  other,  and  this  without 
betnj^jng  the  slightest  consciousness  or  impntienoe.  Put  a  jwu  into  bis 
bood ;  this  will  inahmtly  nwiilccii  In  hiiti  the  dmire  of  writing ;  he  will 
nuuUe  about  for  ink  oiul  pa|^r,  anil,  if  theae  be  placed  before  bint,  he  will 
«rit«  a  ver}'  wiiaiblc  biiaiiKxKi  luttvr  ;  but,  whtu  the  tit  in  uvur,  he  wHI 
rsooUcct  iiiitliiiig  at  nil  u)K>iit  it.  Gi^-i;  hiui  wuue  oigarettv  |>n])cr,  and  ha 
will  instantly  take  out  hi*  tolxw^o  bo^,  roll  a  dgixrcttc  rurj-  clcforly,  and 
ligbt  it  with  »  match  from  hiit  own  Ih>x.  Put  tWiu  out  onu  oftmr  onotber, 
be  frill  try  from  firat  to  loet  to  get  a  light,  and  put  up  in  the  end  with  hin 
Ol-soooess.  But  ignito  a  match  younelf,  and  give  it  tura,  he  will  not  um 
Ht  and  let  it  bum  butwtwii  bia  Angora.  Fill  hia  tobaooo  bog  witli  aajthing, 
DO  matter  what — ahavinga,  cotton,  lint,  hay,  &c.— he  will  roll  Iiia  uigorvtto 
jont  the  same,  light  aud  nnioku  it  without  puixeiviuij  tho  luMU.  But, 
better  atlll,  put  a  jioir  of  gloxiMi  Into  Ma  hand,  luid  ho  will  put  tlwu  on  at 
OPoc ;  thiti,  reminding  him  of  hia  prafcoition,  will  uudiu  him  look  for  bis 
tnuoic.  A  roll  i>r  paiwr  tn  then  given  to  Utni,  iti>i>n  whit^h  lie  omuniw  the 
attitudv  of  a  eiugur*b(.-fore  the  pubUc,  and  warbltw  tonic  piece  of  hia  ropar- 
tory.  If  you  place  younwif  Iwfore  him  he  will  fMtl  about  on  your  jiemon, 
and,  mooting  with  your  natch,  he  will  trans'fi.T  it  from  your  |Hicket  to  lu» 
own  ;  but,  on  the  other  liand,  he  »ill  allow  jrou,  without  any  resintnncv  or 
impattcnoe  whatwer,  to  take  it  book  again. 


910 


SOKXAUDDLISX    AN[>    BTPNOTISM. 


§  OjI.  Morbid  AiuUomy  and  PkyaMoffy.—l 
eznmiDstioiis  have  only  rerealed  cbaoges  io  tbow  c— e»  in  whifi 
catalepny  and  its  allies  are  mere  symptom-i  of  gravr  orpnc 
disuaae.  ScliwarU  reporia  the  caao  of  a  boy  who,  a/tar  m 
iuyiry,  suQ'cted  at  first  froiu  an  afiectioo  reeembling  cborai.aai 
later  cataleptoid  attacks,  and  who,  oitcr  two  jous,  died  Irai 
amcRiia  and  marasmus.  The  aatopsy  rerealed  secxKis  < 
in  the  arochauid,  eofieuiDg  of  the  oorpaa  liriaium  and 
tbalamaa,  especially  of  the  left  side;  and  a  brownith- 
Ukc  moas,  coveriDg  the  spiual  dura  laator  along  the 
surface  of  the  cord  from  the  cervical  to  the  lumlwr  enl 
Meissner  examined  a  man,  47  years  of  ago,  who  mffand 
catalepsy  for  six  years,  and  in  the  three  last  jean  of  hia 
froiQ  maaiacal  and  epileptic  symptoms,  with  paraljni  d : 
right  side ;  he  found  an  epithelioma  growing  from  tbo  di 
mater  io  the  anterior  fossa  ovgf  the  ethmoid  bone;  the  BOt*> 
rior  thin.1  of  the  right  cerebral  hemiipbere,  as  well  aa  tb*  i^ 
corpus  striatum,  was  much  softened.  Laaegoe  fouad  do  chufi 
in  the  brains  of  two  men  afTocted  with  catalepsy  i  i  ■iiiiari 
by  him. 

The  information  obtained  from  post-mortem  examioatioa  ii 
as  yet  for  too  scanty  to  throw  much  light  od  thia  patbologf  ti 
the  diacaw.  Ouu  noteworthy  fact  in  coDDectiiia  with  tbt 
slighter  forms  of  cataleptic  attacks  ia  tbctr  amilaritj  to  ana* 
cases  of  the  petit  mal  of  epilepsy.  It  is  a  eomewbat  a^ptificsat 
fact  that  tu  fileLSftoer's  case  of  catalepsy  the  diseaM  wu  sit«al«J 
in  the  pnofroatal  r^on  of  tba  cerebral  hemt^tliarM.  i 
fuDCtJonal  or  organic  leuon  of  the  cortex  of  the  cerebrau  mifb 
no  doubt  account  for  the  sudden  lost  of  consciouanaes,  bat  tbs 
most  cbara<t«ristic  features  of  catalepsy — the  mnscolar  rigidity 
find  Qexibilitas  cerea — are  still  ttnexplaioed.  Uott  utbw 
beliovo  that  the  cataleptic  rigidity  is  only  aa  iooraaw  of  iW 
normal  tonuti  of  the  voluntary  muscles,  and  Bomo  think  tte 
the  diminution  or  losu  of  voluntary  innervation  which  occunii 
catalepsy  cau»es  au  iocreaae  in  the  reflL'x  tonus  of  the  nwdM 
just  AS  reflox  ezcitAbility  is  increased  by  the  i«moT«l  of  thf 
CBiebral  hemispheres  in  froga.  But  do  amount  of  iocreaM  ii 
the  reflex  tonus  wotild  account  for  the  conditioo  koowo  h 
flexihilitas  cerea,  and  what  is  a  itill  mora  faul  objection 


l^ly 


SOMNAilDULISU  ASD  fiYPKOTJSU. 


du 


theory  is  that  geoeral  reflex  irritability,  instead  of  being  increased 
ID  catalepsy,  is  on  the  contcaiy  oftca  much  diminiHlied  or 
Abolished. 

We  have  already  seen  tbat  complete  hemiouieBtlicaia  is 
jKwbabiy  caused  by  a  temporary  or  permanent  arrest  of  the 
foDctioRB  of  the  coutripetal  fibres  io  their  ascent  through  the 
interoal  capuulc,  or  of  that  part  of  the  cortex  of  the  brain  which 
ia  supplied  by  the  posterior  cerebral  artery.  Suppoee  now  that 
a  complete  bilateral  hemianipstheaia  exists,  what  wonld  be  the 
condition  of  the  patient  1  There  would  be  complete  toes  of  every 
form  of  cutaneous  and  muecular  sensibility  &s  well  as  of  seniia- 
tioQ  in  the  bones  and  joints;  there  would  be  loss  of  tante  oa  both 
tides  of  the  tongue,  and  of  smelt  in  both  nostriU ;  and  instead 
of  there  being  amblyopia  and  partial  deafness  un  one  side, 
as  in  beiDEaQn>8thcBia,  there  would  be  complete  blindness  onU 
deafness  on  both  sides,  luasmiich  as,  nccerdiug  to  the  hypothesiii, 
the  seoMry  centres  iu  bulb  hemisphereti  either  have  ceased  to 
act  or  the  impressionn  made  on  the  peripheral  sense  organs  fail 
to  be  conducted  to  them.  But  impreasions  made  on  the  peri- 
phery would,  however,  reach  the  cortex  of  the  brain  through 
the  optic  thalamus,  aud  the  subject  of  bllatfral  hemianesthesia, 
although  effectually  cut  off  from  tliu  external  world  no  far  as 
the  anatomical  substratum  of  consciousaean  is  concerned,  would 
perform  various  complicated  actions  in  response  to  peripheral 
impressions,  but  without  being  attended  by  consciousness.  The 
condition  woidd,  indeed,  be  very  similar  to  that  observed  in 
Bonuuimbulism,  tho  mcamcric  state,  and  various  poat-epilcptio 
and  allied  conditions. 

§  9.'>2.  Diagnosis. — During  the  presence  of  muscular  stiffooiltg 
and  floxibUitnij  cerea,  the  diagnosis  can  present  no  difficulties. 
Only  very  cleverly  executed  simulation  could  give  ri.ie  to  any 
doubt ;  and  in  these  casus  careful  testing  of  the  sensibility,  reflex 
initability,  and  electrical  reactions,  along  with  comprehensive 
observation  of  the  concomitant  symptoms,  ought  to  bo  suffi- 
cient to  afibrd  a  safeguard  against  deception. 


§  923.  Prognosie. — ^The  prognons  of  uncomplicated  cases  of 
catalepsy  is  always  favourable  as  regards  life;  but  with  respect 


indication  can  be  beat  effected  when  the  cause  can 
in  catalepsy  due  to  malaria,  quinine  alone,  or  coi 
morphia,  may  effect  a  complete  cure.  Favonrable 
been  obtained  by  the  use  of  tonics,  iron,  ergot,  i 
cold  douche,  and  the  faradic  current  The  gal* 
bas  hitherto  proved  useless. 

A-ttempts  to  put  an  end  to  the  attack  itself  h 
very  successful.  A  alight  peripheral  irritation 
patients  in  hysterical  catalepsy,  but  in  the  idiopati 
strong  cutaneous  irritation  has  often  no  influen 
tracted  ca^es  artificial  feeding  by  the  stomacli 
nutritious  enemata  must  be  had  recourse  to. 

Trance  must  be  treated  on  the  same  general 
hysteria,  while  those  who  are  liable  to  attacks 
bulism  ought  to  have  their  bedroom  windows  an 
fastened  at  nigbt 


$13 


CHAPTER  VL 


EriLEPSY    AND    ECLAMPSIA. 


(1.)   KPILEP8Y, 

Efilepst  IB  a  cliroDic  fuDctlonal  disease  of  the  nervous  system, 
characterised  by  recurring  paroxysms  of  impairment  or  loea 
of  eonsciouBDCse,  accompanied  generally  by  partial  or  general 
eoDVuIsioDs, 


§  1155.  Rtiologt/. — Hereditary  predieponition  plays  an  impor- 
tant part  la  the  production  of  epilepsy.  The  Iraiisiaissiun  may 
be  direct,  as  when  the  progeny  of  an  epileptic  parent  are 
affected ;  or  indirect,  nhen  one  or  more  generatioQS  escape, 
aod  the  disease  reappears  iu  tlio  desceudanta.  But  iu  other 
casea  the  hereditary  tendency  is  still  more  indirect.  The 
family  of  the  patient  may  have  a  proclivity  to  nervous  diw^asc, 
declaring  itaelf  as  tuaanity  in  one  membt-r,  a*  hysteria  iu  a 
second,  indulgence  in  alcoholic  excess  in  a  third,  nenralgia  io 
a  fourth,  and  epitepay  in  a  fifth,  while  other  members  may  only 
exhibit  the  slighter  forms  of  instability  termed  ucrvousaeas. 
A.  hereditary  taint  may  be  traced  in  rather  more  tban  oue-tbird 
of  all  cases  (Ueynolda,  Gowere).  The  children  of  consaogui- 
neoua  marnBges  appear  to  suffer  from  epilepsy  in  greater 
proportioD  than  other  children.  All  family  peculiarities,  whether 
good  or  bad,  are  intenaitied  in  the  children  by  intennairiage ;  and 
when  both  parents  inherit  an  unstable  nervons  tiyHtem  the 
probabUtty  of  some  nervous  disorder  appearing  in  the  progeny  is 
greatly  increased.  Under  these  circumstances  one  or  more  of 
the  children  may  suffer  from  epileptic  convulsions  when  the 
parents  manifest  only  nervousness,  neuralgia,  or  bysteria.  The 
ooo 


EPILIPST. 


of  external  objccU  io  the  opposite  i1ir«ction,  ftn*l 
quentl;  complains  of  Lbiogs  whirling  fuudJ  bim,  of 
in  the  head,  or  of  vertigo  and  sickneM.  At  tiniei  pfttienu  ■• 
objectH  recede  from  thcoi  aod  become  smaller  or  approach  Ui^ 
and  become  larger,  sonsatiuns  probably  dopendtog  upon  «an»- 
UoQS  in  the  tension  of  the  musclea  of  acconnnodatjoa.  Om 
of  the  most  remarkable  features  presented  by  motor  aor*  it 
tbat,  as  a  rule;  all  of  them  begin  in  small  muscles,  rocb  , 
of  the  eyeballs,  tongue,  face,  and  handa  These  nm 
engaged  in  the  mo£t  special  actions,  and  consequmtly  the : 
aune  may  be  eaid  to  begin  in  the  more  special  aud  to 
dually  to  the  more  general  actions.  Sometime*  the  Aura 
in  muscles  liko  those  of  the  shoulder  engaged  in  general 
while  the  muKlea  engaged  in  special  actions  are 
involved.  Such  cases  are  probably  always  due  to  organic  i 
of  the  brain,  the  lesiou  being  situated  near  the  longitoifiBil 
fissure  and  away  from  tbe  special  ceutres  of  the  c 
Sometime*  the  aura  may  occur  in  Iwth  bands  or 
simultaneouily,  or  there  may  be  a  Beaaatioo  of  trembling  n 
muiiclat  of  the  haclc,  while  at  other  timea  geuecal 
jerking  of  the  muscles  is  complained  of 

(6)  Senmrif  Auroi. — ^Tbe  sensory  aune  may  be 
any  of  the  centripetal  nerves  of  the  body,  namely, 
the  skin,  muscles,  and  bones,  the  nerves  of  speoal 
the  nerves  of  Uio  viscera..  As  already  remarknl.  it 
always  easy  to  determine  whether  the  senutions  refiTTvi] 
poliente  to  the  extremities  ure  due  in  any  purtictilar  oai 
discharge  from  a  sensory  or  a  motor  centre  in  conocctioa 
the  part.  Dr.  Qowers  remarks  that  there  are  two  in«d« 
which  the  aum  extends  from  the  arm  to  the  log,  Umj 
continuity,  the  sensation  passing  up  the  arm  aw) 
trunk  to  the  legj  and  the  other  by  separate  couraencviai 
tbo  muscles  o^  the  lower  extremity.  The  same  is  also  tn>e  i 
regard  to  the  method  of  invasion  from  the  lower  to  tbr  Q|i|ar 
oztremity.  In  the  continuous  method  of  ianuion.  Dr.  Qowm 
believes  that  the  discharge  from  the  sensory  o'ntie  ta^Mtia 
lead,  while  in  the  diecontinuoas  mule  of  iuvaaton  the  dwehsy 
of  tbo  motor  centre  is  primary.  Tbo  sensory  aura  tamttmm 
consists  of  a  feeling  of  general  beat  or  cold,  and  at 


otM|g| 


EPILEPSY. 


916 


attacks  during  {lentition  frequently  develop  true  epilepsy  at 
puberty,  but  it  is  probable  that  there  exists  in  sitcb  cases  a 
stroDg  predisposition  to  iha  iliseajie. 

The  iafJuence  of  sexual  excess  in  the  production  of  epilepsy 
ia  probably  over-estimateiJ,  Women,  the  subjects  of  epilepey. 
Dot  unfrequeotty  suffer  from  a  fit  during  the  meoatrual  period, 
and  the  disciutu  muy  be  cauiicd  by  utciirie  aud  ovarian  derange- 
ments Hod  tiy  pr^nancy.  Among  other  reputed  cauaets  of 
e|nl«p8y  inay  be  mentioaed  diarrlKea,  dysentery,  overloading 
the  stomach,  irntation  of  the  intcaiinul  cauol  from  the  presence 
of  worms,  the  paseiage  of  gall  utonefi,  over-exertion,  ftad  exposuro 
to  cold. 

Epilepsy  is  also  Hftble  to  become  established  in  tlie  course  of 
or  during  coavalescence  from  acute  febrile  djueases,  a  con- 
siderable proportion  of  mtch  coses  following  scarlet  fever.  In 
these  aconsection  between  tbo  eclampeiaof  scarlnlinal  nephritis 
and  the  subsequent  recurreuce  of  cunvulniuus  can  only  ocoa- 
aiooally  be  traced  (Gowers).  Chronic  leatl-poiiii^tting  iH  some- 
times  attended  by  recurrittg  convulsions  like  ihoBe  of  epilepsy. 

Injuriea  to  the  head  and  Huastroke  are  frequently  followed 
by  epilepny.  Ciuex  in  which  the  skull  15  fractured  or  coarse 
stractutal  changes  are  set  up  iu  the  braiu  are  at  present  excluded 
from  oousidenitiou.  Injuries  to  nerve  trunks  are  liable  to  be 
followed  by  epilepsy,  and  the  first  seizure  usually  txxunt  weeks, 
months,  or  even  yearn  after  the  injury.  The  conrulsioo  ia 
geoemlty  preceded  by  some  peculiar  sensation  proceeding  from 
the  region  of  the  affected  nerve. 


§  956.  SifmptomA. — The  symptoras  ot  epilepsy  may  be 
divided  into  [l)  tJiow  which  precede  the  puroxysm,  (2)  those 
occurring  during  the  paroxism,  and  (3)  those  observed  in  the 
intervals  between  the  attacka 

(1)  l^remoniUirff  SyviptoTnu. — The  premonitory  symptoms 
of  the  epileptic  attack  may  be  subdivided  into  remote  and 
imtnodiatc  wuruings,  the  latter  formiug  the  auTce  epilcpttco! . 
The  remote  waniinga  way  extend  over  hours  or  days  before 
the  oocurreace  of  the  attack ;  they  usually  consist  of  sueb 
symptoms  as  headache,  dixxiness,  confusion  of  thought,  or  name 
mental  change,  the  patient  becomiug  depressed  at^  morose,  or 


916 


EPILKPST. 


excited,  lively,  and  irritable      la  •  «u«  roMotly  Qodtr^ 
care  the  patient  stated  tb&t  for  bourei  before  ao 
became  eomettmes  very  mach  depresMd  in  sptriti  awl 
picious  that  liis  friends  were  qwaking  aad  plotting 
while  at  other  times  bo  mu  noaooouatably  joyoua. 
Tolunteered  the  statement :  "I  am  expecting  an  attack 
for  inailajice,  I  feel  so  liappy  aud  Joyous,  and  there  ia 
in  my  circumstaacea  to  make  me  bo,  as   I  have  joat 
situation  through  tbese  fits."     During  examinatioo  his 
cbeek  waM  •mfFused  with  a  bright  red  btuah  ;  white  tbe 
was.  as  hi-?  face  bad  hitherto  always  been   when   I  n 
remarkably  ptUe.     If  the  cortex  of  the  hemiapbere*  of  the  I 
were  as  freely  uupplled  with  blood  aa  the   right  check. 
might  account  for  his  joyous  feelings. 

AuTir    EpUfjttie(v. — Our  infonnaiioD    with    rrgtid  la  I 
immediate  warning  of  the  epileptic  paroxysm  cotudata 
Bubsequent  account  which  the  patient  is  able  to  give 
feetioge  before  toss  of  consciouancsa  is  complete.      In 
theoretical  language,   the  aura  is  the  mental  oont 
the  commencing  molecular  cbango   in    tbo    bnuo. 
the  physical  cause  of  the  epileptic  attack.     Cooa 
abolished  bo  won  that  thoie  is  oo  nura  dcKnbed  in  abootl 
the  cases. 

The  aura  may  be  (a)  motor,  (b)  seoMry,  (e) 
secretory,  or  ((f)  psychical 

(a)    Motor  Aunt. — It    is   not   always   easy   to 
between  a  motor  and   a  sensory  anfa^     In  epileptic 
where  consciousaess  is  retained  throughout  the  attadc,  orl 
only  at  a  comparsuvely  late  period,  tho  patient  is  often 
describe  the  convulsions  of  the   limbs  in  objediv* 
He  may  be  able  to  tell  that  be  first  felt  the  thoinb 
across  the  palm  and  the  fingera  flexed  on  the  thumbs 
he  bad  then  to  hold  the  cooTulsed  hand  with  the  < 
order  to  arrest  its  movemeota. 

A  patient  of  my  own  was  in  the  habit  of  acting 
students  with  great  fidelity  the  phenomena  of  the  attack. 
first  produced   twitching  of  tbe  muscles  of  the  ao^  of] 
mouth,  then  rotated  bis  bead  and  eyes,  and  finally 
flngerSi'aod  shook  his  arm  to  show  how  lb*  ooBi 


BPILEPSr. 


917 


invaded  the  upper  extremity.  Tbe  attack  ia  thia  case  was  due 
to  ooarec  Ic&iou  of  the  cortex  syphilitic  in  orijpn,  and  cooacioas- 
ness  wa£  only  partially  suspcadcd  toward*  the  torniinatiou  of 
the  attack.  lu  idiopathic  epilepsy,  on  the  other  hand,  con- 
Bciousnc«8  becomes  coiifuaed  at  Buch  an  enriy  period  that  the 
patient  is  miahle  to  describe  his  fitelinga  ia  objective  language, 
although  he  mny  still  do  so  in  suhjective  language.  When,  for 
inatance,  the  coavulsiou  begins  in  the  hand,  tbe  patient,  instead 
of  da^cribing  the  thumb  as  being  drawn  into  the  palm,  says 
that  he  feel.s  n  dragging  sensation  in  the  thumb  or  a  feeling 
of  cieeping,  or  uuinbaess  in  the  baud,  which  gradnally  passea 
up  tbe  arm.  Th«  «ensation  begins  sometimes  in  the  musclea 
of  the  sbonlder  and  pa.<i»e-8  down  the  arm  ;  but  these  cases  are 
probably  always  a^uciutc-d  with  a  coarse  lesion  in  the  brain. 
When  the  cooTuUion  begins  in  the  lower  extremity,  the  aura 
generally  begins  as  a  crce}Hug  sensation  in  tbe  big  toe,  which 
passes  up  the  leg  and  may  txtcud  to  the  arm  befocu  uncou- 
sciouHDcm  supervenes. 

Tbe  motor  aura  begins  not  uDfrequeutly  in  the  aide  of  tha 
^c,  and  is  generally  dcacribeJ  as  a  feeling  of  "  the  face  being 
UrawD,"  or  it  may  begin  in  the  side  of  the  tougue,  and  be 
desoribed  as  a  feeling  of  something  crawling.  The  tongue  ia 
awociatcd  in  ita  actions  with  different  sets  of  muscles,  according 
as  it  is  engaged  in  artioulatioo,  mastication,  or  deglutitioQ,  and 
these  associated  movements  appear  to  h«  Bomotimcs  dimly 
represented  by  the  epileptic  aura.  In  a  caae  mentioned  by  Dr. 
Goworti  tingling  in  the  tongue  was  SHRocintod  with  twilching  of 
the  lips,  in  another  with  a  sonsation  of  lateral  movements  of  the 
jaw,  aad  in  a  third  it  was  followed  by  a  feeling  of  Mickness, 
succeeded  hy  a  ien.>iatioa  of  HomeUiiiig  rising  in  the  thioat  and 
then  by  palpitation  of  the  heart. 

The  aura  cousiBtM  BOmetimes  of  sudden  iuahility  to  apeak — 
a  temporary  aphakia. — or  there  may  he  mutor*aunu  referred 
to  the  eyeballs,  which  are  generally  described  in  subjective 
language.  The  patient,  for  iniitance,  never  says  that  the  attack 
began  hy  a  squint,  but  states  that  he  suffered  from  double 
vision.  On  rare  occasions  the  patient  may  describe  that  bis 
eyea  were  turned  in  a  particular  direction ;  but,  as  a  rule,  the 
rotation  of  the  eyeballs  is  felt  by  the  patient  as  a  displacement 


922 


BPnBPST. 


oedence.  The  associatioo  of  theu  leua&itoiii  a  rvailttj  a* 
plained  by  the  proximiljr  of  the  visoa)  and  auditory  ceotrsw 
determined  by  Ferrier.  In  sorae  cases  the  cpigBfltric  tan  u 
followed  by  an  emotion  of  fe&r  or  of  fioguifth,  and  the  pliMl 
may  have  a  facial  cxpresaon  corresponding  to  it.  It  bu  \am 
auggesled  by  Hugblings-JacksOD  tliab  there  may  iiftca  U  • 
determinate  relation  between  iteiisory  and  visc«Fal  aunr.  toi 
between  the  "  dreamy "  state  of  psychical  aaiK.  muA  pHt- 
epileptic  actions ;  but  liltte  or  do  progress  baa  bitlierto  bM 
made  in  collecting  materials  to  decide  tbd  qu««tio&. 


J 


(2)  Tfie  EpitepHc  Panyxynn.  —  The  sy^mptonu  ol 
pafx>xy8in  are  very  variable,  but  for  pnrpoaes  of  d«cri: 
they  may  be  divided  into  (a)  epUeptia  mUior,  or  U  pdU  wti^l^ 
wbicb  there  is  impairment  or  abolition  of  consdounica^  lH 
no  manifest  Spasms;  (6)  epiiejma  gravior,  or  le  homi  mi 
in  which  there  is  loss  of  consciousnese  aloi^  vith  genetal  tMC 
and  clonic  convulsions;  (c)  epitci>tif&rm,  aeizurca,  in  wbtch  jn- 
nouDced  spasms  are  present  in  half  tbe  body,  bot 
ilight  suBpenftioD  of  couBciou8Q««a 


(a)  Ejiilepeia  mitior,  or  U  pttit  jmii.— The  d««eri| 
the  minor  attacks  of  epilepsy  need  not  detain  a«  k>ag.  TV 
attack  comists  of  momentary  confusion  of  tbuogbt,  or  (laanMy 
unconsciotisoess.  Tho  pationi,  for  tostanoe,  may  be 
while  speaking;  he  becomes  suddenly  ooeonscioas,  tbeta 
pause  probably  in  tho  middle  of  a  sentence,  bat  in  a 
seconds  speech  is  renumed  at  tbe  point  where  it  was  inl 
rupted  and  tbe  sentence  is  finished.  At  times  the  attack  an' 
conaiKt  of  a  feeling  of  fainting,  along  with  uoDftuion  of  mioA 
In  other  cases  there  is  momentary  vertigo,  slight  pallor  of  lis 
face,  and  transitory  unconsciousness.  Indeed,  any  oo«  of  ik 
numerous  aune  just  described  may,  along  with  slight  coofaM 
of  mind,  constitute  a  minor  nttock  uf  epilepsy.  Uany  of  tb» 
sensations  described  as  immediate  warnings  may  be  eapenaxwt 
in  the  abnence  of  epilepsy :  but  if  the  •eosatioo  nciir  tf 
periodical  intervals,  and  be  attended  by  some  omJmw  ^ 
thougbt,  the  occurrenoe  of  genaine  epilepsy  m*y  ba  ■Qiyirtrf 
although  a  visual  Bonsatioo,  along  with  some  coofbiHa  ^ 
thought,  often  precedes  an  attack  of  migraine.     If  lb«* 


EPILEPSr. 


923 


Tnvoliintary  discharge  of  urine  or  faeces  during  the  attack  the 
affection  is  Hndoubtedly  epileptic. 

In  many  of  these  slighter  attack))  loss  of  coDeciousnesD  is 
accompanied  by  minor  degrees  of  tnuHculiir  Bpft«m.  At  the 
onset  of  the  attacks  the  countenauce  becomes  ghastly  pale,  the 
pupils  contrncled,  and  the  eyes  fixed  and  stfiring:.  or  there  may 
be  titight  simbismiis  or  drawing  of  the  mouth,  while  ia  other 
eases  there  may  be  partial  rotation  of  the  hfiad  and  eye»,  chew- 
il^  movements,  or  rolling  about  of  the  ton^iic.  There  may  be 
again  momentary  rigidity  or  slight  tremor  of  all  the  muscles  of 
tbe  body,  while  transitoty  arrest  of  rettpiration  ia  not  uncotnmoa. 
Sometimes  the  pntieut  ultcra  a  shriek,  reeta,  or  walks  hurriedly 
round  tbe  room,  and  then  recovers.  At  times  tbe  unconscious- 
Dees  may  last  for  a  considerable  period,  but  the  patient  may  go 
On  with  the  work  in  which  ho  was  engaged  as  if  he  were  con- 
»cic>ua.  In  a  case  mentioned  by  Trouasean  the  patient  continued 
to  play  the  violin  with  accuracy  during  short  periods  of  uneon- 
aoionsnesss.  It  must  be  remembered  that  the  slighter  attacks 
of  epilepsy  are  linble  to  bo  followed  by  tho  condition  named 
"epileplic  rnauiu,"  to  bo  subsequently  described. 

(5)  Epilepnifi  f/i-ainoT.  or  U  haut  mal. — The  epileptic 
paroxysm  may,  for  tho  purposes  of  description,  be  divided 
into  three  stages.  The  first  is  characterised  by  loss  of  conscious- 
nesa  with  ttmic  npaam ;  the  second,  by  loss  of  consciousneSB 
witb  clonic  spasm ;  and  the  third,  by  cessation  of  the  spasm 
and  gradual  restoration  to  cousciousnt-SH.  A  fouHh  or  ajier 
stage  may  be  added. 

(i.)  The  Firat  iita4}e. — The  true  epileptic  attack  is  ushered 
io  by  three  prominent  symptoms  occurriug  simultaneously. 
These  are  loss  of  consciousness,  sudden  falling,  and  groat  pallor 
of  tbe  face,  while  a  fourth  symptom  is  often  present  in  the 
form  of  a  loud  and  piercing  cry.  The  loss  of  coDsciousDess  it 
sudden  and  complete,  every  form  of  sensibility  and  mental 
operation  being  completely  abolished,  although  certain  reflex 
actions  are  retained  (Romberg).  The  patient  often  falls,  as  if 
■truck  by  lightning,  either  forwards  on  his  face,  backwards  on 
his  occiput,  or  latterly,  and  so  instantaneously  that  he  has  no 
time  to  select  a  place  or  attitude,  and  may  consequently  fall 
into  fire,  water,  or  from  a  height.    At  other  times  the  parent 


m 


KPILEIW, 


■ 


has  BuflScient  varntiig  of  the  irnpeodiog  attack  to  eoab1«  bin  l> 
sit  or  He  dnwn.  Pallor  of  the  face  in  protjnblj  olwajs  priwl 
at  the  begiuniug  of  the  attAck,  although  the  Bymptom  a  wtm- 
time!)  so  tranHient  that  it  may  pass  unob«erved. 

The  opiloptic  cry  which  iho  patient  ofteo  altera  imawdnl^ 
before  or  during  the  fall  is  loud  and  piercing,  and  klinn^ 
acconling  to  Itomborg,  both  man  and  anitnalL  Wbtn  tU 
patient  falU  to  the  ground  he  remains  for  a  period  of  from  tio 
to  forty  seconds  in  a  rigid  condition,  cautMsd  by  a  tonic, altfaoogk 
ane(\iial  contrnction.  of  all  tberausclesof  the  body.  VAriookifia- 
tortiou!!  art-  thun  produced  ;  there  is  conjugate  dertftliaii  of  lie 
eyes,  with  rotation  of  the  bead  and  neck  ;  the  paptb  ar«  iBWiel 
and  iasenBible  to  light;  the  oountenance  is  rarioiuly  ahairii 
the  jaws  are  firmly  closed,  and  thu  ton^o  may  be  seroilv 
bitten;  there  ia  opistbotoooe ;  aod  the  different  sefSKItU  if 
the  lower  extremities  are  extended  upon  one  aaotbw  Hi 
upon  the  trunk,  the  foot  being  rotated  iavrards  and  tb«  la* 
widely  separated ;  the  segmentB  of  the  upper  oxircroilMi  ■(W 
are  ttexed  upon  one  aaotber,  the  thumb  being  bent  tale  tk( 
pnim,  the  fingors  closed,  and  the  band  pronatod  ;  and  tbe  fcnaia 
is  flexed  or  sometimes  extended  upon  the  arm.  Tlie  ntfkrMirj 
muscles  are .  in  a  state  of  tonic  spasm,  and  tho  brmtbiag  ii 
arrested.  The  btdeoua  cry  uttered  as  the  patient  fait*  b  pio- 
bably  produced  by  spasm  of  the  expiratory  muscles  with  cttMd 
glotlis.  The  pallor  of  the  face  is  soon  replaced  by  a  dull  rtd  oc 
dusky  hue,  and  the  veins  of  tbe  bead  and  neck  become  pvsll; 
disteaded.  the  carotids  throb  violently,  aud  tbe  actioa  of  ife 
heart  is  forcible,  although  the  pulse  is  small  or  imperDeplible  at 
the  wrist. 

(ii.)  7'Ae  fkcOTtd  Period. — After  a  rariable  period  of  from  tn 
to  forty  secooda.  the  tonic  given  place  to  clonic  apaama.  whic^  sr* 
osoally  more  proaouuccd  on  one  side  of  the  body.  The  musdt* 
of  tbe  face,  tongue,  pharynx,  and  latrnx  are  usually  Bnt  a&oMd 
by  clonic  spasm,  and  thoae  of  the  trunk  and  ojctreuittcs  st 
aftenrards  invaded. 

Tho  patient  now  presents  a  hideous  app«<u«ae«,  tb* 
Alternately  drawn  laterally,  or  forwards  and  backwards; 
eyeballs   arc   conruUivoly  rotated    io   Tarinua   dir<>cCiijB«, 
rotation  in  an  upward  aud  outward  direction  pr^omii 


EPILEPSY. 


Oii 


that  the  pupils  are  hidden,  and  only  the  whites  of  the  eyes  are 
viaible  under  the  blinking  half-closed  Hds ;  the  face  is  variously 
distorted,  and  the  convulsive  closure  of  tbe  jaws  is  often  so 
violent  that  teeth  are  broken  and  the  tongue  sererely  bitt«D, 
while  the  blood  from  the  wound,  mixing  witb  the  saEivo,  oozes 
through  the  clenched  teeth  as  a  Bangiiincoua  froth.  The  trunk 
and  limbs  are  variously  thrown  about,  and  the  contents  of  the 
bladdt-r,  rectum,  or  veeiculfe  seminalea  may  be  cvacaatod. 

The  venous  byperaemia  reaches  its  maximum  just  aa  the 
clonic  spasms  are  begiQDing  to  ahitte  in  severity ;  and  the  skin  is 
bathed  ia  sweat,  which  in  some  cases  ha«  a  fa^tid  odour.  The 
heart  beats  tumultuously ;  the  carotids  throb ;  and  tbe  pulse,  if 
it  can  be  felt,  is  fuller  and  more  laboured  than  during  the 
period  of  totsnic  contractions.  The  pupils  are  alcomntcly 
coQtracted  aud  dilated,  aud  are  said  to  be  slightly  sensible  to 
light  This  Ktngc  may  last  from  a  few  seconds  to  five  or  ten 
miuutcs,  the  average  duratiua  being  from  two  to  three 
miI)utCi^ 

(iii.)  Tlie  Third  Stage. — Daring  the  thinJ  stage  there  is  a 
gradual  return  to  conseiousness  and  voluntary  power.  The 
convulsions  either  cease  suddeoly  or  wear  off  gradually,  the 
period  of  transition  being  marked  by  partial  jerkings  of  some 
muscular  groups,  or  by  a  diffused  tremor  of  the  body. 

General  muscular  relaxation  ia  now  estahlished,  but  coma 
persists  for  a  short  time  longer.  The  patieut  soon  attempts 
to  change  his  position  ;  he  opens  his  eyes  and  looks  around  him 
vith  a  bewildered  expression,  and  perhap  attempts  to  speak. 

Tbe  respiratory  movements  hare  become  more  natural  in 
rhythm,  although  they  are  still  somenhat  irregular;  the  pupils 
are  contracted ;  the  pulse  is  variable,  but  generally  full  and 
quieter  than  during  the  previgus  stage ;  tbe  conjunctiva;  are 
injected  ;  petechiie  are  often  obser^'ed  on  the  eyelids,  forehead, 
aod  temples ;  and  the  patient  is  exhausted  aud  disposed  to 
sleep. 

The  attack  is  often  followed  by  vomitiDg,  and  a  large  quan- 
tity of  pale  urine  is  often  passed.  The  temperature  of  the  body 
appears  to  be  normal  after  single  attacks  of  epilepsy. 

(iv.)  The  Fourth  or  After-Stage. — The  aftor-gymptoms  of 
epilepsy  differ  greatly  in  duration,  severity,  and  nature     The 


BPtLBPST. 

poUeot  recover*  oocagionally  Id  about  a  quarter  oi*  an  Iwrar  ifuf 
tbo  attack,  and  resumes  hia  previous  occupation;  bal,Mai«]t, 
recovorjr  is  delayed  for  a  much  longer  period.  He  soflmftn 
laasitude  and  stupor,  from  wbicli  bo  ia  aroused  with  diSktt^^ 
and,  if  awakeued,  be  is  peevinb  aod  irritable,  whiJe  l)i«  gMMol 
muscubtr  relnxntion  is  oocauooally  interrupted  bjr  iimiiMiilMl 
clonic  ttposuB  ur  BbrilUry  contractjoiu.  The  s.veng«  dtinlM 
of  the  Btupor  ia  about  an  hour  when  the  attadc  ocoun  dima| 
the  day;  but  when  it  occurs  in  the  eveuiu)*  it  pones  ■"— "^ 
into  tbc  ordinary  uooturual  altt-p. 

Complications. — Various  mental  disturbaocea  are  by  fii  tb 
moat  Lmpcntaut  of  the  complicatioas  of  epilepsy.  The  paaM 
aoraetimes  exhibita  marked  mental  deraogviiient  immsdiabb 
before  as  well  as  after  tJie  patoxyam,  aud  a.  rpftniivral  oomBIm 
couBtitutee  uorngtimea  tbo  principal  feature  of  the  attack.  1 
person  the  subject  of  epileptic  vertigo  may  continue  f  -  — 
seconds,  minutes,  or  even  hours  in  a  dull,  hah  stupid  v  - 

He  may  mutter  a  few  incoboreut  words,  or  some  lewd  czpruM^ 
no  matter  how  foreign  to  his  habit ;  he   may  unbottM  Ul 
clotlies  and  expose  his  person,  urinate  in   a  public  vwmVj, 
exhibit  himself  nuked  to  his  domo8tU!%  or  even  walk  in  paUe 
nuked    unless   prevented,   and   on   recovery  he   haa  «ih'  thi 
vaguest  revoUeclioD  of  what  has  occurred     Thuse,  bovrtrct,!!* 
ouly  a  few  of  the  miuor  actioua  which  may  be  done  by  a6r> 
duals  subject  to  epileptic  vertigo  immediately  after  the 
The  most  motiveless  and  atrocious  crimea  aro  aorootimei 
mibtcd  in  ibia  condition,  so  that  6ome  medical  junsts  an  d 
oiniiioa  that  no  epileptic  is  responsihle  for  his  actions.   £pil*|ttt 
Bometimce  bare  a  warning  uf  the  approaching  maniacal  iai% 
JBO  that  they  can  warn  their  friends  to   protect    tbe»MJf«; 
but  gbueraUy  the  seizure  is  more  or  leaa  euddeo.    Then  a 
every  variety  of   inlurmcdiatu  form  between   the  mitdtf  urf 
severer  casea.     Rejoolda  aays  that  eyilcpiic  nianiu  ocma 
about  ooc<tenth  of  all  cases  of  epilcpiiy,  including  (lie 
attacks  of  epileptic  vertigo ;  having  occurred  in  the  caw 
one  individual,  it  is  apt  to  appear  again,  eapecialljr  when 
liiA  have  followed  in  rapid  succosaion. 

Epileptic  delirium  is  not  always  furious  aud  dauuerwuL 
tOKj  a^'^vwc  \ti  the  form  of  preteruaturul  gaiety  or  illaitf 


Brn-Epsy, 


927 


«r  the  senses  bcforo  tbo  attack,  or  duriog  the  internals. 
UdeoiajptiB  has  been  known  to  follow  epileptic  paroxysms ;  but 
it  ia  generally  the  result  of  nn  injury  inflicted  by  tlic  faU,  and 
l>oth  apoplexy  and  pormnnent  paralysis  are  rar«  vomplicationd 
ii^  idiupalbic  epilcpny.  Idiocy  and  epilepsy  are  not  unfrequently 
MBOoiated,  in  whicb  case  the  former  disoaae  is  goncrally  cou- 
mnitaL 

I     Attacks  of  U^slero-epilepey. — Hyatero-epileptic  attacks  are 
not  often  seen  in  tbis  country  in  tbe  cUusical  form  described 
by  French  author*     ITie  patient  in  the  intervals  suffers  from 
^varioua    by3tc:riciil   symptoms,    the    most  usual  of  which  are 
iDonaplete  or  incomplete  hysterical  buroiaon^tbcsia,  and  ovarian 
lijrperaestbesia.     The  paroxyam  is  always  preceded  by  an  aura, 
consisting  of  a  suosatiou  proceeding  from  the  region  of  the 
' bypcrscstbvtic  ovary  towards  the  epigastrium,  and  ascending 
to  the  throat  and  fiually  to  tho  head,  when  the  patient  ult«r8 
»  loud  abrick  and  falls  iaaensible  to  the  ground.     All  the 
moacles  of  the  body  now  become  tho  subjects  of  tonic  spasm; 
tbe  bead  is  retracted,  and  the  body  and  limbs  are  arched  back- 
wards and  rigid ;  tbo  respirations  ar«  stertorous  and  infrequent ; 
and  foam,  sometimes  blood-stained  on  account  of  the  tongue 
baving  being  bitten,  generally  issues  from  the  mouth.    The 
tonic  stage  is  followed  by  a  few  clonic  convulsions,  but  these 
Boou   cease,  and  a  NUite  characterised    by  general    muscular 
relaxation,    stertorous   respirntion,   and   coma  terminates  the 
portion  of  tbe  attack  resembling  the  epileptic  parojcysm. 

Tbe  second  stage,  or  what  the  French  call  th«  "  iifuuse  dea 
^ffnfnds  motivementa."  now  makes  its  appearance.  It  is  chaiac- 
Iterised  by  violent  contortions  of  the  body,  and  gesticulations 
having  a  purposive  character.  Thero  in  opisthotonos,  or  the 
,body  IS  beut  forwards  or  laterally;  while  at  other  times  it  is 
|inaintaincd  in  a  rigid  position,  with  the  lower  cxtremitiea 
ieztended  and  the  upper  stretched  out. 

The  third  stage,  or  stage  of  emotional  attitudes  (phaae  dea 

itUUtbiUs  paeaioniUea),  now  appears,  and  during  its  continuance 

the  patient  assumeo  in  rapid  succeesioa  attitudes  and  gestures 

expressive  of  various  emotions.    Tbe  first  attitude  assumed  by 

ftLe  patient  is  usually  a  threatening  one ;  she  raises  herself  in 


990 


EPltEPST. 


epilepsy.    Tlie  claBsicat  cases  of  Julias  Cmsar  and  Na 
botb  of  whom  Buffered  from  tho  diMSM,  mn.y  be  cited 
examples. 

Slight  impairment  of  memory,  especially  with  legsnl  to  i 
events,  wliiie  the  rememhraace  of  remote  occurreQcea  ii  b 
is  the  most  comtoun  aud  generally  the  fint  mrotal  di 
The  next  grade  of  mental  impairment  declares  itself  to  ■  i 
amount  of  mental  dulneas  and  want  of  apprebeneiioa  ; 
BtUl  lower  degrad&tioD  is  manifested   by  oonfuaiuo    of 
fi[eneral  want  of  comprehcnsiou,  and  deficiency  tu  lot 
activity,  associated  with  a  stupid  and  vacaut  cxpreiutto«. 
moral  nature  is  almnst  ioTariably  pcrTertcd,  the  patiosbi 
gloomy,  irritable,  and  distniHtful. 

One  or  otber  of  tbeae  minor  mental  defacts  mAy 
to  exist  without  any  appreciable  chango  during  a  series  of  yein: 
but  lit  other  times  the  mental  chsogo,  beginning  vith  vMI 
degrees  of  impairment,  passes  through  lower  and  lowvr  dsfm 
uf  deterioration  until  the  patient  onivue  at  a  condition  of  eetD;' 
pltU^'  imbecility. 

The  conditions  which  determine  mental  fiuliir*  in  vgil 
have  been   carefully  eicaraiaed  by  Dr.  Russell  Reynolds; 
following  are    the   mc«t   important  conclusions   at 
arrived.     Hereditary  taint  It  without  influence,  and  tfa«  i 
may   be   said   of  the   duration   of  the   disease,    llie 
the  general  health,  the  number  of  attacks,  the  nature 
exciting  cause,  and  the  severity  of  the  paroxynm  when  y 
by  the  duration  of  the  subsequent  cotna.     Frtnjueacy  of 
renoe  of  the  seizures  exerts  a  oertain  amount  of  iotioeDce  ii 
production  of  mental  impairment,  yet  there  ta  no  constant  < 
nection  between  the  two  phenomena.     Mental  impaim* 
according  to  Re)'no1ds,  more  frequently  associated  with 
than  with  major  attacks  of  6pilep«y,  and  appeare  to  1 
in  dirt£t  but  rather  in  inverse  proportion  to  tb» 
muscular  manifcRtation. 

Motor  Jfani/MtoJionsL— Semt  motor  ilistiirbaceai 
the  iotorvals  between  the  attacks  in  the  majority  of 
These  appear  in  the  form  of  itinple  mnacular  tran 
there  may  be  clonic  or  tonio  ^>aains  in  single  groups  o 
Clonic  aposm  is  the  most  fraqnoDt,  and  may  occur  in 


EPILEPSY. 


929 


wtient,  wlio  lies  on  her  back,  may  be  propelled  from  one  end 
of  the  room  to  the  other.  Id  suU  other  cases  t^e  attack 
Xmiiitx  of  gre&t  ilitticulty  of  breathing  caused  bj  intense  reapi- 
itory  spasm  (Gowers). 

(c)  JSpileptiform  Seisures. — This  form  of  epilepsy  was  firat 

d««cribeJ  hy  Bravais,  bat  its  pathology  vras  fully  iovesUgated 

ty  H  ugh  lins;&- Jock  ■son,  and  il  ia  couscqucutly  named  "Jack- 

Bomao  Epilepsy."    In   it  the  convulsions  arc  partial,  being 

imitcd  to  one  half  of  the  body,  and  consciousness  is  either 

retained  throitghoiic  the  attack,  or  loet  only  at  a  comparatively 

late  period.     The  lits  are  accompanied  or  fullowcd  by  paresisof 

(lie   eoDVulsed  limlwt.     Tliese  seizurea  are  caused    by  coarse 

HHaatse  sitnated  near  the  cortex  of  the  brain,  the  most  common 

Pmbu  being  a  ^umma.     The  convulsious  which  supervene  upon 

the  cpaatic  hemiplegia  of  childhood  (unilateral  atrophy  of  the 

brain)  are.at  ^rst  partial,  but  after  a  time  become  generat.    An 

interesting  cai^e  of  epilepsy  in  s  girl  aged  0}  years  is  recorded 

Ity  Dr.  Starge,  in  which  the  convulsious,  which  began  when  the 

patient  van  6  months  old,  were  at.  first  limited  to  the  left  half 

of  the  budy,  and  always  began  in  the  lefi  Imnd  after  they  bad 

become  general.     The  left  half  of  the  body  was  observed  to  be 

weak  for  some  time  after  each  partial  cuutnilBion.    The  patient 

was  born  with  att  extonhive  "  mother's  mark"  on  tbfi  right  tide 

of  the  heai^l  and  face ;  it  exteuded  to  the  mucous  menibrane  of 

the  tongue,  uvulu,  and  pharynx  on  the  same  Bide,  the  sobrotic 

coat,  retina,  and  choroid  of  the  right  eye  being  also  implicated. 

Dr.  Sturgc  makes  the  very  probable  conjecture  that  the  attacks 

were  due  to  a  "  port  wine  mark  "  on  tho  siirface  of  the  right 

hemisphere  of  the  brain  similar  to  that  on  the  face. 

(3)  Thi  IiUer paroxysmal  Coitdition. — The  condition  wbicb 
exists  during  the  interval  between  the  epileptic  attacks  was 
Unit  fully  exaiained  by  Br.  Kubseil  Reynolds,  and  deserves 
careful  attention.  The  most  important  phenomena  observed 
ace  tboee  which  belong  to  the  mental  condition  of  the  patienla 
la  a  oonsiderablu  number  uf  cases  uu  mental  disturbance  or 
weakness  whatever  can  be  discovered  In  the  condition  of  the 
patisDt  between  the  attacks,  and  occasional iy  individuals 
of  high  intellectual  powers  are  ihu  subjects  of 
BBU 


932 


KPtLBpar. 


1 


aurm  whicb  ia  fttways  of  the  saiao  kitiil  io  the  same  iaditii 
and    begins   in    tlie   regioD   of  tfac   injure'l    aentL     Wbn  t 
cicatrix  is  found  lo  the  eouree  of  tfae  aiTected  oarv^  as 
may  occatuooatlj  be  produced  by  preaung  apon  U.    t 
reporU  a  case  in  which  aneizure  could  be  prodttoed  by 
the  upper  extr^rnity.  but  th«  epileptogeootu  xooe  ia  not 
disiinctly  marked. 

(bj  Fre<juencif  of  AUaeka.— The  paroxjmu  aa  a  rule  rav 
veiy  irregularly,  but  Beynolds  thinks  that  Erei|tieDUy 
reourreoce  of  attacks  ba«  some  relalioa  to  time,  as  nuukad 
its  natural  diviaioa  into  days,  and  periods  of  seroD  daj\ 
multiples  of  seven  day&     Thus  a  Urge  number  of  cpilif^' 
baru  their  seizur«<  every  day,  every  two  weeka,  time  weab^jad 
four  wti-ks,  while  only  a  much  smalla  aambw  mffsr 
irregular  loterraU  a$  cafioot  be  thus  exprened." 

Somotimos  the  mode  of  recurrence  i«  what  baa  been 
"  aerial."   The  patient  suffers  fnm  two  or  more  atUcks  to  a 
usually  within  twelve  houn,  and  then  there  is  a  free  is 
from  one  to  eereral  weeks.    This  mode  of  recamnee  u 
tVequent  in  the  female  than  in  the  toale  sex. 

The  frequency  of  the  paroxysms  varies  witbio  wide  lii 
some  patients  only  having  one  seizure  a  year,  others  ha 
thousands  ;  but  Reynolds  states  that  half  the  case*  are  fi 
hare  a  rate  of  Fecurreoce  rangiiig  from  one  attack  in 
to  one  in  tliirty  days.  A  high  rate  of  freqaency  Is 
observed  io  those  who  are  in  more  or  Um  robcLst  healtfa;  mi 
a  low  rate  of  frequency  in  those  whoee  geaenl  ooBditioa  ha 
undergoae  marked  doterioratioo.  GarJycDmnaDoemeol  of  «fi- 
lepay  ia  commonly,  but  not  always,  aasociated  with  a  high  rait 
of  frequency  of  recurreooe. 

Th(]  groups  of  attacks  may  be  oompoeed  of  fium  Turn-  te  s 
bondrod  or  more  single  eeizuree  in  twenty-lbur  boom  Hit 
eoodttioQ  may  eitcod  OTera  much  longer  poriod,  aad  Dsliiiiw 
saw  in  a  boy  of  fifteen,  within  one  month,  a  "ooU«ettve  •eime' 
which  was  eompoeed  of  S.5M  "  fra^meaUry  eeizuras*"  Ai 
FrsDcb  have  designated  this  condition  ^kU  df  mal  ^ptbpfifs* 
faiatv^  epiispiieua},  and  Boumeville  baa  rteeoUy  drawn  ait«»- 
tion  to  the  great  Increase  of  temperature  wbieb  cbaraeterisB 
the  oondition.     The  patiwts  lie  Id  profouod  eooia,  aad 


BPILEPSr. 


9SS 


temperature  may  riae  to  107 '6°  F.,  and  Blill  higher  in  fatol  casca. 
In  favourable  casoe  the  temperature  jfradually  falls,  but  in  other 
cases  a  subsetiueiit  riae  takes  place,  coma  becomes  profound, 
and  the  pntieot  dies,  often  with  symptoms  of  collapse  ossociatod 
with  the  iormatioa  of  acute  "  bod-sores." 

It  is  well  to  remember  that  the  attacks  frequeDtly  occur  at 
Dight.  and  e«pocta!ly  is  epilepsy  apt  to  comnaence  in  this  way. 
Our  atttrutioD  ghoiild  be  directed  especially  to  this  fact  if  a 
previously  healthy  patient  complain  sometimes  oq  waking  in 
the  morning  of  such  i)ympt,oni3  as  depression,  stupidity,  and 
headache;  tlie  surmise  of  epilepsy  will  be  reudered  certaiu  if 
Id  addition  there  bavo  been  involuntary  diucLarge  of  urine  or 
(aacefi,  if  the  tongue  be  bitten,  or  if  small  hemorrhages  into  the 
akin  he  found. 

§  057.  CoiLree,  Bttraiwn,  and  Tei-TiiiitationJ!. — Epilepsy  is 
essentially  chronic  and  may  last  for  years,  and,  although  death 
occasionally  occurs  during  a  paroxysm,  this  is  exceudin^ty 
rare.  The  course  of  the  dUease  does  not  appear  to  bo  much 
influenced  by  surrounding  circums lances,  and  not  nearly  so 
much  is  might  be  anticipated  by  the  health  of  the  patient  io 
other  respecU.  The  abuse  of  alcoholic  liquors  aj^sraTatea  the 
attoclES,  and  even  drinking  a  moderate  allowance  of  beer  or 
wine  appears  to  act  unfavourably  on  the  course  of  tlie  diaeefie. 
Excees  in  eating  and  drinking  tea  and  coffee  al^  appears  to 
Ujggravate  the  disease.  The  influence  which  a  moderate  indul- 
^^BDce  of  venery  exerts  upou  the  cuitrue  of  opilejuy  is  not  well 
determined,  llany  instances  are  known  where  a  paroxysm 
came  on  during  coitus,  and  venereal  excess  doubtless  aggravates 
the  disease. 

During  the  course  of  acute  iliseases  the  epileptic  paroxysms 
usually  cease,  but  generally  return  during  convali-scence;  a 
similar  etfecl  is  sometimes  piuducod  by  external  iujuries. 
Chronic  diseases  act  in  different  ways,  sometimes  mitigating,  at 
other  times  a^ravatiog  the  puroxyams.  and  at  still  other  times 
not  appearing  to  exert  any  inBucucu  on  the  course  of  the  dii>easc. 

Mental  affections  of  one  kind  or  another  ar«  frequently 
aasociatod  with  epilepsy,  but  Reynolds  has  shown  that  their 
ooaoomitance  ia  not  nearly  so  freqiient  as  was  at  one  time 


934 


EPILEPSr. 


Buppueeil.     It   appears   that  some    mental    affection  ii 
associated  with  «pU«pay  ju  about  oo<!-tbird  of  all 
eiipeciaUy  in  chose  cases  vhera  the  pafoxyams  follow  mA 
ID  unusually  rapid  Huocp^ion.     la  some  of  tboau  caaw 
every  riiasoD  to  coaclnde  that  the  mental  affection  oftil 
attacks  are  joint  effects  of  one  common  lesion. 


§  958.  Morbid   Anaiffmy. — Post-mortem    examinatioo 
levealsd  the  mo»t  various  aoalumical  changed  after  death 
epilepoy  in  almost  erery  organ  of  the  boily.  but  none  of  thi 
constant  and  some  are  quite  exoepttonaL    Various  ii 
liave  been  found  in  the  structure  of  the  skull,  especially: 
disease  lie  hereditary  or  hare  existed  from  an  ewl^  aft. 
boDCH  of  the  skull  may  be  thickened, and  there  nkajlM ' 
on  the  internal  surface  of  the  skull,  or  contraction  of  the  ' 
foramen  or  of  the  foramen  magnum. 

The  meninges  of  the  brain  are  mmetimes  opaque,  tliickc 
or  distorted,  especially  if  OBteoscIcrosis  exist  at  the 
VariouH  statements  have  been  made  with  respect  to  tb* 
of  the  bmiu,  Echeverria  oonwdering  that  the  brain  is  ti 
in  weight,  while  Meyoert  found  a  decrease  in  weight  in 
insanity.  AsymmetTT  of  the  cerebral  hemispheres  has 
observed  pretty  frequently.  Ueyuert  abto  found  a  di 
between  the  two  hippocami  majorea.  catued  by 
atrophy,  a.%ociated  with  cartilaginous  baidoesa  of  ooe  of 
but  he  regarded  this  coDdiltou  not  ao  much  a  catuu  aa  a  rtanl 
of  epilepsy.  Ad  abnormal  distribution  of  the  grey  sobstaAOsdl 
tbe  cerebrum  and  cerebellum  bus  been  met  witli ;  bnl  tliti 
condition  hax  aim)  been  fuund  apart  from  epiIop«r. 
of  the  pituitary  body  is  sometimes  astwciated  witli  i:-ptlepsy. 
chrome  cases  microscopical  changi«  have  frctjucntly  been 
by  Schroeder  van  der  Kolk.  Ecbeverria,  and  L.  Meyer  iaj 
medulla  oblongata,  and  also  in  other  parta  of  the  bcali ' 
ui^rmost  part  of  the  cervical  region  of  tbe  eonL  Tbo  • 
obwrvc-.)  consisted  of  s  ijrunular  albuminous  exu-Iation,] 
cells,  dilatation  of  capillaries,  with  itnfteuiug  of  tbeir 
pigmentation  of  the  gaaglion  cells,  especially  in  th«  nt 
origin  of  the  hypogloeBu<i  and  vagus.  Aoalogoiis  cbaajes' 
found  in  various  parts  of  tbe  cerebruni,  cersbellDm,  and 


EPELEPST. 


935 


r)ia.  The  cortex  of  tbs  brain  is  affected,  oilhvr  (11160117  '"^ 
iodirectly  iu  tb«  large  majority  of  cax«s  of  epilepsy.  The 
primary  laorbtd  change  may  then  be  found  in  the  skull,  dura 
mal«r,  pituitAry  body,  tbe  cortex  its«lf,  or  evi-u  the  white  aub- 
StsDce  boDeath  it ;  but  it  is  probable  tliat  implication  of  the 
cortex  by  the  lesioo  in  the  etisential  coDditton  in  all  of  tbem. 
Id  epileptiform  seizures,  from  coari^c  disease  of  the  brain,  tho 
le&ioD  i»  always  situated  in  or  Dear  tho  cortex  of  ttio  brain. 

ErpenmifU^t  Rettar^het. — The  conn««tJAn  mihtuAting  1>etw««n  general 
OOnnikioiiA  iinil  nnif  ntin  nf  tlic  Imiin  hix  nlrviidj'  brcn  consi^lvi^d.  Rtu«* 
■unl  anit  Tuitaor  found  that  whon  tlie  bmiti  in  aniiDAlB  ts  rapidly  dc])riv«<l 
tt  arturiitl  blood,  eitbcr  by  blc«iling  or  ligature  of  the  Tour  givttt  nrterieH 
gonig  to  tlie  bend,  gonera]  convulHioits  lUiJ  Iosb  of  ooi»douflne««  wen; 
invambl;  prodiHxwl.  Thoy  abo  cndcjivonred  to  imHluoe  an  uidleiitin 
attaek  by  fiunJuution  of  the  sympathotic,  but  only  Biicocederl  in  oii«  caao 
afber  boUi  vert«liniU  and  nno  cuvtid  were  lig&timM).  T)k-  rx|ioriinc'ut«  of 
Biown-S^uard  on  giiiiiwi-iMjft,  with  tlie  view  of  det«maituiig  tint  nntiitv 
«f  flpilc{»y,  an  very  importuit.  He  found  that  injury  to  vnrioiin  ]iart« 
of  the  tiervniis  «y«tcni  developed  In  thaw  uiimiil*  mi  ciiilngitio  tiirKlitiiiii. 
S«c4Jou  vf  K'lac  uf  tlic  bu^r  nerrv  truulu,  such  us  thottciatic,  iotonud 
p«plit«ftl,  and  )><ist«rior  ruots  of  thp  uen'M  of  the  Ug,  partial  or  ootn|d«te 
aocUon  of  the  §pinal  cord,  and  wnunding  of  tho  meduUfi,  cnim  cerebri,  c«- 
eotponi  quodrigpTDiDa  or?  the  letiions  loiMt  sunly  followed  by  epilepsy. 
Allar  Ihm  wounds  koal  a  etato  of  inurcaaod  oxcitabtlity  penitBtB ;  BpOBinodic 
twitdiea  appear  first  la  cartidn  groups  of  Biuscl«e,  and  after  a  time  tbe 
an'm**"  ore  oviiGed  with  wuijik-tc  epdu^iv  attacks.  H«  alao  fouud  that 
irritation  of  the  sidn  over  a  oertiiii  limited  area  in  the  antero- lateral  region 
4f  the  nojk— t^cuerally  the  area  of  dietributiou  of  the  tnf(emiuua  uihI 
M^pltaliH—di'tt^niiincM  an  iijuleplic  atUu^k,  stid  that  a  cnmiidemble  pro* 
-portion  of  tho  nubwcqtwiit  progeny  vf  thow  nnituula  nrw  qiikptios. 

At  till!  Eueeliug  of  the  Britudi  AH»>uiutic>ii  nt  birvriiuol,  iriiere  I  was 
preacub,  Dr.  llK>vii-K£<iuaKt  exhibited  i^  ileaecndant  of  a  guinea>pig  that  bad 
bdcouii?  ejiilvptic  from  svctiuii  uf  tliv  Mintii:  iivnir,  and  nu  gently  ruffling 
tlw  hair  at  the  bock  af  one  car  ad  opiloptic  n,ttM:k  wa«  induoed.  The  por- 
tion ofslcia,  irritation  of  which  catMcstlic  o(iilo|itivatbuik,  Bruwii-f^tftpianl 
has  cflllcd  th«  *piUpto<j»nt»u  font,  lUid  it  in  iEaportant  to  notice  that  it  la 
alight  and  auperficial  irritation  of  it  which  prorokoa  the  attadc ;  aerere 
initatioti,  like  pinching,  may  e\*«ji  arreet  a  coDunondng  attack,  and  if  tho 
din  ia  liuriieil  ur  rut  it  Inatn  itn  et''I^P^8*'i""">  character.  Tho  sldn  of  the 
ARaia,  indMd,  to  aeerUdn  dagre*  anatlhtile,  and  in  tho  animals  wlik'b  aft«r 
a  long  time  rBOOiTr,  an  aniiie  of  theiii  do,  the  anscsthosin  of  tho  cpilcpto- 
gnom  Bona  gradually  diminlsh««,  und  diiuippoarii  along  «ith  the  ejiileptit.' 
teodM)^. 

Another  n«t«wwtby  cinmiurtaaoo  with  reaped  to  tlw  epil^rtngenoua 


^  Hlbtishiu)  in(!n»i(i  BrHfirfnl  efilep^  tw  Injury  t4^*9 

^^^^^^^^1  tbo  anterior  cnmnity  ;  and,  accorditig  to  Fcrnur,  mn  iifOt 

^^^^^^^^1  b«  inditoad  hy  ptuHing  an  iiMlurtitin  cttmnt  nrmodotrntc  ■ 

^^^^^^^^1  tlie  ouiex  ot  one  of  tiw  l)oaiis|ihore6w  In  tiio  auae  uf  n  wnd 

^^^^^^^^1  wail  more  or  l«n  expend,  in  oanaeqiieaDe  of  ouitwrotu  | 

^^^^^^^^1  nkiill,  Dr.  BartluJiiir  applied  ait  imluvtioii  uurrvut  dlxcEtq 

^^^^^^^^1  tliv  ivgifiii  or  the  |M»t«n>-|iarictnl  IaUi — b  ^jrooutiditig  wkk 

^^^^^^^H  oonTiilBKiDS  of  13mi  oppooitc  cxtmtiiitiosi 
^^^^^^^^H  Variowi  ex|Miiiii«Dta  bavv  bo«D  iindertaJcen  with  tlu  vt< 

^^H^^^H  tho  stortiDg  point  of  the  gcitoml  oontntLuoos  in  trpUcpsj. 

^^T^^^^l  oouful  of  tliis  kind  are  thmo  of  Notlmagpl,  who  proTeai  I 

^^^1  rolajODii  Bay  lie  itnlucMl  by  imintioa  of  a  ciraimacii'ilnd 

II  i  't    '^^^1  "'  '^  foiiith  \-cnlriclc,  a  spot  vhich  be  calh  the  **  txmvii 

^^H  §  959.  ;Vor/>'uI  Phyaioloi/i/. — In  tdiopathto  ej 

^^H  st&nt    anatomicai    leition    tiati   b««a    discovered, 

^^^1  thorcforo  be  inferred  ibat  the  leeion  is  a  mo3«et 

^^H  qut^Etion  we  haTC  now  to  tlelorinioe  u  whetbor 

V^H    .  diffuseil  one,  affectiug  the  whole  Dnvou«  ttyiitein, 

■  affoctin^  only  a  definite  regioD.  In  anemia.  Tor 
B  is  au  excesH  of  irrilabUity  of  the  whole  nervous  »yt 
I  the  pntients  Hubject  to  mental  iirtlabiUtj-,  and  la 

■  gtaud  any  exi«rna)  cau84f8  uf  irritation.     In  such 

■  excen  of  the  irritAbility  of  the  QeTvoim  ti;«teni 
H  somethiDg  more  than  this  is  necessary  to  conslitutt 

..       I        .^K not  Hufficicut  tliikb  there  should  be  a  diffiisod  cxcoa 

^^^^^^^^^^^^^^^^^B.    the  nature  of  tbe  epileptic  paroitvam  and  ita  narii 


EPiLEPST. 


937 


jtne  cases  tbero  is  &a  cpilcptogccous  zoDe,  in  otiicrfi  it  is 
it ;  and  in  some  again  tb«  sciatic  norvc  has  been  injured, 
probably  remfrins  in  a  pcnnanently  irritablu  conditioD. 
to  the  spinal  cord,  the  tiasuea  of  which  may  be  presumed 
Remain  in  an  abnormal  state  of  irritability,  may  also  be  a 

re  of  epileptiy.  But  Che  iQore  or  tes>ft  uniform  character  of 
epileplic  paroxysm  shows  thai,  iio  matter  what  other 
pons  may  be  afft»clod,  a  moleculnr  disturbance  must  take 
ea  io  some  one  definite  region  of  the  nervous  system  in 
liy  attack.  Is  it  possible  to  localise  this  region  \  Tbe  most 
■ortant  problems  in  the  pathology  of  epilepsy  chister  around 
jjanswer  to  this  question. 

Ehe  epileptic  paroxysm  consistt  of  loss  of  Ronsciou»ae8S  aod 

{mlsiond,  and  our  problem  now  is  to  determine  what  are  the 

Uities  diiitUTbaoce  of  which  will  produce  these  fuoctioDal 

InrbancM,     Nothimgel   has  shown   that  there  is  a  certain 

■ted  spot  in  the  floor  of  the  fourth  ventricle  by  irritation 

irhich  it  is  possible  to  throw  the  whole  of  the  voluntary 

bclcs  iuto  tonic  and  clonic  spaamt^,  and  h«  has  eonse({uently 

Ited  it  the  "coQTulsion  centre."    He  l)elieTea  that  irritation 

this  centre  is  a  necessary  concomilaut  of  every  epileptic 

^ynn.     But    although*  irritation   of   this   centre    might 

Mint  for  tbe  convalsioos  it  woyld  not  account  for  the  lose 

■onsciousneas.     But  the  vnso-motor  centre  which  it)  tiituated 

Veen  the  upper  part  of  tho  medulla  oblongata  and  the  pons, 

s  to  the  convulHion  centre,  is  aUo  supjKi&ed  to  be  implicated 

be  molecular  diKtiirbance  during  the  pnroxjum.     Irritation 

he  »a80*motor  centre  causes  contraction  of  all  the  arteries  of 

body,  including  the  arteries  of  the  brain,  and  ii  is  to  the 

imia  caused  by  the  contraction  of  the  veaHtls  of  the  brain 

\  the  loss  of  consciou&nesft  is,  according  to  this  theory,  to  be 

ibuted.     Combined  excitation  of  the  vaso-motor  and  cou- 

[QD  centres  is  then,  according  to  Nothnagel's  theory,  the 

Bry   pathological   condition   of  the   epileptic  paroxysm; 

tation  of  the  former  centre  induces  contraction  of  the  vessels 

he  brain  and  the  coni^c-quRut  anii-min  causes  loss  of  con- 

BsneBs;  while  excitation  of  the  latter  centre  induces  the 

icular  contractions.     Tbe  muscles  of  the  face  and  neck  are 

attacked  by  convulsions,  and  by  their  conlractvwcA  \V«> 


i  ■  =j-n    r 


m 


938  XPXLEF8T. 

large  veins  of  the  neck  are  presBcd  a| 
blood  from  the  braio  is  thus  prevented,  t 
the  Ordt  moiueDta  is  succeedetl  bj  an 
setnia  which  au^toentc  the  irritability  of 
and  prolongs  the  convitlMon  and  coma, 
have  shown  that  when  the  brain  is  rapid 
blood,  either  by  bleeding,  ligature,  or  cc 
great  arteries  goiog  to  the  head,  com* 
twitoliings  are  jnvnriably  produowL  It' 
bon-ovcr,  that  (hey  did  not  suooeod  u 
producing  loss  of  conscioiumeas  merely 
cervical  sym pathetics.  And  if  the  local  i 
arteries  of  the  brain  caused  by  faradi 
Bympathetics  will  not  cause  loss  of  cotud 
it  is  not  probable  that  the  controctifl 
body  geDeralljT  cauiwd  by  «xoiiation  oT 
will  c&aae  these  states,  ioasmueh  as  tbe  | 
will  be  raised  and  the  more  powerful  a 
which  will  enHue  will  uiAintaiu  the  cere 
hypothesiR  also  overlooks  the  fact  that 
the  predominant  feature  of  epilepsy,  as 
Some  cases  of  true  epilepsy  are  charac 
porary  lo«  of  consciuusuBSS  without  a 
disturbance,  a  state  which  differs  widdj 
by  ana'inia  of  the  brain,  and  is  unlikel] 
motor  action. 

Dr.  Todd  was  the  first  to  attribute  ej 
of  DCn>'u  force ;  but  this  theory  has  aMV 
the  bauds  of  Dr.  Hugblings-Jack&ou,  wl 
Tulsioiia  of  all  kinds  associated  with  los» 
caused  by  discharging  lesiona  of  tfa«  ooH 
hypothesis  bas  received  a  couaiderable  ai 
verification.  Hitzig  wag  able  to  datormi 
by  various  injuries  to  the  cortex  od 
obtained  a  similar  result  fay  paxsin^ 
moderate  inteusity  through  tbe  cortex, 
widely  separated,  so  that  a  large  port! 
included  in  tbe  circuit. 

A  survey  of  tbe  anatomical  cL 


'■'■■I  ■  - ' '  ■" 


KPILEI«Y. 


»S9 


already  shown  us  tbM,  of  all  the  roanirold  loeions  obeoi'ved, 
diseaw  of  the  cortex  of  the  brain  predomiuatea.  Other  facts 
t«nd  to  tbe  same  conctusioo,  such  m  that  wbdre  epilepsy  is 
associated  witli  imbecility,  struclaral  clmnges  arc  often  found  od 
(he  surface  of  the  brnin,  und  that  general  paralyeis  of  the  iiisaiie, 
«  diMMO  ID  which  structural  changes  are  genetully  fouad  to  the 
cortex  of  the  prefrontal  region,  h  very  often  accompanied  by 
epilepsy. 

Acoordiog  io  TwM's  theory,  as  elaborated  by  Hugblingg- 
tTackson.  the  coiivulKionK  of  upilepiy  are  due  to  a  large  diKcbarge 
of  nervouH  energy  from  the  cortex  of  the  brain  along  tbe  cen- 
trifugal nerve  paths,  and  the  loss  of  consciousneN  U  caused  by 
the  temporar)'  exhaustion  which  tniccvedii  to  excessive  nervouH 
discharge.  The  temporary  paralysis  of  the  coDvuleed  limba 
obBcrved  after  epileptiform  seizures  ia  also,  according  to  this 
liieory.  due  to  temporary  exhaustion  of  nerve  force  following  the 
excesaive  discharge.  But^  if  this  be  so,  it  may  be  asked,  why  are 
geDcral  convulatons  not  followed  by  temporary  paralysial  The 
reply. is  that  tbey  are  so  followed.  After  au  epileptic  attack 
there  in  complete  muHCuIar  relaxation,  but  as  the  patient  is  at 
the  same  time  uuooiiscious  tbe  degree  of  paralysis  prc^scnt  ean- 
Doi  bo  ostimatcd.  Even  after  coniwioiUDess  iit  regained,  general 
muscular  feebleness  often  remains  for  a  time,  which,  although 
not  colled  paralyBis,  is  really  paralytic  in  nature  (Hughlings- 
JftckBon).  The  unseemly  and  apparently  immoral  actions  per- 
formed, and  the  alrucinuti  crimes  nften  committed  by  patients 
afier  minor  nttitcks  of  epilepsy,  may  be  expUined  on  iho  sup- 
position (hat  tbe  inhibitory  influenco  of  tbe  highest  centres  is 
temporarily  suspended,  thus  permitting  the  centres  which  pre- 
side over  automatic  actions  and  animnl  iuHtincta  to  spring  into 
greater  activity  (Anstie).  Irritation  of  the  peripheral  nerves  or 
of  the  floor  of  the  fourtb  ventricle  may  delermiiiB  the  nervous 
diactiarge  from  tbe  cortex  which  constitutes  epileptiy,  as  well  as 
direct  irritation  of  the  cortex  itself. 

Epileptifurm  seisuros  ore  always  caused  by  a  coarso  lesJOD 
fiiLuatcd  in  or  near  the  area  of  distribution  of  the  Sylvian  artery 
to  the  cortex,  and  it  may,  therefore,  be  inferred  that  when 
attacks  of  idiopathic  epilepiiy  arc  ushered  in  by  a  motor  aura, 
the  molecular  diaturbance  hegina  in  some  part  of  tbe  motor 


940 


BPILBP8T. 


area  of  the  cortex.  When,  oa  the  other  bauil,  the  Mr* 
of  soDsory  disturbooces,  the  discharge  probably  b^gio*  it 
area  of  the  cortex  BuppUed  by  the  posterior  cerebral  utKj. 
When  the  ntira  conaints  of  emotional  states  of  fear  aod  anger,  it 
is  probable  that  the  discharge  also  begtnfl  ia  the  area  of 
posterior  cerebral  artery,  inasmuch  as  these  emotiooM  art 
bablj  oflcn  preceded  by  hallucinations  of  the  aenaea,  or  at  li 
by  Rome  disturbance  of  the  sensory  apparatus.  When  Um 
consixta  of  "  droaroy "  states,  the  diacharge  probably  Upa 
in  the  region  of  the  cortex  supplied  by  tbo  anlerior 
artery,  and  the  cases  in  which  tinconsciousuew  sa: 
suddenly  without  being  preceded  by  an  aura  probably  abotaii 
origin  in  a  molecular  diitturbaace  of  this  area. 

g  900.  Z>ra^noffw.— Epilepsy  i*  oftxoi  simulated  by  tmpetin 
and  sometimes  so  successfully  that  it  is  very  difficult  todilKl 
the  fraud  The  physician  must  take  into  considentioo  rf 
the  circumstances  of  the  case,  but  the  symptoou  vrhioli  ou 
hardly  be  simulated  are  pallor  of  the  face,  aiid  dilstiM 
and  iiiseuBibility  to  light  of  the  pupil  at  th«  bee  ■r'^ 
the  seizure.  The  slighter  attacks  of  epilepsy  are  i: 
described  by  the  patient  as  slight  "fainting  fits,"  and  it  ■ 
somewhat  difficult  to  distioguisb  the  two  aSdoUooa.  U  bi 
attacks  recur  at  regular  iDtervala  in  the  absence  ot  aoy  i«Ui' 
hance  of  the  circulation  to  acoount  for  them,  they  nasi  b 
regarded  as  epilepsy.  The  diagnosis  is  rendered  clurer  d,  * 
addition,  an  epigastric  or  other  sensory  aara  be  daicrtlM^* 
if  the  attack  be  attended  by  coDvulnon,  twitching,  or  in|Ui' 
consciuuiineKii. 

Hytteria  iu  its  ordioary  form  may  be  readily 
firom  epilepsy  by  the  history  of  the  catie  before  the  attack, 
by  the  abusnce  of  the  distortion  of  the  fc-atures.  dilatalioairf 
insensibility  of  the  pupils.  Hysterical  attacks  are  udm^ 
pauied  by  complete  loss  of  coDSCiousDess,  the  tuo^oe  ii  id 
bitten,  there  is  no  marked  asphyxia,  and  the  patient,  sitbiif^ 
exhausted,  docs  not  pnsa  into  stupor  befon?  rvco-nrt.  Vl 
dia^osis  between  hysteria  and  hystero-epitopsy  ti  rcsK 
mode  when  the  patient  ia  seen  dunug  an  ntlaclc.  Altdi 
ot  Wa\B.v\«T  wtft  A'«v3%'^«tfiinA!^Vi'^  a,a  aurik,  auil  there  ii 


EPILBPST. 


941 


B,  although  it  may  be  transitory,  loas  of  coDBciousness.  The 
hosts  between  eptlepny  and  eclampsia  will  be  considered 
Q  the  letter  disease  is  uuder  consideratioQ. 
flhen  ori/anic  duKoea  of  tfic  nervous  ayatem  arc  attended 
I  convulsions,  they  preBent  other  BymptomB  over  and  above 
[fits  by  meana  of  which  they  may  be  diBtiD^fulshed  from 
KMy.  Tlic  mo&t  usual  iaLracraDtoI  diHcaties  associated  with 
luUtons  are  tumour,  chronic  softening,  ami  chronic  lueuin- 
1;  but  ID  all  these  diseases  some  characteristic  symptoms, 
i  M  optic  neuritis,  paratyeis,  or  peraisteot  psychical  distur- 
W,  atB  present,  which  render  the  diagnosis  betweeu  tbeiu 
igCDuine  epilepsy  comparoitivcly  ca«y. 


S(H,  Prognos^U. — The   prognosis   in   genuine  epilepsy   is 

jTOurable  as  regards  complete  aod  permanent  recovery, 

pially  if  the  disease  ha^i  been  establiMlied  fur  bume  time.     It 

It,  however,  to  be  remembered  that  a  few  cases  are  com- 

Uy  curable,  and  that,  even  when  the  disease  haii  been  of 

Wtanding,  a  considerable  improvement  may  take  place.    In 

ttmderable  number  of  caaes.  probably  the  majority,  no  treat- 

I  hu  hitherto  produced  any  beatificial  effect, 

lie  rollowing  circumstances  influence  the  prognosis.     Hera- 

'^  taint  gives  an  unfavourable  indicatioo;  but  an  early 

Uoucuiiicat  of  the  disease  is  favourable.      Herpiu  thinks 

MM^ilepsy  begins  after  the  fiftieth  year  the  proepectd 

BuDener.    The  longer  the  disease  has  lasted,  the  greater 

fuprobability  of  recovery.   Roynolda  thinks  that  thoaa  caSM 

titch  tiie  iulervaU  between  lUe  attacks  are  mucb  prolonged 

pss  amenable  to  treatment  than  are  thoee  which  exhibit  u 

t  rapid  recurrence,  while  Herpiu  thinks  that  the  prognoBia 

ines  more  unfavourable  in  propurtion  tu  the   number  of 

ires  sutTered  in  a  given  time.     When  the  epileptic  attacks 

nused  by  penpht;ral  irritation  the  proguoois  is  favourable, 

IB  the  disease  has  already  been  long  established,  while  of 

)e  ou  the  otliur  hand  ccmral  disease  renders  the  prugnons 

irourable.     Mental  failure  is  of  evil  omen,  since  it  iudicates 

U  probability  that  a  profound  and  permanent  molecular 

ge  has  taken  place  in  the  gruy  matter  of  the  cortex.     The 

ler  to  life  is  remote,  aince  it  is  rare  for  an  epileptic  ta  di& 

le  of  the  fittscka. 


»4S 


EPILEPST. 


§  962.    TitatmenL — Hie  txeaUnent  of  cfNleps^r 
dtrecl«d  to  Ibe  remonU  of  the  ooodiuonfl  opoo   wluob 
attacks  depend,  and  to  the  mitigatioo  or  ftvoidjuie*  of 
B6izuru»  tljeoiselvea 

When  thu  attacka  are  raaintaioed  by  a  penpber»l 
irritation,  tbia  must,  of  course,  be  remoTed  if  poMibl«. 
lias  somHinies  b««a  kii&wii  to  disappear  after  the  extii 
a  cicatrix,  the  removal  of  a  tumour  pnmog  oa  a  ncrvo, 
opening'  of  an  abscess;  and  tbe  Rame  result  bas  b«ea  ot 
by  tlie  removal  of  eouroes  of  initation  in  ibo  alLmcDtar^  i 
Btsch  as  worma.     Wben  an  aura  constantly  raeorred  i) 
coutK  of  tho  tome  oerre,  it  wa^  formerly  tfa«   prariie 
perform  neurotomy,  or  to  amputate  a  finger  or  ereo  tbe 
No  good  resultH  atteodf-d  tliifi  practico,  and  it  i«  do* 
Tbe  pnictico  of  trepbining  wax  also  extensively  emplo} 
former  tiraea  iu  every  ciuie  which  reaisted  medical  tjeati 
tbla  treatment  may  possibly  be  vuccead'ully  used  in 
number  of  caHes  of  epilepHy  from  organic  diaeaie.     It  is  i 
nece^ary  to  add  that  in  epilepsy,  as  in  all  other  chronic  du 
the  general  health  must  be  carefully  attended  to  am)  Ihei 
regulated.    Alcohol,  tea,  and  coffee  should  be  spariugly 
articles  of  diet. 

Excessire  meatal  effort.  emotlonsJ  excitement,  and 
must  be  av4Hded ;  but  a  moderate  degree  of  intellectoal 
may  bv  uiscful.  and  a  certain  amount  of  bodily 
of  fatigue,  fibould  be  enjoined. 

Souie  epilcpUca  bavu  been  much  improved  by  the 
adopted  in  hydropathic  eatablisbments.    The  a|^icativo 
bags  along  Ibe  spine  was  strongly  reeommcndcd  by 
but  Kcynoldx,  who  baa  given  the  treatment  a  fair  trial. 
that  be  has  found  tbe  retiults  abtolutely  negative.     Elf 
ID  iu  various  forms  has  been  employed  in  tho  trwUBtal  (f 
epilepsy,  but  with  little  success. 

Counter^irritatJon  was  at  one  time  extensively  ased,  batj 
prevailing  opinion  at  present  is  that   tbe  practice  is 
If  the  presence  of  an   cpilcptogeoous  zone  be 
blister  over  the  sensitive  area  may  be  attended  irith  beDc6l 

Brumide  of  potassium  biw^been  found  more  genenilly 
in  tbo  treatment  of  «pilep.<ij  than  any  other  drag ;  to  <1«  | 


BPII.BPSY. 


943 


jst  be  giYCD  ia  doscB  raugiu^  from  tcp  to  forty  gruius 

!C  times  daiij,    The  results  of  this  treatment  are  tbat  a  few 

IS  have  beeo  completely  cureJ ;  in  other  case;*  the  attacks 

■  been  arrested  lor  varying  periods  of  months  or  years,  but 

I  recurred  on  the  drug  bL-ing  omitted,  and  ceased  again  ou 

>eing  readmiQtstered.     In  still  other  cases  the  attacks  have 

diminished  in  severity,  although  uot  removed ;  while  in  a 

tiea  the  drug  doen  not  appear  to  exert  any  influence  on 

liseflse.     When  large  dosea  of  bromide  of  potassium  are 

liittered  for  some  time,  it  Ix  apt  to  produce  an  cniption  of 

which  soon  eubsides  on  the  drug  being  discontinued;  or 

iption  may,  according  to  Br.  Wilks,  be  preveuted  by 

ling  arsenic  with  the  bromide.     Chloral  is  flomeltme!i  a 

III  adjunct  to  the  bromide   of  potassium.     Next,  to  the 

tide  of  potassium  the  isnlts  of  zinc,  eapcciaily  tlio  oxide, 

I  proved  the  meat  gcneraJly  useful  in  the  treatment  of  the 

tfe.     This  remedy  appears  to  be  more  etHcienl  with  pntiente 

|b  twenty  years  of  age  tbaii  iu  those  of  maturer  age.    The 

may  be  given  in  doses  ranging  from  two  to  five  grains 

times  daily.     The  sulphate  baa  aUo  been  employed  in 

^osos  with  frequent  success.     The  stulphnte  may  be  given 

Bt  in  doaea  of  three  grains,  and  progressively  iocreased  to 

doses  three  times  a  day.     The  bromide  of  zinc  has  been 

listered  in  grjidually  iucrea&ing  dosea  up  to  a  scruple  three 

la  day. 

oxido  of  zinc  may  be  combined  with  the  extract  of  bella- 
b  or  hyoacyamus,  or  with  the  powd*?red  root  of  valerian, 
ke  ammoniO'Sulphate  of  copper  was  at  one  time  much  used 
B  treatment  of  epilepsy,  but  liaa  lately  fallen  into  disuse. 

E  nitrate  of  silver  was  at  one  lime  much  relied  upon  iu  the 
ent  of  epilepsy,  but  confidence  in  its  curative  power  is 
I  shakcu  in  the  present  day.  The  records  of  the  older 
trs,  however,  amply  prove  that  beneficial  results  foUowod 
Inployment,  and  it  may  be  worth  while  to  give  it  a  trial 
I  other  methods  of  treatment  hare  failed. 
Iladonna  has  been  long  used  as  a  remedy  for  epilepsy,  and 
itiyita  alkaloid,  atropine,  has  been  substituted  for  it.  The 
neut  formed  by  Reynolds  is  naw  pretty  generally  endorsed 
itbors,  namely,  that  by  means  of  betladoDoa  an  ameUam.viTk 


9U 


eriLETSV. 


IB  often  obtained  Tor  varioaa  troublesome  coocomituit  i 
SQcb  as  (lUturbed  sleep,  trembling,  and  oenrous 

Digitalis,  eitber  atone  or  in  combinattoo  with  broiniii*  «/ 
potatHium,  13  useful  id  some  cases,  especiallj  if  ihen  ha  ngai  al 
cardiac  &iluTC. 

Iniliaa  hemp  baa  been  found  useful  as  an  ■coeMory  ia  IW 
trealuieut  of  epilepsy,  and  by  its  means  headache  aod  ratka- 
oeiis  have  bcuu  relieved,  but  it  doee  not  appear  tmu  lo , 
appreciably  mitigated  the  disease^ 

If  tberu  be   a  suspicion  of  STpbtlis   being   Uio 
e^lepsy,  iodido  of  potasnum  abould  of  course  be  gir«B. 

The  treatment  of  the  oUlaei:  should  be  directed  to  tta ; 
tion,  and  tbis  is  only  possible  when  it  is  preceded  by  a  i 
wamiog.  When  an  "  aura  "  is  present,  the  attack  may  i 
times  bo  arrested  by  cauterising  or  blistering  ibe  surface  htm 
vliich  the  aura  commences,  or  by  applying  preesum,  as  bys 
tight  ligature,  between  the  starting  point  of  the  auta  aad  tha 
trunk.  Some  patients  are  able  to  arreet  the  paroxysm  b^  s 
xtrong  menial  effort  to  perform  a  detioite  acliun. 

When  the  aura  consists  of  coutmctioQ  of  a  definita  giua| 
muscles,  the  attack  may  be  arrested  by  forcible 
them.     There  are  some  grounds  for  belicTing  that  tba 
may   be  iwmetimes  arrested  by  a  sudden    imptvsawa  00 
surface  of  the  body.     Inhalation  of  chloroform  or  of 
or  a  draught  of  some  diffusible  stimulant  admintiLeiod  at 
moment  of  onsetv  may  arrest  an  attack. 

Dr.  Criohbon  Bronue  was  able  to  ward  off  seTenl 
cauung  the  patients  to  inhale   nitrite   of  amyl    when 
threatened.     The  well-known  action  of  this  agent,  in  paiml] 
the  voMj-motor  nerves,  supplies  the  rationale  of  tbe  treat 

When  the  attack  is  onoe  established,  it  pastas  through 
regular  phoAes  without  being  inflaenoed  by  treatment.  UeMam 
must  be  adopted  for  preventing  the  patient  iojuring  hinatf 
All  tight  bonds  about  the  throat  must  be  loosened,  and  a  piect 
of  indiorubber  or  wood  should  be  passed  between  the  teeth,  i* 
prevent  the  tongue  being  bitten. 

When  the  paroxysm  is  over,  the  patient  ought  to  be  plsoid 
with  the  head  and  shoulders  raised,  and  allowed  to  aleep  witkrt 
interference. 


ECLAKPSIA.  945 

If  the  parojxysm  be  loug  continuod,  bo  tliat  tbcrc  is  dojigcr 
I  of  death  BUperreaing  from  coogestion  of  tbe  Inngn,  blood-letliag 
m&y  relieve  the  circulation  so  much  as  to  arrest  the  attAok. 
Wbon  tbe  fits  are  violent,  a  careful  trial  ma;  bo  made  of  the 
inhalation  of  chloroform,  which  is  so  useful  in  th«  treatment  of 
eclampsia. 

km.)    ECLAMPSIA. 
963.  Definition. — Eclampsia  ia  an  acute  affection  arising 
out  structural  leaiou  of  tbe  neiVous  system,  and  charac- 
terised by  partial  or  general  convalaion.s,  accompanied  by   a 
more  or  leas  complete  losa  of  couaciousuess. 

§  9CV  ECwhijif. — Age  U  a  most  important  predisposing  caone 
of  eclampsia.  ConTuUioos  are  frequent  during  the  6r8t  two 
jears  of  lire,  but  become  rare  after  the  Bftb  and  exceptional 
after  the  scveuth  year  of  life. 

The  influence  of  hereditary  prcdiapositioa  in  the  produotioD 
of  convulsioos  is  ahown  by  tbe  fact  that  succensive  infante  of 
ODc  family  are  liable  to  be  attacked  with  convulsions  ia  the 
absence  of  any  duRnito  cause.  Bouchut  mentions  ao  instance 
of  a  family  of  ten  persons,  all  of  whom  had  conruUions  in 
iofancy.  One  of  these  married  and  had  ten  children,  and  uino 
of  them  suffered  from  conTuIsions.  Tbe  children  of  porenta 
who  manifest  evidences  of  a  neuropathic  c^ostitutioa,  as  hys- 
teria, neuralgia,  or  epilepsy,  are  more  liable  to  be  attacked  by 
ooDvuUions  than  the  children  of  the  healthy. 

All  debilitating  causeR,  as  inaulBcient  food,  profuse  diarrhtBa, 
copious  bHimorrbages,  malarial  cachexia,  and  various  diseases, 
greatly  increase  tbe  tendency  to  convulsions.  Amongst  the 
debilitating  diseases  which  predispose  to  CDnvuUions  ricketa 
holds  a  prominent  place.  Out  of  Qb  infants  attacked  with 
oouvulsioos,  Dr.  Gee  found  that  no  less  than  AG  of  the  number 
were  racbitia  Conmlsions  occur  more  frequently  in  cliildren 
during  hot  than  cold  weather,  and  some  authors  aiisert  that 
they  are  more  frequent  iu  female  than  in  male  infanta,  but  the 
ioflucoce  of  sex  is  not  well  ascertained. 

Eclampsia  has  been  divided  into  several  varieties  acoording 
to  the  exciting  cause  of  the  convulsions.  These  are  :  (IJ,  Idio- 
III 


948 


1 


CCUIXPSU* 


Btin 

1 


patbic  oonrulsions ;  (S).  Reflex  oonrn] 
of  fever ;  C*).  CoDvulsions  of  aaphyiitt ;  ( 
(6),  Puerperal  coavulsioas ;  (7).  Toxic  e 

(1)  lu  hiUopatJtie  conruUion*  tbe  e 
Date  to  the  predisposing  cause.  Son 
disposed  to  coQvul8ion»  that  the  ali^^hti 
as  fear,  anger,  or  a  slight  colic,  may  ioi 
at  other  times  an  attack  Bupervenea  ii 
aoj  appreciable  cause. 

(S)  Rejlez  couvulsioos  are  oocaaoni 
oxtremitioa  of  tbe  peripbera]  nerrei.  1 
of  the  external  irritatiou  varies  iodeliDl'l 
usual  causes  of  irritatiou  pricking  b]M 
of  the  surface  of  the  bodj,  reteotJon  ■ 
calculus  iu  the  Icidoey,  foreign  bodiM 
mealUH,  and  initatioa  of  the  digeetil 
of  worms  or  undigested  food  and 
dentition  may  be  mcutioned. 

(3)  Ft^yrila  convulsions  manifest 
acute  diseimes,  more  particularly  in  lobi 
tive  fevers,  and  intermittent  fcvvr.    M 

This  form  of  convulsion  appears  IP 
which  ushers  in  most  acute  febrile  dii 
if  oot  caused,  it  is  at  teadt  accompw 
teupefature.  Il  must  oot  be  oocfouiu 
which  suporvcDc  id  tbe  course  of  fe] 
latter  are  usually  symptomatic  of  oei 
some  form  of  meningitis. 

(4)  ConTuUions  duo  to   wpKyxia 
diseeaee  of  the  resjuratory  organs ;  tbey 
during  severe  attacks  of  whooping  ooi 
terminal  pbeuomeoa  in  moat  of  tlw  dii 

(5)  Uixemie  oodtuIsiods  in  chlldtw 
scarlatinal  nephritis,  but  tfaey  have  be 
immediately  after  birth.  These  codtu 
io  other  forms  of  both  acute  and  dron 

(6)  Ptterperal  ecUmpaia  is,  as  ^ 
ursemic  cooTulsioDS,  although  some  M 
by  reflex  irritation  through  the  uteO! 


ECLAMPSIA. 


947 


(7)  Toxic  coorulaions  might  be  held  to  include  uneinie 
convulsions,  inasmuch  ns  tho  tntter,  acnordiog  to  same  ptttho- 
Ipgists,  result  from  the  accumulation  of  urea  ia  the  blood,  and 
its  coDTeiBion  into  carbonate  of  ammoDia.  This  bypotheois  is, 
howcrer,  doubtful,  ood  it  is  thorefor^  better  to  place  unemto 
poDvulsioiu  ID  a  sepamte  category. 

CertaiD  metallic  and  organic  poisonB  and  irrespirable  gans 
give  rise  to  attacks  of  coDvulsions.  Aiuong&t  thes*  agents  tha 
most  Uiiual  am  pnisinc  acid,  nicotine,  picrotoxine,  wnauthe  cro* 
cata,  carbonic  oxide,  and  carburetted  bydrogeo. 


§  {)€£.  SymptomH. — An  attack  of  eclampsia  cannot  be  din- 
tingaisbeii  from  a  true  epileptic  seizure,  and  it  io  therefore 
unnecessary  to  givv  a  tniaute  description  of  it.  Infantile  con- 
vuUioQS  bare  been  divided  into  iiiiamal  and  eacta'ntU,  the 
mu4cl&9  of  the  glottia  and  the  respiratory  muscles  being  chiefly 
affected  by  spasm  in  the  former  and  the  muscles  of  cxteroal 
retatioD  in  the  latter. 

The  symptoms  caui^d  by  spasm  of  the  glottis  have  already 
bcea  described  (§  279),  aad  we  ehall  consequently  limit  our 
ftutbflr  remarks  to  the  external  convulsionti  of  children.  An 
attack  of  eclampsia  may  occur  either  with  or  without  pre- 
roonitory  symptoms;  the  invasion  without  prodromata  bciog, 
according  tu  Rilliet  and  Barthez,  the  more  common. 

The  premonitory  symptoou,  when  present,  usually  connist  of 
aleeptesHnesa,  and  reatlessuesM  or  drowsiDeiis  for  a  day  or  two 
before  the  attack;  while  immediately  before  it  the  pulse  is 
often  bard  and  wiry,  the  countenance  a.>«sumeH  a  frightened 
expression,  or  the  child  starts  up  frightened  from  a  fitful  and 
uneasy  sleep.  The  conviiUion  usually  begins  by  conjugate 
deviation  of  the  eyes,  and  slight  jerkiag  contractiona  of  the 
mu&cles  of  the  anglt^s  of  tbe  mouth.  Tbu  natural  took  of  the 
iafaDt  is  now  exchanged  for  a  tixed  stare,  followed  eooa  aflor^ 
wards  by  an  upward  rotation  of  tbe  eyeballs,  the  latter  being  in 
its  turn  followed  by  a  fixed  stare  and  that  again  by  an  upward 
rotatioD  of  the  globes.  Tbe  eyeballa  are  often  rotated  to  tbe 
rigbt  or  left  aa  well  as  upwards,  aod  the  two  are  generally 
moved  aneqiialty,  so  that  a  considerable  degree  of  strabismus 
may  occur.    The  pupils  are  lomotimea  dilated,  sometimes  ood- 


lips  being  covered  by  a  frotb;.  and  ofteo  gUgbtl; 
mucua.    The  superior  lip  is  nometioiBS  drawn  upi 
expose  the  teetb,  and  the  counteQAnce  theo  auai 
savage  exprvasioD.     The  inferior  jaw  is  aomoiinM 
clonic  spaatns,  irbite  at  other  timos  there  ia  tmmi 
from  time  to  time  by  grinding  of  the  teeth.    The  1 
strongly  retracted,  and  somctimea  rotated  to  oi 
thumb  ia  flexed  into  the  palm,  and  the  fi  ogers  are  a 
thumb;  the  Foreann  is  bent  u[>on  the  arm  and 
agitated  by  alight  morcments  of  Mmiflexioa  and  « 
the  hand  is  alteniat«Iy  pronated  and  eiipiuatad  ; 
inent<i  of  the  auperior  extremiUeB  are    ooatortol 
imaginable  shape.    The  inferior  extremities  *i^ 
similar  manner,  although  to  a  less  degree  tha,a 
The  raoBcles  of  the  trunk  occa-iinnally  participatl 
convulsions,  but  as  a  rule  the  trunk  is  maintained  I 
contraction  of  its  moidw.    The  contraction  of  tl 
one-half  the  body  may  predominate  over  those  ofl 
side,  and  then  the  child  is  arched  kter&Uy  to  sq 
he  may  be  projected   out  of  bed  by  the  com 
apasmodic  contraction  of  the  diapbragnu  and   ol 
of  the  Urynx  produce  a  peculiar  and  charact«uriat 
air  ia  drawn  into  the  cheat  during  inspiratioD. 
evacuatioas  may  occasionally  take  planu   duri 
Deglutition  is  rarely  impossible,  although  ftttetD; 


urinfl 

lletai 


jerking  of  the  tendona;  and  tlio  respirations  are  accelerated, 
but  atertorouB  only  in  aggraviited  caaes. 

The  ocular  mtisclee  auil  tlioae  of  facial  expression  are  usually 
the  firsf  to  be  affected  with  clonic  spaani,  and  then  the  oiiuicles 
of  tUe  fingers  and  forearm.  la  tbe  more  severe  convuisiona  the 
muitcles  of  the  shoulders  are  affected,  but  tbe  spasms  do  not 
implicat«  the  muscloo  of  tbe  back  and  lower  extremities  except 
in  ver/  aggravated  cases.  Tbe  great  tonic  contraetiona  which 
form  the  first  stage  of  the  epileptic  attack  frequently  fail 
altogether  in  eclampsia. 


§  966.  Conne,  Duration,  and  Terminations. — The  duration 
of  ao  attack  of  eclampsia  varies  considerably  according  to 
orcamstaocea  Tito  couvulaioa  may  sometimes  ceaiie  in  a  few 
miautes,  while  at  other  times  they  recur  for  hours  or  days, 
with  only  short  intervals  of  calm. 

The  iermiiud  convUflsions  of  asphyxia  are  generally  partial, 
iacompleie.  and  atteraate  with  coma.  The  inituU  convulsions 
of  fever  aie  intense  and  gtaerali&ed,  but  are  usually  limited  to 
a  aiagle  attack.  Urxmnic  convulaiona  are  characteriaed  by  their 
violeuce,  the  frequcDt  rcpelitiou  of  the  parux^siii,  and  the  pro- 
found coma  which  altcruatea  with  or  succeeds  the  latter.  After 
violent  and  prolonged  convulsions  ecchymoaes  of  the  skin, 
etpecially  over  tbe  face  and  eyelids,  and  acute  pains  of  the 
affected  limbs,  are  frequently  observed.  Fractures  of  long 
bones,  dielocatJona,  and  rnpturea  of  tendons  have  been  rarely 
recorded. 

An  attack  of  convulaiona  is  frequently  followed  by  complete 
and  mpid  re-eHlablishment  of  health,  but  in  other  caaefi  recovery 
takes  place  slowly.  When  the  convulaiun  'u  due  to  a  meningeal 
luemorrbage  or  some  other  organic  lesion  of  the  brain,  it 
generally  assumes  a  unilateral  character,  and  is  followed  by 
paralyiiis  with  contractures,  choreiform  movements,  apba«ia.  or 
idiocy.  Bssential  convulsions  Hometimca  end  tn  death,  which 
may  result  after  a  single  violent  seizure,  or  after  a  series  of 
tbem  occurnDg  in  rapid  succession.  Death  is  usually  produced 
by  asphyxia,  either  occurring  suddenly  from  spasm  of  thu  glottis, 
or  more  slowly  from  coma. 


ECLAKTSIA. 

9Q7.  Diagnosis. — Id  aoy  particoUr  cam»  of  eclmfflpiii  it  ii 
difficult  to  decide  wtietber  or  not  the  caa«  is  one  of  OMWtal 
ooDvulsions,   epilepsy,   or  oooruUion   symptomatic   of  (jrpik 
IcsioQ    of  tlie   braio.     The   cliief  poinU   wUtcli    ougfat  ta  hi 
attended  to  in  order  to  arrive  at  %  probable  dtagnoais  ai«  tk 
age  of  tbe  patieut,  the  state  of  tbc  teiDperature  and  unoe.  iW 
charACter  of  the  convuUions.  aod  the  previooa  health  im»i 
the  iutenraU  botwecu  tbe  attactta. 

Eclampsia  is  tnait  frequeally  observed  daring  tbe  6nt  ytaa 
of  life,  and  in  rare  beyond  that  age,  except  aa  the  renbif 
definite  cauaea;  such  as  albnminuria,  and  the  iDTastoo  rf 
cruptire  fever  or  other  acute  diaeaae.  When  the  attacb  •> 
repeated  beyond  two  yean  of  agfe,  at  irre^Iar  ialimk  4 
montha  Of  jmus,  epilepsy  may  be  iDrerrod.  DoJesa  synptiM 
poioUDg  to  a  focal  leaion  of  the  brain  are  preaeDt  Tbe  tMi  4 
the  tcmperatore  \»  tbe  best  guide  in  deddiag  betweea  «mbi 
conviilsioaa  and  tbe  ioitial  couvaUions  of  aout«  diHHM  Bi 
tberinoRieter  being  i]«Arly  normal  in  the  former  and  rioif  tl 
between  103'  F.  and  104°  F.  in  tha  latter.  Tho  uriiw  t^mii 
always  be  examined  for  albumen  in  casee  of  oonvoLmiM  * 
order  In  determine  whether  or  not  the  attack  depend!  apea  dl 
prenence  of  Bright's  disease. 

If  the  ccoivulaions  are  unilateral  in  character,  or  eoonl^ 
local  spaanu  without  Iom  of  coDAciousnese,  they  ore  likely  tab 
due  to  organic  disease  of  tbe  brain  or  its  mcmbntitcs  &ik 
caees  are  generally  followed  by  some  degree  of  paialyMs  will 
subsequent  cootracturo.  If  tbe  convulsion  be  preoeded  kya 
veil-marked  aura,  if  its  onset  be  marked  by  a  sudden  paliuc  tai 
a  }Herciag  cry,  and  if  the  first  atage  ho  attended,  by  weU<«MU 
tonic  coQtmctious.  the  mouth  covered  by  froLb,  and  tbe  Um^ 
bitten,  the  attaek  ia  oue  of  true  epilepiy.  In  epilefsr  tk 
return  to  health  afier  the  attack  is  rapid  and  perfaci.  aa^  ii 
the  intervals  between  tbe  sererer  poroxyaois  the  patiest  mt 
Buffer  from  attacks  of  petit  mat 

§  96S.  Proffiums, — The  progoosisof  eolampsia  dopeoda^a 
the  character  of  tbe  attacks,  and  the  cauaea  by  which  Ibsyas 
produced. 

¥t«>i;Qfib\,  leij^iAlkn.  t£   ^ioA  oaQTuUiooa,    Uw   proswiw  d 


ECLAMPSIA. 


9S1 


stertor.  cyaaosU,  or  tpasm  of  the  glottix,  and  a  Bnmll  uDcouutable 
pulse  affonl  a  grave  prognoniii,  wbatever  may  be  the  cause  of 
the  attack. 

Eiiscntlal  coavulsionn  nre  only  grave  as  indicating  a  neurotic 
disposition,  atid,  when  the  attacks  lecur  frequenOy,  there  is 
danger  lest  they  dovebp  into  confinncd  vpilepsy. 

CoQvulsioQS  occurring  in  cachectic  infants  and  in  thoeo 
exhausted  by  profuse  diarrbma  are  almost  alvays  the  precurson 
of  death. 

The  ioitial  conruUioDs  of  fever  derive  all  their  significance 
from  the  disease  with  which  tbey  are  astaociatcd.  The  convtit- 
sions  which  occur  in  the  coufbo  of  fevers  always  justify  a  grave 
prognosis. 

The  convnlsiont  of  aapbyxia  are  almost  always  fatal. 
Unemic  convulsions  temiinato  more  frequently  in  recovery 
than  in  death.  If  tbe  infant  survive  tbe  6rst  24  or  36  hours 
he  may  be  regarded  as  safa 


§  969.  Trw.tmerU, — The  moat  obvioas  indication  of  treatment 
is  to  remove  the  cause  of  the  attack,  aud  iu  reflux  convulsiou  the 
removal  uf  tbe  cause  is  often  successful.  If  the  gum  be  tightly 
stretched  over  a  tooth  it  may  be  scarified,  but  the  tooth  should 
be  near  the  surface  and  the  gums  hot  aud  iujlamcd  bufore  this 
liractice  ia  adopted.  If  the  bowels  be  constipated,  and  especially 
if  they  be  tynapaoitic,  an  injecttOD  of  warm  water  is  useful  I 
have  often  seen  tbo  cunvulsions  coa»c  immediately  on  the 
bowels  being  opened  aft«r  an  enema  of  warm  water,  If  the 
convulsions  are  the  result  of  a  smart  attack  of  diarrhcea,  and 
CBpocially  if  the  fontancllcs  are  depressed,  a  small  starch  enema, 
with  half  ft  teaepoonful  of  brandy  and  from  2  to  5  minims  of 
tincture  of  opium,  may  be  administered.  If  there  l>e  grounds 
ff>r  believing  that  the  convulsions  are  caused  by  the  presence  of 
worms,  an  anthelmintic,  and  if  from  the  presence  of  undigested 
food,  a  smart  purgative  should  be  administered.  Predispasing 
causes,  such  as  auiuinia,  iuaufiicient  nourishment,  and  rickeU, 
must  be  removed  by  appmpriate  treatment 

Duriug  lbi}  convulsioD  plenty  of  fresh  air  should  be  admitted 
into  tbe  room,  and  all  articles  of  clothing  should  be  removed 
from  the  neck  and  chest  of  the  iafant.    A  warm  batli  is  often 


»M 


TOXIC,   UTD  7BBBU.B  JLKD 


the  temper&tiire  is  sligbtljr  elerated  ;  aod  the  puU«  is 
large,  soft^  and  dicrotous. 

Tremors  are  alnuys  present,  aod  are  only  ao  aggra< 
a  slighter  degree  of  the  aamo  which  hod  exuted  for ' 
ptevioasl;  (ABstie).     HallucioatiooB  of  special  eciDBe  twv 
tbeir  appearance,  those  of  eight  being  most  commoiL 
patieot  ficea,  especially  at  oight  wbco  about  to  go 
sparks  of  fire  aod  fiostiog  bodies;  but  kk>d  distiDct 
especially  those  productive  of  disgust  or  terror,  are 
broad  daylight     The  patient  sees  binweirKorroaDdad 
snakes,  rata,  and  monsters  of  variable  shape,  and 
pursuing  him  with  throateniDg  giwtaros.    Ha  tallu  ii 
in  an  incoherent  and  rambling  maQner.  and  looks  su 
under  the  bed,  and  in  every  comer  of  tbe  room,  to  i 
that  none  of  the  imaginary  beings  by  which  be  fancii 
■arroandcd  are  lodging  there.     His  Actions,  indf><<d, 
be   lai^ly  determined   by   tbe    Dalure  of  bis  baU 
At  times  he  will  busy  himnelf  in  endeavouring  to  oatdi 
iosectc  which  crawl  over  his  bed.  or  he  will  get  up  aod 
everywhere  for  something  which  has  disappeared  in  a 
of  the  room;  while  at  other  times  he  will  dodge  aixMit  ia 
to  avert  a  threatened  blow,  or  endeavour  to  mo  or 
abject  terror  behind  ao  article  of  furniture,  in  order 
from  some  pursuing  foe.    The   prevailing   mental 
during  the  attack  u  ooe  of  terror  and  cowardice,  oIi 
patient  may  occadonikUy  turn  upon  his  atteodaot  to  the 
that  the  latter  is  plotting  against  bim,  or  is  about  to  inflict 
him  some  bodily  injury. 

As  a  rule,  the  patient  is  very  tncUbIc  to  bis  meitietl 
dant,  and  gives  ready  obedience  to  his  oommacds  d 
▼isit;  but  he  is  not  unricquontly  violent  towards  hti 
and  especially  to  bis  wife. 

At  the  end  of  tliree  or  four  days,  or  at  moat  a  wwk 
commenccmcDt,  tbe  patient,  vben  the  attack  is  about  to 
note  favourably,  falls  into  a  quiet  sloop  and  awaka 
and  calm.     Some  cases,  especially  if  the  patient  have 
■ufferad  from  repeated  attaokik  terminate  fatally  by 
BsUieuia.     In  fatal  cases  tbe  temperature  rise*  to  1 
104"  K;  the  pulse  is  extremely  rapid  and  feeblo;  tb« 


POST-KfiBKILE  NEllVOCS  DISORDERS. 


909 


become  general,  aad  associated  with  Bubeultas  teodluum ; 
epileptic  couvuliiious,  followed  by  coma,  may  supervene  and 
prove  fatal,  or  bed-sores  appear  and  the  patient  dies  exhausted. 
Death  is  Qot  unfrcquontly  caused  b;  an  intercurreat  attack  of 
pneumoiiia,  or  some  otUer  acute  disease. 

§  971.  Alcoholic  ParapUffia. — Dr.  Wilkg  has  drawn  atten- 
tion to  a  condition  of  partial  paraplegia  associated  with 
anffistbesia,  or  pains  in  the  limbs,  which  is  liable  to  occur  in 
peraoua,  especially  womeu,  who  have  indulged  iu  alcoholic 
excess.  Chronic  painti  in  the  limbs  may  be  complained  of  long 
before  the  ftymptoms  of  paralysis  appear,  or  there  inay  be  a 
certain  degree  of  laotur  iDco-onlination.  The  immoderate  use 
of  chloral  hydrate  may  occasion  chronic  pains  in  the  limbs 
(Aostie),  and  a  distreiuiiig  caite  came  under  my  own  obsenratJou 
in  which  the  same  symptoms  were  caused  by  the  prolonged 
and  intemperate  use  of  cblonxlyno.  The  pains  in  the  limbs 
disappeared  rapidly  when  the  drug  was  discontinued. 

§  972.  Ti'catment. — The  patient  should  bo  placed  in  a  dork 
mom,  and  the  utmoRl  quiet  enjoined.  He  should  be  constantly 
watched  by  one  or  two  trustworthy  att^ndautfi.  and  the  use  of 
mechanical  moans  to  rcAtrnlu  his  niovemf;nt»  ehuuld  if  possible 
be  avoided.  Nutriment  should  be  frequently  administered  Id 
the  form  of  beef-tea,  soups,  milk,  and  eggs.  A  full  dose  of 
chloral,  either  alone  or  combined  with  bromide  of  potassium, 
may  be  given  at  once,  and  emaller  doses  repeated  at  stated 
intervaJs.  If  sleep  be  not  procuretl  on  the  second  night,  a  full 
dose  of  opium  or  morphia  may  be  administered  on  the  third  and 
subsequent  evening^  at  the  usual  bed  time.  According  to  my 
experience,  opium  acts  better  when  given  after  chloml  has  been 
used  than  at  the  outbreak  of  Ihe  symptoms.  If  symptoms  of 
asthenia  he  present,  it  may  be  necessary  to  give  a  certain  amount 
of  the  alcoholic  stimulus  to  which  the  patient  has  been  aocus- 
tomed ;  but,  as  a  rule,  alcohol  should  be  wholly  forbidden. 

(n.l    aATUBNINE    NBIIV0U3   DI3KA3E9. 
§  073.  It  is  impossible  to  enter  into  a  full  discussion  of  all 
the  deleterious  effects  produced  by  the  prolonged  introductiOD 


956 


TOXIC  AND  FE&IULB  AXO 


of  small  qaaatitjes  of  lead  into  the  lyRtem;  it  most  wSMt* 
mentioQ  a  few  of  tbe  leading  aenrotu  afifecttoDS  caused  b;  tUi 
poiBon. 

Chronic  lead-poisoaiog  at  one  time  fneqaently  resoltcd 
the  uM  of  drink  iog-water  stored  in  leiiden  otteroa  or  ooan|«d 
through  leadeo  pipes,  but  thU  seldom  happens  now.  hmi- 
poisoiUDg  is  most  frequently  met  with  atnong^tt  patnten,  mi 
workmen  punuing  various  trades  in  which  lead  t<  ii»tsl.  Tin 
poiwm  may  enter  the  system  by  being  swallowed  along  wtk 
the  Faliva,  through  the  lungs  by  fine  parttcloe  of  tlic  eai 
b«ing  diffused  ia  the  air,  or  through  tlie  iducoub  memboHdl 
the  Doae  hy  the  adulteration  uf  snuff  with  red  lead  (WtsUiV 
Some  individuals  are  much  more  susceptible  to  the  mtiH»4 
lead  than  others ;  and,  as  was  first  suggested  fay  Dr.  Otmd. 
those  who  inherit  a  predispofiition  to  gout  appear  to  he  ptfti- 
eulariy  liable  to  become  poisoned  by  lead. 

§  971  Symptom$.'~0ti6  of  the  most  valuable  iDdtcatioMW 
the  presence  of  lead  in  the  system  is  afforded  by  tbe  focmtMi 
of  a  blue  line  along  the  edges  of  the  gums  immediately  t^m^ 
iag  the  teeth.  The  blue  line,  although  situated  in  tfa*  n^ 
stance  of  the  gums,  appears  to  be  produced  by  the  fomatiMif 
a  sulphide,  the  latter  being  formed  by  sulphuretted  bydmgK 
emitted  from  decomposing  matters  on  the  teetli. 

Sensory  Ditturbarux, — Pbenomeoa  of  sensory  irritatioB  mtf 
be  manifested  in  the  form  of  hypersMtfaeaia  of  the  niparfdil 
and  neuralgia  of  the  deeper  parta  Romntlial  state*  till 
cutaneous  hypersratheaia  ofien  accompanies  paroxysms  of  pM 
and  that  it  may  alternate  with  ansstheaia.  ArthTtjJgut^preitJi^ 
of  a  neuralgic  character,  is  a  promineot  ayraptom  of  cfan^ 
lesd-puisoning.  The  pains  in  the  joints  occur  ia  pajuijMK 
and  may  appear  in  the  upper  or  lower  eztremtttca,  or  is  thi 
jaw&  Lead  eoUo,  probably  also  of  neuralgic  origin,  is  osttf 
the  most  frequent  and  important  symptoms  Tbe  paim  mi 
chiefly  rt-ffrrcd  to  the  umbilical  r^ion;  they  are  QaUfett 
paroxysmal  exacerbations  of  great  severity,  altboogh  a  ««^ 
derable  degree  of  uneasiness  or  pain  remains  daring  tbe  bur 
vala  (§  334). 

CMVxn«o'«%  wiux^Umi^  \ft,  V•^-«(%<a«,T^  taach  more  (maaittf 


POST-FEBRILE  NERVOUS   DISORDERS. 


967 


observed  than  hypeisealbesU,  and  ia,  acoordiog  to  Beau,  one  of 
tbe  most  characteristic  sjmptomB  of  chronic  lead-poisoniDg.  It 
is  variable  in  itn  diatributtoo,  and  may  bo  complete  or  iccom- 
plcte.  Tactile  aofe^tbesia  is  often  associated  with  motor  para- 
lyais,  colic,  or  arthralgia.  It  is  most  frequently  situated  on  tbe 
skin  of  tbo  backs  of  the  hands  aod  forcarRiit,  the  external 
surface  of  tbe  calves,  and  tbe  abdomen  and  cbest,  tbe  skin  over 
the  epigastrium,  however,  rem&iniag  always  free  (Bean).  Loas 
of  feeling  sometinaes  extends  to  the  veil  of  the  palate  and  uvula. 
In  other  cases  analgesia,  therrno*  anaesthesia,  and  loss  of  the 
senaibibty  to  tickling  may  be  present,  vbiie  tactile  sensibility 
Hmains  unimpaired.  Tbe  electric  senaibility  is  often  lost 
(Raymond).  Tbe  aneBStbesia  i>  often  tranaitory,  and,  acconltiig 
to  Renaut,  is  sometimes  caused  by  cutaneous  auxmia,  and  may 
be  made  to  disappear  by  rubefaciants  and  profuse  diaphoresis. 

Deafness,  according  to  Tanqucrol,  frcc|iieDtly  follows  an  attack 
of  aithralgia,  aud  diiuiuutioQ  of  taste  on  half  the  tongue,  and 
of  smell  in  one  nontril,  has  been  observed.  But  tbe  affections 
of  sight  uj-e  more  frequent  and  important  than  those  of  ttie 
other  tipecial  senses.  These  consist  of  traository  amblyopia 
without  ophthalmoscopic  changes  ;  pcnistent  amblyopia  pojtsing 
on  to  amaurosis  of  botb  eyes  and  rarely  of  one  only,  attended 
by  atrophy  of  the  optic  nerve;  amblyopia  with  double  optic 
neuritis;  and  amblyopia  with  albumiaiuic  retinitis,  in  asso- 
ciation with  granular  kidneya 

Motor  DieluTlaiuxs. — Motor  are  more  commonly  observed 
than  sensory  disorders  in  lead-poieoning.  Almost  all  the 
mosctos  of  the  body  may  be  affected,  although  certain  groups 
are  attacked  by  preference.  In  partial  paralysis  the  extensor 
muscles  of  tbe  forearm  are  more  frequently  affected  than  any 
Other  group ;  and  consequently  when  the  arms  are  held  out 
horizontally,  with  the  hand  in  a  state  of  pronation,  tbe  hand  is 
flexed  at  tbe  wrist  and  cannot  be  extended,  thia  condition  being 
tcchoically  called  vrrist-drop.  The  common  extensors  of  tbe 
fingers  are  Urst  attacked,  then  tbe  extoosors  of  the  index  and 
little  6ngcrs,  and  lastly,  in  succession,  the  extensor  secuudi 
interaodii  pollicis,  tbe  extensors  of  the  wrist,  the  extensor  primi 
intemodii  [ralUcis,  and  tbe  extennor  ositis  metacarpi  pollicis.  The 
sapinatoi  toogtu  is  spared  until  a  comparatively  late  period  of 


^Sl 


m 


958  TOXIC,  AND  fsbril: 

tho  disease,  and  U  never  affected,  dl 

tbe  pftralyns  extend  to  tbo  muscles  of 

times  the  ptiralysiB  begins  in  tbe  muscl 

then  tbe  deltoid,  biceps,  ooraco-brsohi| 

are  aflfected  (the  upper  arm  type  of  BM 

muscles  of  the  toferior  extremities  u 

muscles  of  tbe  leg  are  generally  the  &n 

tibialiit  aoticus  is  often  spared  under 

some  cases  all  tbu  muscles  of  both  upp 

are  paralyaed,  and  on  rare  occanioos  tl 

and  back,  thotse  of  pbonatbn  and  speed: 

and  even  the  diaphragm  bare  bceo  a 

remain  always  unaSectod  in  the  pan 

of  tbe  muaclee  of  the  glottis  has  been  o 

borios  employed  in  red- lead  factories. 

undergo  rapid  atrophy,  and  loae  their  fa 

voluntary  power  is  completely  abolishi 

degoneratioo  appears  ia  them  at  an  aai 

The  duration  of  lead  paraiysis  is  ve 

for  a  period  of  weelt!),  months,  or  yaai 

colic  are  liable  to  recur  on  renewed  tctf 

Trenior  is  somctim&s  observed  in  Ie« 

limited    to   the  upper  extremities  m 

may  extend  so  as  to  become  gener«fl 

occasionally  been  obsenred,  and  are  gi 

amesthesia  (lUymond).     The  patients 

from   chronic  dyspepsia  and   oocasioni 

there   is   pronounced  aD»::mia ;    the  ar 

degenerations;  and  chronic  Bright'^  dis 

effects   on   lixo   mechanism   of   tbe  eu 

obeervod.     It  is  scarcely  necessary  to* 

which  is  apt  to  occur  from  rupturft^ 

under  these  circaautaocee;  must  bai| 

lead  paralysis.    Women  poisoned  by  lea 

disorders  and  profound  atuemta,  and.  ii 

frequently  abort  or  have  stillborn  child 

and  opilepay  appear  to  be  frequently 

children  of  wi>rlter«  in  lead.     Im 

adranced  cases. 


PgycJiicfd  Dinturbancea, — Before  the  oatbreak  of  pronouQced 
cerebral  eynaptoms  the  patient  oftea  auffera  from  headaclie, 
vertigo,  au<i  drowBioess  during  the  day  and  sleepleaaucas  at 
Dight ;  or  tbcre  may  bo  a  state  of  agitatioD  or  complete  apatlty. 
Cerebral  disturbaace  sotnetimea  aseumes  the  form  of  quiet 
dolirium,  accompanied  by  halhicinntionn  of  sight  aad  Kcariog, 
or  on  the  other  baud  Ibe  delirium  may  be  furious.  But  the 
most  common  cerebral  disturbanoe  is  convul^ons.  Sometimes 
tbe  lo«8  of  consciousnoas  is  not  complete  and  the  convulsions 
may  be  partial,  and  limited  to  the  muscles  of  the  face  and  of 
_  ODO  or  more  limbs;  or  they  may  bo  general  and  roprosoDtod  by 
womeral  trembling  of  the  body.  At  other  timee  tbe  attack 
BHtume;!  the  form  of  eclampHia.  'fbeiie  conTuUlons  are  gene* 
rally  followed  by  a  prolonged  stage  of  uncooaciousnesB,  with 
iCertorou!!  breathing.  The  patient  may  be  comatose  after  a  first 
attack,  or  after  a  succeaxioD  of  attacka  quickly  following  each 
other,  and  separated  iu  aome  cases  by  intervals,  during  which 
there  is  furious  delirium.  Tbe  patient  generally  rc-corert  from 
the  first  attack,  bat  is  liable  to  die  in  subsequent  att-acka. 
Apoplectiform  attacks  may  oocur  in  the  later  titagu  of  lead 
paralysis,  and  are  accompanied  by  paralysis  of  variable  distrt- 
butlM) ;  ioaemuch  as  the  patient  often  recovers  motor  power 
quickly,  tbcso  attacks  caaaot  always  be  due  to  haemorrhage. 


§  975.  ^orHd  Anatomy. — The  moTbid  anatomy  of  lead- 
poisoniog  has  boon  studied  by  Lanceraux.  Gombault  and 
Charcot,  Westpbal,  Vulpian  and  Kaymoud,  Erb,  and  many 
others  ;  n  careful  papor  on  the  aubject,  by  Dr.  S.  Moritz,  of 
ilanchcster,  has  recently  appeared  in  the  "  Journal  of  Anatomy 
and  PbysioLojty."  The  microscopical  changee  observed  in  the 
musolca  are  more  or  le^a  similar  to  those  already  described 
as  occurring  in  progressive  muscular  atrophy  (§  41+).  lie 
naoBt  important  cbangea  observed  have  beeu  in  the  intra' 
mascular  nerve  libre:i.  The  connective  tissue  is  thickened,  the 
sheath  of  the  primitive  fibres  is  also  thickened,  the  nuclei  are 
lai^ely  developed  between  them ;  the  axis- cylinders  are  some- 
times distinctly  visible,  and  at  other  times  apparently  disappear 
(Moritz).  The  nerves,  upocially  the  mu»culo- spiral,  have  beeo 
foaod  altered  in  various  degrees.    Kussmau  I  and  Meyer  observed 


TOXIC,   JUfD  FEBRILE  AND 


sclerosis  of  the  caBtiac  and  upper  cervical  ganglia,  with 
ration  of  the  connective  tis&ua  and  defonniiy  of  tba  ctlW 
Valpian  observed  vitreoiu  dcigeneratioa  aad  atrophy  of  tht 
ganglion  cells  of  the  anterior  horns  of  iba  spinal  oord,  aod  u 
similar  observation   has   recently  been  ouuta   bjr   Moaak— . 
Other  Abserrera  have  failed  to  detect  any  diangoa 
spinal  oord. 

§  076.  Morbid  PAyswrfosry.— There  can  be  little  doubt  tij 
as  6rst  tiuggexted  by  Duchenne,  the  muHcular  dineaae  i| 
paralysis   is  Hecondary  to  oerronB   changea     Soma 
believe  that  the  disease  beginii  in  the  intra-moacali 
fibnsB ;  while  others  believe  that  the  primary  disease  is 
in  the  ganglion  colls  of  the  spinal  cord.     It  ia  at  leant 
that  the  muscles  are  affected  in  groupa  according  as  tbey : 
OBsocialed  in  their  aclioos,  and  not  aooordiiiK  to  the  distnlntida 
of  a  particular  nerve,  such  aa  the  maseulo-Bpirai.    Thu  modad, 
invasion  corresponds  to  what  ocean  in  infantile  paralyus 
progressive  muscalar  atrophy,  both  of  tbom  spinal 
aod  diffets  from  that  of  paralysis  of  peripheral  origin. 
consideratioQs'tond  to  show  that  the  parolytis  is  probahtj 
spinal  origin  (Remak). 

§  977.  Diagno»i»  and  Prognosis.—  Saturnine 
generally  easily  reeogoiaed  by  the  knowledge  of  th« 
of  the  patient  and  the  presence  of  a  blue  line  oo  tb» 
The  prognosis  ia  at  first  favourable,  but  if  colic  have  frequaoUy 
recurred,  or  paralysis  have  existed  for  a  long  time^  aod  tbtn  ba 
much  muscular  wasting  and  cacbezia,  it  become*  ^OMsy. 
especially  when  the  patient  remains  exposed  to  the  poison. 


§  978.  TVeotment.— Patienta  whose  oocnpa^oDs  ezpoan 
to  poiflODing  by  lead  should  if  possible  seek  otbcr  empkgn 
If  this  bo  not  possible,  the  patient  ought  to  be  i 
observe  great  personal  cleanliness,  to  wash  the  teeth 
to  rinse  the  mouth  &cquently  with  cold  water, 
lemonade  made  with  sulphuric  acid  is  said  to  prevoit 
poisoning  by  converting  the  carbonate  of  lead  in  tb* 
into  ao  insoluble  sulphate.    The  most  important 


POST-FEBRILE  KtHVOUS  DlSoaDKlW, 


961 


for  procuriDK  elimiimtiou  of  tbe  poisoa  appears  to  1m  the 
internal  adinioiatratioa  of  iodide  of  potassium,  which  is  said  to 
jjpftnvert  the  insoluble  salts  of  lead  deposited  io  the  tlBsues  ioto 
k  aolabic  double  salt,  capable  of  being  removed.  The  warm 
batb  may  be  used  as  aD  adjunct  io  treatment ;  no  benefit 
HpiWwni  to  result  from  tbe  addilion  of  a  soluble  sulphide  to 
^M  wat«r. 

Lead  colic  must  be  treated  on  the  same  geueral  principles  as 
other  forms  of  colic  with  conslipation  (§  336).  The  paralysed 
muscles  must  be  subjected  to  electrical  treatment. 

(IIIJ   UEBCUBIAL13M. 

§  979.  Chronic  mercurial  poisoning  may  be  due  to  tbe 
alnorplion  of  mercurial  preparatious  through  the  skin  or  mucous 
membraue,  or  to  tbe  inhalation  of  tbe  vapour  of  mercury.  The 
workmen  engaged  in  quiuksilver  mines,  and  in  trades  iu  which 
mercury  is  employed,  such  as  that  of  gilders  and  looking-glass 
makers,  are  liable  to  be  affecteil  by  it 


§  QUO.  Sifviptwia. — The  symptoms  of  chronic  poisoning  by 
mercury  often  begin  by  sHght  numbness  in  tbe  bands  or  feet' 
and  occasional  neuralgic  pains  in  certain  joints,  especially  those 
of  the  thumbs,  elbows,  feet,  and  knees.  These  sensory  dis- 
turbfinces  are  nccompanied  or  sooa  followed  by  slight  tremor, 
which  may  for  some  time  remain  limited  to  the  hands  and  arms, 
The  tremor,  like  that  of  disseminated  sclerosis,  only  reveals  itself 
■lien  the  patient  makes  a  voluntary  effort ;  but  at  an  advanced 
period  of  the  disease  it  persiatB  during  repose,  and  may  even 
continue  duriog  sleep.  The  tremor  gradually  becomes  more 
pronounced,  and  extends  to  all  parts  of  the  muticutar  system. 
The  lower  extremities  tremble,  especially  at  the  knees,  when 
the  patient  standn  or  walks,  and  the  patient  is  incapable  of 
performing  any  delicate  manipulations,  while  in  aggravated 
cases  he  may  be  unable  to  carry  a  glass  of  water  to  bin  mouth, 
as  in  disseminated  sclerosis  The  head  and  neck  are  main- 
taised  in  a  state  of  con&taut  oscillatory  movement  when  the 
patient  is  in  the  erect  posture;  the  lips  are  tremulous;  tbe 
utterance  becomes  broken  and  indistinct;  mastication  is 
JJJ 


TOXIC,  AND   rRBRILR   JkKD 


reuUered  difiicuU ;  and  «reD  tcspiratioa  becomes  u 
.lalNured.  The  musclee  of  the  ejeballs  arc  aiud  D«iec 
affcctfld  in  mercurial  powoninp,  a  fact  of  grreat  imj 
dinttnguitibiDg  it  from  cerebru-tjpioa]  multiple  sclenxii. 
ciilar  weaknesa  U  asaociat«d  with  tlie  tremor,  but  «ltHia4 
panlfsis  does  not  occur,  and  there  is  do  lots  of  mhbImi 
WhoB  the  tremors  attain  great  iiit«uaitj,  they  pcniit  iNraf 
repoti^  and  render  the  patient  reatlest  and  aleaplen  at  oi^ti 
the  appetite  fails ;  the  pulse,  alroog  aud  alow  at  fint, 
small,  feeble,  and  firequeac;  while  the  patieot 
emaciated,  aod  aaaumes  a  cachectic  appearaoo&  Id 
advanced  stage  of  the  diseaae  aerioos  cerebral  Bymptoma  i 
Tenc,  such  as  constant  headache,  steuplessaesi,  lo«  of 
epilepsy,  and  coma. 

§  9SL.  Treatment— The  patient  must  6nt  of  all  be 
from  the  inOueQce  of  mercury,  whatever  be  the  waj  is 
be  may  be  exposed  to  it.  Iodide  of  potasdum  may  bo  admiais- 
t«red  with  the  view  of  converting  the  mercurial  ooinpcNuid 
already  ia  the  syglom  into  a  soluble  double  aalL  The  aflactad 
QiUKcles  are  to  be  subjected  to  local  treatment  by  galranisiB. 


IT.)    STPBIUS  OF  TUB   N*EBTOU$  ST9TK1L 

It  has  been  abundantly  shown  in  the  courae  of  Mm  * 
ByphiliK  may  bo  a  cause  of  almost  all  the  or^aoio 
which  the  peripheral  iienrea,  spina)  cord,  and  brain  are  [iaUa 
Syphilis,  indeed,  as  Mr.  Jooathan  Hutcliiaiion  remarks,  minia 
nearly  all  the  organic  diseases  of  the  nervous  system,  as  w«fl 
as  tboee  of  other  orgaoa.  Instead,  therefore,  of  attamptiag 
to  write  a  detailed  description  of  the  numerooH  tnanifeataWM 
of  syphilis  of  the  nervous  aystem,  it  will  suffice  here  if  «l 
recapitulate  briefly  the  anatomical  alterations  produced  by  tkt 
action  of  the  poison,  bring  into  promuience  the  obtif  paiati 
wliicb  must  be  attended  to  in  recogniaiiig  its  praniuot, 
make  a  few  reakatks  on  treatment. 

§  982.  Morbid  >l7w/ofBy.— Syphilis  of  the  nenwu 
usually  boloDgs  to  the  later  secondary  or  to  the  tocttai; 


PUST-FeBllILG  NKftVOUS  DISOltOKItS. 


B6S 


featatioiiB  of  tUc  diseaae,  altliuugb  in  rtu-e  ciiaeit  it  mAy  appear 
in  tbe  first  few  months,  or  the  year  following  infecLton.  Syphi- 
litic growlhR  are  sometimes  developed  in  the  nervous  syRt«ni  a» 
many  tm  twenty  or  even  lliirly  yearn  after  the  primary  iufeclion. 
Syphilis  of  tbe  aervuus  Hystem  occurs  with  greatest  j'rec^uency 
ill  middle  age.  AfTectioDs  of  the  nervou»  system  not  unfre- 
ijuently  occur  during  the  first  fow  years  of  life  as  the  result  of 
the  cuDgCDital  diMiaiie. 

SypLUitic  lesions  may  be  subdivided  into :  (1)  Primary,  or 
thoHe  which  are  directly  due  to  the  action  of  syphilis  ;  and  (2) 
Secondary  lesiuuH,  or  tiiottu  wbicli  are  iadiruct  and  remotu  oon- 
aoqucuccs  of  it> 


(It  Pbiuibt  Stphilitio  Luiom. 

(a)  Diveate  of  tiu  Bones  and  Periosteuvi. — Syphilitic  exos- 
toses, periostitis,  osicittii,  and  caries  of  bones  in  the  neighbour- 
hood of  nervous  structures  may  implicate  the  latter  in  disease. 
In  this  manner  the  peripheral  nerves,  as  they  ^fona  through  bony 
cbaimels,  may  be  compressed  or  otherwise  injured,  the  vertebral 
canal  may  be  narrowed  and  tbe  spinal  curd  pres^>ed  upon,  and 
disease  may  be  set  up  in  the  bmin  and  its  membranes  by 
syphilitic  alfcctions  of  tho  cranial  bonea 

(b)  Fortnatitni  of  Gummata. — These  have  already  been 
described  sufficiently  for  our  purpose  (§  732).  Gumm&ta  may 
grow  in  the  dura  mater  or  pia  mater.  When  a  gumma  grown 
io  the  dura  mater  it  develops  between  iu  two  layera  and 
becomes  encapsulated.  When  it  is  developed  in  the  subarach- 
Qoid  space  all  the  surrounding  tiseuos,  iucluditig  the  membranes, 
the  blood-vcaaela  and  nerveft  which  traverse  the  itpaoo,  and  the 
subatanco  of  the  brain  itself,  are  involved  in  the  lesion.  The 
nuyority  of  cerebral  gummatn  originate  from  the  subarachnoid 
space  and  pia  mater,  and  grow  towards  tbe  substance  of  the 
bmin.  If  tbe  growth  be  situated  on  the  convexity  and  lateral 
sarfaees  of  the  hemispheres,  the  dura  mater  becomes  so  closely 
adherent  to  the  cortex  that  tbe  former  cannot  bo  tteparateJ 
without  producing  [aceration  of  the  latter.  If  it  be  situated 
at  the  base  of  the  brain  the  dura  mater  is  lei«  frecjuently 
implicated,  and  the  new  growth  then  usually  fills  tbe  xpaces 
around  tbe  chiasma  and    infundibutum,  the  iuterpeduucuUr 


964 


TOXIC,   A8D   FElUtlLB  AKD 


space,  and  tho  spaces  at  the  aoterior  and  posterior 
the  pons. 

Qummata  may  also  grow  between  tfae  layers  of  tb«  dvi 
mater  or  in  the  subaracbooid  space  in  the  Teriebnl  cackl 
The  membniaes  become  adherent  to  oaa  anoiher,  aod  ik 
Rpinal  cord  is  compressed  and  giudnallj  destrojmi  ml  iht  Iml 
of  the  growth. 

The  peripheral  uerve«  may  also  be  a&cted  bj  a  gamm 
situated  in  their  neighbourhood,  or  by  the  extennoo  d  tin 
infiltratioD  into  the  substance  of  the  nerve  Tfae  cranial  aoiM 
are  most  coiumuuly  implicated  at  their  pointa  of  origtSi 
before  they  become  covered  by  a  prolong&iion  of  the 
mater. 

(c)  Sypiulilio    In^rattan. — The   gammatouii    fo 
aomettnies  forms  a  diffnaed  infiltnitioa  in  the  subetjuiae' 
nervous  tissues  instead  of  forming  circumscribed  tumi 
layer  of  gummatous  tissue  may  in  thin  manner  be  formed  Ull 
pia  mater  on  the  surface  of  the  coorolutions  of  the  braiiL 

{d)  StfphU'Uh  ScUront, — It  is  very  probable  that  sypbiliM 
sclerosis  is  always  preceded  by  an  infiltraUoa  of  the  Mrrm 
litsuea  by  young  oells  similar  to  those  obsenr etl  in  the  jninii 
toufi  intiltintions.  These  cells  become  inBltrmtttd  aroond  thi 
vessels  and  iu  the  coDuective  tissue  septa  and  Deangli».a0l 
subsoqueutly  undergo  partial  organisation  and  cicatricial  Mfr 
troctioD.  This  process  leads  to  the  gradual  dtjstruetsoo  of  Iki 
□erve  elements,  just  as  occurs  in  ordinary  chronic  ioiMstilaJ 
inflammation  of  the  brain,  spinal  cord,  and  peripheral  nerna 

(fl)  SyphiUiic  Adhesion  and  Opacities. — When  tb«  osUiilil 
infittratton  occurti  In  the  membranes  aud  subaeqavottj 
goes  organisation  and  retraction. a  fibroid  tissne  is  formad' 
renders  the  portion  affected  dense,  opaqoe,  and  inelaatic; 
siona  form  belwoen  the  dum  mater  and  pin  mater,  and  betl 
the  latter  aud  the  cortex  of  the  brnin  or  tbe  sutfaoe 
spinal  cord.     Wheu  the  membmuea  orer  the  base  o(  tbe 
and  brain  uru  affected,  the  cranial  oerres  may  be 
by  cicatricial  tissue.     When  the  pia  mater  becomes  todt 
the  calibre  of  the  reaels  supplied  to  tbo  cortex  of  the 
liable  to  be  diminisbod,  and  the  nerroos  tismes  are  tboi  ii 
fectly  supplied  with  nourishment. 


POST-FEBBILE   KBRTOITS  DISOKDBBa 


969 


if)  SypfiUitxc  Periarteritei  and  EndarterUe6.~lt  ie  prolabl© 
that  the  advtiutitia  i>f  tlio  smaller  arteries  aro  implicated  to  a 
gT6at«r  or  lesser  extent  iu  all  the  sypbUitic  procceses  which 
have  heea  described.  Medium  sized  vessels  may  sometimes 
bo  8urroundc<l  by  cooccntric  layers  of  gummatous  tissue,  which 
ultimately  compress  them  ao  as  to  cause  their  partial  oblite- 
ration, A  gumma  may,  like  any  other  tumour,  during  its 
growth  couipro&s  anil  obliterate  both  artorieA  and  voins  la  its 
neighbourhood.  But  the  walls  of  the  arteries  are  liable  to  he 
affected  in  syphilis  Id  a  much  more  direct  iitnnner  than  by 
any  of  the  processes  just  described.  The  subataucB  of  the 
walls  may  be  infiltrated  with  cells,  and  these  may  undergo 
partial  organisation  and  cicatricial  retraction,  or  form  gumma- 
tous masses.  The  infiltration  may  take  place  chiefly  into  the 
adveatitia  of  tho  vcsael  (poriartcritiH)  or  between  the  inbima 
and  endothelium  (endarteritis),  but  it  is  probable  that  in  most 
cases  all  the  coats  aru  more  or  less  infiltrated.  When  the 
cellular  inliUration  in  diffused  throughout  all  the  coats  of  the 
ve»el  and  undergoes  partial  orgaaisatioo  and  cicatricial  re- 
traction, the  walls  of  the  atleoted  artery  become  iuelastic  and 
bnttle,  while  its  calibre  is  uniformly  reduced  in  size.  When, 
on  the  other  band,  the  laBltration  is  more  limited,  hard  cir- 
cunascribed  spots  may  be  found,  which  project  from  the  ex- 
teroal  or  internal  surfaces  of  the  voasel,  distorting  it  in  various 
waye.  It  would  appear  that  distinct  gummata  may  form  in 
the  wal!^  of  arteries,  and  either  project  from  its  external  surface 
or  into  its  ttimon,  and  in  the  latter  case  may  cither  obstruct 
the  resHel  completely  or  be  washed  otV  to  bo  arrested  as  an 
embolus  in  oae  of  the  smaller  hranehes. 


(2|  Sbcqsdabt  STrnn-rno  Iduiox^ 

Thp  processes  which  result  indirectly  from  syphilis  are — 
(a)  InfUtnimation ;  {i)  Partial  isoftesmia,  with  necrotic 
aofteninrf. 

{a)  InJIammaticn. — Syphilitic  diseaaes  of  tlic  bones  of  the 
cranium  may  set  up  suppurative  arachnitis  (Wi)ks  and  Moxon), 
but  the  purulent  affection  is  of  itaelf  not  a  syphilitic  lesion. 
Syphilitic  guuunata  act  like  foreign  bodies  on  the  surrounding 
tissues,  and  conse«iucntly  the  mcmhraDes  in  its  neigbbourfaood 


d66 


TOXIC,  AND   FEBRILE   &K0 


n 


ure  UBuallj  thickened  ftntl  adherent,  while  the  cerebral 
sarrouHdiQg  it  13  maiDtaioed  in  a  state  of  iiritation.     It  it  | 
bahlfi  that  the  thickened  layer  by  which  a  ffumma  if  Bornvtinar' 
encrusted  is  formed  by  partial  organisaiion  of  JaStvimaUtj 
prodiicca  in  the   tJsauea  immediately  aiijmniag   tbo  lyphiliDe 
tissue.     Some  cn^es  reported  appear  to  show  that  the  fotmam 
of  a  gumma  ou  the  surrace  of  the  braio  may  act  op  as 
attack  of  meningo-encephalitis  (Gamel).   Acute  msoendiiigi 
panttjm  is  liable  to  oocnr  in  syphilitic  sabjecta,  but  ia 
cases  it  ia  difEciilt  to  determioe  whether  or  not  th«  IflMflO 
primary  or  secoodary  result  of  the  ifiyphilitic  potaoo. 

When  ODce  a  sclerosis  of  Dervous  tissues  is  set  gp  fcy  > 
syphilitic  lesion,  it  is  probable  that  the  process  may  BaKaHs 
progressive  character  indepeodently  of  the  syphilitic  poiaoa. 

(6)  Pariial  lacheemia  end  SecroHc  Softening. — When  a 
portion  of  the  pia  mater  undRrgoes  libroid  thickcoiag  a 
syphilis,  the  calibre  of  the  veeseU  which  pass  through  it  to 
Qoarish  the  subjacent  nervous  tissues  is  reduced  to  sin^  ml 
these  tieaues  sutfer  from  anffimia.  As  the  Bbroid  thi<A«itH 
is  probably  always  local  in  syphilis,  the  resulting  aucaia  ■ 
also  local.  Uuch  more  important,  however,  in  the  aMHUt 
caused  by  obliteratiou  of  vcasels.  Obliteration  of  Uie  tomIi 
may  occur  in  several  ways ;  but  ooctusioo  of  no  mrtery  by  ih* 
formation  of  a  thrombus  at  a  point  where  its  inner  mobm 
has  been  rendered  uneven  and  its  calibre  diminished  is  by  br 
the  moat  oommon  and  important  of  these.  Oblttt>raliiMi  of  aa 
artery,  in  whatever  way  it  may  be  brought  about,  i^  foUow^ 
by  partial  ischfflinia,  and  local  softening  in  Ihoae  portions 
brain  where  the  terminal  arteries  do  not  anastomose  with  i 
RDothcr. 

SiiKudton  and  Mode  of  Duitnbution  of  Byphiiitic 
From  what  has  already  been  said  it  will  ho  aeen  that  gatni 
as  a  rule  form  iu  the  memhraaee  of  the  brain  anj  s[niud  cnei 
It  foltom  that  the  cortex  of  the  brain  and  tha  white  colaniBf 
of  the  spinal  cord  are  especially  liable  to  be  afTected  by  gttm- 
luata.  The  favourite  situations  of  guramaia  in  the  hnio  aft 
the  base  and  cortex  of  the  convexity  in  the  region  of  distorg 
bntioo  of  the  middle  and  anterior  cerebral  arteries. 

Sypliilitic  thrombosis,  like  every  other  form  of  ofaati 


POST-FEBRILE  NERVOUS  niHORDERS. 


MT 


of  arteries,  assumes  greater  importADoe  when  it  occurs  iq  the 
art«rie3  of  the  brain  than  in  thoae  of  other  parts  of  the  nerrous 
sjffltem.  Tlie  middle  cerebral  artery  and  ita  branches  are 
particularly  liable  to  becorae  occluded  in  syphilis,  lieoce  the 
frequeDcy  with  which  Uemiplegia  with  or  without  aphasia 
occurs  in  Kyphilitic  Rubjecta 

Ounimatous  growtb,  whether  it  form  a  circuniecribed  tumflur 
or  be  iuflltrated,  ia  usually  more  or  lens  localiKed,  luid  con* 
sequently  gives  rise  to  the  symptoina  cbaracteriatic  of  focal 
diHeasen  of  tbe  braiD. 

Sj'philitic  le»iuUK  are  very  liable  to  be  multiple,  or,  in  other 
words,  to  appear  at  diHcrcDl  parU  of  the  nervous  aystem  at  the 
same  time,  so  that  the  nymptomH  produced  are  6ucli  as  those 
reaulting  from  more  than  ouu  focuM  of  discaite.  When  the 
leuous  are  bilateral  they  are  seldom  symmetrically  placed,  they 
otteu  appear  at  difFcront  times,  and  froqucutly  diH'er  in  kind. 
A  syphilitic  lesion  compresHing  u  craoial  nerve  oa  oac  aide  may 
be  aasociated  with  a  gumma  of  the  cortex  of  tbe  opposite  hemi- 
«pbere.but  rarely  with  a  gumma  compressing  the  corresponding 
aervc  on  the  opposite  aide.  A  aypbilitic  lesion  of  one  of  the 
cranial  nerves  ia  often  associated  with  eypbilitic  thrombosis  of 
cerebral  vessels,  but  these  lesions  usually  appear  at  different 
times,  »o  that  there  ia  a  hislory  of  two  separate  attacks. 


§  9S3.  Diar/noau. — In  some  cases  consLitutiooal  symptomH 
are  so  apparent  that  the  presence  of  syphilis  cnnnot  he  over- 
looked. If  characLeristic  cutaneous  eruptiuus  and  uti!« ration x, 
osHeoua  defects  in  the  nose  and  pnlatt*,  be  present,  the  nature 
of  the  c»8e  can  hardly  remain  in  doubt ;  although  it  muHt  not 
be  foi^'olttn  that  piiraona  who  have  previously  suffered  from 
syphilis  are  alio  liable  to  nervous  diseases  of  noa-syphilittc 
origin.  Nervous  affections,  aa  a  rule,  belong  to  the  later  mani- 
fc«tationB  of  the  diaeaitc,  and  make  their  appearance  long  after 
the  more  prominent  symptoms  of  the  coostilutioDal  disease 
have  ceased  to  exist.  Search  must  then  be  made  for  cicatrices 
on  the  genitals  or  on  the  groins,  round  pigmented  spots  on 
the  (tkin ;  depressed  and  irregular  cicatrices  over  the  forehead 
and  front  of  the  legs  with  the  integument  adhering  to  the  sub- 
jacent bones ;  radiated  cicatrices  on  the  mncous  membranes. 


968 


TOXIC.  AMD  FBBRIXK  JUfI> 


espec'mllf  of  the  mouth ;  circular  deprBMtotu  on  the  trtitm  i 
the  palate  or  tonsils,  which   look  as  if  s  piece  of  linoe  bid 
beoD  punched  oat ;  irregular  prutuberaooM  od  the  •nrfun  af 
the  bouea ;  a  moderate  dR|rree  of,  but  bknl,  swelliDi;  of  Om 
occipital,  cervical,  or  cubital  lymphatic  glands;  and  enlargvaHal 
aud  knobby  induration  or  atrophy  of  one  testicle.     An  aifintj 
into  the  history  of  a  case  may  throw  great  light  upon  iu  oaliM. 
If  the  patient  be  a  man,  it  may  be  atiked  whether  he  hafctv     i 
suffered  from  syphilitic  infection.     In  the  caae  of  a  maniiJ  J 
womhn,  valuable  iuformatiou  may  be  obtoioed  by  asoertaiaiii^l 
whether  or  not  she  has  had  miscarriages,  if  aocne  of  her  dtSdlf^^ 
were  still<born  or  died  soon  after  birth,  or  whether  th«y  naai- 
feat  any  of  the  oharactoristic  jtymptomn  of  ooogtaital  sypMia 

CI)  Syphilitic  lemons  of  the  Peripheml  Aenm. — S^r^Ufitie 
leeioDs  of  peripheral  nerres.  like  all  other  timilar  leai«M,«» 
manifested  by  symptoms  of  irritation,  a»  byp«na•tb■ii^  urn- 
ralgia,  and  epaam ;  followed  by  ^rmptoms  of  JepraHm,  a» 
simple  ansMithcsia,  anceathesia  dolorosa,  or  paralyia  in  tbi 
region  of  distribution  of  the  affected  nerrt*,  the  Rympbmti 
depreanon  being  much  more  important  and  freqoeat  IfaaatlMM 
of  irritation.     Syphilitic  disease  of  the  peripheral  spinal  mttii 
may  oocur ;  hut  the  cranial  nerves  are  inoch  more  fireitiHatly 
affected.    In  Kyphtlilic  disease  of  Iho  motor  Qervea  the  panlyn 
is   mmetimeii   limite<l    to  a   single   muscle;   while   th«  olh« 
muscles   supplied   by  the   same  nerve   remain   unaffected, 
manifent  only  a  nlight  degree  of  weakne«a.    The  oculo-i 
appears  to   be  ibe  most  frequently  affected  of   the 
oorves,  and  piosia  generally   precedes   pHialyiiia  of  tba 
muscles.   When,  therefore.  ptoaJt  is  suddenly  developed  vii 
any  apparent  cause,  syphilis  shoald  be  nupectod    '  It 
be  remembered  that  poralyus  of  one  or  more  of  tba  oeolu 
muscles  ia  liable  to  appear  in  the  e«rly  atage  ol  tocoBWW 
atuy,  and  cum  prtMtating  these  symptoms  abould,  UunliM^ 
be  carefully  oxamined  to  see  whether  or  not  laneinating  patu 
absence  of  the  deep  reflexes,  or  ataxia  bt  proMBt. 

If  double  optic  neuritis,  paroicysmal  vomitbg,  oihI  b«4kdw 
be  present  along  with  (be  paralysis  of  tha  third  nwv«,  the  bltic 
is  caused  by  the  pressure  of  a  tumour  ott  the  Derv?  at  the  base 
of  the  h<«io,  but  even  then  the  tumour  ntay  be  of  arphihtic. 


POST-FEBaiLE  SERTOUS  DISORDKBS.  969 

origin.  Aneutism  of  on«  of  tbo  ftrtcrios  nt  the  base  of  the 
bram  may  gjvo  rise  to  similar  symptoms,  but  it  is  froqiicoily 
sa80cint«d  with  TOgotattoos  oa  the  oardiao  valves  (Ogle,  Church). 
Basilar  meoiDgitis  may  also  paralyse  the  third  oerve;  tlie 
acute  form  of  thia  disease  bears  no  nwemblaace  to  syphilis,  but 
the  chronic  form  of  meningitis  may  be  indislingiiishahle  from 
it,  except  by  the  ioct  that  treatment  in  not  followed  by  favour- 
able results.  The  eiictb  nerve  is  also  frequently  affected  ia 
syphilis,  either  BOparately  or  along  with  the  fifth  or  ReTcalli 
nerve  on  the  same  side  Syphilitic  disease  of  the  fifth  is  not 
DDfreqiient,  and  the  nerve  may  be  affected  at  its  origin,  at  the 
Qasfterian  ganglion,  or  id  its  separate  divisions.  Disea.se  of  thia 
nerve  fint  declares  itself  by  oeuralgic  pains  in  the  region  of 
ita  distribution,  which  are  liable  to  ooctunial  exacerbation*, 
And  oocacionally  annvtthesia  may  be  associated  with  the  pain. 
The  motor  root  of  the  nerve  is  often  affected,  and  tlicn  there  is 
masticatory  pamlysitt  with  atrophy  and  the  reaction  of  degenera- 
tion in  the  afl*ected  musciea.  Tiie  paralysis  is  sometimes  preceded 
by  apftemodic  movements  of  the  affected  muscles.  When  the 
Oaaecrian  ganglion  is  implicated  there  is  lachrymatioa  and 
neu  TO  paralytic  ophthalmia.  Syphilitic  affectioos  of  tbc  fifth 
□ervc  are  probably  never  bilateral,  and  if  both  be  paralysed  by 
ibe  preuure  of  a  tumour  at  the  base  of  the  brain,  the  growth 
is  likely  to  be  cancer  CHutchinson). 

The  seventh  norve  i«,  with  the  exception  of  the  motor  nerves 
of  the  oyebail,  more  frequently  affected  in  syphilis  than  any 
other  craninl  nerve.  The  paralysis  may  affeot  all  tlie  branvhos 
of  tbo  nerve,  or,  contrary  to  what  occurs  in  central  paralysis  of 
the  facial,  the  muscles  abont  the  eye  may  be  thu  first  to  become 
paraly!<ed.  The  hypoglossal  norve  is  probably  never  subject  to 
isolated  paralysis  tn  syphilis.  The  optic  nerves,  cbiasma.  or 
tracts  may  be  the  Bnt  to  suffer,  and  unilateral  amaurosis  with 
descending  ncuro- retinitis,  or  different  forms  of  hemiopia  may 
occur  according  to  the  situation  of  the  lesion.  Some  cases  of 
amblyopia  or  anuuiroMs  have  been  recorded  in  which  do 
lesion  could  be  detected  by  ophthalmoscopic  examination, 
bnt  which  were  cured  by  anti.syphilitic  treatment.  Various 
forma  of  neuralgia  are  held  to  be  of  syphilitJc  origin  in  the 
absence  of  aualomicol  proof,  because  tliey  occur  in  sypl 


970 


TOXIC,  AKD  rCBRILB  AND 


subjects  and  ji«1d  to  LoUsyphUitic  treatment.    The  moa  fn-^ 
quent  of  theste  axe  itciatica,  occipiul  Deuralgio,  aud  ufMin!^ 
of  the  teKttcle,  scrotum,  and  various  TiBcera. 

C-)  Syphilitic  Lettiona  of  the  Spinal  Cord  and  iU 
bratus. — TheiH!  form  late  maaifestatioii*  of  tbe  dvmMae,  and.! 
iL  rule,  miukeJ  cachexia  is  praHent  before  their  tip\ 
The  Dcrrous  symptoms  are  generally  preceded  by  gcae 
languor  and  a  feeling  of  debility ;  aAer  a  time  sympUmt 
acnsory  irritation  set  in,  which  may  last  for  mooihs  vit 
poaralysis.  Palos.  increased  by  pressiire,  are  aometlmm  ait 
at  a  fixed  spot,  ovor  ttifi  %-ertobral  column,  in  tba  oerrtcal.  IumW, 
or  BBcral  region.  At  other  times  they  are  tituatdd  tn  the  d- 
tremities;  at  firat  limited  to  an  arm  or  \eg,  but  later  inTohai 
the  other  limbs.  The  pains  arc  more  rbeumotie  than  m- 
ralgic  ID  character,  and  are  subject  to  groat  vari*tioM  n 
duration  and  intenaity  (Heubaer).  The  patient  ofteD  ooraplsu 
of  pamiSthesifG,  such  as  formication,  tingling,  and  numl 
the  affected  extremity. 

After  a  time  motordisturhances  appear  in  the  form  of  i 
and  temporary  spasms  of  groups  of  muscles  or  an  eit 
The  symptoms  are  liable  to  great  fluctuaUons.  and  nwy« 
disappear  for  a  time,  the  free  intervals  being  lomnlJiBM 
several  mouths'  duration.  Sooner  or  later,  however,  tke  i 
toms  of  irritation  giro  place  to  those  of  peralyua.  The  patieni 
complains  of  increasing  weakness  in  one  1^  or  In  both  the  )t| 
and  arm  of  the  same  side  if  the  lesion  be  situated  in  the  tm- 
vical  re^on,  and  in  a  short  time  complete  paralysis  is  deretapeJ. 
Before  long  the  oppoaite  side  of  the  body  is  afiiected,  and  tb( 
paraplegia  becomtrs  complete.  The  accompanying  dtitiirbuiees 
of  Sensibility  do  nut  increase  in  correepondiog  ratio  as  tbey  dt 
in  myelitis  or  other  tumours  of  tbe  cord.  The  extent  of  Utt 
paralysis  will  depend  upon  the  ftcot  of  tbe  lesion.  When  ibc 
lambor  region  is  affected  both  lower  extremities  will  W 
paralysed,  but  one  nsually  to  a  greater  extent  than  tile  other. 
find  the  sphincters  will  also  be  involved  in  the  parmlysis. 

Aft(>r  a.  time  the  symptoms  remain  stationary  for  a  cotuHtt- 
able  period,  and  the  patient  is  oondned  to  bed  for  w««k*' 
even  months.    If  energetic  trratment  be  adopted,  the  < 
slowly  improve  and  terminate  in  comparative  reooveir, 


POST-FKBRaB  NERVOUS  DISOEDEaa 


m 


tnMt  fftroarable  cases  beiag  those  io  wbtcb  Ibe  morbid  process 
is  limited  to  the  lowest  part  of  tbe  cord. 

Improvemeot  begius  in  tbe  less  affected  extremity,  wbich 
after  a  time  completely  regains  its  motor  power;  but,  although 
the  other  extremity  improves,  a  certain  degree  of  motor  weak- 
ness perfiista.  When  the  Rphioctcrs  aro  affected,  bed-sores  and 
cystitis  with  their  usual  dolotorioiu  conscfiucoccs  aro  npt  to 
develop. 

Wbea  the  cervical  regioD  is  implicated,  and  especinlly  the 
upper  portion,  the  prognosis  is  very  grave,  a  conditiou  of  general 
paralyttiti  biding  r»piilly  dijvctoped. 

But  even  aggravated  cases  may  improve  under  enei^etic 
antisyphilitic  treatment,  although  the  spinal  cord  remains  to  a 
greater  or  lesser  extent  permanently  diseased.  If  the  syphilitic 
lesioD  have  extended  from  the  pia  mater  to  the  Iat«ral  columns  a 
spastic  paraly»i.>t,  reKemhling  more  or  Icsui  that  of  primary  lateral 
sclerosis,  is  developed ;  while  locomotor  ataxia  is  simulated  if 
the  loHioo  be  limited  to  the  posterior  columns.  In  the  above 
cases  the  syphilitic  legion  consists  of  the  formation  of  a  gum* 
matoiiR  tifffiue.  either  iu  the  form  of  a  more  or  less  circumscribed 
tumour  or  diffused  ioBltratioD  into  the  spinal  cord ;  at  other 
times  the  lesion  appears  to  assume  the  form  of  a  chronic 
degeneration  or  sclcroaia  from  the  commencement.  It  is 
probable  that  about  half  of  the  cases  of  locomotor  ataxia  oro 
of  syphilitic  origin  (Buzzard,  Cowers,  £rb),  aod  in  most  of  these 
the  IcsioQ  is  probably  from  the  first  a  chronic  dc»cncrntioo. 
The  gr«y  matter  appears  to  be  primarily  affected  at  other  tim^a 
Progressive  musculnr  atrophy  k  probably  mmetimes  of  syphilitic 
origin,  while  labio-glosso- laryngeal  paralyRis  i«  frequently  and 
exopbtbalmoplegia  externa  is  said  to  bo  always  of  Ryphilitic 
origin.  A  case  came  under  my  own  observation  in  which  the 
symptoms  of  acute  spinal  paralysis  of  adnlta  occurred  in  a 
man  at  the  age  of  S3,  while  he  was  suffering  from  secondary 
symptoma  He  was  47  years  of  age  when  I  saw  him,  aod 
Che  symptoms  present  were  slight  ptosis,  paralysis  of  the 
superior  rectus,  and  comparative  diUtation  and  sluggish  mov^ 
ment  of  the  pupil  of  the  right  eye,  a  slight  degree  of  atrophy 
of  the  right  half  of  tbe  orbicularis  oris,  paralysis  with  decided 
atrophy  of  the  muscles  of  the  right  half  of  the  tongue,  and 


974 


TOXIC,   AND   FUIRILE  AXD 


oomplete  paialysut  and  atrophy  with  Iqm  of  the  electric  ooa* 
iraclility  of  nil  the  muscles  which  produce  dom\  flcxiao  cl 
ihe  foot  All  soDSory  duturbonoca  trcTe  absent.  Tlin  pnmna 
of  multiple  lesions  in  this  com  points  to  its  syphilitic  orip!.. 
It  mnat  also  be  remembered  that  acute  ascending  pftnlyMf 
apt  to  become  dcvuloped  in  sypl]tlUi<:  aiihjects;  but  ao 
which  can  bo  regarded  as  cbaractcri&tic  of  ayphUii  hu 
dUeovervd  in  the  spinal  cords  of  such  cnse& 

(3)  Sifphilitic  Lesuma  of  the  Brain  and  U»  Mtrmii 
The  outbreak  of  cerebral  6ypltili«  is  generally  preoMled 
premonitory  FEymptoins.  Headache  ia  the  most  conataot 
important  of  these,  and  it  mny  precede  more  pronoancodeeittnt 
symptoms  by  days,  moDtb&,  or  oven  years.  It  oeean  ii 
paroxyBcns  which  are  sometimes  eo  intense  as  to  be 
iosupportablc.  The  pain  is  seldom  dtt1'ii««d  over  tb« 
bead,  but  generally  occupies  the  kteml,  anterior,  or 
half,  or  is  limited  to  a  very  circumscribed  region  which  is 
to  pressure.  The  headache  ia  liable  to  ooctumid  ei 
of  great  severity,  while  there  is  a  remission  or  complvta 
mission  iti  the  morning;  it  may  entirely  disappear  ftir  weeks  v 
moatbs,  without  trcatmcnlv  and  afterwards  recur  wilb  grtal 
saveriLy,  SleepUMnena  is  another  important  eymptoin  of  thii 
early  stage ;  it  is  sometimes  but  not  always  the  reaolt  of  tbt 
headache,  and  may  continue  during  the  remiaaiocn  of  Iks 
Utter.  Other  premouitoty  symptoms  of  less  oonstaDcy  tai 
importance  are,  alticks  of  dizziocsa,  feeling  of  faiotii 
Dumbness  in  the  head,  sbootiitg  pains  in  tbe  extretait 
general  discomfort,  slight  loss  of  memory,  mental  ooof 
great  excttabiUty  of  manner,  and.  irritability  of  temper, 
of  those  symptoms  probably  occur  in  every  case,  bat  they  tsaj' 
somotiTnes  be  bo  slight  atul  transient  that  tbe  patient  doM  Mt 
complain  of  them  unless  (|ae8tioned. 

Tlie  purely  ccrroue  symptoms  depend  upon  tbe  nature 
situation  of  tbe  lesion,  and  may  be  divided  into  the  fotU 
varietieai :  (a)  Symptoms  caujted  by  the  proeeDoe  of  a  gtuni 
within  tbe  cranium,  (h)  those  caused  by  oocliuioQ  of  ooe  of  tb* 
Arteries  of  the  brain,  and  (c)  those  caused  by  chronic  degeoen^ 
tive  chaQges. 

(a)  Gumma. — If  the  gummatous  tisrae  farm  a  diitinc^jf. 


ireaH 


i 


IcircumsGtibed  growtb,  it  gives  rise  to  double  optic  neuritis,  and 
iQ  other  symptoms  which  cbaracteriee  intracranial  tumonra. 
If  the  sypbililic  tissue  be  iaBltmted,  tlie  symptoms  of  a  focal 
dieeasc  arc  probably  present,  but  without  doublo  optic  neuritis. 
We  have  alieady  seen  that  syphilitic  growths  are  situated  near 
the  surface  of  Ibe  brain.  When  the  lesion  is  situated  at  the 
•base  of  the  brain,  the  moat  prominent  phenomena  will  be  tboHe 
ftf  pressure  upon  the  craolal  nerves,  which  have  already  been 
>nsidered.  When,  again,  the  growth  is  situated  on  the  con- 
rexity,  the  most  prominent  symptoms  are  due  to  implication  of 
the  cortex  of  the  braiu.  ITie  primary  leaioQ  of  tho  cortex  is 
enerally  irritative;  but,  as  the  growth  enlarges,  part  of  the 
)rtex  is  injured,  so  that  a  destroying  lesion  is  supenulded  to 
le  irritative  or  dinchargiog  ona  If  the  lesion  be  situated  in 
le  area  of  distribution  of  the  Sylvian  artery,  the  syraptoms 
'liegiD  by  a  unilateral  epileptiform  attack,  usually  followed 
by  some  degree  of  paralyaia  of  the  muHcles  finit  implicated  in 
Hitiic  coDvutaions.  These  epileptiform  convulsiona  (Jacksouiau 
Epilepsy)  have  been  already  fully  considered,  and  it  in  un- 
DOcessury  to  describe  them  further.  If  the  syphilitic  lesion  be 
situated  in  the  region  of  the  anterior  cerebral  artery,  iiiva 
psychical  disturbances  predominate,  coneisLiug  of  a  drowsy 
deUrium  followed  by  a  somnoIeDt  cooditioiii  and  more  or  less 
coma. 

1(6)  Ncurotk  Softening. — Occlusion  of  a  cerebral  tcfscI,  as 
tho  result  of  syphilis,  produces  aU  the  usual  symptotns  of  that 
accideDt  from  any  other  cause.  When  a  ve^cl  is  occluded, 
unless  coHateml   circulation    bo  soon  established,   n  focus  of 

^  BoftcnlDg  results,  which  produces  the  usual  phenomena  of  focal 

^  disease.  If  the  vessels  of  the  lenticular  nucleus  are  occluded, 
bomiplegia  may  bo  produced,  but  the  patient  recovers;  occlu- 
sion of  Broca'a  artery  causes  ataxic  aphasia,  and  of  tlie  posterior 
branch  of  the  Sylvian  artery,  amnesic  aphiuua;  while  softening 

win  the  area  of  the  anterior  cerebral  artery  gives  rise  to  toss  of 
memory,  confusiou  of  ideas,  and  other  psychical  disturbanoea. 
What  distiQguishes  syphilitic  thrombosis  from,  other  forms  of 

■  occlusion  of  TcBKoIs  is  that  it  often  occurs  at  a  comparatively 
early  period  of  life,  when  atheroma  uf  the  arteries  is  not  usually 
present,  and  in  the  absence  of  all  the  conditions  which  give 


' 


974  TOXIC,   ^HD  PEBRILB   kSD 


1 


31 


rite  to  emboUsm  or  hteraorrliage.  STpbtlitic  Uinxnbonf  ■ 
bwidn  often  asiiocialed  with  peripheral  pnrBljvis  of  out  d 
tlie  crajilal  nerves.  It  must  be  remembered  that  aDiUuiil 
am&arcMls  may  occur  in  syphilis  from  tbroioboftijf  of  the  oj^nt 
artery  of  the  roliDOL 

(c)  CltTunic  D<igeneratiw  Changes. — In  caaes  of  xim* 
the  counw  of  the  diaeaie  ia  more  or  less  like  that  oi 
paralysis  of  the  iosaoe.  The  symptoma  begin  iDaidiooaly,  wit^ 
fceliugs  of  geueral  uueasiucss  aud  di^omlort,  the  health  loflcR, 
there  is  au  unusual  dL^^ree  oi  mental  irritability,  or  yrWl 
mental  actirity  inteirupted  by  attacks  of  confosion  of  idMi 
The  patient  commonly  has  ideas  of  grandeur,  and  may  ittd«]|l 
in  extmragance  much  beyond  his  means.  Ia  caaes  of  tiwluMl 
tbo  syphilitic  affectioo  ia  liable  to  manifest  itself  by  a  tmt 
attack  of  coiutitutioDal  symploma  in  the  throat,  noeo,  ur  I 
After  a  time  new  oymptoms  make  their  appearance ;  the  | 
is  eaaily  fatigued,  bo  is  do  longer  capablo  of  niidfli^sotnf  i 
tained  exertion,  the  gait  is  staggeritig,  and  his  moreDMDti 
uucortatn  and  heaitaling.  The  patient  complaina  of  onml 
formication,  and  shooting  pains  in  one  of  his  limbs,  the  tpuA 
is  hesitating,  and  stammering,  the  tongue  trembles,  and  meauxy 
aud  intelligence  dccroaw  gradually  and  Bt«4u)ily.  Variouiforw 
of  paiBlysia  now  make  their  appearance  ;  the  gait  is  ataxic;  tbt 
writing  is  irregular  and  ultimately  becomee  ill^ibt*);  and  afw 
a  variable  poriod  of  yean  the  patbot  di««  with  cyciitii^  bed* 
aore«  and  their  consequeDoaa,  uoleas  earned  off  by  some  ji 
correot  afiectioo. 


oany^ 


§  984.  Trmtment.  —  The  treatment  of  syphilitic 
affections  must  be  prompt  and  eneigetic,  inasmuch  as  delay  ny 
lead  to  irreparable  injury  being  done  to  the  part  aSecbed.  If 
the  presence  of  a  gumma  be  suspected,  the  iodide  of  pofaunuB 
should  be  at  once  administered  id  doees  of  a  scruple  to  half  a 
drachm  three  times  daily.  The  iodide  may  from  the  fintbt 
combined  with  mercurial  troatment,  or  the  admioistratiaD  ef 
the  latter  may  bo  deferred  until  the  former  has  bod  tiiiM  to 
dissipate  the  gumma.  The  iodide,  howeref,  should  uever  bs 
trust'&d  alone,  as  the  lestoa  is  likely  to  recur  in  eoine  o<li<r 
situation  within  a  period  of  a  few  months,  uuleea  tpecoBiy  t> 


POST-FEBRILE  NBBVOUS   DISDUUKRS. 


976 


administered.  In  aggravated  cases  from  three  to  four  scruples 
of  mercurial  ointment  hIiouIJ  be  rubbed  daily  over  the  lower 
ADt]  upper  extremities,  the  alKlomen,  und  back  during  the  first 
fourteen  day&  If  improirement  be  mnnifeated  at  the  end  of 
this  time,  the  same  quantity  should  be  rubbed  ixx  every  other 
day  for  sovcrat  weoka,  and  then  half  the  quantity  at  the  same 
intervaU  for  several  additional  weekn.  The  month  aod  teeth 
should  be  frequently  washed  during  this  treatmeot,  in  order  to 
prevent  salivation.  la  milder  cases  the  intcriial  administration 
of  mercury  is  more  convenient  than  the  inunction,  and  equally 
efficacious,  and  no  proparation  can  answer  the  purpose  better 
than  the  bichloride. 

lu  aypliilitic  epilepsy  the  bromide  of  potaBsium  may  be  com- 
bined with  tht^  iudide,  luid  lo  allay  neuralgic  and  other  pains 
morpbia  must  be  had  recourse  to.  In  the  treatment  of  painful 
aOectioua  of  the  petipberal  nerves  chloral  may,  according  to 
Dowse,  be  added  to  the  solution  of  the  iodide  of  potaaslum. 


(V.I    F£UltILB   AND   POST-FEDRILB   NEUROSES. 

§  9S5.  Numerous  nervous  disturbances  are  liable  to  occur  in 
the  course  of  or  during  convalescence  from  febrile  diseases. 
The  diseases  which  are  most  commonly  oecompatiied  or  foUovcd 
by  nervous  disorders  are  typhoid  fever,  the  acuto  ezanthnmata, 
acute  dyaeulery.  pnoumouia  and  pleurisy,  nephrilia  and  (.-yalitis, 
acute  rheumaltHm,  intermittent  fevar,  and,  above  all,  diphtheria. 
The  nervous  disorders  of  febrile  disenite  are  generally  the  same 
as  titose  vrhicli  ari^te  from  other  causes,  and  may  affect  th« 
penpberal  nerves,  the  spinal  cord,  or  the  brain. 

(1)  Neurosis  0/ Ttfjihoid  Fever. — During  the  first  stage  of 
typhoid  the  patient  may  complain  of  cutaneous  hjrpertestbcsia, 
which  may  involve  a  considerable  portion  of  the  Hmbs  and 
trunk.  UypeTS^etheaifl  and  neuralgiform  pains  are  often  pre- 
sent in  the  muBctea  of  the  hmbs,  neck,  thorax,  and  nbdomeo. 
These  paiue  ate  frequently  associated  with  cutaneous  hypenea- 
tbeeia;  ihoy  cause  severe  suBenng  to  the  patient,  and  oil 
movements  tending  to  stretch  ibe  affected  muscles  are  avoided. 
Ana^sthettia,  either  complete  or  partial,  and  of  variable  distribu- 
tion, may  appear  in  the  course  of  the  fever,  and  may  be  present 


TOXIC,  AKD   FEBRILB  AND 


paralyBis  of  the  diaphragm.    The  seosory  disturt 
of  bypcrssthcsia  at  first,  followed  b^  Dtiinbn«M  uid 
Tbe  Beoae  of  taste,  smell,  «  bearing  OMjr 
aSocted,  and  distarlwacM  of  viaioa  ar«  fr«quciit  Tb« 
of  sigbt  may  be  caasod  by  paralysis  of  some  of  tbe  ext 
iat«roal  muscleii  of  the  eye  ;  there  may  be  oomplet«  omanr 
which   may   contioiie   duriog   st«roral   we«k«,    do    appi 
changes  being  present  iu  tbe  discs. 

(S)  Paralysis  of  Acate  Febrile  Dtseaau. — Acute  rbeumaf 
i«  sonietimes  followed  by  a  local  paratyii*  in  tbe  region  of  dl 
bution  of  oue  of  tbe  peripheral  nerves.    Pneumoota  and  pleti 
are  sonietimea  complicated  bjr  puvplegia  or  hemiplegia,  but 
doubtful  whether  there  is  anything  more  than  an  acdd 
connection  between  tbe  local  disease  and  the  dcttoui 
The  forms  of  paralysia  termed  reflex  hare  already 
aidored. 

(4)  Ncnrotis  Dviordera  of  InUrmUlent  Fever. — V» 
sometimes  appears  suddenly  during  tliu  febrile  paroxvMn, 
eeates  suddenly  with  it ;  at  other  times  it  oooatitutea  tho  oolj 
eridcnce  of  the  presence  of  malariaJ  poisoning  (peniicuws  paca- 
lytic  fever),  and  in  other  case«  it  assumee  a  chronic  form,  and  ■ 
associated  with  great  cachexia.  Of  the  forma  of  paralyxb  wbich 
occur  suddenly,  hemiplegia  with  apbasin  is  by  far  tbe  okM 
usual.  In  the  pernicious  paralytic  variotj  paraplegia,  witk 
partial  anffi«lhenia  and  dUturUiuicea  of  sigbt  and  be«ring,  b 
aometimes  found  associated  with  aphasia  O'ioi^^dO' 


^ 


§  9SG.  Morbid  Anatomy  and  Pkynology. — Tbe 
which  tbe  muscles  undergo  in  acute  diseases  hare  been  carefaD) 
studied  by  Uayem,  but  this  subject  is  moch  too  wide  to  bl 
diacuised  hero.  The  local  paralyses  ateociated  witb  ajUBStbeni 
occatrii^;  after  acute  diseaaee  are  doubtless  of  poripbeml  oriyis 
and  are  probably  caused  by  aeuritia.  Kven  in  paraplegia  tbi 
disease  in  the  spinal  cord  is  supposed  by  some  aatbon  lo  h 
secondary  to  that  of  the  peripheral  nerves,  and  the  retelt  of  ai 
asceodiug  neuritis.  In  diphtheritic  paralysis  Charcot  a»d  Xvir 
piaa  observed  degeneration  of  the  motor  nenrcs  of  the  nkw 
palatl     Bubl  states  that  there  is  a  nuclear  exodatioD  ial 


|g| 


POST-riOlltlLC  XE&TOL'S  msotu>p.Bs. 


979 


tiheathB  of  tbe  panilyged  nerves  Binular  to  the  diplitlieritic 
exudation  occuriing  into  the  connective  and  mucous  lisniea. 
Pierret  observed  spots  of  false  membraQe  on  the  Kpinftl  cord 
and  medulla  ublougata,  associattfd  with  peri ueuri lis  of  the 
roots  of  the  correspondinf;  nerves.  Yulpiati  observed  nlight 
changes  in  the  ganglion  cells  of  the  anterior  borra  in  two  cafles, 
but  found  nothing  abnormal  in  a  third.  D^^jt-riue  found 
neuritis  of  the  anterior  roots  and  of  tbe  intra-muBCuIar  nerre«, 
along  with  slight  alterations  in  the  grey  jiubatauce  of  the 
cord;  the  posterior  root«  and  white  subtsutQce-^  wcfo  not  mat 
Weetpbal  fouDil  spots  of  softening  disaeminated  throughout 
the  spinal  cord  in  a  case  of  paraplegia  occurring  in  tbe  course 
of  smallpox.  It  is  manifest  that  various  atid  mnnifold  leftions 
may  be  found  in  febrile  and  poat-febrile  niTvouw  disordcm 
affecting  peripheral  nerves,  spinal  cord,  or  bruir.  The  nature 
of  these  leaious  is  probably  very  various,  Sonielimes  the  lesion 
cuiisiatB  of  liypera'mia,  at  other  times  of  nnaimia,  either  gcueral, 
or  partial  from  occlusion  of  vossels,  or  it  may  be  inflammatory 
or  degentrative  from  the  first. 


§  987.  DiagnoaU  and  ProgtwaU. — That  a  nervous  disorder 
baa  occurred  during  the  course  or  shortly  after  an  acute  disease 
is  rendered  evident  by  tlie  history  of  tbe  case.  The  chief 
problem  of  diagnosis  then  is  to  determine  whether  or  not 
tlie  lesion  bo  functional  or  organic,  or  localised  in  the  peripheral 
nerves,  spinal  cord,  brain,  or  sympathetic  system.  In  order  to 
detenniue  the  latter  question,  it  is  neccasary  U>  pusscsu  au  accu- 
rate knowledge  of  all  the  diseases,  especially  all  the  forms  of 
paralysis,  to  which  the  nervous  system  is  liable.  No  number 
of  special  diagnostic  rules  will  supply  the  place  of  this  koow- 
l«dg«,  and  such  rules  are  superfluous  to  those  possessing  it, 
■It  is  scarcely  neceisary  to  remind  the  reader  of  the  value  of 
relectrical  examination  of  the  paralysed  nerves  and  muscles  in 
determining  whether  the  paralysis  be  of  peripheral,  spinal,  or 
cerebral  origin. 

The  pTognosie  \s,  as  a  rule,  favourable  in  the  nervous  disorders 

occurring  in  connection  with  acute  diseases.     In  diphtheritic 

paralysis  recovery  usually  talces  place  in  some  weelcs,  but  in 

.  Hvere  CMes  it  may  be  delayed  for  six  mouths  and  upwards.  Tbe 


wo  FEBBILK  AND  P08T-PEBBILB  DISORDEBS. 

severity  of  the  primary  diphtheritic  attack  bears  no  proportion 
to  the  inteosity  aad  duratioo  of  the  subseqaeot  paralysis. 

§  988.  Treatment. — The  treatmeot  moat  vary  accordiag  tti 
the  nature  of  the  lesion  aad  other  circuoistancea.  If  there 
be  evidence  of  hypersemia  of  the  spioal  cord  or  brain,  cold 
applicatioD  sbootd  be  employed.  As  a  rule,  however,  tooic  and 
stimulating  treatment  is  required.  If  there  be  no  organic 
disease  strychnia  is  indicated.  Tbe  best  results  are  obtuned 
from  electrical  treatment,  hydrotherapeotics,  and  change  of  air 
and  scene. 


D8I 


INDEX. 


riuat. 

AbdonlMt  mmclM,  pinljkii  of    . .     .  .1.  MU 
AbdMnlM]  iMrUaii  uf  Uio  tymfm»hMla, 

dbMMSur L  MS 

AbiUu«<i*  norw.  ^«A|>  ariHn  and  BurfmH 

ituchmmu  ur, .     ..     ..     ..I.JKI 

A1idiuwi*iiar*B,  (Ar^fui  af  ..      ,.     ..LUT 
Abmw.  chrviilc,  ul  llip  brala         . .     . .     Ml 

jirlDiBtj ..     TBI 

4f  iDiitom*  vf  ll»  KUnl  ptriixJ     TBI 
uTOiiliHiu    uf    til*    (viniiiaJ 

l»rl»l  .733 

■ooiiilarf  TM 

VutrtiH ,734 

infVbitt  luiiibuaij      ■ ,  T95 

AAlllt^Undou  nUlii        L  110 

AehruuutviJtui ,,     ..t.)<0 

Aciuualli:  nan*.  JlnuMMOf       ..     ..     ..LIM 

Awiiailc  undaj     ..     ,.     ,,     „     ..     ,.       M 

Aoll'iii,  ■nliniiiitlD ,.     ,.      Tfl 

nllH         ,.      ..     ,,      TS 

loluiiUiT        -     •■     •■       "^^ 

A<tlr«  «M^«J««B(HUaii        ..     ..     ..     Dm 

Atou  alraplila  iplual  pknljata     ..     ..    IVA 

drtnlUoB.  hlatorr.  *tiolng*..      ..     IHA 

lafutlto  IM 

■■fMlulti IIS 

■rmptoai*        iM,  110 

•wotiM        ..     .. iir 

■BorMil  noatonr m 

boillmlUoB    lu    tb*    MilartW 

bonit      IST 

uiDTblil  pliyilaltv 1>B 

dUfDufU „    ..    ..    m 

pt<vm4> IM 

tfwttanit m 

Aont*  m  —  ling  canlf  lU        MM 

dtdfUUoA.  blnoi},  •UnldO' .  Ml 

9jjafAornm  ._  ,•     .,  ,.     MA 

illlCnHU „     ,,     ttt 

uortriiJ  uiatduf     ..     .,    .,.     ,,     MO 
uuirbiliJ  ptijidplofy . . ITI 

CpuHti.  InoUDaDl      im 
Wr  ii>;*liUi       MS 

■Hitbld  aiuuutnj     ns 

A«to«wml  av<UlU      lU 

mortrid  ■nataur    va 

AMIUOMTUkltMDMMMMflUlIl..      ..      187 

AatadlStand  mjdlU* ITt 

iMnlUM,  MAlaop       nt 

VMpHma  ..     ffn 

watm        tn 

mlmMonlal  ■utnuikllOD  ..    ..    HI 

luvrliUI  pli7>lHlii|7 tn 

<njiM4a Bt. 

iUmbo*!* in^ 

■MgMrii IM 

inUnMii* »l 

A>nte  dta*ntiuil«d  mr«Utfi MS 

nuirUd  UMatBj     M 


1-4  ««. 

Atmtvdoniftl  tnnnflnH  [n;«tlili  SI 

Acata  ijcma-liaiutui  'ju»<«>*  dijsUUi  ttt 

Acuta  •iio(|iIiaUlb TIT 

Amtd  li*iiul«Unhl  in^ dUU*  18T 

AenM  InlUDiiiuUunut  lbaBN7UMl*f 

barru Hft 

Airut*  ai^clo-iotatiicitS* tt> 

morlilil  uuLlaaij      Ml 

AculaunrtOi     L  IM 

Auniapgrmib  mofiilialjUi Tit 

AdiitatpJDal  l«lMoia«(ilii^U#  --      .  Ml 

Auiito  imBMn*  nyilitla  ....  IM 

A04l*  QDlTanal  »M*bnkl  lUUMnia     .      ..     AM 
Auutanaanf  rMuii,  dlmlDUllan  u(       ..l  IIA 

Mawuf        ..     ..I.JI4 

A<1tU*tfii'i  rllaofwc         L  m 

A(IiluiitaiiiiIbiiU>tbl|)i^oiKicnatuniiirt  I,  tM 

JUhMtonuoM L  Rk,  I.  il,  L  M 

utloulu     ..     .       ..      ..     ..     ..lUI 

"—«.       LUI 

i-l»«r»l      _ LIU 

AffHMii  t^xm,  iMph[(  cantn«f  ..1  M 

AfUr-tenuUDU*.  lianlMtul 1 141 

Aci*|ihi* .,     (W 

AnHprtdlitnatug  taatlaoHa,.     ..     '.X    ft 

AtniBUt ,.t.    M 

nfln  ..I.  I«T 

Bf  tlM*<>laatuitD>nKl«            .     ..L  1)1 
HamUlad  ajniitiiDH L  IM 

JUo^KillO  prnrf*!'  ..  .     M* 

A  lei^Mllfl  narfom  illMaaM  MS 

Altaroato  twmltdiCW  . .     .  ...    MB 

AmiweMa  _    LSU 

umpMiBi LIU 

Mbrilw .L*V 

AmUjopU LtW 

oiaptMW ins 

Anlmb .     ..       .     .,     ..    «1< 

Ainarticdd  DunsiMatt I.     J 

AiBiiiiR«hte  UtMwl  Klno«U SU 

VBpUoia „    ..    ..    IM 

AiPTftolaW  piiBlwi U9 

JuDjiaM  viryiifim M 

AUaiBiU..       L*H 

AiiKniU''f  thabrslii    .     ,         .....     4H 
hinotr.    tiportmetital    lBi««tl|>i 

(ion .     (» 

•Ualacj      ....  Me 

unU  anlnn^ MM 

cttnnia  BDlTanBl     W 

Rjmptan Oi 

luhoUl*     ..    M> 

aarUd  uwMn  J IM 

•MrtU  pbriioliicr .    4W 

mam,  diapiciu.  ptifnaMa  . .    *W1 

iMklnnt     .     ..     ..     .       ..       .101 

Anaulaof  UisojvluIlktiUuutiiU   .     ..    lis 
An«Mi..Iik«1.  aflhf  ikln         .     ..     ..L  1*1 

AimiiU  at  Uia  (i^inal  rail      114 

AcwcthvU      .     .. t    U 


!)82 


INDBX. 


I  niilfl*  - 

•«H«tu    ..  ..   ..    ~   ..   ..tua 

ladtaMj    ..    t,    a.    ..    H    •xua 

dHUBMrtlMl L     « 

cm^naoui  .,     -. •<!■    V9 

In  tka  (Crmof  k^ldls  ..      .,     .-L    M 
■rflbaUiroK  i-tu 

launBlw ..     ..LIIO 

gUWitdtJ  ■■      -I    3M 

OMll 1   ilJ 

puM*l         1.  >17 

tfartUllMUiVi 1.  IIT 

UcUU I.  IW 

Uu«iOD        L  IM 

lu  Uu  WnlU*7  oritonfM        .,L  IIT 
AHMUM4a4«l]«f>MK l-ftM 

AulavU      .. LM.  LWr.LIO* 

*Uanl       f.  II' 

AmmlMLia.  imra^mM    ..     ..    ..    ..    UT 

tmjn>  niiliiik  ..    ..    .•     1.    •!    ..1.  tn 

oudiir      ..    I.    ..    <•    u    oL  kTT 

■raptam* !■  '''* 

ninrittd  iiiMa«7      ..I.  if* 

(DDTUd  jibjrioiiisr ■  '*" 

•uliUo   .         I.  Ml 

•JUCiKak.  fvoftractl        t  Ue 

tm»t4BM.l  ..     - IMS 

AUfluiuB        ..     ..     ..     ..     ..     ..     -■     MT 

Aagioiivuniava      ..     ..     ••     «*     ..     •>!  11^ 

vrsbml      DM 

mUnaoM  ..     ..     ..     ..     ..     ..1  ItV 

pw)»bMU, Lie 

iW>l ..    .i-itt 

ilSSSr  ::  :::;  ::  ::  ::i|» 

KSraSi  ;*  ■'  "  "  !."  "  '.'xnv 
Aakla olcnraa. .    ..    .•    ..    ■•    >.    •-L  IM 

AnUwrafttc ..    ..t.  tlO 

!.»« 

tfaanktln  . .     ..  L  MB 

l>niB«pab.  trMtna-H  L  >1« 

ABklaolaDU*        ..     ..  I  IW 

Jbnkbnau         i  IM 

AnoOBlk       .-     ..     .-t.  Mt 

IrsHBiUla 1.M0 

prDcnulik  tnaUnaiDt      I UO 

atoeaptioD  L    II 

AdlMlMftMa*4(li*tktUl.brianlH  ..    «BI 

Aa  Win  r)*?  >■""» llBSaVr 

il«t»l(^iin)M  vf       .....  O 

Antactaini«HU>c4thaU(,BUMa*f  ,  .1.  US 
AfiMrtnt  pnwDUa  ..  ..  l  M,  a.  ».  O 
Antatiui  not-MMk     ..     S).  t>,  SI,  ST,  M,  ra 

AiibMla.  ■(■■M ..     ..     *M 

uqdmM       «IS 

nur  Md  maiMmf     Ml 

morMd  nlifaloldfj Mt 

IBVlllBllMt  of  10 

ADtloola  pukljllM     ....  .  i  *a 

■pMllo       .1  'tis 

Aioplaay,  BMolncnl M 

SSS^"*::  ::  ::  ::  ::  :i « 

j^hnitu    no 

AnahiuM,  «l*al4l  nn  «t       I 

•cinklputa/ 410 

JranaW  BUw      H  W.  *t>  H,  «U 

Araof  uilml'K  atfiteidulwj.  tll>,MI.  «4I 

i>>i.»>.lu  ,.      ...  ..     Md 

Arn  a(  nuhll>  owvbml  MtH7       . .    Ml.  «t3 

ItilaulB    .         ON 

An>«r  iMMirkrnTtbmlafUtj    ,,    ««0.M1* 

iMiMutn  . HI 

Armt  at  tb«  tkvH,  rMOMtlr*  ia»m» 

■t.,       .     .7^ IM 

A>uU-lt«bMimi  •jwptaa      L  IM 


.  .  .  i  »■ 
Aitertw  tf  tats  . .     .. 

U  emMtaw  .. 

of  nainltai 

orroMVuaUl 

oftpiMlMrd  ..  It 
ArthwiMM*  .... 

AHIcoUt  ■rthi  y  J— >M—  ;fl 

ArrtlMillianlla    .     .  >  I'l 

AMa»llM4«fw«aa«*  r 

AQKautl^  ....  .  ui 

»«<Hill>Him >  *.  1  II 

iBiiirtiaf  .1  l» 

AMhMA  bMNMbW*       ..  <» 

tnfM«>.  lalMxfj, hialwm  -L  « 

AalliB*  haraMM       .....  .       .  i  K« 

AUtha    ,               .      .      .  L   :i 

At«M».|i|«iliit        ....  .       .Its 

Ataltenll M 

A<»«y.  liwifcr.  MqBB^M  ■  -    (It 

AUwenMi       m 

Alxk^ J.W 

AtrajAi*  m— miiwi  BpfjiiMi  m 

Aln^  nf  U*  bMa  .  r^ 

CMMnI       ..     ..  -: 

Aliopb;  uf  Ihi  I  m  ■Mill  I  .     TM 

AtfDplu  of  IW  f MB,  ttftifalMM  li* 

■nnl>«      .IM 

AtaaqthroflhtmaKb^  MMito  .      ..lM 

Alnchr  or  Um  bmt*       . ,      .  L  «k  I  W 

At«BiikT<ir  umofmim**  laa 

Attsphy.  niacaliv.  puijiln  MI 

Abumii*        ........  LM 

AtU*«.  hJMMtiid      .  M 

kjitora  iiilntM  WS 

An4<l>«7  mumAmlu  .  i.  M« 

AuiltUrr  >ffnlh»^  .  ■§ 

AuJItMj  Ii7p«ntp«a  i  M 

AmUUtr  VMllgil  «i 

Amb  «raniMM  .  W 


L  If 

I   IIT 


A«W— aiMw«'t**iwi: 


r-trh-ni.. 

OBlUUnl 

Bm*^  uiuttM  or 
B»i— dudi  iM»<»i 


IWHtlufMor 

taAiMdf    . 

ll«U>      


>.l» 


UI 


i 


>41k(mm  ..  . 
■•U^pmlnli  . 
WaowilirjMtto 
WUIIir.nwTOlitoal. 

h  nsMUf* 


II  lu.  lH)>rto  h 

■  ur    . 

BnOa  of  ha*n  MNB  ud  klfiia 
AaIU    ^kd     b' 
dilWMMbM 


« 


I.SDKX, 


083 


rta*. 
Bnln,  ^Imtmtoti 

diitaa^    ..     ..    - TBt 

|;nipi«l» ,.     ..  'tti 

TraalniMil 7*1 

Hnlu,  klianula  ot       ,. MS 

Bnin.  kilniliaiir ..     ..  4SS 

Bnln.  uro|jh]F  of ..    ..    ..  701 

Bnln.  ehtunlukliMMicf  ,, TU 

Brain,  oaiu|iraBjon  of. .     .. 711 

Brala,  oocttfuMUii  uT  .,    ,•    .,    ,.    ,,  T]# 

■tialni;.  (ympu^..    ..    ..    .,  ?]• 

QDan* , .     .. TIB 

tnorbld  uiftUmj  utd  phfilalaar. .  719 

■Uipioua     ..  7tV 

pnvonut,  tnatinditt     71D 

BwitB.  rnrnitinil  rr«'f 'nnill-Tin  itf     ..  M7 

fMn,  cBuiuloD  ul    TX) 

BiMb,  tortloil  Iwloni  if  MM 

Bia»,<iml«aam\<4 M 

BHlM,fHI(niUlU|lllJltf »I3 

BndMi  vrnwuUaf affi 

MpapMna  ..     ..     ..     ..     ■.     ..     MR 

iMnUilauMav     OVa 

morbid  rli7lu>i<8r 'W 

dliMlMMl* TOT 

cnn*.  iiTDBinit.  uwtmwLl       . .    TO! 

Brtla,  br Mrtrtptu  rf     TO* 

•udIobj,  vuipl'inu ^^ 

IBOibU  MiaUiB7      707 

a>UTi«  . .  Ton 

di«^i>A«iA.  |iiri^fnn«u.  Ir^tm^ikt  . .     760 

nnlD.  law  of  JUKilutlan  oF      M7 

finlO,  MlultHf^f       s» 

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BHtn-mbtunra.  baUnMoirLaof     ..     .,    7W 

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ili<^i< I-IIT 

BfnunliliilM.  tinuucf -.1  ttS 

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llbn.»r     «M 

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Cit|>Bt  i4i>U)MiB  ■puilenn      1.4X1 

UuvlnotB*       L}(4,  tot 

Cu<dlw  pUnu.  u»Bni—  at      . .     . .     -.1.411 

fiMiJt«t|i» ..I  tM 

CMdtHtWTOWUWhMlIm      ..      -.      ..L  ITS 
•MloDof 1.  1T» 

■IMlllllBIHBOr ..L  IBO 

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CMitevn       0M 

w&Aetr      ....-, *>* 

tvmMaON  u     t.    ..    »M 

mn.im MM 

iH>|mA  111^  iimtiiiMli ni 

ImlMMit    .  Via 

tawUo* tM 

iMlauof •«« 

Ou«l«U ..    ..    ..Liai 

(MtdVDtmta       ..  „    , L    10 

CMtwMalnuM L    10 

0*lfcs«fi»kl^« «l* 

Owlnlpv  ownaiu    .     ..    - t,*i 

fl^Tvfopriwfit  of         .q      .,      ..      p.  M 

riinciiutia  nt       ..     ..     ■*     ..     >•  Tt 

Cvotnl  fr>T  tabs        ..     ,.     ..     .,    ..  ) 

(letalanmait  oT. .     .■•..••.  tl 

OMtfvnanW ..    ..  «t 

lotoea AM 

tafotnghrtl *a 


Mat. 

CapbdalRU L  MH 

Cmktiiir  pniJ«iiDti-<y«iMn 1.  t4 

(h>*1)«llar  i1«umj      1. 1«0 

CaMbdlM-MtwiHaMdina       ..     ..     ..L 160 

CWvWls*)ilii>IonadiiDtlHf  i^allu..     .,L   M 

Ca*a>Hllo^iialVM<fi> 1-61 

tO-wnUttad      ..     .. L   H 

CMaMlam    ..     ..  ,.    .,    ,.LSa,tll 

OKabailntD.BtFvpbjrer    J** 

•tlwkvap,  ifuifitonu..  ..    IH 

aemi  mnttmaj     7H 

oaiit|>Uc«tJD»*  uid  dlactival*..     ..     IM 

OtdMIiiiii,  truiBor L  OX  til 

Bilc^niu  uf..     .. 413 

niiiuniiiif til 

mu<j       tlS 

flUlCtiulU  of        ,,      ,«      ,«      ■•      ».  tTV 

gray  iD4tUr<4                 .,     ..  t.  HI  tlS 

liitcniiolUu  guiRK*  of L  t* 

liitaninl  tttunUita  of              ,.      ,.  411 

Itfl—at        •      .         ,_      ..  «S 

IKllUllcl V  I1[ tit 

nblls  Ultttar  of         tlR 

CmlriiUum ,  loAvou*  in        CTl 

CirtbrfLl  aiMSDU ..  (V 

C>n<>r>l  utorba,  UMuInn  rf t>iT 

Cfniinl  artpiia.  otilBitao  at til 

Dtinlnj      nt 

(tmiitonii  .,     ..             tit 

dl^tinai*,  lancUfl  ajiftCdni J  .,  tU 

•ip«ninw>t*l  iuicaugaltoEi..     ..  MT 

Di  fWillilijndalcfT  ..       .       .      ..  SIT 

tjngmwM.  tfrtnwiit     (IS 

On«b««l  0*|tlUH<-.  mliulna  nf    , .  &U 

MMw,  ■7iiiI>i<'D», .  E>U1 

toKlnnil Mi 

Orebnl  (tiiiiUuiu     .       .  I.  SJtt 

Onbral  fwliJ  r&rmljd*  1.  »7it 

Cannnl  basmortiiime . .  MH 

OuBbtalliTpHHnU    ..  Mil 

Omalinl  mkaato ....  i.  \t9 

(MvbmlDMll^aMlftaa*  >M 

Ccniinl  mm  AnaMtcoi bu 

OaahnlaMMgaMoM    ..  .  I.  lU 

Oinbtal  puMtM      . .       .     (W 

CDmbnl  pMaMHon^nMB  L>l,  LM 

Onvbialiliwx^UtnaboaUof     ..     ..    MB 

Mialou        MB 

mjaiptoma Mil 

itU(iMiU.  oinim     UU 

profuoiU.  mfirliHI  uuiloKijr  . .     .  ■     US 

UMabnd  IBSUHU*  . .     MT 

nrlXMa UB 

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fiiricll<J>l»  or      ..     .-     - L    W 

C*nI>n>i|<liAl  whI  «»t«llft4attul  qr*. 

touih  M^iM(»Ua«  or      ..     ..L    M 
LVnbiiM|BiialnalBid«a«lM<alt    ..     ..     8M 

OBnbmm tin 

hkMlBUiatlkcr       «S4 

sranAatMoa  of . .     tIT 

Ihali  dtralonoMin Mt 

ibati  r«UU>Mit  l«  Ibe  ikdll   ..     4H 
dialr  nUclona  U  Uwuwaof 

(kail       ..     4t( 

«a)Ul«t tW 

cm>cr 1U 

MMrtQr«f tlA 

diMinaitf 417 

Uiaii  nUlluaa  ta  tlw  WMa  of 
■koU        4SS 

Bif  ntUmrai 4411 
MraalparMor tn 

Intwval  a(nwt«n  of 441 

brtMof         117 

ladnnalMer ^    . .     tU 

■nltldoitr      43S;t» 

•bit*  DBtUr  itf        tVI 


984 


IKUES. 


tmit, 
Ctrrlal  put  tt  Uw  wtrul   ttni,  iIm- 

MMOt       ..     IMa 

Minto LUa 

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tanMB     LMI 

Or*l«alvwp<«bMle.Ik|QllaM    ..      ..L  Mt 
UrtitMl  ■npMliiUcv  f«w«t«Ml  ASM- 

UmMof LBU 

Uwfim^iniehU  n««l|U       t  «S& 

«m«nl  ulwwwi,  MMeo  . .     ..!.«» 

qviptomi. L4M 

»iin«dwH«a«  lyiBUi L«ir 

<top>ct«.  WiM»fH,       4.4N 

Onrtcw^Rttiul  aMn%t*     1.4W 

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ChlMnw. .ttao 

L-Uanl  hrdmla I.M0 

Ctombalp«aM ,.i,  Tt 

€*■(***  IMl—B,  liJi—  ««      LIM 

Chan* Ui 

•«l>teo      ,  Mt 

■JBptMBI «ll> 

a«LT*4.  jhumUai,  and  tcrraiiTWdM    GSD 
■mrlitd  aMioov       ...       .        .an 

narUd  plinMan ,     BIS 

^VnJIrT^ W 

w^e^*  ...,.,.,..     .     n* 

tllWIBt O* 

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Ctimn*.  T—ii>iuiJ«gic      in 

Uhoirtbmn  BknaaMot*     H4 

Chwvomtapiii,       LID 

ChnmtOamlM       L  II* 

UhrMMamkif  .(^ulpintiiii  ..    ..    |M 
MUillliHi.  bhtaij.  Meha,  tfa^ 
tmnt  it$ 

■HttMHUlMBJ       HI 

dUfnaMc  ..     Itt 

pncnoik  UwiaMt     It* 

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Cbrook  MBlnl  dano-Unbw  nfvlfUi .  -  W 

CluniilccanilnJ  mnllUB   ..    ..     ..     ..  B> 

Chwaiit  MnlmU  Jimwi m 

ChnmUi  (wriiki  truMvn*  niiaUiti     ..  SK 

not^iit  *aaiani7      ..     ..     ..     ..  Ml 

ClumtcJlOliHlBiTdlUi m 

(Uanlllaa.  iBil^ „  fn 

•/nptuni* ,.    ,.  tM 

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DurUd  ■uisoir      ttt 

BJematokacaialBtftai     ..    ..    MT 
»«tod«r^.^r a* 

ilUgpod*.  p*B<M«li,  t»i1»lh>  ■■    tU 

Chfa»M  iihwiimj  wj«itin Ma 

ChPMtotawlnibvtnMiraiwnrallU*  Ml 
CteMritdMMlifaMTmanvaUUt..  ..  Ml 
ChiMl*MhwHfttao(tte(ftiul«Md.  »« 
Ctmal*M«l>>-M-infia> Ml 

mgiwdMMtanj     Ml 

Ch>Ml*HMrliU LMI 

Chronic  proftOHm  bitlbM  ptntr^  ..  ITS 
Cbnnt*  iplul  faflMDMitB^lk      ..    ,.    (M 

ChroototnuHTHMmraDU*     HI 

L-hMM«  mnl*«nd  amknl  uwwM      ..    •» 

CUUiT  — di»  piwlw»  «<     i  IM 

tfwniaC  ., LU* 

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ClnU^ 1-tO* 

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CtaMtoaa     1M.IM 

IMaMOf «• 

CUnwnaalMt B*.  ai 

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aUuMcnrM      Lwr 


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cwtei 

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fiiiM  iitiiii^^ 

fil '-'— .  kite  af., 

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P»*»«       

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OwBMUn  Hmv,  awrMI  «^i^Bd 

~   maf     ..     .. 

ef 

OmMmmumm     

CMnMNiitr. 


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OlIlMftnn      ... 

nmuMt..    .. 
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to 

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CMnvUotIt 
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Caf*nn«MMK  ..  LI 

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C«rt«Bll«MM.. 

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QtfWirftU— tw.hii»hMrf 
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UfDEX, 


985 


CM(n<(  Uwomtnat 

u«rikiN)Mwor iw 

ladDngf MM 

iiKitar  ana..     ..     , 4S> 

muloraantn     „     .. *s% 

■nohiraaUata 4BI 

tmimnfmrm      ..     ^     ..     ,,     ..  4Bt 

Muan>7  c«1ttl«  ..     ..     ,.     ..     ..  tB3 

•anaoT' IDlat* *Sl 

CDttugftluMmbnm.  HantMlliAt    .    4M 

f)DitiadaA(tI«iiaafi)l«Mb     «IS 

CortiiMl  hruhUI  monoplHln  . .     . .     . .    ff)S 

Oonloal  bnuLUI  miimpwak*, .     ..   tCS,  104 
CMtlari  bndUlJ  inMtaainwiU . .     ..   6»i.  L9a 

OortlMt  tntUo-irnusl  udduiiIihIw  . .  tOi 
OonlMl  biMlitD-Uclnl  lUDiiniilaflir       . .     «/! 

OprUail  eantm  of  HuutlDD,  IomUi^ 

Uoogif i» 

OortlnJ  ervmi  iiiam>pt«flai     Wi 

CoTtinl  vnual  mooMfHinw AM 

Ooriloal  anml  pfObvpuiM    Wfr 

CmilHl  Itdkl  nMWoiVHm*  ..  ..  CM,  tM 
Uonln]  UOtl  ftOimiamat     ..     ..   aiU.  AM 

OoHl«I  li«nil|4(«i*     .     SOD 

ODCilal  miKlikitlimi  uf  ■ftlmua,  IncallH- 

daii  of <M 

CMtiatJ  iiutlaisMl  vciihi-uatar  mmih 

pitcto COB 

Oni^li.  (PMUoadh)       L  ISO 

CoanMf  JiillaUoD      I.  W 

l.-nu>i|i    ,.     - I.  lal 

Cminia,  (u-onliiinM I.  ICl 

Oraiibl  mrnii,  iatf  stMb  aail  toiha* 

■IWtMiBli  «!. 1.  M 

ptaca  Af  wHt  <( 1.  U» 

€nm«arrbr<       L    6T 

osUataf     MT 

rniMs  nt     ..     . iST 

iSwi  of  ih*  «vr«bn]  ptduncis,  Btum  of    IM 

Otjixft**     I.  «« 

CuiwiU  r.i»ln>liH      K\ei 

OulUMoii*  aiUHtbaiia        L    W 

■ymptonu I,   W 

dwUllruUBn  gf ..     ..I.   M 

CttMuMOUi  hyiHMMIhBte I.  Ids 

Oituiaaa*  h7p>r»l(«t» I.  lift 

CDtuManatMnwaf  tbatranll  . .  ..1.  iST 
CotwiaMi*  uanw  of  (tu  Unnr  utnodlf  I.  t)5 

Ob1»i»«bm  pm(|»a> I.  lOS 

CoUsMiii*  falUsaa       I.  IBl 

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CUaiwrnu  MUMtluiiv  MttdUB       . .     .  .1   V> 

•|mU <•   n 

tMUIa I.    OS 

OAUMaiiXtaphJcaaMUoU I.  DOS 

liMtrjot    ..     .L  no 

Cydnplt^    ,.      ..      1,145 

CjitUHCua  OdliiLwH JM  Mt 

l^tt       ..      3».UT 

DalbHitam     .     ..     .  LIIIO 

DmAuv        LBia 

Dtwblnu  WDliu       i.  Sll 

oIuqqIciu  dcapln  .,  „  „  ..LtU 
Da««lnsUniH      ,     .,     „      .  ,1  tM 

•kuikIact  .,     ,.     .,     .,     ,,      Ht,  M9 

Holwrias!)!,.     ,,     ...   , f.OT 

UaUdiun  tmBHw        M.i 

OMiMMnacM     I.  M.  41S 

IMieMidliit  dtfuuntljn   . .     . .     . .  OS 

IVTlwtM,«tianilu7,  BfUMKMUid  •}«.  t  ITS 

IJUbMiam^ltai. L  Ml 

Ul*Bi>»<l>.  a>D«nL  pUbslDglMl     . .     .  .L  Hi 

Uipo«n>[ililgi^^ 1.1(1 

lH>rl>n«nMUe  jwnlr^ 1.  Ul 

IIM^nwii,  du(il<  iiwai  of L  MT 

irMtDMM  .. LMI 

DUiihrMoi >  tooK  ipMin  of     ..    ..    ..LMT 


rMB. 

PUphnfdi.  Mii««;ua«(.  IMiltMnt    L  MT 
VimlxUmnia  Damn  dUankm       . .     ..    VTT 

l>1ptMMfiuWli i.WH 

DipUvU,U<H-)«l« <■>«> 

UiraBtCMVlMllar flDna      ..     ..     I.  W,  »1.« 
IUt«M«anh*|[arUut.Auiatl<intor  «f 

KlaroUsof isn 

Iiirwt  (*>«bnil  pui&lfil*   ..     ..     ..     ,.     (SI 

IMMwImllnuaa ^.La,  I.  II 

IHnwH  of  ih«  meafiiaUm.  <1mMIm- 

lloBol 90* 

rawhld-BiiMaDr of..     ,.     ..    ..    Ml 
DiHMMof  Itia  n(4iillB  uUuh^Ik,  vIh. 

tfOMIiaaaf  ..too 

DIhmw   pf  tin  Hilukl  vonl,   <Ui«iB— ■ 

Hon  of. . lOa 

Pliw«—  of  tfi*  mrrotmyitaB.  j«iiM»nt  1-    71 

ciuliwlu 1.    T9 

iriLrinilc     ..     ..1.    71 

D1b«ibIii*1-<1  MilMail*,  *M  aslfTijala,  siut- 

tiiiia .   tm 

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|unly*i*(ir         14VT 

tcHloml  . .     . .      I.  4M 

DomliiBriM^diMMtsr..     ..     ..     .  t.  MS 

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Dura  fiut«T,  fnmiftj  p«n  40V 

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l>:rMHih«iJt t.  lot 

T^^avAAio  Binnal  uiinnia  A10 

I>ttp)u<U  |>w»l]rtliM I.lll 

■jmiikrmi  ,.    ,.     ..     ..     .,     ,.L<II 

|>ri^Iib«l<  UaUoxnt      1.411 

Uf Mn^ir.  iwnnitic  ..     .,    ..    ..    ..L  •» 

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JbUrtMiMtni*  bonlni*       ..     ..    ..  M&  tMt 

Kgluawk      »« 

MnlUoD  .,    ..       Ma 

vtlobfj      ..     ., M» 

QiaptOBM M7 

onuH  and  duruloii        . .      .  ft49 

dUpuMte  pragDUai*  UO 

UlBtlaMlt --        .      9SI 

BdUBpila  wnUM       .....  .     .1    UT 

mmtttf «07 

Ba«e> LSm 

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uultltf 4» 

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naitltevf   .. 1  IM 

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ohnnlad •.    ..    ..I.  ITZ 

lodDtad tMa 

ElMrioSV.  TUaoT     lira 

BlanwilVT  iu4U>r^tvrbauD«B,  tuMiv 

of .1.    88 

ouioiiiir  ..    ,.    ..    ..    ,.L  n 

llapbuiliitu  OnBoodUB L  tlR 

BlcnathuBm^MCMntTUBcWof      ..1.   40 

dfipan  of L  (OS 

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or  MTBtml  ]U1HlM Ill 

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loiiiSkU tIB 

buoUonal  muMiMi* L    U 


988 


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llMnUaiTluuMl : 

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tl»i.K«¥tnK«  iii*«  tb*  mWmm*  of  «i* 

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HjHimrttiHP  ■■'■^  Um  Mhrtaiiat  at  Uw 

canlnni     . tn 

Ht-Tii-rtfurt  JiitT  th«  mnlilU  iililinnMa  tlT 

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HHiriurt)ii4c*u(UMlBlrMn>UlaMt>lM|«i  Ht 

llauiiiirThaci  of  ibaiplnal  nwiil»(M     , ,  M 
RjHAmrrlutfic    iriUmul     aptnal    |i4clif. 

lUllDllbiti.  atiolooj- US 

irrapuaa..     ._     ..     _.     ..     ..    tO 

nuuUl  aruloinj  M 

tTMtnHit    .     ..     ..     ..       .     ..    no 

Hair.  UggtilB  dlanlMi  of i.  114 

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mmn  «f  luMnaMOOt  owkIh  •(.  .i  Ml 

HwA,  njtuela  or L  Mi 

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4tafMMi 


a;  II  M»iliMlt     

HrrctMM  oiMrii  ajwau* 

uplift VUlU  r4  ik-  ' 

«f  tlM  (Hdltlia  dOb 

oftlMnUialaaU 
u(lkB«plM>l^nl 

ajtLW  iiiim     ..   .. 


wmaiitu 


^tilrOayMrf 


.XM 


nrp-um^ ... 

BdbMnI 
OnaUMM*..     ... 

UiKn  ad    ,^ k  « 

»«**—   -.  .Ai 

«BqQI»>IMii  |g»[M»Mi  ..      .       .in 
lAllAlIBlBli      ...  _k« 

Hwifn»l«  ...  1  • 

MBtlniUla        ..     ■ 

«rikaMrM>      . 

wiflH  vhI  >ni  JiMial  iT 

Brwrt* 

laartMi 


INDEX. 


987 


PAOC. 
Kill  uerra,  spurn  in  tlie  ngioo  of  dli- 
tHbutlon  at: 

•tiolDgy.  dlvuMt* ■- 101 

pngnoai*,  UvMEDtDt       L  40S 

|Ui  DBTve,  trophic   albetioaa  In  ths 

territory  o(        1.  SBS 

bxon  ot  the  leg,  ipuni*  of L  613 

i        tiHtmaat L  512 

Ixor  oommani*  digitoram  podk,  pam- 

Uljiiiof        i.6» 
poUicii  lonnu,  faaljiitot..     ..I.  iit 

M.K>taof i-fiia 

trotd  saoratnentM  .  .i.  1A2 

kMrm,  miucls  of    , .       1. 180, 1. 184,  L  4B5 
t        inrbca  of 1.  IW,  i  481 

^■110  ntlcDlari*    . .      . .  SS,  SS,  H,  68,  SB 
ioUon  ., 1.  IDS 

toil -     ..     ..     183,  «7 

Mrth  DBrre,  origin  and  attaohmflnt  of,i.  SS5 

■Wtarea,  Bpantaiieoua      .L  S34 

fioMwork  of  ipinal  mid.  oampealliioil 

o( S 

ainlnCioD I.  !sa 

TftriatlHof        LSW 

auiaiD.. 1.  M9 

Uooa.  exterual      L  SflT 

Cioiuof  tha  oortox  of  tbaoanbnun.l.  4TB 

CiXpailmeDtitl  datanaituUion  of  . .  L  48S 

ooa,  tha  wrtical  Ideational  uva  . .     ISO 

BXparimental  detsriDi nation  of    . ,     IBT 

Uoiia  of  the  cortical  motor  eeatre* 

133,481 

^       aiperiineatsl  determliKtloa  of  . .     188 
faetioui  of  tha  Hoiorj  cortical  oeatTM 
r  181,183 

h       eiperimanta]  datennlnUioa  of   . .     IM 
^diu    of  tJia    eye.    oplithAlinaaoo|iia 

/'  appaammof L  B13 

JBowadband US 

W^atudc 311 

\       hamiplfl^e ,, 681 

^      tuBmodia  . .  . ,  . ,     Sfil 

kmiilc  aidtability 1. 113 

inniHtlon       1. 1T3 

>      Tuiatinof L  ITS 

tranlnn L  2T1 

h      methods  of  applioalloD  of     ..     ..i.}73 

|«llondllg       Ll»,  8 

i      »poUr L    le 

Baale'a       i.    SI 

UpoUr       L    IS 

L     OMdato      1.   IS 

^     multipolar        1.    19 

;      iphelical     1,    IS 

HClloD-oelli.      morbid     chAUgai     of, 

■trophr  of 84,  8fi 

oollaid  daAaneration  of  , .  86 

h jpertro^y  of. 84 

nnelens.  multlplioatlon  of    . .     . .       84 
pigtannuxy  deEenentionof  ■■     ■■       8& 

ihrinklngof      84 

TkCDoUtiOU  of ^4 

M^on-oelt  uraup*,   longitndinii  dle- 

Crlbutinoorin  theipinal  cord       31 
M^on-oell  prooeaH*.  biaucbed  .,  1.  IS.  1.  30 

twilled        i    Bl 

.      nnbntDcbed       1 18, 1. 10 

em  guiliOD      L  Z8S,  i.  .tH3 
Kla      1.  688 

Hrio    branchca  of   tha  Ta^na.  anMa- 

thesiaof i.  UT 

Ario  plainc.  nearoaea  of  L  483,  I.  688 

Ibodyirla  iieuraigloa     1.668 

Mtml  ooDTulfliauB,  thooiy  of . .  .  ,L  3^ 

Mnldikgnoria 1.941 

BKsl  etlulogy i.    TH 

■Km]  morbid  luuttomy i.  IMS 

Mtal  morbid  phj^oloiy       i.  233 


PIOE. 

OenenJ  pktholoiT       L     8 

Oaneral  prognodi       L  MO 

Oanenl  nmptomotalogy L    79 

OianteeUt      46! 

Girdle  mdmUod L  lOS 

QluuU,  tiophoiiauroMe  of        L  UT 

of   the  dlgaatlte    tnet,    tnplio- 

neiuoaaa  of 1.  UT 

of  tfaegenlto-arinuTapHratna,.!.  ISO 

Uohrymal L  SIS 

aaliiarr     L  »»7 

oftheakln L  IIB 

Glaoooma  ilmplaE      1.  S9S 

Qtloma I.  30!,  STS,  878,  S6S 

Qloao-phaiyngaal  nerre i.  388 

diagram  of I.  187 

origin  and  attaobmeDt  of      . .     . .  L  388 

Gloaaoplegla i.  883 

atiologj,  aympUnoa L  381 

diagnodi,  pcognoaia,  traatmant  .  .1.  383 

OlowraUn L  313 

Qlottis.  ■pum  of t.41B 

etiolofT.  pndlapoalDg  oaoiai        . .  1.  418 

oooulonu  oaiuea       .     i.  130 

patboli^,  afrnploma    i.  410 

ooaoomitant  ■ymptoma 1.421 

oooTM,  dlagnoafi      1.411 

prognoal*.  treatment      L  433 

aiottii  Tocalla       1. 113 

OlotU*  raaplia>->riB      L  US 

Ologa'a  oorpiuolea  ..  88 

Otutaalragloii,  moacleaof..     ..    L  608,  L  607 

Olyoocaria      L  191 

Oall.(iolumn*of i.  S6,  38,  W,  SI 

fonctiona  of       83 

Otaphoapiaiaiia 1.401 

piumljtlo  (bna,  aymptoma  . .  L  486 

apaaticfoim,  aTrnptiinu 1.  M& 

tremnloDi  form,  ajmptomi  ..     ..1.486 

Tariatica      L  106,  I.  487 

etiology      i.  487 

dlagutaia,     ptognodi,     trsat- 

maot       L«e8 

Qratiolat,  optio radlatiooa of    ..     ..L  61,  469 

OnTn'dtMMa     1.680 

etioksT,  ajmptomi L  601 

morbid  uiatamy     L  606 

morbid  phytiology 1.  6M 

dlagnoau,  prognaaii,  treatment  . .  L  689 

Gray  daganeration       1,  181 

Gray  matter,  oumpcaltlon  of 8 

of  tba  oerebellam 118 

of  tha  cerebnim       148-408 

of  medulla  obtonga^  aapeiadded.      60 

Qfej  iQbslanoe I.    SS 

of  theoarabrum      148-468 

of  tha  eoaphalou i.    48 

of  the  Hudnlla  oblongata      , .      . .  88-00 

of  the  aplnat  ootd g,  11.13 

deralopment  of  . .  . .  11.31 

rearrangamant  of S3.S7 

railitanoa  to  diaeaae  of 87-93 

Qrovth i.     9 

ra[mdnction  and  aotioa,  antago- 

uiam  betwaon 1.    11 

Gumma 1.  303,  337,  667 

Ouatalory  nervta,  aiunthtda  of     . .     .  .1.  341 

dlaaaaeaof i.  338 

dlatribntton  of i.  SS9 

hyaiBatbeaia  of 1.  340 

pamathaaia  of 1,341 

Gjmnaalloa,  Swadlah 1.  308 

Hannatomyelta 3tl 

Hnmaiomyelltia 386 

iTmptoma 386 

HMmaloirliaalila 881 

etiology      SSI 

•ymptomi 38! 


D90 


tin>nL 


(SkW      -    .-    «• 

<ltiB|<«i— HT 

0iwn«.iMrtUMaU>7.dii«B^i   MA 

pfWHia.  crMtB»*Bt     3M 

IMIMB  of  Um  MHOVl  *JM«IB.  tttmtt- 

«bM«r         .. i.to 

taiMUea     L»T 

*rlM-i-i*> LHT 

«-«J^»« 42 

Urtt-Ur. Lttr 

I  MllMM  Mlllimi*!  im  Ihrfl  llllH       ..       ..L  ttl 

drcwDMnbad !.»» 

fcotl L  ktS 

<li»Md      lt» 

hMokci^     L  ns 

aolw I  BC 

MOkOBlat L  IM 

iV>MMtie..     LM 

l«lin«Hiillift  II  Hull  iwiiii  ..I  tH 
Wff^W      L  «U 

aMiB—Ti   Lst.iii« 

IliM—Miy L  04.1  MS 

aiiBlmli J.  MS 

Mxb j^    .J.n» 

mnmrti 11(4 

VMcakr     .. LSI.I.  H4 

LMi>MM*«««Mbk<WllKUH>u      ..L  Ml 

OMMteUg -LMB 

BwtffcwH Ll«l 

qriMl.. Ltta 

t.1BB« «f  Mw  WW M»efc*rtM  ..  ..L  IM 
UadlMlODAf LIM 

iwiumih.  iwiiMi Lna 

L^ratHpJkU,  iwnlTiltirf      ..     ..     .  .L  «ff 

LBfMMfBlMn  nrMnMU,  iMHlnU  tf  L  tU 

VM«*( I  Md 

t  Iffitptimi  aM<wnl»W      a 

L^MlncpdM J.  Its 

Lifona..^^ MI 

LiT»r,  n»Brg<it  inl«HM»iirt  ■f  .,  .  J.  IM 
liflil  iinfHt.  tiiHii— litiiiiiniiTiM  iif  I      a 

Loal  trrtuOan L    79 

L«BlHr,(MortlMMOM«f L    M 

ld«n-tiiT.tuU        LI&I,Lt9 

VBVtaU' LUf.LtM 

•u-  ..     ..     LlMLLtM 

liimRK4i«  Mau,  ■rvfnMl'** td 

dMalUnu.hlM> «l 

«*fc>bV       *» 

VMUtsoa  ..     ,.    ..    , SIS 

nrMln t» 

OMUM J.     .1,     iiii      ..     MB 

■wtddaMMnr    M 

35Sr-r:: :: ::  ::  i2 

pwwwfc »• 

tiwtaail H« 

LiNMalfK M« 

iMdiMi. us 

UBibarM«n«EM     L  Me 

MtifQ      XM 

,  — t-.  -J J.-, 1     1,}^ 

Jii  III  in* l.«^tM« 

LBBbo«M«alwa  iM«n%la -L  iW 

LoM.  nnnar  «U>«  <■(     W 

■■MUU (.ttV 

MwalaagMkMta      t  UB 

■lUiMallb .J.tM 

IHifcn«tiiMn>iifnltl«»4 tt 

Hmm^ L  MT 

MMkMmtMlrrf* ,    ..L«« 


"'^Syi*' 


NmMMr^ltol 


INDEX. 


9»1 


rui(. 
UtnhuiUaj^llu  eanrultj  a(  the  InlQ : 

svoTt*,  dantlcin,  «id  UtniiuaUooi    m 
BMhtn  anMainy     Tti 

<il>fl>l«»ta Ttt 

plUCDMlS lis 

UmUimdI TM 

Maiiinitiit.  fpUraUa  ccivhro  iplnal     , .  tcti 

.l<Bnltiaii M4 

bUtorj       ,       ....  aw 

■*in]ili<n» its 

mar*^  tii'd  AxinXiiru        .4     ,,     .a  ABB 

ODmnliiBilaii*  fiuilMiiaMn  ..     ..  11)9 

luormil  aii4i*iu|'      ,•     ..      ..     ,«  iSV 

moibld  Uvvlaiocj B4U 

ilM^<nl*kDil  pTUfnocIa MO 

tnUOMUt  ..      ..     ,,    ,,.    ,1     ..  StI 

HMlniltli.  tHMMUa      ;si 

mIoIdsj       ,     „     , .  7H 

itirpldnii   ..     ..     ,,     „     .,     ,,  7M 

TUTi^Ut*         ,.       .,       ,,,      a.      a,       ,,       791 

morbiil  uutomy      TM 

dUfOwal*.  imDuMia,  and  tniitoKiit  T8S 

Mealium*.  munuiic       ;m 

rttolufj-        ?iW 

lIDpuma . .    irii 

mmMh  dnmtloo.  ui<[  UminUiaiL*    T^ 
norhld  wuHuj  uiil  jilijuul-oify. .     Im 

ilUenoaUiiBil  prsgiinn* :m 

UvAfrjitaiL  ,. ,.     .,     7^;* 

Mwiirtiicla.  loiwnuIiir.jfrtijiltMaplMliut 

iKUl> ,,    ,.    TM 

Hocarlal  prqitnUoM     1  HO 

HanaHalUm , M 

Viiipliitiia  .,     „     ,L    J.     >.     ..     Ml 
IMaiBimt  ,.     .,     „     ,.     ,.     ..     SB 

HlddJig  tvuiulwon     ..     .. MB 

lll«nln*  l.M~ 

Muoio  DDUVSiUoil  ,,       .. t.  Ml 

MbalofwU  innlfiJ*       t.  Us 

Mliol  sijiiilBl  luarH,  dla*HM  of  ,.     ..     M 

Haf«r*j>bl> I.  4M 

MoaDiftm*  . .      ..     ..     &IM 

mlnlaof,. rtm 

ooftlod       UKbtt 

Hum  Vaaaii*.  BianlRtkal       I.  Ml 

Miirhirl  iii^riiiiii  trrivnrirai  uid  fnucUDU. 

Mului  apinrnlui.  meilioriiuf  aaiuliitiic     lis 
gvnarjai  »XBMiiit4ti4b  «.     lilt 

■pcclbl.  stimluflUon        110 

Moioi  acMaUoi  ymmun  vaioU  ..  .  .1.  IM 
llM«t«niital  iMrr«,illMiMn<if  ..  .,1.  sm 
■IMqrwaUllfimHiUBpalDW       ..     ..i.lM 

HonnaM  uf  iIm  ^■M^  n^auiiiit  up 

TDiunuitna  of.. L  ITV 

W^iwtBt*.  miwamic     LtiLM 

nOn 1    U 

•pUltWMCKU i.      • 

volonMrr  ,.     , L    U 

Ualtlpla  trUnmla.  tt  mkriiaU,  nnllipla     801 

MiWDtc,  healthy,  itniclaniut      I  Ml 

Hii«lt4.  »<iM).[ij<>f I.  2UI 

ottL  uuuinr  lirubfuitlati     ..     ..!■  KU 

HiwlH.  Mrrh-bUor I.  Ua^  I- *M 

MuhIsi.  rlntrical  ajuuulimtluik  at..  ..f.  IX 
Muvlei  rifUinnrui.  iiaumof L  Ml 

MbkIm  uf  I'la  tsir,  (iiMiBcf I.  in 

MuiKlia  i^niivDjitral]  i  Bit 

attachmaulvHUili^xiaot  raWUan  i.  Mt 
MOHlairfAiiiianlrMlM  ..  ..  I.  UIA,  I.  SOT 
MtNCtaoTilUUkll^aii   ..     ..    1.  Uids  I.  Su7 

VVtrtlM        .1.  4M 

•impttf&u ,    .,    ,.L  iH 

dlWnwli,  UMmaBl      U  4ftt 

Hoadaaotlujuz        L  (13 

BCUilBIt^ , I.«]3 

H«KlMofl(t       „     .,      f.MT,  LUa,!.  an 


Hoaalnmatlni  thaaoft  tAlJM       ..     ..L<M 

a«tioiMirf   .,      ..  L  109 

MuKha  uvrtsif  lliaaaft  priala.  vtntn*' 

of ..    ..i.ior 

dbuniniB,  pn>cn«[i,  ttMlt^t  ..i4M 
XlUtla  (rf  Iti*  Wiurni       ..     ..    l.4m,L4IO 

utllHucf L  IIU 

Muclsof  the  lliiunlj.  uiHitlini  of  .       .i.  its 
Mowtaof  tha  era.'k  ..     ..     ..    i.t:D,i.i;g 

Hiuclc*.  palaljanJ,  ki>uilij(ical  sliiki-itt* 

ID ..      -llM 

lIilr«l*B,nUil*«liiiiiiBnltrnt(«pu*]jit*l.lM 

MUtlivlUbUICrUnHinililiin     ..L  I6S 

lunlnUof  '  .  .  ..LITS 
MiiacW  *ilp^]l*d  lij  U'*  criu«l  Barr*^ 

fUmlfitot l.tW 

Monlw  nppHal    by   tli*    lijfci(ki^ 

■a**.(vilT)l>of I.M8 

■[■■mnf -LMitt 

HohUb  nipiriM  bT  (be  (loMal  Darra, 

lanHjriaaf L  MT 

JIiihIm  (DpptMt  if  tbainnllaji  uartsk 

pvaljilaof       ..     ..  ,.L«M 

HuMloa  fup]Ji«4  by  4tLaibn»eulovuUiba- 

Oiia  uam,  panU^^a  uf  . .  ,  L  ttV 
lliwElta  MpplMl  fey  tha  iiiii«aUMplml 

oam,BtnlytU  at i  «I 

llnadtaaiiitpll*i1>j  ilu  oManuwnana, 

yaimifmlat;,!..  ..  .,  ..  ..J.MT 
MuwIm  cniipllid  ligi  ((■•  •eUUc  IHn«) 

p...J.«.^f  .    „    ..    „    ..tut 

ellQli-O,  ■]  riiiiUiina  „ 1  Ml 

<lia^uu*i»,  jn^uuAla..     .,     ..     .  .L  Atf 
UaABDOBt LMI 

Hnaalaa  lOpplM  t^  Iha  hUiu  mna^ 

■pHKiiif   .. L  an 

tnattoimt , i,U$ 

HweiiluwiiiaaUiaiik ..     .,L  lU 

MiuciiLUBanlncUiMi,  lawaf L  IM 

Mii»ml«r  atoa,  miB|jidtlon af . .     ..     ,.L  Ml 

■■•nlt^maui  uf L  m 

Muieulu  Bhn.  iMliad     L  Ml 

UnnlnaUBU  tdDnnwlii        ..     ..L  tO> 

MiueuUt  li7p«nMilMdk L  IW 

MuKvfai  b^vanlnaa      l  Lit 

MiiauuUr  iimt>xl(ia     ,.     .. L  IIA 

BluBiuUt  aaboa     ,,     ,,     ^,     ,,     ,,     ,,|,  t^ 

laau  Air      L  lull 

Uiwmlar  H-nitUlIlr L  IM 

Uali  flir I.  luB 

MUBfltlir  tauurfdlatsrlwilcaa       ..     ..I.  ID* 

UuwBlat  trwpbouaanaa Llil 

llilaaulu  taouM IIU 

M|itilMl*pu«ljUiB Law 

Ur^UtU.  dllTiH^  MUa m 

dafliiiikm,«(l«l>icr ..    tn 

qrmplMM M     ••     Xn 

••'"-. ..     ..     W 

nucbU  uMoaj     ,.    ,.    ..    ,,  9* 

DOThU  tihyiliriiiar «t 

micUn     m 

diigBori*    ..    ..    .. 3M 

)iru(iniu( ,     „     ,,'    „  in 

traaimaBl  ..      ,.     ..     „    .„     ,.  M 

ll)*llll>,  •tmuol.  (Iirunl*       in 

deaiilUou,  tUuluO ..     ,.     „    ..  CM 

^TBlptmM ,.     H     •■  *M 

■HIM »     ..    ..  W 

mnrlild  •.iiKUmr      MM 

iBurlilil  |>lij>ULi0 ..  nc 

(ftrlMisi                     MN 

iliutiuau,  juvguivl^  tnatnwDt  ..  >H 

Hjeloaijilieu       ,  -m 

■}-Dt]'hiiDtk  nirbld  ■■katamf       ..  Sv* 

uiuiljHl  |i)i;aiulu|0,  ■"niltl't*      ..  SIM 

ir«iliu«u( Mt 

MTnnniiiJilfIa       i     ••,     ..    ..L 110 

MjuiaJiLte  aanmetUM      I.  IHt 


tHDBZ. 


etMw. 

Mjafa LIM 

iwalTtfM LIM 

I^iimU  LHI 

lln»«»(iiDk tfl 

MfSoru I.  WltM 

Jtr-iu-Mtnoon      ....  , .     IT» 

Saol  Bifinsnl'i'd  ..     .,      .,1.119 

Xilb.tiaiibiodlionhEnaf..  ..     ..LIID 

VKk.iuiue)Mq(.. Lin 

>lttn<mirm,  taiioa  td I.   tt 

!C(fM4<«aiKnUdn     .       ..     DM 

Oiniiyat L  W 

XfTT^tbRK  uli^jllHln  ot t.   n 

«iiDM*l^t>MiMarftaof      ..    .A,  H 

•ImiButMjAwllxif L   n 

HkiiTUi'*  aad«B«f  ,.     ,,     .,     .  .L    H 

Komlltni^aAratit,,     „     ..      LMiLMt 

KKitoiin     ..     ..     ........       U 

knouM      M,*1>M 

MMTlftpl 1-    41 

•atdnut ,,    ,.    ..L   41 

oonunwunil  *•    ..    ^.L   4X 

•Aniil  ..  ,.  )■  ,.  fc  Mb  L  at 
of  irar  ■uAW  ■  ■     •■    ••    •■    ■■       ' 

iBtomnma       1    41 

nolttlUtol       t   n 

I    41 

Mva-BMdallHid       L  S 

McnUn XU.L0 

Mupbia .  l4l.ilT 

at  whUa  Duiuw  "  • 

ihrT*BteM,»iutMl«MtB     LtM 

!tHT»UirM,  faneUi**  «< L    W 

Umdunot      L  fltt 

)IWT*fmi4tliHi*.awMraIlb«t3tf..  ..I.  n 
MtnaniMMBUvo  ..    ■■    ..L  IK 

N«na  HwtBhliis I.  Ii¥ 

Nairn,  tangHtj  at     •>    ..    ••    •  >     .  .i.  m> 

iMosiahio I.  IN* 

MM0dM7 ^"^ 

UWPWM.  proffnoii^  IntWHM.  X  3W 

lt»n—,eimfHt/aiaf..      L  SH 

S*m»,  cntnlti.  oUsUi  tod  klMohUMDM 

ot  .    .     Lssum 

plunorental      I.MI 

KMw<liHaH«,winaat L   IS 

piwUipiaillM  M     L   n 

y<n>«.  olmrlal  mmhi»l»B  of  . .  .  .L  1M 
yfrrw^  bf^^nnmift </. .  ..I  IBf 

•jinpioiiM ..  .  L  Bl 

!Vw>n,  liyft—trafhyf I.  Mt 

Kam,  luMmuiMa  i( I.  M 

Bttubo       L1H 

nUIMODM  ..      1,      .. I    IN 

OnUM I.IM 

wattU  aatiMV     '-  *** 

dlacntali .X9t 

ptOtBMia,  uwtoi*!      I.  IM 

Htnat  aaaiiluUotonnUMMlB  ..  ..LML 
SwTMof  rowUi— m,  .Im—IJ*..     ..(.  Mt 

*f . .     . i.  tn 

MmtvmmiAaii !■«• 

ifHUMn*  .. L  UO 

mismlt,  BMbotocr.  trMtnml .  .1-  431 
Xarroui l«t«H.  duilfcaUun  (4  ..  ..I.IO 
X«mnu  «jrt«,  »■  '  ii  i  cj  |iar«>f  nf   ..1.   W 

(Ooctnttiuiul  ■  -t.   4t 

J — i.-r-^.-i  -:-.i f I.  M 

tnardMnlHMaar  ..  ..  .  I.  H 
Uw  of  n>.ta(Mn  of I.  T* 

^'■'»iMllMii«i.  iiimiiiwd )t     ,.     ..knt 

eonmmtuoatl L   tS 

4ramimutatt      Lit* 

:(«ai«l|l>      LM.1.IM 

■wmkI  maptMiM    .,    ..    I,  M,  I.  Ml 

RiaMpttui .xm 


*>rira*<vaMa«a    ....  ^  ^  'ii 

-  XwinJ— ■    ....  .  wl 

NMM)fU.-ii»B         ..  ..  1    ifl 

(nnM      -     -.     -     Jk.lm 

K«wr»H>slw  li.ln«^«lli  ..      .      .LM 

•Uaiao im 

unnmia .sm» 

«MWi*     .. i.»    , 

XMnliU.  AmumIm  .  ^M 

ii— ii—i ..     \m 

iBlWwtowlw    . 
Vtonlipa  WMmUm   .. 


VaanlHat 

y«w«lgl« NmN  iMi^a JU  -     ..     ..L< 
MaonlBla  MaaMtai        i  M 

?Xr^.-.  .:  r.  ;IS 

tlwlawtf .  i  M> 

KMnlfU  BMW  nMtk , .     ..       .  ..iia 

mws«lN LIN 

•MaratOT L  >«   I 

t>|4iUulMtak     .  .  ^a 

|MtM    ..     ..      .  i^M 

pknnkik     ..      .  ifl| 

lOiutMto     ..      .     .. LiWl 

pariaalo  ktMonktMaM      ..  .  I W 

1  I* 
iiUtam  I.  Ml 

'  ■     ■'    ■     |i  I  •'  oM 

x.witiu»r      ..  .  aM 

HmtIUi ..  ^M 

Aiiokta 
V 

eavrm 

■wM4i 

tat: 

»SH^MinlW»aM       ..      _     .».» 

lt«wid>M«aiB   ..    . 
!c«M|ito     

anwiBUy  a>  . 

4»«M«fMiaw  «< 

HaatMriMMM 
SiaiiMMa 

ma     ..     .. 

illiJ<J1li>T1iH 
hba 

aUoli^ 
IwvlraiMB 


INDEX. 


¥ 


rMk. 

Koil  I »  fcypwhiilif      t   M 

Hnmow ••   •■   ••Ltn 

thp* (wnuiioDB ,.   ..    ..LMS 

■UlhiHX* «    ..    ..LM 

ilu«r«aa  of ..    ..    ..LOT 

ongiii  4iid  AlUt^nivat  vf  .  -  L  flIT 

Kucleni..       .     ..     .,     ..     ..    ,,     ..1.     • 

Slulvua  nncUliu        US,  Ul 

laluiuor    ..     ..     ..     SM 

Nnii  1*111  UoUculuto Ue,  UO 

NjrcialDput ,.    ..    ..t.  ttt 

HjUvntw I-MT 

•Hvlvir.  WoMn* l>** 

Obtantcv  nnn^U t.  aM 

UUIqniuliiraniiTSCuU.  mfi^^cf    ..L  HC 

UoninUl  lubM,  ImIoui  of SM 

Otaiu  niuHlaa,  isnljiU  tt    .,     ,.     ,.L  Mt 

(HKntl  nniRrki      ..L  Mt 

■«aaiml  vUolacT       L  IH 

Hiiinml  iiniiMBmi  ..     ..     ..     ..LtM 

u^iim LUI 

UcdUt  muiilM.  tinnriMlwpmiljakOf, 

*■<  Oi>litlWni»pl>1|UalMnA    L  WD 
Ui:alu  miucilc*.  ipuiDi  cil       ..     ..     ..L  Ml 

Omilu  uerra*       I,  fU 

diHWHDl L>U 

Oeula-nwtonu*.  fslcUi.  Mid  altMliDMBt 

u t.ia 

MKlyiUaf       LRU 

tao<nn|.l<to. .  ..       .     ..t.SU 

t£Bp)ucBtl  iduhiLb.  panlsataaC  ..    ..LMV 

|frlt-ir,  ifigftTTl  -if   ..  .,L4M 

(KaapltilKLuiliu      UlU 

<Jl«>|i]>uu>,  iHMlf^a  of .L  «I* 

""-—- T "— ^ LKM 

bnmMhMk LBOT 

fen«>l«^>    XM 

Otraeu»Tl«t»      MB 

Olbciorj  D«r>«,  dUi—  ii( L  Mt 

vCTilo Mkd MMbnaito Of  ..  ..I-SB 
MUimij  IndT  ,     ,.     .,     , 10,  ra 

■UMTWr    .•    ••    •■>•••••      M 

Uunluu         L    » 

Opnoolum ,    <•    ..    411 

Opbtbatanb  Monlito      .LBH 

Uplltt«lBojil«|la  «u«niB LHC 

qpDpwoiu    ,     ,.       ,  ..     ..1.  SW 

DMtCU  nuilnllljr  ..      ..L  Ml 

Monod*,  tnMiDMt      I.  :iai 

dboc-ia  DRCB^iU LIU 

^Smwi.rT^. LBM 

OpUu 1  SU 

OMnMoo,  tnttni  or      .. klU 

O^aiiMMlimli LHS 

•rnptoo* L  alt 

Optla  uuBAlnala.  pirtUI        L  ni4 

t^tia  •oauftlKars  *4h1  intb,  dliw—  oLL  ttlt 

tgmgimiu - i.3i( 

Otttofcnuiwttwli Llll 

OpUdbjrtniffitB    Llll 

OptkMM* »a,43» 

iMtMltcf ftW 

Ti«>«r     L»i 

tdspla LSa 

•aauiuJar; ..     ,.     ..L  M> 

bj  oilufMliB Lsn 

•jBIikiiu L  30 

t»  omu  tiaoitu*       Lno 

to«MliantlaA«4  tmmI*  ..L  Stl 
Wdu««td«-NUnUM  ..  ..Lul 
MnMnlU*|iifiiMatoM  ..  ..i.ai 
tVMMMUDU L*U 

momd,  uataiur,   rooiw^    pMi< 

DAM      i.m 

tMUinit LW 

Optic  Mfa.  ■U'BiM  of LUt 

iluil>Ja  ciiiifoitliiii  of      LtM 

LLL 


OMl«B«r*<kUnMUi«af LU* 

OiiiieiMvtilt      Lttt 

MlolofJ      LIB 

*ul>af*     LMI 

nmVitaM LSM 

gnM^tftufK^m LSM 

■—-"■'  -"J— J      LIM 

tnatOMM LMI 

OpOataiUiiilaaaorarMloiM    .,     ..L(I,IM 

iMlauoT Ul 

OvUBttulMol       iKr,M«,4M 

DpUatrut «1B,  «l 

ehfawawvf LSI 

url(Ui  unlMuatiaMnvr     ..     ..I.  Bt 

lomUot LMI 

OHola L«M 

Oimidnal*    ..     ..     Lilt 

Otaoaat  tmUnt  la  ttia  iamat    .,     ..     ,.Lttl 

Ob*d<u  Uapboomi  rtaia LM 

of  ooQlr^  vh^in  ,,     ..L  90 

of  parlphf nl  oilfln       . .     . .    . .  L  Bl 

ef  •pinal  orWin        LIM 

rMaDnik 4«s.iar 

OMMBMMjgik       I.IIS 

Uat*Hd    IDMOt*    at  Um    onn*   U&, 

fanlrriitf        Ltfl 

OtMUck     LMt 

Ovaitao  hfpBMHbMk     LIM 

nwtlllODkui  laaliw      «lf 

^udiTiiMujtBitu  oarvbtmllt  vaMnw       ■  -  70 

■Unbifr       711 

ipaitamt fU 

Bwriilil  uutonir      ..    ..    ..    ..  VM 

ptncnodK  IMBtmaot      M 

FKbjDMDlaiiii*  sanlintti  InlMM  hv 

awrrbwla        TU 

■Uokvr      •  TU 

tjaiftvmt TU 

TknniiM  ..    , T47 

amirw  BiHliiDiaUoa.  ,.     .,  TW 

autriai  utMtaaa ..  T4B 

tKosDoM    .,     7H 

tnMmwtt 1W 

h«liju«ttlii|iil**pliiaUiMldn«  ..     ..  IM 

ctiotao.  ■ftBpMu* 9t 

•OBfW,  SHMMil  UlMutll)!  . .       ,.      tW 

dligMidi.  pMpMBU.  uounMil  .,    IM 
H«hy««<Bim»,   •ulnaJia    uLMu  iim- 

Monhicin IM 

MMloair.  inkiinKii . .'    .,    mt 

vvfUM    7.   .»  Ml 

MlnMhni,  dUnlaij Mt 

4]nDMviB*  ..  .,    .,    „    ,.    Mr 

niuiMil  luutonqr     .,    ,.    .,    „    Ml 

IrHIDIUli  .,     ..     , IH 

J'unAU  |»iciM      ^W 

lldiu       ..     t    n 

1-*Um.  noMla nf       L«4.L«M 

Palttw-plutjniviu,  pumlrali  at     ,.     .J.  MB 
&I>111™«       ..     ..     ...Ml 

ett^Mtitti  tnulnBtlaa     .,     „     ,,     ,.     M 

rMsadmU L   U 

IftaJfiiim       ,     .,     „     ,X    M 

nmntam LIM 

TiMlVia  Llll 

pHnI;M4  Bimcla.  luucbiil  di>ii(«*  ta  ,.L  ITS 
PuiJ)>Md|itftA  tMariaUdmoVMMDtaaCL  M3 

Panljnta  aMradio*  ac*!*. sm 

Pwslyviiai'OBB Td 

■ttaOW       T»l 

qsMoow 7»1 

MOctMuMlMar       .....,,       TV? 
martM  i^ltfohvT  -       ■  M 

Ma 


•^. 


994 


Qtmx. 


PanlfAi  wlww.  uaMiMcii    . , 

■ucivto I  IM 

rmOrtM  MStfaMm* I.  in 

mphr* L>» 

hnfW«iM  djiMnabiaa Ill 

FhwUm^  UuMnaM       |  wr 

panUoTihy,  MaroCIs . . L    N 

rvuU*Br7  tedj .,     ,,     ,,      M 

ruOklopliewiMUMMa Lin 

rwUU  mtntj  fnljWl* L    VT 

TMMMot DM 

PuUU  MOMTT  ptnljik I.    IT 

IHl*tlBI*« LIM 

Vtmitt  cnnbnl  aonewlMn      m 

FaMlUr  t*»>tuB  rWhs L  HI 

kbuUilHd LIM 

diBBkMad LIM 

aunoatad      LIM 

MthlsdMiifiala L    n 

Pwwwtn  m»ioi,  ■anlrda  oT L  470 

nlauT,  BUalpHCf L  170 

FadniulB  <t(  >■•  <Mi*WliUi,  MnMcUoiH 

of CI 

Ivlonaof    ..     .. ifn 

FxtoDotaof  llMaR«(injn,l^oulB 

P^oootttu  KbtiB,  liflloM  af Ml 

FMBifttca* ..LUI 

rtnli,  M«)»I(U  Of     L 

rw  il^ajmal  ■pJUli L 

nn  nmnwiia t 

fwtHvvUw an 

l^aimfMon  ..    .. LM 

J<Ki.n>ariU( L  »a 

fwtHMiiMl  nilaai     i.  IH 

Fw)4HbiniMiaBaitk •« 

rwipkiMid  CMdd  ivtlTita      L  na 

P<fi|feani  •«*>.    MtanUis  dhMib' 

MNHll .,      .,LIH 

<!■<■■  tl LMI 

bjHrHWpby  «( ,.     ..LMl 

IM*l*aibfUaMi«. LIM 

Ttn^timAxa>tmlJ9*l*i!p*»   —    ••    .'    Ml 

l>tn)anu  bnrrU.  panljMa  of LMl 

iimgrn*,  pknljsltot 1.  IM 

rtiirjiiCBkl  otaHla.  ttUont  ot  .  ,L  41* 

puk^vtoor       I.  «1« 

rhu7nc«»l  id«nt,  iHaMMi  tf        , .     .  1.  W« 

Phwrni,  mutls  a( 1  tW,  I.  4I* 

nsnMta  IwyBCi^  Minlr'*- i  4M.  L  4M,  i  (Vr 

nonbiva* LMl 

MMaMfai      i.*» 

rfaMftio  noanlala  ..  . .  x  Hi 
FU  oMtw,  ilkHM  or  .  .  TU 
rteiBUu,onuU]      .,     .      «I0 

•BiMl 1 

riM<iKM|<if«B-qi«a i.«M 

nn'tnUill-mnflhtiHIii  ■Hiralli^tU  t  tif 

PtMvJ^DdT  -.      ..  4M 

riuitarNaanVB      !.l.fl7 

riMani       L   « 

PMaMpMrleiMrt«,dlK>*««(  ■■     ..L  <» 

ortflii  aarf  ailMtaMMl  «r     '.'.     '.'.L 
MMa*lHlikfMln ..LM 

dMltMUMX         LIOT 

fiOknii     i.va 

pnMon     LIM 

rollnnmU  liji  uMKt  unM IM 

MnitMa,UMn7,««blg)7  ..     ..  IM 

It^MMU ....                     . .       .  IM 

V-l*—-  ..                                ,.  IM 

•  . IM 

IM 

IIT 

BMbidtutMJi   m 

ttmatm  ta  tte  Wt>tr>l  —■*■    tM 
UtaltMtm  IB  d*  MMrtar  bMM   ifT 

MMM»fej«»4«r m 


INDEX. 


M6 


Pn>Mp>)g:ts (.  XM 

PntaplMDi I.     T 

fcl<llfM»« • MA 

fMBBonwn     SbT 

tmmioiimtnifltUf^ljtit      ..    ..  Mh 

Mniuiui,  biMMT W& 

«UDl<icr     >« 

vapMSM ,.    ..    ..  UT 

ooona        IM 

dUwMMli m 

mnibid  uMoanir    ..    ..    ..    ..    ion 

|uUli>Iuc; ..     ..     ..     3M 

utukucbU.  INMraMt     .,    ..     ..    110 

n7<hu«l  utlonik  ualura  at tT9 

UKlntenaa     L    TB 

iWtai,  eliHiaauion  Of W 

IHihH      .. LM* 

rulmanuy  plmu.  mnfi—  af       ..      ..I.4W 

PjruBU,  uDnlaiu  of ..      ..      M 

nraMidal  column      .. SI 

^nobUlnwl  ..      L  SI,  U,  At-ST,  «M,  «H 

MBWMrr  poniM  of      n 

hMtlHIBtf       „      ,.      .,      .,      ..       ■ 

MmwoI  ..    ».   .1    ..    »    ..   H» 

Fr«tti I.  ju 


Hrm,  ■■i>rHll4pii(lii|IfiiianiniiiflHaiiB  I.  TS 
IbnTlsi'i iKtl«    .,      ..     ..     ..      ,.      ..L    M 

nHHim.  naunil|fla))<  .      ,. L  BBl 

lUniu  ML ifmiu  atoll,  ptntjriatf       ..I. an 

■pMiu  u( IHT 

Rfclin  inl«niu KCoU,  pUkljakaf..     ..L  aH 

Vfoait t.a«T 

RMttu  laimlar  omil.  p>ialj>liiir  .    ..LUl 

RceiiiLnia  Huueilllr I.MI 

Rdnliiit  ...    ..     .X  IM 

lUtlar  ■'iilniA.  tiuaiHslrid  Ah    ..     ..1. 1U 

>u1«Uoi4<        L  IM 

IUfl»  ikinaaU f.  IVT 

hitnklMali     LIST 

dMivteMMor LUW 

BMniMdhuiiNa  «f  llMbatn,  dMnrb> 

uoMof L1T*,1.1W 

Riflai  iDoiamanM L    Bl 

RaOMiMiMi'^ Hft-HI 

■MkMk  OKMiMoiK  atlmall  of      ..    ..I.IM 

imp 1.1*0 

bwd^ LIU 

PNtMMkl LIU 

■vpMttgU I.IW 

MiillBaai.atliBBBat    LIID 

Rail,  ItUndor      MP 

IlamaLObmor i     ..        Lit 

Kiia«ll»       LIM 

■itMIiBl      LMI 

liitMiuJ         l,n« 

ltanilnMT(hr7BCwl|anlfML.  (.4Ki.«tT 

KaltftimVidr ,    ..     « 

B«Hfb«lWB«iiiUli..    ..    ,-,    ,t    .J.  tM 

Cinvonu*     .. i  nt 
it<t,  pw«ir*i* «i iffo 

lUiranutle  1u}d||m1  pknIjrM        . .     .  .1.  «H 

11111(111;.  «tnMter     ..     Lin 

«rlj Mt 

UU an 

AoUihIo.  OMura  ot     1X1,  tm 

n«r  tuhwoiaof      n 

■oMmiU*  gsUUnMaof T 

HaUUon  M  IiMd  and  Mak      L  M 

8Mnl  iHr<*>,4i«(mn  of. .      t  IID 

datnl  pisiiu.  nwinlcia  In  til*  icffm  •(  L  M9 

iWaMD  OMVaUdii      V  Ot 

eallm?  Itaadfc  ucnhMwantM  «r. .  ..LBT 
eaUaMritMB MI 


8*ltel«T  •(BuiB.  WMlafOl MI 

BkMBlamiDA LSM 

8«»>a aH,>n,wr 

SMuniiiia  uamMi  diMMM      tW 

■juMotu VM 

mtibU  kuMMir      •    ••    BH 

■unUd  phf  riokD MO 

JlnnoWi.  fiwuwb. Nt 

tMBtaiMii no 

S«lpbU*r*Ma( I.l» 

Heltxnn.  iliuth  of     .,      L    It 

Seuala   nom.   larmljna  ti  tba  ni»dB 

■upplial  1^        LUIS 

<VOpla«u .,     ..     .  J.  SW 

dlHMtfcpTOfMiU..     1.     ••     ..km 

UMlnsnt I.BB 

BdUlC  DMT«k  Mwu  «f  lb*  nwda  M^ 

pUailtT       ■       1.39 

UhUhuI l.itt 

Bebtlot LtM 

*\\r,t><f3      ..     LHS 

anaiumicai  chMifM !■  SU 

flaptaa*  ..     ..    ., ,L  SU 

cDium  dUoato ■    ..LCU 

pnfaimaa L  HT 

inatnwil ,.LA1* 

SuKruH  liUriil*  uofMniiililqii*  . .  . .  IM 
Salami,  ol  llw  eDlmnn*  ol  Ooll  . .  . ,  M» 
SdariHiaflftlisdlnrtsmtaUutniM  ,.    lU 

Bdoraiii,  UI.nI «l 

edMVabi  nnlUpl*      StO,  ML 

d^ultko m 

hUMrr        Ml 

■jntiunik Wl 

wuiw.  JmMIPii.  «DJ  twintwMt«—    Wt 

innriM  anUuiiiiP     aW 

■botMiI  pbr^ol^  . .     .       . ,      .      (1* 

tittnatU Ill 

|«>«n(«»     Bit 

irMUiuit ,.    m 

SMacaa, J.aU 

■dotUUUoi       .-     .,     ^     „     .Xtm 

fMoOtuUij  la|«a4ntlaiu .,      M 

aJlu  aiiiiniMliiiiii  ..    „    ,,    ..      M 
■wwidinc    ,.     ..     .,    ..    ..    ..     fS 

JmmuUuS H 

dlMitbnUonof  ..     ..     .,     ..     ..      M 

hMi>t7<if ..     ..      M 

Bmindxr  launlidarari*..     ..     ..     ..    m 

^^ytonH  M^ att 

SMDMlatj  mjralllf*     Mt 

Ottnnilary  PMMiUfta. MS 

SwoimUi7  Mlwoliarih*  caKUM  DfthU  tao 
niiiWBif  ■■■wiow ■umnoiM      ,.    ..I.  nr 

BMMtknu,  (olaHvai L   at 

ttnniDflii     ^k    ••     *a     at    ••     *«■•    H 

•P*i>)       X  H 

hnUla L   at 

(UbHilieiiacf  t«apmtBf«,  tataot       ..L    aa 

daiMaut  loodUr.  MaUirf tW 

at  ^— gf.  lMfc«t       i.    IM 

-*  -r'-'   -" f L»0 

AiniWlMMl  kSMtlcn*  of  ..      ..1,115 
aMiH<>r>'ii*ll.*i»lti^ar      ..     ,        .  LH8 

krp*nBnhHla  at L  0T 

B*tt>«UatMrtli« .  I  M» 

SmnIUUV.  nounnl L  M 

Tm      ..     -  I    aa 

SMi«a7«<n2Dall«.lMt«fnpUttror-L   Sa 

BMH«fyp«4iUMk(taM Wt 

Ummfl  .    Ml 

8«aM7  p«Mir>fa,  pMiia I  «r 

mtiUB    i  M 

taiui I.  or 

Somiu  nu^aw  pw«l}Mi«r ..    ..     ..t  tri 

•Tiuptiinu  ..    ..    .. I  <'? 

llCMIHMl .1.  ITS 

SvnMk  HUW  d«r«a l  UB 


»96 


IKDKX. 


r*aa. 

MMHOn  Buoliiaf U 

4h«nn<l LSM 

dkHMof LM 

oricbi  UKJ  MtMhwMrta  nf     ,.     .  I.  SW 

pu*];«li  (* I.  m 

■fum  in  til.  »(H  aldMrlltiUnn  (^.L  Ml 

8m,  m  pwril^alm  Ut  <11mm» L   Tt 

8w>ulnMM ..      ,.L    n 

anul  IMlSfi,  uoUinik  t<        ,,     .  L  IIT 

nliiiiiMfciiir  i|««iii ..     ..L  MT 

OefclHdiKlM        ..i.Mt 

SUmMlU     ..      , Lin 

Hnnttiu  L«T 

aiiUi  onuiUl  amm,  oittta  u4  aUiub* 

luantoaf     ,.       ,L)t3T 

ranlrdior       I.3U 

Wo,  IomJ  MMUUcf L  Ua 

lM«lliTI>annal««f ..     ,,     ,.     .XUt 

Moaofy  dMHubuMa  ttf t.   M 

mmmj  pgif»l)r««  vt .  1.  *T 

Skin  ptcnMnlMloD,  alunUlon  fa  . .     .  .L  911 

8k«II,i.n*..r      4« 

iHDMaUaf lb*  uiB«  of         ..     ,.    4M 
UiMlnrarfa  cm  >ti  jiirfw  t^. .     ..     4H 

Bio*  WPiiiiiMlai „     .,     ,.     .,1.    n 

SmdLhiiluiuUitiiiir   ., LNir 

tUodcaiiiif t.»M 

aniHcllif.  MUatainr ..i.tm 

a«ft  pateM.  nwudw  vinlnf  Ifct     ..     -L  4M 

■oUoiuar t.«M 

8oA pnUta,  panl/ili •# ,     .,LMT 

■niptooB ..LMT 

<Cbfiu»te.  pKVMdl .L  «M 

IrwiiBMat l.«n 

SDftpUaKipmaf  ..     ..    »    ..     ..I  MT 

MaofbM LMt 

SpMDOlie  «nitb ..L410 

■pMmoJk  ■i-IhI  ruttfilB       „     ,,     ,.     m 

SpMin* LIM 

•knU LUt 

■rvpnoM LiiB 

t4Bl« Lm 

gMpMMi L  m 

tmtinauaaiwipuiim i.tu 

IIIWIIMll  !■  «JltliiBM     ,.      ..      ,.LIM 

|g^BT8  prfnll I.  Ill 

SpMiDII*  lupllHtcrllU         UM* 

a|a>tlch«iilpli«uctf  tnbii^ m 

SjihUI  aMnaUgna J,   M 

Spetdi.  attir^tn  at C|) 

tmtHindcfutBMdt «f  ..     ..     ..     CIt 

aM(wu**ilip«n>Hntaf      ..    ..    «ii 

MMbuilHBBf «n 

OlUmttmirUiltyianir^iit     LAW 

ftmaat  I  tu 

SpUaUhU  .  .....    tM 

drtnlUnn   .  «H 

■ntpboa  . tH 

^aginKf      «M 

nml  m 

WwnyBWH.  nfi— a»y  WMtilrf    U 

4l«mnor L«M 

«II—Bf  I.  m 

■rlltai  u4  ■HKkBMM  <rf   ..     ..Lit* 
Sptnal    tOMBuir    nnn^    panlnla  of 

a«m«l  tnMh  (i i  <41 

*UDlof7.  iimptMM 1.  tU 

bHilMMl  .         .       .  .  1  «49 

Bpilul  amanfr  natTSt  tvatm    M   tlia 
PMlMi  of  lbs  aitanial  taaoth 

i»r ttW 

»f  ptBW* L  U4 

dWHd>,iiMtbUMaMM]>  ..        t  ua 

pnviMM,  IMUMCU      J.  Uf 

BfjBd  ■paplK* Wl 

BflMlanAlilVk MO 


aBla»l«>i«rt.ao«Bli.i«     „    ..    „ 
MlalMj 

dJacBD 

tivvAvi 
Splati  aBTd.  mnmtm  itf 
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lBH«^—i Jmm     ..  L  iia 

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lit     -.    .j.ai 
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998 


IKDKX. 


TrlCMkUw  ».— Ow*  tff 

tflmfiumf.  flii^nJi       LBH 

UaMlnm  . .  L  MT 

Iljailnlliin,  antrum*  <4  \.  UT 

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«VIn{4dlDa  .         ....  ..1.911 

('•rlsUB       (.Ml 

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t.fUi*iK»BdilirkIga«f  ..LSH 
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UMMunt DM 

dWntoUM  of  . .     . .     . .     .  .L  409 

>iUri<vr l-'to* 

MDilMaw  • - 1.4(0 

iU*ciuia*.  prani^  inaMMai  -.1  4(8 
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{■KtiUBia.  iKSIONal      -  -    . .    .  X  401 
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(crrlt«i*r  .      ...       ..I,  MS 

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of  til*  ii  iiw  L  m 

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TaWMbdotoNM LSM 

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L  «a,  L  IM,  I   4n 

Unlbuml  ;in>|it)id«*  tew  UMnbr      .1.670 
huloiT        ..     ..      ..1.  &TU 

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titalBO.  ajmfUim  Ml 

(•■ilcUa*     ....  MS 

taiabU  plvdahiu  .  MS 

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iUMfrmla,vn^mU..     ..  ,    Ml 

PwartpJiiMdw.  nrwuira  of  I  Wi 

Vppac  wm,  uiimIm  of      i  tit 

tlpiar  MUam^tr.  isnlj •!■  of  Um  lunai 

of L4t» 

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rf   .  .  ...    .1  11? 

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litrrni^snl  brantlw*  of     .       ..     ..LJIf 

Vafiu,  dtasrun  uf  .  .1.  tM 


of  .  I 

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V«— K  l»U— wilal.  .Mfc^w  ■«  01 

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ssr*. .; 

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TUM^  ktlirainaa  <tf L  «l 

alUtMfaB  ia  tha  6M  >tf  IW 

r>«apwlwtta»iiwM|iWipUi»i<H  n' 
4iBlnUaa  la  Ik*  aanf—  W  1.  ni 
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irf  M 

ilrT«lM^ik«ip1  iT  II 

nuauimi  ut  a 

InofitadlMl  OMMtaHw  of  C 

inrnmtmiii%  vt  ..  m 

WliJ tMii 

wiitkdKiaif  ..   ..  *mm 

WMtoMcRMp     .  >   U^l 

liaMOliaifc  quntoua  l  iM      T 

patal^Uf^  lyamtiw      .  i.  4M 

nniip      .     ......      .x«r 

lla<li«*Mi»fi*.WMMMi     .L«M 
Wij  imt      LIB 

■MfMae L*U [ 

Jmiu*i^  mmM  anataaj  •  <4fl 

(rnillLMMIMMt  >  *JH 

Tamrii^anaakiaf  i   »M™ 

Htm  L 


ERRATA.. 


VoLVUI  I. 

P*g»4l.  Ifim  Hth  f imn  ibe  top,   ■ 

„  I4ne  13lh  from  ihe  top.   (or  "wntm"  nad  "OTrtex," 

„  Ijtne  Utb  fre4B  tli<  top,  I 

„    48.  Line  I6tli  (rt>i»  lh»  inp,  (or  "  o«ii«r«am  "  fmmJ  "  etnMwum." 

n    48.  Liii«  nUi  frutn  tlt«  Wltc-oi.  Fur  "  P  "  nt4  "  p.** 

H    76>  Line  lUli  fmm  Ike  bnttnm,  far  "  WniiKThiilkl "  rrad  "  bKmorTkiMiU." 

„    ;r.  Line  :fiid  from  thf-  tnp.  for  "  MlttoktiUr  "*  rekd  "  kdvantltiH  " 

„  104.  Lino  IZth  Iroiii  the  lop^  for  *■  irfhaur  "  nwd  "  <f»I*mm»:" 

„  23fl.  I.ino  llthfmm  the  hntiflm.  ("r  "onll<w"  t«u1  "oalluii." 

„  U58.  Line  lltb  fr«tn  th<  bottocn,  for  "bMoicea"  te*d  "bocom*'.'* 

„  440.  Lia«  Sth  from  the  hattom,  lar  "  SUrualatui  "  niwl  "  SUmut^U*." 

„  40tf.  Iiiiwl6thfrc>ialhabutUitD,  (cq-  "  Inject  ion  "  rcMl  ''injictinnofBiarplii*." 

,.  0C9.  LhiB  till  fitiin  thr  hotUim,  for  "  nttntie  "  tMd  "  Bitrfts." 


ML 


VoLUKI  II. 
Liae  lllh  (rnn  the  Iniltiim,  for  "  dueiUHtiRg  "  nad  "  (ItCUMatlnK." 
Lioi.  Iflth  from  th#  top,  fnr  "  Cmrielhisr  "  r«»d  "  CniT»ilhi«." 
Lino  1st  M  tbo  ti.'p,  f»r"Gr«ringw  "  rtMcl  "Ufic»mg«T." 
Lioe  lit  lit  the  top,  for  "  ibtrty  "  rtaJ  "  IvreMy." 
LiM  11th  (rooi  tke  top,  for '"  oarinlli "  rcfcd  '"  VnrwUi." 
Line  Itith  (pom  the  top,  tnr  '■  VwrloJii "  r«*d  "  VwcliL" 
Ijua mh  Iniui  tUe betlom,  f'lr  " tfthf  Stall" tvd  "to tin  Skull." 
Linn   IDth  from   tlw  bottom,   ror   " torpnra  ttriatum"  fMul    "torfHU 

Mrialtim." 
line  19th  fima  the  beHoin,  for  "  (nwoOM  "  tfd  "  gruniL " 
Lino  l.tth  (ri>m  tbe  top,  fur  "  begao  tbc  "  nuA  "  bctrnn." 


■iKCHUrni : 

VaiirTID  >T  ALBXIXDU  tUtUKO  U(D  ca., 
MU.  MALL. 


UNE  MEDICAL  LIBRARY 
STANFORD  UNIVERSITY 
MEDICAL  CENTtR 
STANFORD,  CALIF.  94305